pharyngitis
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Introduction
Inflammation of the pharynx.
Etiology
- infectious
- bacteria
- Streptococcus pyogenes (17-30%, 10%[18])
- Neisseria gonorrhoeae[19]
- Corynebacterium diphtheriae
- Mycoplasma pneumonia (5%)
- Arcanobacterium haemolyticus (Corynebacterium haemolyticus)
- Fusobacterium necrophorum
- 21%, twice as common as S pyogenes in young adults[18]
- secondary syphilis[19]
- viruses
- fungal
- Candida
- histoplasmosis
- case with associated tonsillar mass[17]
- bacteria
- environmental
- drainage
- post-nasal drip
- gastroesophageal reflux (GERD)
- inhaled medications
- pharyngeal ulcers
- aphthous stomatitis
- herpangina
- fusospirochetal infection
- Candidiasis
- Herpes zoster
- chicken pox
- primary or secondary syphilis
- other rare causes
History
- recent orogenital contact suggests gonococcal pharyngitis
- a history of rheumatic fever suggests group A Streptococcus
Physical examination
- cardiac auscultation for murmur to assess potential rheumatic fever if etiology is group A Streptococcus
Clinical manifestations
- fever*
- pain on swallowing
- pain on extension of neck
- pharyngeal erythema
- tonsillar enlargement & exudate* suggestive, but NOT specific for streptococcal pharyngitis
- enlarged & tender anterior cervical nodes* suggests bacterial infection (group A Streptococcus)
- enlarged & tender posterior cervical nodes suggests viral infection
- cough & coryza suggests viral infection
- group A Streptococcus without cough*
- pharyngitis with normal throat examination that becomes worse on swallowing suggests thyroiditis
- pseudomembrane suggests diphtheria
- ulcerations may be present
- drooling suggests epiglottitis
- cobblestoning in posterior pharynx suggests chronic post-nasal drip
- generally resolves with 2-7 days when due to common cold[15]
- persistent fever & progressive difficulty swallowing suggest suppurative pharyngitis[16]
- headache & sudden onset consistent with group A Streptococcus[26]
* Centor criteria: predictive of group A Streptococcus
* image[26]
Laboratory
- rapid screen for group A streptococcus[9]
- not indicated if < 3 Centor criteria[4]
- negative rapid Strep antigen test followed up by culture for beta-hemolytic streptococcus (gold standard)[7]
- monospot test
- complete blood count (CBC)
Radiology
- lateral neck films if epiglottitis suspected
- CT or MRI of the neck if retropharyngeal or peritonsillar abscess
- CT of the neck with contrast if Lemierre syndrome suspected
Complications
- post-streptococcal glomerulonephritis
- rheumatic fever
- Lemierre syndrome due to Fusobacterium
- suppurative complications uncommon (1%)[16]
- history & physical exam findings not predictive
- culture results not predictive
- antibiotics not preventive
Differential diagnosis
- epiglottitis
- peritonsillar abscess
- dysphagia, trismus (lockjaw)
- asymmetric swelling of peritonsillar area
- laryngitis
- mononucleosis:
- tonsillitis:
- enlarged tonsils
- Ludwig's angina:
- edema in the sublingual area may push the tongue up & back
- drooling
Management
- viral
- symptomatic
- aspirin or acetaminophen
- lozenges (Cepacol) cetylpyridinium or benzocaine/cetylpyridinium/menthol or dyclonine (Sucrets)
- saltwater gargling
- fluids
- dexamethasone (0.6 mg/kg, max 10 mg) may be of benefit[8][23][24]
- bacterial
- Centor scoring system for Streptococcal pharyngitis used for determining therapy[11]
- antibiotics after laboratory confirmation of group A Streptococcus[14]
- only patients with confirmed Streptococcal infection should receive antibiotics[20]
- only patients with >= 3 Centor criteria need testing or treatment
- penicillin for group A streptococcus (1st line)
- prevents non-suppurative sequelae if started within 48 hours
- 10 days of therapy recommended
- penicillin V 500 mg PO BID (as effective as TID or QID)
- amoxicillin also 1st line[22]
- erythromycin or other macrolide in penicillin-allergic patients; macrolides do not cover Fusobacterium
- ampicillin sulbactam for Fusobacterium[4]
- prednisone 60 mg PO once (adults) may diminish pain[10]
- Centor scoring system for Streptococcal pharyngitis used for determining therapy[11]
- Candidiasis
- nystatin swish & swallow
- ketoconazole
- diphtheria
- rare in immunized populations
- diphtheria antitoxin within 48 hours
- retropharyngeal or peritonsillar abscess
- intravenous clindamycin or nafcillin
- surgery
- unproven therapies
- xylitol chewing gum of no value[25]
- probiotic capsules (Lactobacillus, Bifidobacteria) of no value[25]
- follow-up
- indicated if symptoms do not improve within 72 hours[26]
- recurrences are common
More general terms
More specific terms
- adenoiditis
- Fusospirochetal oropharyngitis
- laryngopharyngitis
- nasopharyngitis; rhinopharyngitis
- pharyngoconjunctional fever (PCF)
- streptococcal pharyngitis (strep throat)
- tonsillitis
Additional terms
- Centor criteria/scoring system for Streptococcal pharyngitis
- epiglottitis
- hoarseness
- laryngitis
- upper airway cough syndrome; postnasal drip (UACS)
References
- ↑ Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 796
- ↑ Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 100-101
- ↑ The Sanford Guide to Antimicrobial Therapy, 29th ed., Gilbert, DN et al (editors), Antimicrobial Therapy, Inc., Hyde Park VT, 1999
- ↑ 4.0 4.1 4.2 Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 15, 16, 18, 19. American College of Physicians, Philadelphia 1998, 2006, 2009, 2012, 2018, 2022.
Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022 - ↑ Journal Watch 21(21):167, 2001 Linder JA et al Antibiotic treatment of adults with sore throat by community primary care physicians: a national survey, 1989-1999. JAMA 286:1181, 2001 PMID: https://www.ncbi.nlm.nih.gov/pubmed/11559262
- ↑ Prescriber's Letter 9(5):25 2002
- ↑ 7.0 7.1 Journal Watch 23(14):115, 2003 Gieseker KE et al Evaluating the American Academy of Pediatrics diagnostic standard for Streptococcus pyogenes pharyngitis: backup culture versus repeat rapid antigen testing. Pediatrics 111:e666, 2003 PMID: https://www.ncbi.nlm.nih.gov/pubmed/12777583
- ↑ 8.0 8.1 Journal Watch 25(8):65, 2005 Olympia RP, Khine H, Avner JR. Effectiveness of oral dexamethasone in the treatment of moderate to severe pharyngitis in children. Arch Pediatr Adolesc Med. 2005 Mar;159(3):278-82. PMID: https://www.ncbi.nlm.nih.gov/pubmed/15753273
- ↑ 9.0 9.1 Humair JP, Revaz SA, Bovier P, Stalder H. Management of acute pharyngitis in adults: reliability of rapid streptococcal tests and clinical findings. Arch Intern Med. 2006 Mar 27;166(6):640-4. PMID: https://www.ncbi.nlm.nih.gov/pubmed/16567603
- ↑ 10.0 10.1 The NNT: Corticosteroids for Acute Pharyngitis. http://www.thennt.com/nnt/steroids-for-pharyngitis/
Hayward G et al Corticosteroids for pain relief in sore throat: Systematic review and meta-analysis. BMJ 2009 Aug 6; 339:b2976 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/19661138 <Internet> http://dx.doi.org/10.1136/bmj.b2976
Little P. Sore throat in primary care. BMJ 2009 Aug 6; 339:b2476 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/19661137 <Internet> http://dx.doi.org/10.1136/bmj.b2476
Hayward G, Thompson MJ, Perera R, Corticosteroids as standalone or add-on treatment for sore throat. Cochrane Database Syst Rev. 2012 Oct 17;10:CD008268 PMID: https://www.ncbi.nlm.nih.gov/pubmed/23076943 - ↑ 11.0 11.1 McIsaac WJ, Kellner JD, Aufricht P, Vanjaka A, Low DE. Empirical validation of guidelines for the management of pharyngitis in children and adults. JAMA. 2004 Apr 7;291(13):1587-95. PMID: https://www.ncbi.nlm.nih.gov/pubmed/15069046
Centor RM et al Pharyngitis management: defining the controversy. J Gen Intern Med. 2007 Jan;22(1):127-30. PMID: https://www.ncbi.nlm.nih.gov/pubmed/17351852
Centor RM Expand the pharyngitis paradigm to adolescents and young adults Annals of Internal Medicine 2009, 151:812 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/19949147 <Internet> http://www.annals.org/content/151/11/812.abstract - ↑ Centor RM, Samlowski R. Avoiding sore throat morbidity and mortality: when is it not "just a sore throat?". Am Fam Physician. 2011 Jan 1;83(1):26, 28. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21888123
- ↑ Fine AM et al Participatory Medicine: A Home Score for Streptococcal Pharyngitis Enabled by Real-Time Biosurveillance: A Cohort Study. Ann Intern Med. 2013;159(9):577-583 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/24189592 <Internet> http://annals.org/article.aspx?articleid=1763228
- ↑ 14.0 14.1 Hersh AL et al Principles of Judicious Antibiotic Prescribing for Bacterial Upper Respiratory Tract Infections in Pediatrics. Pediatrics. Nov 8, 2013 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/24249823 <Internet> http://pediatrics.aappublications.org/content/early/2013/11/12/peds.2013-3260.full.pdf+html
- ↑ 15.0 15.1 Thompson M et al Duration of symptoms of respiratory tract infections in children: systematic review. BMJ 2013;347:f7027 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/24335668 <Internet> http://www.bmj.com/content/347/bmj.f7027
- ↑ 16.0 16.1 16.2 Little P, Stuart B, Hobbs FD et al. Predictors of suppurative complications for acute sore throat in primary care: Prospective clinical cohort study. BMJ 2013 Nov 25; 347:f6867 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/24277339 <Internet> http://www.bmj.com/content/347/bmj.f6867
- ↑ 17.0 17.1 Durand ML et al Case 32-2014 - A 78-Year-Old Woman with Chronic Sore Throat and a Tonsillar Mass. N Engl J Med 2014; 371:1535-1543. October 16, 2014. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/25317874 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMcpc1406191
- ↑ 18.0 18.1 18.2 Centor RM et al The Clinical Presentation of Fusobacterium-Positive and Streptococcal-Positive Pharyngitis in a University Health Clinic: A Cross-sectional Study. Ann Intern Med. 2015;162(4):241-247 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/25686164 <Internet> http://annals.org/article.aspx?articleid=2118593
Linder JA Sore Throat: Avoid Overcomplicating the Uncomplicated Ann Intern Med. 2015;162(4):311-312 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/25686170 <Internet> http://annals.org/article.aspx?articleid=2118605 - ↑ 19.0 19.1 19.2 19.3 Barbee LA et al A History Lesson. N Engl J Med 2015; 372:1360-1364. April 2, 2015 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/25830427 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMcps1308900
- ↑ 20.0 20.1 Harris AM, Hicks LA, Qaseem A et al Appropriate Antibiotic Use for Acute Respiratory Tract Infection in Adults: Advice for High-Value Care From the American College of Physicians and the Centers for Disease Control and Prevention. Ann Intern Med. Published online 19 January 2016 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/26785402 <Internet> http://annals.org/article.aspx?articleid=2481815
- ↑ Weber R. Pharyngitis. Prim Care. 2014 Mar;41(1):91-8. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/24439883
- ↑ 22.0 22.1 Hersh AL et al. Frequency of first-line antibiotic selection among US ambulatory care visits for otitis media, sinusitis, and pharyngitis. JAMA Intern Med 2016 Oct 24 PMID: https://www.ncbi.nlm.nih.gov/pubmed/27775770
- ↑ 23.0 23.1 23.2 Hayward GN, Hay AD, Moore MV et al Effect of Oral Dexamethasone Without Immediate Antibiotics vs Placebo on Acute Sore Throat in Adults. A Randomized Clinical Trial. JAMA. 2017;317(15):1535-1543 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/28418482 <Internet> http://jamanetwork.com/journals/jama/fullarticle/2618622
- ↑ 24.0 24.1 Sadeghirad B, Siemieniuk RAC, Brignardello-Petersen R et al Corticosteroids for treatment of sore throat: systematic review and meta-analysis of randomised trials. BMJ 2017;358:j3887 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/28931508 <Internet> http://www.bmj.com/content/358/bmj.j3887
- ↑ 25.0 25.1 25.2 Little P, Stuart B, Wingrove Z et al Probiotic capsules and xylitol chewing gum to manage symptoms of pharyngitis: a randomized controlled factorial trial. CMAJ December 18, 2017 189 (50) E1543-E1550; <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/29255098 <Internet> http://www.cmaj.ca/content/189/50/E1543
- ↑ 26.0 26.1 26.2 26.3 26.4 26.5 Sinert RH Fast Five Quiz: Pharyngitis (Sore Throat). Medscape. December 14, 2022 https://reference.medscape.com/viewarticle/984986
Acerra JR, Taylor P, III Pharyngitis (image) Medscape. April 6, 2022 https://emedicine.medscape.com/article/764304-overview - ↑ Klein MR. Infections of the oropharynx. Emerg Med Clin North Am. 2019;37:69-80. PMID: https://www.ncbi.nlm.nih.gov/pubmed/30454781