key: cord-0059513-73mo9rq6 authors: Al-Qahtani, Abdulsalam; Altamimi, Zaid title: Pharyngitis date: 2020-07-07 journal: Textbook of Clinical Otolaryngology DOI: 10.1007/978-3-030-54088-3_49 sha: a9b1b67295a8afa688d64d9d0e1db493938993ff doc_id: 59513 cord_uid: 73mo9rq6 This chapter covers pharyngitis etiologies, general principles of diagnosis, investigations, management, and complications. Pharyngitis and sore throat are one of the most commonly encountered complaints in clinical practice. Pharyngitis can be classified into infectious and noninfectious or to acute and chronic pharyngitis. This chapter aims to provide an overview of these etiologies where it is further described in this chapter as an infectious and noninfectious pharyngitis. Infectious pharyngitis is divided into bacterial, viral, and fungal. Noninfectious pharyngitis is divided into inflammatory/autoimmune acute pharyngitis, membranous pharyngitis, radiation pharyngitis, and chronic inflammatory pharyngitis. This chapter provides a detailed overview of pharyngitis that can help the practitioner to reach the proper diagnosis and treat the patient accordingly. papillae anteriorly, and by the palatopharyngeal arch and palatine tonsils laterally. The hypopharynx extends from the superior border of epiglottis to the inferior border of the cricoid cartilage, contains the pyriform sinuses, post-cricoid region, and posterior pharyngeal wall. The pharynx contains the Waldeyer's tonsillar ring (pharyngeal lymphoid ring), which consists of the pharyngeal tonsil (adenoids), tubal tonsils (Gerlach tonsil), palatine tonsils (commonly called "the tonsils"), and lingual tonsil. The superior, middle, and inferior constrictor muscles from the external open-tubed structure of the pharynx, and fuse in the posterior midline at the pharyngeal raphe. The pharyngeal wall is surrounded via fascial layers and deep neck spaces. From anterior to posterior these are the buccopharyngeal fascia, retropharyngeal space, alar fascia, danger space, and the prevertebral fascia. In children, bacterial pharyngitis accounts for 30-40% of cases while in adults it accounts for only 5-15% [3] . Most cases of bacterial pharyngitis are caused by group A beta-hemolytic streptococcal (GABHS) pyogenes [4] . Group A beta-hemolytic streptococcal (GABHS), also known as Streptococcus pyogenes is the most common cause of acute bacterial tonsillitis pharyngitis. GABHS are Gram-positive cocci. Spread mainly through aerosolized microdroplets. It is a precursor of two serious conditions acute rheumatic fever and poststreptococcal glomerulonephritis. • The disease often affects age group of [5] [6] [7] [8] [9] [10] [11] [12] [13] [14] [15] years, especially the early school years, but it can affect any age. The incubation period is 1-4 days. Considered contagious during the acute illness and one week after, it becomes noncontagious after 24 h of antibiotics use [1] . • Note that cough, coryza, and nasal congestion are not suggestive of bacterial pharyngitis [5] . • Diagnosis of GABHS depends on clinical judgment and laboratory testing. • Rapid strep test (rapid antigen detection test, RADI): detects antigen (group-A streptococcal) from a swab. It is highly specific but less sensitive than culture and allows for immediate antibiotic treatment of a positive result. Carriers of GABHS, are around 5-10%, and they will have positive strep testing without acute symptoms [6] . • Throat culture: The gold standard laboratory test with the sensitivity of 90-95% [6] . • Supportive treatment including analgesics, antipyretics, bed rest, and hydration. Noting that GABHS is usually self-limited and resolved within 3-10 days. • Antibiotics: avoid the overuse of antibiotics in case of other pathogens, especially in the case of viral pharyngitis. Penicillin or amoxicillin is the drug of choice for 7-10 days. If suspect resistance uses amoxicillin + clavulanic acid or clindamycin. Corticosteroids have not been proven to have benefit in acute streptococcal pharyngitis. The major aim of antibiotic use is to reduce the rate of rheumatic fever, rheumatic heart disease, suppurative complications, and abscess formation. Noting that antibiotic therapy does not prevent poststreptococcal glomerulonephritis [7] . • Tonsillectomy in case of recurrent infections, despite appropriate antimicrobial therapy. • Suppurative complications such as peritonsillar, retro or parapharyngeal abscess, lymphadenopathy with abscess, bacteremia, and sepsis. • Scarlet fever. • Rheumatic fever: occur in 3% of untreated GABHS patients, risk can be reduced to 0.3% with the use of antibiotics [1] . • Rheumatic heart disease. • Poststreptococcal glomerulonephritis. Disorders Associated with Streptococcal (PANDAS) infections: tonsillectomy in these patients can resolute the neuropsychiatric symptoms [8] . This condition caused by gram-positive rodshaped Corynebacterium diphtheriae. A significant reduction in the incidence happened after the introduction of the Diphtheria vaccine [9] . The incubation period for diphtheria pharyngitis is 2-6 days. Spread mainly through infected secretions from the nose, throat, eyes, or skin lesions. • Treatment consists of antitoxin and antibiotics; penicillin or erythromycin are the recommended antibiotics [1] . • Early administration of medication specially antitoxin significantly affect the outcome. • In rare cases, with extended pseudomembrane to upper airway intubation or tracheostomy is needed to secure the airway and avoid aspiration. • Confirm eradication of the disease by having two negative cultures after completion of the treatment. • Diphtheria toxoid booster injection is recommended every 10 years in adults. • Diphtheria exotoxin is toxic to heart and nerves that can occur up to the second or third week of infection. • Heart involvement includes; myocarditis, arrhythmia, and acute heart failure. It can improve at 2 weeks after onset [7] . • Neurological involvement affects mainly the motor nerves. Commonly affects the soft palate and pharyngeal muscles, other muscles like the diaphragm and ocular muscles can be affected. It can improve from 3 to 7 weeks later [7] . • Other organs can be involved; the larynx with airway obstruction, the kidney can lead to acute tubular necrosis. • Death can occur due to cardiac or neurological involvement, or from asphyxiation from membranous pharyngitis. • A viral infection is the most common cause of infectious pharyngitis in both pediatrics and adults [3] . The most common viruses causing the infection are rhinovirus followed by coronavirus and parainfluenza [4] . It comes with gradual onset, as part of the common cold, symptoms typically include rhinorrhea, cough, and diarrhea, and usually, it is self-limited. Presence of pharyngitis with conjunctivitis, coryza, hoarseness, and cough suggest a viral etiology. Spread is by direct contact and inhalation/ingestion of respiratory secretions. Determining the virologic agent is unnecessary as it does not affect the management. Different viral pharyngitis has been described including the following: Epstein-Barr virus (EBV) is a common cause of acute sore throat in adolescents and young adults. 80-90% of adults are seropositive for EBV [11] . EBV has been associated with nasopharyngeal undifferentiated carcinoma, Burkitt lymphoma, and posttransplant lymphoproliferative disease (PTLD) [7] . It has an incubation period of 3-7 weeks. • Affects mainly older children and young adults. The classic triad of sore throat, fever, and lymphadenopathy. • Splenomegaly can be found in (50%), while hepatomegaly (10-15%) [11] . • Characteristic feature: Petechiae at the junction of hard and soft palate typically 1-2 mm in diameter, although these are not diagnostic. • Diagnosis is usually based on the clinical picture. • Blood test showed near normal white cell count with increment in lymphocytes, of which 10% are atypical on the blood smear. • Serological tests: Monospot and Paul Bunnell or Ox-cell. Hemolysis test shows high titers of heterophil antibody. When the Monospot test is negative, but still infectious mononucleosis is highly suspected, EBV-specific antibody studies (to viral capsid antigen) can confirm the diagnosis [11] . • Symptomatic treatment including rest, analgesics, antipyretics, and hydration. • A single dose of dexamethasone during acute symptoms can relieve the symptoms. The steroid also is recommended for complicated infections with upper airway obstruction, severe hemolytic anemia, severe thrombocytopenia, or persistent severe disease [1, 12] . • Antibiotics: has no role except in secondary bacterial infection. Amoxicillin or ampicillin should be avoided as they can cause a maculopapular rash (salmon-colored rash) in 95% of the patients [12] . • Management of upper airway obstruction: nasopharyngeal airway, high dose steroids, tonsillectomy, endotracheal intubation or a tracheostomy (rarely necessary). • Recovery from acute phase may take 2-3 weeks. While feelings of malaise may persist for weeks or months. Avoid contact sports to decrease the risk of splenic rupture and hemorrhage until ultrasound examination confirms the resolution of splenomegaly. • Secondary bacterial infection up to 30% [7] . • Hemolytic anemia, thrombocytopenia (25-50%). • Hyperplasia and severe tonsillitis which may cause upper airway obstruction occurs in fewer than 5% [7] . • Splenic rupture, elevated hepatic enzymes. • Severe neurologic complications occur in 1-5% [7] . Mostly it affects children 3-10 years of age. Characterized by a painful vesicular eruption (enanthem) in the palatal and anterior tonsillar pillars area. Treatment is symptomatic, spontaneously resolve in 1 week. Most infections are asymptomatic, except in immunosuppressed patients, especially posttransplant patients. Infectious mononucleosislike illnesses but heterophil antibody test is negative. Monoclonal antibodies against CMV is diagnostic. Treatment is symptomatic. Adenovirus (pharyngoconjunctival fever), measles, Herpes simplex virus (HSV). Mainly occur in immunosuppressed and chronically debilitated patients as an opportunistic infection [7] . Different Candida species are isolated in oropharyngeal fungal infection. Candida albicans is the most common isolated organism [13] . • It can occur in any age group with immunocompromised status. It is more common in adults, but neonates can be affected as well in 2-5%, which is typically self-limited [1] . • Isolated patches on the pharyngeal mucosa and larynx may be due to inhaled steroids from asthma treatment. • Inflammatory/autoimmune acute pharyngitis: • Viral infection is the most common cause of pharyngitis in children and adults. Rhinovirus is the most common etiologic agent. • Bacterial pharyngitis in adults (~10%) is less common than in children (~40%). • Group A beta-hemolytic streptococci: It is the most common cause of bacterial pharyngitis and can be complicated with deep neck abscess, rheumatic fever, and poststreptococcal glomerulonephritis. • Poststreptococcal glomerulonephritis risk does not decrease with the use of antibiotics. • Candidal pharyngitis is common in immunocompromised patients and postradiotherapy patients. Bailey's head and neck surgery: otolaryngology Does this patient have strep throat? 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