Pharyngitis differential diagnosis

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Overview

Pharyngitis should be differentiated from other infectious causes which mimic sore throat that includes oral thrush, infectious mononucleosis, epiglottitis and retropharyngeal abscess.[1]

Differentiating Pharyngitis from other Diseases

The major goal of the differentiating patients with sore throat or acute pharyngitis is to exclude potentially dangerous causes (e.g. Group A streptococcus), to identify any treatable causes, and to improve symptoms. Identifying the treatable causes is important because timely treatment with antibiotics helps prevent complications such as acute rheumatic fever, post streptococcal glomerulonephritis.[2]

Disease/Variable Presentation Causes Physical exams findings Age commonly affected Imaging finding Treatment
Peritonsillar abscess Severe sore throat, otalgia fever, a "hot potato" or muffled voice, drooling, and trismus[3] Aerobic and anaerobic

bacteria most common is

Streptococcus

pyogenes.[4][5][6][7]

Contralateral deflection of the uvula,

the tonsil is displaced inferiorly and medially, tender submandibular and anterior cervical lymph nodes, tonsillar hypertrophy with likely peritonsillar edema.

The highest occurrence is in adults between 20 to 40 years of age.[3] On ultrasound peritonsillar abscess appears as focal irregularly marginated hypoechoic area.[8][9][10][11][8][9] Ampicillin-sulbactam, Clindamycin, Vancomycin or Linezolid
Croup Has cough and stridor but no drooling. Others are Hoarseness, Difficulty breathing, symptoms of the common cold, Runny nose, Fever Parainfluenza virus Suprasternal and intercostal indrawing,[12] Inspiratory stridor, expiratory wheezing, Sternal wall retractions[13] Mainly 6 months and 3 years old

rarely, adolescents and adults[14]

Steeple sign on neck X-ray Dexamethasone and nebulised epinephrine
Epiglottitis Stridor and drooling but no cough. Other symptoms include difficulty breathing, fever, chills, difficulty swallowing, hoarseness of voice H. influenza type b,

beta-hemolytic streptococci, Staphylococcus aureus,

fungi and viruses.

Cyanosis, Cervical lymphadenopathy, Inflamed epiglottis Used to be mostly found in

pediatric age group between 3 to 5 years,

however, recent trend favors adults

as most commonly affected individuals

with a mean age of 44.94 years

Thumbprint sign on neck x-ray Airway maintenance, parenteral Cefotaxime or Ceftriaxone in combination with Vancomycin. Adjuvant therapy includes corticosteroids and racemic Epinephrine.[15][16]
Pharyngitis Sore throat, pain on swallowing, fever, headache, abdominal pain, nausea and vomiting Group A beta-hemolytic

streptococcus.

Inflamed pharynx with or without exudate Mostly in children and young adults,

with 50% of cases identified

between the ages of 5 to 24 years

_ Antimicrobial therapy mainly penicillin-based and analgesics.
Tonsilitis Sore throat, pain on swallowing, fever, headache, and cough Most common cause is

viral including adenovirus,

rhinovirus, influenza,

coronavirus, and

respiratory syncytial virus.

Second most common

causes are bacterial;

Group A streptococcal

bacteria[17]

Fever, especially 100°F or higher. Erythema, edema and exudate of the tonsils,[18] cervical lymphadenopathy, and Dysphonia.Invalid parameter in <ref> tag[19][20] Primarily affects children

between 5 and 15 years old.

Intraoral or transcutaneous USG may show an abscess making CT scan unnecessary.[21][19][20] Antimicrobial therapy mainly penicillin-based and analgesics with tonsilectomy in selected cases.
Retropharyngeal abscess Neck pain, stiff neck, torticollis, fever, malaise, stridor, and barking cough Polymicrobial infection.

Mostly; Streptococcus

pyogenes, Staphylococcus aureus and respiratory anaerobes (example; Fusobacteria, Prevotella,

and Veillonella species)[22][23][24][4][25][26]

Child may be unable to open the mouth widely. May have enlarged cervical lymph nodes and neck mass. Mostly between 2-4 years, but can occur in other age groups.[27][28] On CT scan, a mass impinging on the posterior pharyngeal wall with rim enhancement is seen[29][30] Immediate surgical drainage and antimicrobial therapy. emperic therapy involves; ampicillin-sulbactam or clindamycin.


Variable Pharyngitis Oral thrush Mononucleosis Epiglottitis Tonsilitis Retropharyngeal abscess
Presentation Dysphagia without odynophagia which will differentiate it from pharyngitis. Usually presents with a classic triad of Usually present with stridor and drooling; and other symptoms include difficulty breathing, fever, chills, difficulty swallowing, hoarseness of voice Sore throat, pain on swallowing, fever, headache, cough Neck pain, stiff neck, torticollis

fever, malaise, stridor, and barking cough

Causes Group A beta-hemolytic streptococcus. candidal infection Epstein-Barr virus H. influenza type b, beta-hemolytic streptococci, Staphylococcus aureus, fungi and viruses. Most common cause is viral including adenovirus, rhinovirus, influenza, coronavirus, and respiratory syncytial virus. Second most common causes are bacterial; Group A streptococcal bacteria,[5]  Polymicrobial infection. Mostly; Streptococcus pyogenes, Staphylococcus aureus and respiratory anaerobes (e.g. Fusobacteria, Prevotella, and Veillonella species)[22][23][24][4][25][26]
Physical exams findings Inflammed pharynx with or without exudate White plaques that reveal an erythematous base when scraped Diffuse lymphadenopathy, particularly bilateral and posterior cervical,Splenomegaly in 50% of cases, Hepatomegaly in 10% of cases, Pharyngeal petechiae, Rash in 90% of patients will develop a pruritic, maculopapular rash after the use of ampicillin or amoxicillin Cyanosis, Cervicallymphadenopathy, Inflammed epiglottis Fever, especially 100°F or higher.Erythema, edema and Exudate of the tonsils.cervical lymphadenopathy, Dysphonia.[31][32][18][33] Child may be unable to open the mouth widely. May have enlarged

cervical lymph nodes and neck mass.

Age commonly affected Mostly in children and young adults,

with 50% of cases identified

between the ages of 5 to 24 years.[34]

Usually in immunocompromised patients, including those with advanced HIV/AIDS Common in adolescents between 15-25 Used to be mostly found in

pediatric age group between 3 to 5 years,

however, recent trend favors adults

as most commonly affected individuals with a mean age of 44.94 years.[35]

Primarily affects children

between 5 and 15 years old.[36]

Mostly between 2-4 years, but can occur in other age groups.[27][28]
Imaging finding — — — Thumbprint sign on neck x-ray Intraoral or transcutaneous USG may show an abscess making CT scan unnecessary.[21][19][20] On CT scan, a mass impinging on the posterior pharyngeal wall with rim enhancement is seen.[29][30]
Treatment Antimicrobial therapy mainly penicillin-based and analgesics. oral fluconazole Supportive therapy

Glucocorticoids may be indicated in such cases of severe airway obstruction.

Airway maintenance, parenteral Cefotaxime or Ceftriaxone in combination with Vancomycin. Adjuvant therapy includes corticosteroids and racemic Epinephrine.[15][16] Antimicrobial therapy mainly penicillin-based and analgesics with tonsilectomy in selected cases. Immediate surgical drainage and antimicrobial therapy. emperic therapy involves; ampicillin-sulbactam or clindamycin.

References

  1. ↑ Vincent MT, Celestin N, Hussain AN (2004) Pharyngitis. Am Fam Physician 69 (6):1465-70. PMID: 15053411
  2. ↑ Del Mar CB, Glasziou PP, Spinks AB (2006) Antibiotics for sore throat. Cochrane Database Syst Rev (4):CD000023. DOI:10.1002/14651858.CD000023.pub3 PMID: 17054126
  3. ↑ 3.0 3.1 Galioto NJ (2008). "Peritonsillar abscess". Am Fam Physician. 77 (2): 199–202. PMID 18246890.
  4. ↑ 4.0 4.1 4.2 Brook I (2004). "Microbiology and management of peritonsillar, retropharyngeal, and parapharyngeal abscesses". J Oral Maxillofac Surg. 62 (12): 1545–50. PMID 15573356.
  5. ↑ Megalamani SB, Suria G, Manickam U, Balasubramanian D, Jothimahalingam S (2008). "Changing trends in bacteriology of peritonsillar abscess". J Laryngol Otol. 122 (9): 928–30. doi:10.1017/S0022215107001144. PMID 18039418.
  6. ↑ Snow DG, Campbell JB, Morgan DW (1991). "The microbiology of peritonsillar sepsis". J Laryngol Otol. 105 (7): 553–5. PMID 1875138.
  7. ↑ Matsuda A, Tanaka H, Kanaya T, Kamata K, Hasegawa M (2002). "Peritonsillar abscess: a study of 724 cases in Japan". Ear Nose Throat J. 81 (6): 384–9. PMID 12092281.
  8. ↑ 8.0 8.1 Lyon M, Blaivas M (2005). "Intraoral ultrasound in the diagnosis and treatment of suspected peritonsillar abscess in the emergency department". Acad Emerg Med. 12 (1): 85–8. doi:10.1197/j.aem.2004.08.045. PMID 15635144.
  9. ↑ 9.0 9.1 Boesen T, Jensen F (1992). "Preoperative ultrasonographic verification of peritonsillar abscesses in patients with severe tonsillitis". Eur Arch Otorhinolaryngol. 249 (3): 131–3. PMID 1642863.
  10. ↑ Bandarkar AN, Adeyiga AO, Fordham MT, Preciado D, Reilly BK (2016). "Tonsil ultrasound: technical approach and spectrum of pediatric peritonsillar infections". Pediatr Radiol. 46 (7): 1059–67. doi:10.1007/s00247-015-3505-7. PMID 26637999.
  11. ↑ Scott PM, Loftus WK, Kew J, Ahuja A, Yue V, van Hasselt CA (1999). "Diagnosis of peritonsillar infections: a prospective study of ultrasound, computerized tomography and clinical diagnosis". J Laryngol Otol. 113 (3): 229–32. PMID 10435129.
  12. ↑ Johnson D (2009). "Croup". BMJ Clin Evid. 2009. PMC 2907784. PMID 19445760.
  13. ↑ Giordano S, Adamo P, Monaci F, Pittao E, Tretiach M, Bargagli R (2009). "Bags with oven-dried moss for the active monitoring of airborne trace elements in urban areas". Environ Pollut. 157 (10): 2798–805. doi:10.1016/j.envpol.2009.04.020. PMID 19457602.
  14. ↑ Tong MC, Chu MC, Leighton SE, van Hasselt CA (1996). "Adult croup". Chest. 109 (6): 1659–62. PMID 8769531.
  15. ↑ 15.0 15.1 Nickas BJ (2005). "A 60-year-old man with stridor, drooling, and "tripoding" following a nasal polypectomy". J Emerg Nurs. 31 (3): 234–5, quiz 321. doi:10.1016/j.jen.2004.10.015. PMID 15983574.
  16. ↑ 16.0 16.1 Wick F, Ballmer PE, Haller A (2002). "Acute epiglottis in adults". Swiss Med Wkly. 132 (37–38): 541–7. PMID 12557859.
  17. ↑ Putto A (1987). "Febrile exudative tonsillitis: viral or streptococcal?". Pediatrics. 80 (1): 6–12. PMID 3601520.
  18. ↑ 18.0 18.1 Stelter K (2014). "Tonsillitis and sore throat in children". GMS Curr Top Otorhinolaryngol Head Neck Surg. 13: Doc07. doi:10.3205/cto000110. PMC 4273168. PMID 25587367.
  19. ↑ 19.0 19.1 19.2 Nogan S, Jandali D, Cipolla M, DeSilva B (2015). "The use of ultrasound imaging in evaluation of peritonsillar infections". Laryngoscope. 125 (11): 2604–7. doi:10.1002/lary.25313. PMID 25946659.
  20. ↑ 20.0 20.1 20.2 Fordham MT, Rock AN, Bandarkar A, Preciado D, Levy M, Cohen J; et al. (2015). "Transcervical ultrasonography in the diagnosis of pediatric peritonsillar abscess". Laryngoscope. 125 (12): 2799–804. doi:10.1002/lary.25354. PMID 25945805.
  21. ↑ 21.0 21.1 Kawabata M, Umakoshi M, Makise T, Miyashita K, Harada M, Nagano H; et al. (2016). "Clinical classification of peritonsillar abscess based on CT and indications for immediate abscess tonsillectomy". Auris Nasus Larynx. 43 (2): 182–6. doi:10.1016/j.anl.2015.09.014. PMID 26527518.
  22. ↑ 22.0 22.1 Cheng J, Elden L (2013). "Children with deep space neck infections: our experience with 178 children". Otolaryngol Head Neck Surg. 148 (6): 1037–42. doi:10.1177/0194599813482292. PMID 23520072.
  23. ↑ 23.0 23.1 Abdel-Haq N, Quezada M, Asmar BI (2012). "Retropharyngeal abscess in children: the rising incidence of methicillin-resistant Staphylococcus aureus". Pediatr Infect Dis J. 31 (7): 696–9. doi:10.1097/INF.0b013e318256fff0. PMID 22481424.
  24. ↑ 24.0 24.1 Inman JC, Rowe M, Ghostine M, Fleck T (2008). "Pediatric neck abscesses: changing organisms and empiric therapies". Laryngoscope. 118 (12): 2111–4. doi:10.1097/MLG.0b013e318182a4fb. PMID 18948832.
  25. ↑ 25.0 25.1 Wright CT, Stocks RM, Armstrong DL, Arnold SR, Gould HJ (2008). "Pediatric mediastinitis as a complication of methicillin-resistant Staphylococcus aureus retropharyngeal abscess". Arch Otolaryngol Head Neck Surg. 134 (4): 408–13. doi:10.1001/archotol.134.4.408. PMID 18427007.
  26. ↑ 26.0 26.1 Asmar BI (1990). "Bacteriology of retropharyngeal abscess in children". Pediatr Infect Dis J. 9 (8): 595–7. PMID 2235179.
  27. ↑ 27.0 27.1 Craig FW, Schunk JE (2003). "Retropharyngeal abscess in children: clinical presentation, utility of imaging, and current management". Pediatrics. 111 (6 Pt 1): 1394–8. PMID 12777558.
  28. ↑ 28.0 28.1 Coulthard M, Isaacs D (1991). "Neonatal retropharyngeal abscess". Pediatr Infect Dis J. 10 (7): 547–9. PMID 1876473.
  29. ↑ 29.0 29.1 Philpott CM, Selvadurai D, Banerjee AR (2004). "Paediatric retropharyngeal abscess". J Laryngol Otol. 118 (12): 919–26. PMID 15667676.
  30. ↑ 30.0 30.1 Vural C, Gungor A, Comerci S (2003). "Accuracy of computerized tomography in deep neck infections in the pediatric population". Am J Otolaryngol. 24 (3): 143–8. PMID 12761699.
  31. ↑ Tonsillitis. Medline Plus. https://www.nlm.nih.gov/medlineplus/ency/article/001043.htm. Accessed May 2nd, 2016.
  32. ↑ "Tonsillitis - NHS Choices".
  33. ↑ "Tonsillitis - Symptoms - NHS Choices".
  34. ↑ Bennett, John (2015). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Elsevier/Saunders. ISBN 978-1455748013.
  35. ↑ Lichtor JL, Roche Rodriguez M, Aaronson NL, Spock T, Goodman TR, Baum ED (2016). "Epiglottitis: It Hasn't Gone Away". Anesthesiology. 124 (6): 1404–7. doi:10.1097/ALN.0000000000001125. PMID 27031010.
  36. ↑ Sharav, Yair; Benoliel, Rafael (2008). Orofacial Pain and Headache. Elsevier. ISBN 0723434123.
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