2. PHARYNGITISPHARYNGITIS
• What is itWhat is it??
– Inflammation of theInflammation of the
Pharynx secondary to anPharynx secondary to an
infectious agentinfectious agent
– Most common infectiousMost common infectious
agents are Group Aagents are Group A
Streptococcus and variousStreptococcus and various
viral agentsviral agents
– Often co-exists withOften co-exists with
tonsillitistonsillitis
5. Acute PharyngitisAcute Pharyngitis
• EtiologyEtiology
– BacterialBacterial
• Group A beta-hemolytic streptococci (Group A beta-hemolytic streptococci (S.S.
pyogenespyogenes)*)*
– most common bacterial cause of pharyngitismost common bacterial cause of pharyngitis
– accounts for 15-30% of cases in children and 5-10%accounts for 15-30% of cases in children and 5-10%
in adults.in adults.
• Mycoplasma pneumoniaeMycoplasma pneumoniae
• Arcanobacterium haemolyticumArcanobacterium haemolyticum
• Neisseria gonorrheaNeisseria gonorrhea
• Chlamydia pneumoniaeChlamydia pneumoniae
6. PHARYNGITISPHARYNGITIS
• HISTORYHISTORY
– Classic symptoms →Classic symptoms → Fever, throat pain, dysphagiaFever, throat pain, dysphagia
VIRAL →VIRAL → Most likely concurrent URI symptoms ofMost likely concurrent URI symptoms of
rhinorrhearhinorrhea, cough, hoarseness,, cough, hoarseness, conjunctivitisconjunctivitis &&
ulcerative lesionsulcerative lesions
STREPSTREP → Look for associated→ Look for associated headacheheadache, and/or, and/or
abdominal painabdominal pain
Fever and throat pain are usuallyFever and throat pain are usually acute in onsetacute in onset
7. PHARYNGITISPHARYNGITIS
• Physical ExamPhysical Exam
– VIRALVIRAL
EBVEBV –– White exudateWhite exudate covering erythematouscovering erythematous
pharynx and tonsils,pharynx and tonsils, cervical adenopathycervical adenopathy,,
Subacute/chronic symptoms (fatigue/myalgias)Subacute/chronic symptoms (fatigue/myalgias)
transmitted via infected salivatransmitted via infected saliva
Adenovirus/CoxsackieAdenovirus/Coxsackie – vesicles/ulcerative lesions– vesicles/ulcerative lesions
present on pharynx or posterior soft palatepresent on pharynx or posterior soft palate
Also look for conjunctivitisAlso look for conjunctivitis
8. Epidemiology of StreptococcalEpidemiology of Streptococcal
PharyngitisPharyngitis
• Spread by contact with respiratory secretionsSpread by contact with respiratory secretions
• Peaks in winter and springPeaks in winter and spring
• School age child (5-15 y)School age child (5-15 y)
• Communicability highest during acute infectionCommunicability highest during acute infection
• Patient no longer contagious after 24 hours ofPatient no longer contagious after 24 hours of
antibioticsantibiotics
• If hospitalized, droplet precautions needed untilIf hospitalized, droplet precautions needed until
no longer contagiousno longer contagious
9. PHARYNGITISPHARYNGITIS
• Physical ExamPhysical Exam
– BacterialBacterial
GASGAS – look for whitish exudate covering pharynx– look for whitish exudate covering pharynx
and tonsilsand tonsils
– tender anterior cervical adenopathytender anterior cervical adenopathy
– palatal/uvularpalatal/uvular petechiaepetechiae
– scarlatiniform rash covering torso and upperscarlatiniform rash covering torso and upper
armsarms
Spread viaSpread via respiratory particle dropletsrespiratory particle droplets – NO– NO
school attendance untilschool attendance until 24 hours after24 hours after initiation ofinitiation of
appropriate antibiotic therapyappropriate antibiotic therapy
– Absence of viral symptoms (rhinorrhea, cough,Absence of viral symptoms (rhinorrhea, cough,
hoarseness)hoarseness)
10. Differential diagnosis of pharyngitisDifferential diagnosis of pharyngitis
• Pharyngeal exudates:Pharyngeal exudates:
– S. pyogenesS. pyogenes
– C. diphtheriaeC. diphtheriae
– EBVEBV
11. Differential diagnosis of pharyngitisDifferential diagnosis of pharyngitis
• Skin rash:Skin rash:
– S. pyogenesS. pyogenes
– HIVHIV
– EBVEBV
12. Differential diagnosis of pharyngitisDifferential diagnosis of pharyngitis
• Conjunctivitis:Conjunctivitis:
– AdenovirusAdenovirus
13. Suppurative Complications ofSuppurative Complications of
Group A Streptococcal PharyngitisGroup A Streptococcal Pharyngitis
• Otitis mediaOtitis media
• SinusitisSinusitis
• Peritonsillar and retropharyngealPeritonsillar and retropharyngeal
abscessesabscesses
• Suppurative cervical adenitisSuppurative cervical adenitis
15. Nonsuppurative Complications ofNonsuppurative Complications of
Group A StreptococcusGroup A Streptococcus
• Acute rheumatic feverAcute rheumatic fever
– follows only streptococcal pharyngitis (notfollows only streptococcal pharyngitis (not
group A strep skin infections)group A strep skin infections)
• Acute glomerulonephritisAcute glomerulonephritis
– May follow pharyngitis or skin infectionMay follow pharyngitis or skin infection
(pyoderma)(pyoderma)
– Nephritogenic strainsNephritogenic strains
30. Recurrent pharyngitisRecurrent pharyngitis
• Etiology: Nonpenicillin treatment ,DifferentEtiology: Nonpenicillin treatment ,Different
strain ,Another cause pharyngitisstrain ,Another cause pharyngitis
• Treatment:Treatment:
TonsilectomyTonsilectomy
ifif
Culture positive, severe GABHS more thanCulture positive, severe GABHS more than
7 times during previous year7 times during previous year
oror
5 times each year during two previous year5 times each year during two previous year
31. Benefit of treatment of Strep.Benefit of treatment of Strep.
PharyngitisPharyngitis
• 1-Prevention of ARF if treatment started1-Prevention of ARF if treatment started
within 9 days of illnesswithin 9 days of illness
• 2-Reduce symptoms2-Reduce symptoms
• 3-Prevent local suppurative complications3-Prevent local suppurative complications
BUTBUT
Does not prevent the development of theDoes not prevent the development of the
post streptococcal sequel of acutepost streptococcal sequel of acute
glomerulonephritisglomerulonephritis
32. Antibiotic started immediately with symptomaticAntibiotic started immediately with symptomatic
pharyngitis and positive Rapid testpharyngitis and positive Rapid test
(Without culture)(Without culture)
• 1-Clinical diagnosis of scarlet fever1-Clinical diagnosis of scarlet fever
• 2-Household contact with documented2-Household contact with documented
strep. Pharyngitisstrep. Pharyngitis
• 3-Past history of ARF3-Past history of ARF
• 4-Recent history of ARF in a family4-Recent history of ARF in a family
membermember
33. PHARYNGITISPHARYNGITIS
• LAB AIDSLAB AIDS
Rapid strep antigen → detects GAS antigenRapid strep antigen → detects GAS antigen
Tonsillar swab → 3-5 minutes to performTonsillar swab → 3-5 minutes to perform
• 95% specificity, 90-93% sensitivity95% specificity, 90-93% sensitivity
GAS Throat culture → “gold standard”GAS Throat culture → “gold standard”
• >95% sensitivity>95% sensitivity
Mono Spot → serologic test for EBV heterophile AbMono Spot → serologic test for EBV heterophile Ab
EBV Ab titers → detect serum levels of EBV IgM/IgGEBV Ab titers → detect serum levels of EBV IgM/IgG
34. PHARYNGITISPHARYNGITIS
• TreatmentTreatment
VIRAL –VIRAL – Supportive care only – Analgesics,Supportive care only – Analgesics,
Antipyretics, FluidsAntipyretics, Fluids
No strong evidenceNo strong evidence supporting use of oral orsupporting use of oral or
intramuscular corticosteroids for pain relief → fewintramuscular corticosteroids for pain relief → few
studies show transient relief within first 12–24 hrsstudies show transient relief within first 12–24 hrs
after administrationafter administration
EBV – infectious mononucleosisEBV – infectious mononucleosis
activity restrictions – mortality in these pts mostactivity restrictions – mortality in these pts most
commonly associated with abdominal trauma and spleniccommonly associated with abdominal trauma and splenic
rupturerupture
35. PHARYNGITISPHARYNGITIS
• TreatmentTreatment →→ Do so to preventDo so to prevent ARFARF
(Acute Rheumatic Fever)(Acute Rheumatic Fever)
GASGAS →→
Oral PCN – treatment of choiceOral PCN – treatment of choice
10 day course of therapy10 day course of therapy
IM Benzathine PCN G – 1.2 million units x 1IM Benzathine PCN G – 1.2 million units x 1
Azithromycin, Clindamycin, or 1Azithromycin, Clindamycin, or 1stst
generationgeneration
cephalosporins for PCN allergycephalosporins for PCN allergy
40. Scarlet FeverScarlet Fever
• Occurs most commonly in associationOccurs most commonly in association
with pharyngitiswith pharyngitis
– Strawberry tongueStrawberry tongue
– RashRash
• Generalized fine, sandpapery scarlet erythemaGeneralized fine, sandpapery scarlet erythema
with accentuation in skin folds (Pastia’s lines)with accentuation in skin folds (Pastia’s lines)
• Circumoral pallorCircumoral pallor
• Palms and soles sparedPalms and soles spared
– Treatment same as strep pharyngitisTreatment same as strep pharyngitis
45. Acute Rheumatic FeverAcute Rheumatic Fever
• Supporting evidence of antecedent group ASupporting evidence of antecedent group A
streptococcal infectionstreptococcal infection
– Positive throat culture or rapidPositive throat culture or rapid
streptococcal antigen teststreptococcal antigen test
– Elevated or rising streptococcal antibodyElevated or rising streptococcal antibody
titertiter
• antistreptolysin O (ASO), antiDNAse Bantistreptolysin O (ASO), antiDNAse B
• If evidence of prior group A streptococcalIf evidence of prior group A streptococcal
infection, 2 major or one major and 2 minorinfection, 2 major or one major and 2 minor
manifestations indicates high probability ofmanifestations indicates high probability of
ARF
46. Acute Rheumatic FeverAcute Rheumatic Fever
• TherapyTherapy
– Goal: decrease inflammation, fever andGoal: decrease inflammation, fever and
toxicity and control heart failuretoxicity and control heart failure
– Treatment may include anti-inflammatoryTreatment may include anti-inflammatory
agents and steroids depending on severityagents and steroids depending on severity
of illnessof illness
47. PoststreptococcalPoststreptococcal
GlomerulonephritisGlomerulonephritis
• Develops about 10 days afterDevelops about 10 days after
pharyngitispharyngitis
• Immune mediated damage to theImmune mediated damage to the
kidney that results in renal dysfunctionkidney that results in renal dysfunction
• Nephritogenic strain ofNephritogenic strain of S. pyogenesS. pyogenes
48. PoststreptococcalPoststreptococcal
GlomerulonephritisGlomerulonephritis
• Clinical PresentationClinical Presentation
– Edema, hypertension, and smoky or rustyEdema, hypertension, and smoky or rusty
colored urinecolored urine
– Pallor, lethargy, malaise, weakness,Pallor, lethargy, malaise, weakness,
anorexia, headache and dull back painanorexia, headache and dull back pain
– Fever not prominentFever not prominent
• Laboratory FindingsLaboratory Findings
– Anemia, hematuria, proteinuriaAnemia, hematuria, proteinuria
– Urinalysis with RBCs, WBCs and castsUrinalysis with RBCs, WBCs and casts
49. PoststreptococcalPoststreptococcal
GlomerulonephritisGlomerulonephritis
• DiagnosisDiagnosis
– Clinical history, physical findings, andClinical history, physical findings, and
confirmatory evidence of antecedentconfirmatory evidence of antecedent
streptococcal infection (ASO or anti-DNAse B)streptococcal infection (ASO or anti-DNAse B)
• TherapyTherapy
– Penicillin to eradicate the nephritogenicPenicillin to eradicate the nephritogenic
streptococci (erythromycin if allergic)streptococci (erythromycin if allergic)
– Supportive care of complicationsSupportive care of complications
50. DiphtheriaDiphtheria
• Etiologic agent: CorynebacteriumEtiologic agent: Corynebacterium
diphtheriadiphtheria
– Extremely rare, occurs primarily inExtremely rare, occurs primarily in
unimmunized patientsunimmunized patients
– Gram positive rodGram positive rod
– nonspore formingnonspore forming
– strains may be toxigenic or nontoxigenicstrains may be toxigenic or nontoxigenic
• exotoxin required for diseaseexotoxin required for disease
52. TONSILLITISTONSILLITIS
Inflammation/Infection of the tonsilsInflammation/Infection of the tonsils
Palatine tonsilsPalatine tonsils → visible during oral exam→ visible during oral exam
Also have pharyngeal tonsils (adenoids) and lingual tonsilsAlso have pharyngeal tonsils (adenoids) and lingual tonsils
• HistoryHistory → sore throat, fever, otalgia, dysphagia→ sore throat, fever, otalgia, dysphagia
• Physical ExamPhysical Exam → whitish plaques, enlarged/tender→ whitish plaques, enlarged/tender
cervical adenopathycervical adenopathy
• EtiologyEtiology → GAS, EBV – less commonly HSV→ GAS, EBV – less commonly HSV
• TreatmentTreatment → same as for pharyngitis→ same as for pharyngitis
55. LARYNGITISLARYNGITIS
• Inflammation of the mucous membranesInflammation of the mucous membranes
covering the larynx with accompaniedcovering the larynx with accompanied
edema of the vocal cordsedema of the vocal cords
HistoryHistory →→ sore throatsore throat,, dysphoniadysphonia
(hoarseness) or(hoarseness) or loss of voiceloss of voice, cough, possible, cough, possible
low-grade feverlow-grade fever
Physical ExamPhysical Exam →→
cannot directly visualize larynx on standard PEcannot directly visualize larynx on standard PE
must use fiberoptic laryngoscopy (not usuallymust use fiberoptic laryngoscopy (not usually
necessary )necessary )
56. LARYNGITISLARYNGITIS
• ETIOLOGYETIOLOGY →→
AcuteAcute [<3wks duration]– Think infectious → most[<3wks duration]– Think infectious → most
commonly viral – symptoms most commonly resolvecommonly viral – symptoms most commonly resolve
in 7-10 daysin 7-10 days
ChronicChronic [>3wks duration]– Inhalation of irritant fumes,[>3wks duration]– Inhalation of irritant fumes,
vocal misuse, GERD, smokersvocal misuse, GERD, smokers
TreatmentTreatment → symptomatic care → complete→ symptomatic care → complete
voice rest, avoid exposure to insulting agent,voice rest, avoid exposure to insulting agent,
anti-reflux therapyanti-reflux therapy
Prevailing dataPrevailing data does NOT supportdoes NOT support the use ofthe use of
corticosteroids for symptomatic reliefcorticosteroids for symptomatic relief
57. PERITONSILLAR ABSCESSPERITONSILLAR ABSCESS
Accumulation of pus in the tonsillar fossa → thought to be anAccumulation of pus in the tonsillar fossa → thought to be an
infectious complication of inappropriately treatedinfectious complication of inappropriately treated
pharyngitis/tonsillitispharyngitis/tonsillitis
HistoryHistory →→
Antecedent sore throat 1-2 wks prior - progressively worsensAntecedent sore throat 1-2 wks prior - progressively worsens
DysphagiaDysphagia
High feverHigh fever
Ipsilateral throat, ear & possibly neck painIpsilateral throat, ear & possibly neck pain
Physical ExamPhysical Exam →→
Trismus – 67% of casesTrismus – 67% of cases
muffled voice (“Hot Potato”)muffled voice (“Hot Potato”)
Drooling &/or fetid breathDrooling &/or fetid breath
look for unilateral mass in the supratonsilar area with possible uvulalook for unilateral mass in the supratonsilar area with possible uvula
deviationdeviation
fluctuant upon palpationfluctuant upon palpation
58. PERITONSILLAR ABSCESSPERITONSILLAR ABSCESS
EtiologyEtiology →→ 90% of aspirated cultures grow bacterial pathogens90% of aspirated cultures grow bacterial pathogens
GAS – most common (approximately 30% of cases)GAS – most common (approximately 30% of cases)
Staphylococcus aureusStaphylococcus aureus
Anaerobes – most commonly Peptostreptococcal microbesAnaerobes – most commonly Peptostreptococcal microbes
TreatmentTreatment →→
Prompt ENT consultation forPrompt ENT consultation for needle aspirationneedle aspiration (*always(*always
send cultures) or possible surgical drainagesend cultures) or possible surgical drainage
Systemic abx –Systemic abx – usually Clindamycinusually Clindamycin andand aa ββ-Lactam or-Lactam or
11stst
generation cephalosporingeneration cephalosporin
Surgical tonsillectomy if:Surgical tonsillectomy if:
1)1) No improvement in 48 hoursNo improvement in 48 hours
2)2) H/O recurrent abscesses – 3 or more (controversial)H/O recurrent abscesses – 3 or more (controversial)
