Pharyngitis overview
|
Pharyngitis Microchapters |
|
Diagnosis |
|---|
|
Treatment |
|
Case Studies |
|
Pharyngitis overview On the Web |
|
American Roentgen Ray Society Images of Pharyngitis overview |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Venkata Sivakrishna Kumar Pulivarthi M.B.B.S [2]
Synonyms and keywords: Sore throat; Group A streptococcal pharyngitis; Bacterial pharyngitis; Viral pharyngitis.
Overview
Pharyngitis is the inflammation of the pharynx, manifested by sore throat. It is a painful inflammation of the pharynx, and is colloquially referred to as a sore throat. [1] Pharyngitis is a common medical problem in the outpatient medical setting, resulting in more than seven million pediatric visits each year. Most types of pharyngitis are caused by infectious etiologies. The most common cause of pharyngitis is viral infection. However, some of the more serious types of pharyngitis are attributed to bacterial etiologies, such as group A-hemolytic Streptococcus pyogenes (GAS). Complications from GAS pharyngitis include rheumatic fever, deep space abscesses, and toxic shock. Although most episodes of pharyngitis are acute in nature, a small percentage becomes recurrent or chronic. With regards to chronic pharyngitis, non-infectious etiologies, such as laryngopharyngeal reflux and periodic fever, aphthous ulcers, pharyngitis, and adenitis syndrome also need to be considered. Both medical and surgical therapies are effective in managing pharyngitis. First-line medical therapy includes antibiotic therapy. For certain indications, surgical management via adenotonsillectomy is recommended. Adenotonsillectomy has been shown to be effective in reducing disease burden and improving disease-specific and global quality of life. Several techniques for adenotonsillectomy exist, including traditional and intracapsular tonsillectomies.[2]
Historical Prospective
Pathophysiology
Causes
Classification
Differential Diagnosis
Epidemiology and Demographics
Pharyngitis is one of the most common disorders in adults and children, with more than 10 million ambulatory visits per year.[3] Viruses are the single most common cause of pharyngitis and account for 25% to 45% of all cases.[4] Group A streptococcus presents in up to 37% of all children presenting with a sore throat to an outpatient clinic or ED and 24% of those presenting at younger than 5 years.[5] Group A streptococcus is by far the most common bacterial cause of acute pharyngitis, accounting for approximately 15 to 30 percent of cases in children and 5 to 10 percent of cases in adults.[6] Peak seasons for sore throat include late winter and early spring.
Risk Factors
Pharyngitis is contagious, so anyone in close proximity to someone with the illness, is at risk. Social situations with prolonged close interpersonal contact are associated with a higher incidence of the disease, such as in schools, dormitories, or military barracks. Other common risk factors include History of ill contact, Over crowding, Frequent sinus infections, Smoking, Attending day care, Immunocompromised etc.
Natural History, Complications & Prognosis
Acute pharyngitis is typically described as the triad of sore throat, fever, and pharyngeal inflammation characterized by erythema and edema, although exudates, vesicles, or ulcerations may also be present. Although pharyngitis may be a primary disorder, sore throat and pharyngeal erythema may also be prominent in systemic disorders, such as the acute retroviral syndrome, or part of a more generalized upper respiratory tract infection. Most cases of acute pharyngitis are due to common viral infections and are benign, self-limited processes. The appropriate recognition of patients with more complicated infections that require diagnostic evaluations and treatment is one of the challenges of primary care medicine.[7] An estimated 1-2% of acute pharyngitis progresses to recurrent or chronic disease.[8]
Diagnosis
History and Symptoms
Pharyngitis is a very common inflammatory condition of the pharynx accompanied by a sore throat and occasionally difficulty in swallowing.[9] Other symptoms depends on the etiology such as bacterial or viral.[2]
| Clinical features of acute pharyngitis | |
|---|---|
| Group A streptococcal pharyngitis | Viral pharyngitis |
|
|
Physical Examination
Laboratory Findings
There is broad overlap between the signs and symptoms of streptococcal and non-streptococcal (usually viral) pharyngitis, and the ability to identify streptococcal pharyngitis accurately on the basis of clinical grounds alone is generally poor.[10][11][12] Therefore, except when obvious viral clinical and epidemiological features are present, a laboratory test should be performed to determine whether GAS is present in the pharynx.[13][12] Even subjects with all clinical features in a particular scoring system can be confirmed to have streptococcal pharyngitis only about 35%–50% of the time, and this is particularly the case in children.[11] Swabbing the throat and testing for GAS pharyngitis with RADT&/ culture should be performed because the clinical features alone do not reliably discriminate between GAS and viral pharyngitis except when overt viral features like rhinorrhea, cough, oral ulcers, and/or hoarseness are present.
The major goal of the evaluation of 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 group A streptococcus (GAS) is important because timely treatment with antibiotics helps prevent poststreptococcal complications such as acute rheumatic fever.[14] The evaluation includes a thorough history, focused physical examination, and diagnostic testing in selected patients.
Key points in the evaluation of acute pharyngitis
- Essential to diagnosis is the identification of treatable causes (e.g. Group A streptococcus) to prevent complications.s[15]
- Signs and symptoms of GAS pharyngitis include acute onset of sore throat with tonsillar or pharyngeal exudates, tender anterior cervical lymphadenopathy, and fever.
- Signs and symptoms consistent with viral etiologies include conjunctivitis, coryza, oral ulcers, cough, and diarrhea.
- Testing for GAS pharyngitis should not be pursued in those with signs and symptoms indicative of a viral etiology.
- Rapid antigen detection tests (RADTs) alone are sufficient for the diagnosis of GAS in adults, but negative results should be backed up by throat culture in children.
- Specific techniques should be used to identify other causes where appropriate.
Centor criteria: It is important to evaluate for definitive diagnosis to exclude GAS and to avoid unnecessary lab tests and antibiotic use. Centor criteria are a widely used and accepted clinical decision tool in identifying patients for whom neither microbiologic tests nor antimicrobial therapy are necessary.The Centor score to use for children and adults with a sore throat to estimate probability of Streptococcus pyogenes infection.[16]
| Modified Centor criteria | Appropriate management according to the total score | ||||
| Criteria | Points | Total score | Chance of streptococcal infection in community
with usual levels of infection, % |
Suggested management | |
| Fever (temperature > 38°C) | +1 | 0 | 2-3 | No culture or antibiotic is required | |
| Absence of cough | +1 | 1 | 4-6 | ||
| Swollen and tender anterior cervical nodes | +1 | 2 | 10-12 | Culture all; treat only if
culture result is positive | |
| Tonsillar swelling or exudates | +1 | 3 | 27-28 | ||
| Age 3–14 yr | +1 | 4 | 38–63 | Culture all; treat with penicillin
on clinical grounds | |
| Age 15–44 yr | 0 | ||||
| Age ≥ 45 yr | -1 | ||||
Evaluation of acute pharyngitis
Treatment
As is evident from potential etiologic agents of pharyngitis, group A streptococcus is the only commonly occurring form of acute pharyngitis for which antibiotic therapy is definitely indicated. Therefore, for a patient with acute pharyngitis, the clinical decision that usually needs to be made is whether or not the pharyngitis is attributable to GAS.[2]
Medical Therapy
Patients with acute GAS pharyngitis should be treated with an appropriate antibiotic at an appropriate dose for a duration likely to eradicate the organism from the pharynx (usually 10 days). Based on their narrow spectrum of activity, infrequency of adverse reactions, and modest cost, penicillin or amoxicillin is the recommended drug of choice for those non-allergic to these agents.[2] Treatment of GAS pharyngitis in penicillin-allergic individuals should include a first generation cephalosporin (for those not anaphylactically sensitive) for 10 days, clindamycin or clarithromycin for 10 days, or azithromycin for 5 days. Adjunctive therapy with Nonsteroidal Anti-inflammatory Drugs (NSAIDs), Acetaminophen, Aspirin, or Corticosteroids may be useful in the management of GAS pharyngitis.
Surgery
Prevention
References
- ↑ Acute Pharyngitis - Get Smart: Know When Antibiotics Work. Centers for Disease Control and Prevention (2015). http://www.cdc.gov/getsmart/community/materials-references/print-materials/hcp/adult-acute-pharyngitis.html July 28, 2016
- ↑ 2.0 2.1 2.2 2.3 Shulman ST, Bisno AL, Clegg HW, Gerber MA, Kaplan EL, Lee G et al. (2012) Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Clin Infect Dis 55 (10):1279-82. DOI:10.1093/cid/cis847 PMID: 23091044
- ↑ Bennett, John (2015). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Elsevier/Saunders. ISBN 978-1455748013.
- ↑ Bennett, John (2015). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Elsevier/Saunders. ISBN 978-1455748013.
- ↑ Cirilli AR (2013) Emergency evaluation and management of the sore throat. Emerg Med Clin North Am 31 (2):501-15. DOI:10.1016/j.emc.2013.01.002 PMID: 23601485
- ↑ Bisno AL (2001) Acute pharyngitis. N Engl J Med 344 (3):205-11. DOI:10.1056/NEJM200101183440308 PMID: 11172144
- ↑ Bennett, John (2015). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Elsevier/Saunders. ISBN 978-1455748013.
- ↑ St Sauver JL, Weaver AL, Orvidas LJ, Jacobson RM, Jacobsen SJ (2006) Population-based prevalence of repeated group A beta-hemolytic streptococcal pharyngitis episodes. Mayo Clin Proc 81 (9):1172-6. PMID: 16970213
- ↑ Cohen, J (2010). Infectious diseases. Edinburgh: Mosby/Elsevier. ISBN 978-0323045797.
- ↑ Wannamaker LW (1972) Perplexity and precision in the diagnosis of streptococcal pharyngitis. Am J Dis Child 124 (3):352-8. PMID: 5056872
- ↑ 11.0 11.1 Breese BB (1977) A simple scorecard for the tentative diagnosis of streptococcal pharyngitis. Am J Dis Child 131 (5):514-7. PMID: 855837
- ↑ 12.0 12.1 McIsaac WJ, Kellner JD, Aufricht P, Vanjaka A, Low DE (2004) Empirical validation of guidelines for the management of pharyngitis in children and adults. JAMA 291 (13):1587-95. DOI:10.1001/jama.291.13.1587 PMID: 15069046
- ↑ Bisno AL (1996) Acute pharyngitis: etiology and diagnosis. Pediatrics 97 (6 Pt 2):949-54. PMID: 8637780
- ↑ 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
- ↑ Bennett, John (2015). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Elsevier/Saunders. ISBN 978-1455748013.
- ↑ Anjos LM, Marcondes MB, Lima MF, Mondelli AL, Okoshi MP (2014) Streptococcal acute pharyngitis. Rev Soc Bras Med Trop 47 (4):409-13. PMID: 25229278