Acute Pharyngitis

Acute Pharyngitis

Pharyngitis refers to the inflammation of the pharynx, primarily affecting the oropharynx or can be generalized inflammation of the whole pharynx. This condition can manifest in various forms, with acute catarrhal or superficial tonsillitis being a common subtype associated with generalized pharyngitis, particularly in viral infections.

Types of Pharyngitis

1. Acute Catarrhal Pharyngitis. This form of pharyngitis is characterized by superficial inflammation and is predominantly seen in viral infections. It often presents with mild symptoms such as a sore throat and discomfort.
2. Parenchymatous Tonsillitis. In contrast, parenchymatous tonsillitis affects the substance of the tonsils. The tonsils appear uniformly enlarged and red in this condition, indicating a more severe inflammatory response.

Demographics

Pharyngitis is commonly observed in adults, whereas tonsillitis is primarily a disease affecting children. The majority of pharyngeal infections in adults are viral in nature, with Streptococcus pyogenes accounting for only 5–10% of cases. This low percentage highlights the predominance of viral pathogens in adult pharyngitis, underscoring the need for accurate diagnosis and appropriate management strategies.

Aetiology

Acute pharyngitis is a common condition that can arise from various aetiological factors, including viral, bacterial, and fungal infections. Among these, viral causes are the most prevalent (40-60%). Acute streptococcal pharyngitis, specifically due to Group A beta-haemolytic streptococci, is particularly significant due to its association with complications such as rheumatic fever and poststreptococcal glomerulonephritis. Bacterial infections are seen in 5–30% of cases. In approximately 30% of cases no pathogen is isolated.

Table: Aetiology of acute pharyngitis
Viral	Bacterial	Fungal	Protozoal
Rhinovirus Adenovirus Influenza Parainfluenza Infectious mononucleosis (EBV) Cytomegalovirus Measles and chicken pox Herpes simplex Coronavirus	Streptococcal (Group A beta-haemolytic streptococci) GABHS Diphtheria Gonococcal	Candida albicans Chlamydia trachomatis	Toxoplasmosis (parasitic, rare)

Clinical Features

The severity of pharyngitis can vary widely.

• In mild infections, individuals may experience discomfort in the throat, malaise, and a low-grade fever. The pharynx typically appears congested, but there is usually no lymphadenopathy.
• In Moderate to severe infections present with more pronounced symptoms, including throat pain, dysphagia, headache, malaise, and high fever. In these instances, the pharynx may exhibit erythema, exudate, and enlargement of the tonsils and lymphoid follicles on the posterior pharyngeal wall.
• In very severe infections, oedema of the soft palate and uvula may occur, along with significant enlargement of cervical lymph nodes.

Differentiating between viral and bacterial infections based solely on clinical examination can be challenging. Generally, viral infections tend to be milder and may present with additional symptoms such as rhinorrhoea and hoarseness, while bacterial infections are often more severe. Gonococcal pharyngitis, on the other hand, can be mild and may even be asymptomatic.

Diagnosis

The diagnosis of bacterial pharyngitis is aided by the culture of a throat swab, which can detect approximately 90% of Group A streptococci. Diphtheria requires culture on special media, while swabs from suspected cases of gonococcal pharyngitis should be processed immediately. A lack of bacterial growth in culture typically suggests a viral aetiology.

Treatment

1. General Measures

The management of acute pharyngitis includes several general measures. Patients are advised to rest, stay hydrated, and use warm saline gargles or pharyngeal irrigations for relief. Analgesics can help alleviate throat discomfort. In severe cases, lignocaine viscous may be used before meals to facilitate swallowing.

2. Specific Treatment For streptococcal pharyngitis, treatment options include

• Penicillin G, administered orally (200,000 to 250,000 units four times daily for 10 days) or,
• Benzathine penicillin G (600,000 units intramuscularly for patients weighing 60 lbs or less, and 1.2 million units for those over 60 lbs).
• In individuals with penicillin allergies, erythromycin (20–40 mg/kg body weight daily in divided doses for 10 days) is an effective alternative.
• Diphtheria is treated with diphtheria antitoxin along with penicillin or erythromycin.
• Gonococcal pharyngitis typically responds to conventional doses of penicillin or tetracycline.

Viral Infections Causing Pharyngitis

1. Coxsackie Virus Infections
   • Herpangina primarily affects children and is characterized by the sudden onset of fever, sore throat, and vesicular eruptions on the soft palate and pillars. These vesicles are often surrounded by a zone of erythema, indicating inflammation.
   • Acute Lymphonodular Pharyngitis. This condition presents with fever, malaise, and sore throat. Upon examination, white-yellow solid nodules may be observed on the posterior pharyngeal wall, which are indicative of the infection.
2. Cytomegalovirus. Cytomegalovirus (CMV) infections predominantly affect immunosuppressed transplant patients. The clinical presentation of CMV infection can mimic infectious mononucleosis; however, the heterophil antibody test is typically negative in these cases, distinguishing it from other causes of mononucleosis.
3. Pharyngoconjunctival Fever. Pharyngoconjunctival fever is caused by adenovirus and is characterized by a combination of sore throat, fever, and conjunctivitis. Patients may also experience abdominal pain that can mimic appendicitis, complicating the clinical picture.
4. Infectious Mononucleosis. This condition, caused by the Epstein-Barr virus, primarily affects older children and young adults. Symptoms include fever, sore throat, exudative pharyngitis, lymphadenopathy, splenomegaly, and hepatitis.
5. Measles. Measles is another viral infection that can lead to pharyngitis. It is characterized by the presence of Koplik’s spots, which are small white spots surrounded by a red areola, located on the buccal mucosa opposite the molar teeth. These spots typically appear 3 to 4 days before the onset of the characteristic measles rash.
6. Common Cold. The common cold, caused by viruses such as rhinovirus, coronavirus, and parainfluenza virus, can also affect the tonsils and pharynx. Symptoms include sore throat, dysphagia, and fever. While the tonsils may be enlarged, there is usually no exudate present, distinguishing it from bacterial infections.
7. Herpes Simplex Virus. Herpes simplex virus can cause either exudative or non-exudative pharyngitis. This infection may also be associated with gingivostomatitis, which involves inflammation of the gums and oral mucosa.

Bacterial Pharyngitis. 

Discussed in detail in the Tonsillitis chapter.

1. Streptococcal (Group A beta-haemolytic streptococci)
2. Diphtheria
3. Gonococcal

Fungal Pharyngitis

Fungal infections, particularly Candida, can occur in the oropharynx, often as an extension of oral thrush. This is commonly seen in immunosuppressed or debilitated patients, as well as those taking high doses of antimicrobials. Patients typically report throat pain and dysphagia, with nystatin being the drug of choice for treatment.

Miscellaneous Causes of Pharyngitis

Other less common causes of pharyngitis include infections caused by Chlamydia trachomatis, which can be treated with erythromycin or sulfonamides, and toxoplasmosis, a rare infection caused by the obligate intracellular parasite Toxoplasma gondii. In summary, acute pharyngitis is a multifaceted condition with various aetiologies and clinical presentations. Understanding its causes, symptoms, and treatment options is essential for effective management and care.

Non-infectious causes of pharyngitis

Dry air, allergy/post-nasal drip, chemical injury, gastro-oesophageal reflux disease (GORD) and smoking.

——– End of the chapter ——–

Learning resources.

• Scott-Brown, Textbook of Otorhinolaryngology-Head and Neck Surgery.
• Susan Standring, Gray’s Anatomy.
• Frank H. Netter, Atlas of Human Anatomy.
• B.D. Chaurasiya, Human Anatomy.
• P L Dhingra, Textbook of Diseases of Ear, Nose and Throat.
   

  Author:

  

  Dr. Rahul Bagla
  MBBS (MAMC, Delhi) MS ENT (UCMS, Delhi)
  Fellow Rhinoplasty & Facial Plastic Surgery.
  Renowned Teaching Faculty
  Mail: msrahulbagla@gmail.com
  India

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