Pharyngitis

Aka: Pharyngitis, Sore Throat

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II. Epidemiology

  1. One of four most common episodic clinic visit reasons

III. Anatomy: Waldeyer's Tonsillar ring

  1. Nasopharynx
    1. Adenoids (pharyngeal Tonsils) at posterior wall
  2. Oropharynx
    1. Faucial (Palatine Tonsils) at lateral wall)
  3. Hypopharynx
    1. Lingual Tonsil at Tongue base

IV. Causes

  1. See Pharyngitis Causes

V. Symptoms

  1. Sore Throat
  2. Dysphagia (Difficulty Swallowing)
  3. Odynophagia (pain with Swallowing)
  4. Generalized symptoms
    1. Fever, Chills, Malaise
    2. Headache
    3. Abdominal Pain
    4. Nausea or Vomiting
  5. Symptoms suggestive of viral illness
    1. Coryza
    2. Conjunctivitis (esp. Adenovirus)
    3. Hoarseness
    4. Diffuse myalgias (seen in Influenza)
    5. Diffuse Lymphadenopathy in Cytomegalovirus (CMV), Mononucleosis (EBV), Acute HIV Infection
  6. Symptoms suggestive of Bacterial illness (Group A Streptococcal Pharyngitis)
    1. Fever (resolves within 3-5 days)
    2. Anterior Cervical Lymphadenopathy
    3. Tonsillar Exudate
    4. Lack of cough

VI. Signs: Red flags (suggestive of serious cause)

  1. Unilateral Pharyngitis
  2. Toxic appearance
  3. Prolonged Pharyngitis >3-5 days
  4. Associated neck swelling
  5. Drooling or Stridor (airway compromise)

VII. Signs

  1. Viral
    1. Non-exudative pharyngeal erythema
      1. Exception: Tonsillar exudate in Mononucleosis (EBV)
    2. Vesicular OR ulcerative Oral Lesions
    3. Conjunctivitis in Adenovirus and Kawasaki Disease
  2. Streptococcus and other Bacteria
    1. Enlarged Tonsils with or without exudate
    2. Petechiae on Soft Palate (pathognomonic)
    3. Erythema
    4. Tender Cervical Lymphadenopathy
    5. Strawberry Tongue (in Scarlet Fever)
  3. Peritonsillar Cellulitis or Peritonsillar Abscess
    1. Unilateral erythema of Soft Palate
    2. Uvula deviated
    3. Dysphagia
    4. Odynophagia
    5. Fever
  4. Diphtheria
    1. Gray membranous exudate covers Tonsils and pharynx
    2. Exudate bleeds easily on removal
  5. Kawasaki Disease
    1. Pharyngitis with strawberry Tongue in age <5 years
    2. Non-purulent Conjunctivitis (also in Adenovirus)
    3. Palmar erythema and cracked red lips after 3 days

VIII. Diagnosis

  1. See Strep Score

IX. Labs

  1. Leukocytosis on Complete Blood Count (CBC)
    1. WBC greater than 12.5 with Bacterial Pharyngitis
    2. Lymphocytes more than 10% atypical in EBV
  2. Streptococcal Rapid Antigen Test and Throat Culture (or Point-Of-Care GAS Nucleic Acid Amplification Test)
  3. Epstein Bar Virus (Mononucleosis)
    1. Mono-Spot (False Negative in young children)
    2. Heterophil Antibody Test (Positive if Titre >= 1:56)
  4. Diphtheria: Fluorescent Antibody
  5. Fungus: Sabouraud dextrose agar Fungal Culture
  6. Gonorrhea Culture
  7. Consider Laryngoscopy for severe or refractory symptoms

X. Management

  1. See Sore Throat Symptomatic Treatment
  2. See Group A Streptococcal Pharyngitis
    1. Antibiotic Management
  3. Consider other important etiologies if atypical
    1. Kawasaki Disease
    2. Diphtheria
    3. Gonorrhea
    4. Epiglottitis
    5. Bacterial Tracheitis

XI. Precautions: Consider serious complications and alternative diagnoses

  1. Peritonsillar Abscess
  2. Retropharyngeal Abscess
  3. Epiglottitis
  4. Bacterial Tracheitis
  5. Fusobacterium Pharyngitis (risk of Lemierre Syndrome)

XII. References

  1. Anderson (2019) Crit Dec Emerg Med 33(9): 3-10
  2. Degowin (1987) Diagnostic Exam p. 149-151
  3. Gwaltney in Mandell (2000) Infectious Dis, p. 656-61
  4. Vincent (2004) Am Fam Physician 69(6):1465-70 [PubMed]

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