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Pharyngitis

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  • 1. In The Name Of God Pharyngitis Dr.M.Karimi
  • 2. PHARYNGITISPHARYNGITIS • What is itWhat is it?? – Inflammation of theInflammation of the Pharynx secondary to anPharynx secondary to an infectious agentinfectious agent – Most common infectiousMost common infectious agents are Group Aagents are Group A Streptococcus and variousStreptococcus and various viral agentsviral agents – Often co-exists withOften co-exists with tonsillitistonsillitis
  • 3. EtiologyEtiology • Strep.AStrep.A • MycoplasmaMycoplasma • Strep.GStrep.G • Strep.CStrep.C • CorynebacteriumCorynebacterium diphteriaediphteriae • ToxoplasmosisToxoplasmosis • GonorrheaGonorrhea • TularemiaTularemia • RhinovirusRhinovirus • CoronavirusCoronavirus • AdenovirusAdenovirus • CMVCMV • EBVEBV • HSVHSV • EnterovirusEnterovirus • HIVHIV
  • 4. Acute PharyngitisAcute Pharyngitis • EtiologyEtiology – Viral >90%Viral >90% • Rhinovirus – common coldRhinovirus – common cold • Coronavirus – common coldCoronavirus – common cold • Adenovirus – pharyngoconjunctivalAdenovirus – pharyngoconjunctival fever;acute respiratory illnessfever;acute respiratory illness • Parainfluenza virus – common cold;Parainfluenza virus – common cold; croupcroup • Coxsackievirus - herpanginaCoxsackievirus - herpangina • EBV – infectious mononucleosisEBV – infectious mononucleosis • HIVHIV
  • 5. Acute PharyngitisAcute Pharyngitis • EtiologyEtiology – BacterialBacterial • Group A beta-hemolytic streptococci (Group A beta-hemolytic streptococci (S.S. pyogenespyogenes)*)* – most common bacterial cause of pharyngitismost common bacterial cause of pharyngitis – accounts for 15-30% of cases in children and 5-10%accounts for 15-30% of cases in children and 5-10% in adults.in adults. • Mycoplasma pneumoniaeMycoplasma pneumoniae • Arcanobacterium haemolyticumArcanobacterium haemolyticum • Neisseria gonorrheaNeisseria gonorrhea • Chlamydia pneumoniaeChlamydia pneumoniae
  • 6. PHARYNGITISPHARYNGITIS • HISTORYHISTORY – Classic symptoms →Classic symptoms → Fever, throat pain, dysphagiaFever, throat pain, dysphagia VIRAL →VIRAL → Most likely concurrent URI symptoms ofMost likely concurrent URI symptoms of rhinorrhearhinorrhea, cough, hoarseness,, cough, hoarseness, conjunctivitisconjunctivitis && ulcerative lesionsulcerative lesions STREPSTREP → Look for associated→ Look for associated headacheheadache, and/or, and/or abdominal painabdominal pain  Fever and throat pain are usuallyFever and throat pain are usually acute in onsetacute in onset
  • 7. PHARYNGITISPHARYNGITIS • Physical ExamPhysical Exam – VIRALVIRAL EBVEBV –– White exudateWhite exudate covering erythematouscovering erythematous pharynx and tonsils,pharynx and tonsils, cervical adenopathycervical adenopathy,,  Subacute/chronic symptoms (fatigue/myalgias)Subacute/chronic symptoms (fatigue/myalgias)  transmitted via infected salivatransmitted via infected saliva Adenovirus/CoxsackieAdenovirus/Coxsackie – vesicles/ulcerative lesions– vesicles/ulcerative lesions present on pharynx or posterior soft palatepresent on pharynx or posterior soft palate  Also look for conjunctivitisAlso look for conjunctivitis
  • 8. Epidemiology of StreptococcalEpidemiology of Streptococcal PharyngitisPharyngitis • Spread by contact with respiratory secretionsSpread by contact with respiratory secretions • Peaks in winter and springPeaks in winter and spring • School age child (5-15 y)School age child (5-15 y) • Communicability highest during acute infectionCommunicability highest during acute infection • Patient no longer contagious after 24 hours ofPatient no longer contagious after 24 hours of antibioticsantibiotics • If hospitalized, droplet precautions needed untilIf hospitalized, droplet precautions needed until no longer contagiousno longer contagious
  • 9. PHARYNGITISPHARYNGITIS • Physical ExamPhysical Exam – BacterialBacterial GASGAS – look for whitish exudate covering pharynx– look for whitish exudate covering pharynx and tonsilsand tonsils – tender anterior cervical adenopathytender anterior cervical adenopathy – palatal/uvularpalatal/uvular petechiaepetechiae – scarlatiniform rash covering torso and upperscarlatiniform rash covering torso and upper armsarms Spread viaSpread via respiratory particle dropletsrespiratory particle droplets – NO– NO school attendance untilschool attendance until 24 hours after24 hours after initiation ofinitiation of appropriate antibiotic therapyappropriate antibiotic therapy – Absence of viral symptoms (rhinorrhea, cough,Absence of viral symptoms (rhinorrhea, cough, hoarseness)hoarseness)
  • 10. Differential diagnosis of pharyngitisDifferential diagnosis of pharyngitis • Pharyngeal exudates:Pharyngeal exudates: – S. pyogenesS. pyogenes – C. diphtheriaeC. diphtheriae – EBVEBV
  • 11. Differential diagnosis of pharyngitisDifferential diagnosis of pharyngitis • Skin rash:Skin rash: – S. pyogenesS. pyogenes – HIVHIV – EBVEBV
  • 12. Differential diagnosis of pharyngitisDifferential diagnosis of pharyngitis • Conjunctivitis:Conjunctivitis: – AdenovirusAdenovirus
  • 13. Suppurative Complications ofSuppurative Complications of Group A Streptococcal PharyngitisGroup A Streptococcal Pharyngitis • Otitis mediaOtitis media • SinusitisSinusitis • Peritonsillar and retropharyngealPeritonsillar and retropharyngeal abscessesabscesses • Suppurative cervical adenitisSuppurative cervical adenitis
  • 14. Streptococcal Cervical AdenitisStreptococcal Cervical Adenitis
  • 15. Nonsuppurative Complications ofNonsuppurative Complications of Group A StreptococcusGroup A Streptococcus • Acute rheumatic feverAcute rheumatic fever – follows only streptococcal pharyngitis (notfollows only streptococcal pharyngitis (not group A strep skin infections)group A strep skin infections) • Acute glomerulonephritisAcute glomerulonephritis – May follow pharyngitis or skin infectionMay follow pharyngitis or skin infection (pyoderma)(pyoderma) – Nephritogenic strainsNephritogenic strains
  • 16. PharyngitisPharyngitis
  • 17. Infectious MononucleosisInfectious Mononucleosis
  • 18. HerpanginaHerpangina
  • 19. PHARYNGITISPHARYNGITIS
  • 20. PHARYNGITISPHARYNGITIS
  • 21. pharyngitispharyngitis
  • 22. Scarlatiniform RashScarlatiniform Rash
  • 23. Clinical manifestationClinical manifestation (Strep.)(Strep.) • Rapid onsetRapid onset • HeadacheHeadache • GI SymptomsGI Symptoms • Sore throatSore throat • ErythmaErythma • ExudatesExudates • Palatine petechiaePalatine petechiae • Enlarged tonsilsEnlarged tonsils • Anterior cervicalAnterior cervical adenopathy &Tenderadenopathy &Tender • Red& swollen uvulaRed& swollen uvula
  • 24. Clinical manifestationClinical manifestation (Viral)(Viral) • Gradual onsetGradual onset • RhinorrheaRhinorrhea • CoughCough • DiarrheaDiarrhea • FeverFever
  • 25. Clinical manifestationClinical manifestation • Vesiculation & Ulceration HSVVesiculation & Ulceration HSV GingivostomatitisGingivostomatitis CoxsackievirusCoxsackievirus • Cnonjunctivitis AdenovirusCnonjunctivitis Adenovirus • Gray-white fibrinous pseudomembraneGray-white fibrinous pseudomembrane With marked cervical lymphadenopathy DiphteriaWith marked cervical lymphadenopathy Diphteria • Macular rash Scarlet feverMacular rash Scarlet fever • Hepatosplenomegally &RashHepatosplenomegally &Rash &Fatigue &Cervical lymphadenitis EBV&Fatigue &Cervical lymphadenitis EBV
  • 26. DiagnosisDiagnosis • Strep:Strep: Throat culture(GoldThroat culture(Gold stndard)stndard) Rapid Strep. Antigen kitsRapid Strep. Antigen kits • Infectious Mono.:Infectious Mono.: CBC(Atypical lymphocytes)CBC(Atypical lymphocytes) Spot test (Positive slideSpot test (Positive slide agglutination)agglutination) • Mycoplasma:Mycoplasma: Cold agglutination testCold agglutination test
  • 27. Differential diagnosisDifferential diagnosis • Retropharyngeal abscessesRetropharyngeal abscesses • Peritonsilar abscessesPeritonsilar abscesses • Ludwig anginaLudwig angina • EpiglotitisEpiglotitis • ThrushThrush • Autoimmune ulcerationAutoimmune ulceration • KawasakiKawasaki
  • 28. TreatmentTreatment ((Antibiotic ,Acetaminophen ,Warm salt gargling)Antibiotic ,Acetaminophen ,Warm salt gargling) • Strep:Strep: PenicillinPenicillin ,Erythromycin , Azithromycin,Erythromycin , Azithromycin • Carrier of strep:Carrier of strep: ClindamycinClindamycin ,Amoxicillin clavulanic,Amoxicillin clavulanic • Retropharyngeal abscesses:Retropharyngeal abscesses: Drainage + AntibioticsDrainage + Antibiotics • Peritonsilar abscesses:Peritonsilar abscesses: penicillin + Aspirationpenicillin + Aspiration
  • 29. Recurrent pharyngitisRecurrent pharyngitis • Etiology: Nonpenicillin treatment ,DifferentEtiology: Nonpenicillin treatment ,Different strain ,Another cause pharyngitisstrain ,Another cause pharyngitis • Treatment:Treatment: TonsilectomyTonsilectomy ifif Culture positive, severe GABHS more thanCulture positive, severe GABHS more than 7 times during previous year7 times during previous year oror 5 times each year during two previous year5 times each year during two previous year
  • 30. Benefit of treatment of Strep.Benefit of treatment of Strep. PharyngitisPharyngitis • 1-Prevention of ARF if treatment started1-Prevention of ARF if treatment started within 9 days of illnesswithin 9 days of illness • 2-Reduce symptoms2-Reduce symptoms • 3-Prevent local suppurative complications3-Prevent local suppurative complications BUTBUT Does not prevent the development of theDoes not prevent the development of the post streptococcal sequel of acutepost streptococcal sequel of acute glomerulonephritisglomerulonephritis
  • 31. Antibiotic started immediately with symptomaticAntibiotic started immediately with symptomatic pharyngitis and positive Rapid testpharyngitis and positive Rapid test (Without culture)(Without culture) • 1-Clinical diagnosis of scarlet fever1-Clinical diagnosis of scarlet fever • 2-Household contact with documented2-Household contact with documented strep. Pharyngitisstrep. Pharyngitis • 3-Past history of ARF3-Past history of ARF • 4-Recent history of ARF in a family4-Recent history of ARF in a family membermember
  • 32. PHARYNGITISPHARYNGITIS • LAB AIDSLAB AIDS  Rapid strep antigen → detects GAS antigenRapid strep antigen → detects GAS antigen Tonsillar swab → 3-5 minutes to performTonsillar swab → 3-5 minutes to perform • 95% specificity, 90-93% sensitivity95% specificity, 90-93% sensitivity  GAS Throat culture → “gold standard”GAS Throat culture → “gold standard” • >95% sensitivity>95% sensitivity  Mono Spot → serologic test for EBV heterophile AbMono Spot → serologic test for EBV heterophile Ab  EBV Ab titers → detect serum levels of EBV IgM/IgGEBV Ab titers → detect serum levels of EBV IgM/IgG
  • 33. PHARYNGITISPHARYNGITIS • TreatmentTreatment VIRAL –VIRAL – Supportive care only – Analgesics,Supportive care only – Analgesics, Antipyretics, FluidsAntipyretics, Fluids  No strong evidenceNo strong evidence supporting use of oral orsupporting use of oral or intramuscular corticosteroids for pain relief → fewintramuscular corticosteroids for pain relief → few studies show transient relief within first 12–24 hrsstudies show transient relief within first 12–24 hrs after administrationafter administration EBV – infectious mononucleosisEBV – infectious mononucleosis  activity restrictions – mortality in these pts mostactivity restrictions – mortality in these pts most commonly associated with abdominal trauma and spleniccommonly associated with abdominal trauma and splenic rupturerupture
  • 34. PHARYNGITISPHARYNGITIS • TreatmentTreatment →→ Do so to preventDo so to prevent ARFARF (Acute Rheumatic Fever)(Acute Rheumatic Fever) GASGAS →→ Oral PCN – treatment of choiceOral PCN – treatment of choice 10 day course of therapy10 day course of therapy IM Benzathine PCN G – 1.2 million units x 1IM Benzathine PCN G – 1.2 million units x 1 Azithromycin, Clindamycin, or 1Azithromycin, Clindamycin, or 1stst generationgeneration cephalosporins for PCN allergycephalosporins for PCN allergy
  • 35. Group A StreptococcusGroup A Streptococcus
  • 36. Group A Beta HemolyticGroup A Beta Hemolytic StreptococcusStreptococcus
  • 37. Strawberry Tongue in ScarletStrawberry Tongue in Scarlet FeverFever
  • 38. Scarlet FeverScarlet Fever • Occurs most commonly in associationOccurs most commonly in association with pharyngitiswith pharyngitis – Strawberry tongueStrawberry tongue – RashRash • Generalized fine, sandpapery scarlet erythemaGeneralized fine, sandpapery scarlet erythema with accentuation in skin folds (Pastia’s lines)with accentuation in skin folds (Pastia’s lines) • Circumoral pallorCircumoral pallor • Palms and soles sparedPalms and soles spared – Treatment same as strep pharyngitisTreatment same as strep pharyngitis
  • 39. Rash of Scarlet FeverRash of Scarlet Fever
  • 40. Acute Rheumatic FeverAcute Rheumatic Fever • Immune mediated - ?humoralImmune mediated - ?humoral • Diagnosis by Jones criteriaDiagnosis by Jones criteria – 5 major criteria5 major criteria • CarditisCarditis • Polyarthritis (migratory)Polyarthritis (migratory) • Sydenham’s choreaSydenham’s chorea – muscular spasms, incoordination, weaknessmuscular spasms, incoordination, weakness • Subcutaneous nodulesSubcutaneous nodules – painless, firm, near bony prominencespainless, firm, near bony prominences • Erythema marginatumErythema marginatum
  • 41. Erythema Marginatum
  • 42. Acute Rheumatic FeverAcute Rheumatic Fever • Minor manifestationsMinor manifestations – Clinical FindingsClinical Findings • arthralgiaarthralgia • feverfever – Laboratory FindingsLaboratory Findings • Elevated acute phase reactantsElevated acute phase reactants – erythrocyte sedimentation rateerythrocyte sedimentation rate – C-reactive proteinC-reactive protein • Prolonged P-R interval on EKGProlonged P-R interval on EKG
  • 43. Acute Rheumatic FeverAcute Rheumatic Fever • Supporting evidence of antecedent group ASupporting evidence of antecedent group A streptococcal infectionstreptococcal infection – Positive throat culture or rapidPositive throat culture or rapid streptococcal antigen teststreptococcal antigen test – Elevated or rising streptococcal antibodyElevated or rising streptococcal antibody titertiter • antistreptolysin O (ASO), antiDNAse Bantistreptolysin O (ASO), antiDNAse B • If evidence of prior group A streptococcalIf evidence of prior group A streptococcal infection, 2 major or one major and 2 minorinfection, 2 major or one major and 2 minor manifestations indicates high probability ofmanifestations indicates high probability of ARF
  • 44. Acute Rheumatic FeverAcute Rheumatic Fever • TherapyTherapy – Goal: decrease inflammation, fever andGoal: decrease inflammation, fever and toxicity and control heart failuretoxicity and control heart failure – Treatment may include anti-inflammatoryTreatment may include anti-inflammatory agents and steroids depending on severityagents and steroids depending on severity of illnessof illness
  • 45. PoststreptococcalPoststreptococcal GlomerulonephritisGlomerulonephritis • Develops about 10 days afterDevelops about 10 days after pharyngitispharyngitis • Immune mediated damage to theImmune mediated damage to the kidney that results in renal dysfunctionkidney that results in renal dysfunction • Nephritogenic strain ofNephritogenic strain of S. pyogenesS. pyogenes
  • 46. PoststreptococcalPoststreptococcal GlomerulonephritisGlomerulonephritis • Clinical PresentationClinical Presentation – Edema, hypertension, and smoky or rustyEdema, hypertension, and smoky or rusty colored urinecolored urine – Pallor, lethargy, malaise, weakness,Pallor, lethargy, malaise, weakness, anorexia, headache and dull back painanorexia, headache and dull back pain – Fever not prominentFever not prominent • Laboratory FindingsLaboratory Findings – Anemia, hematuria, proteinuriaAnemia, hematuria, proteinuria – Urinalysis with RBCs, WBCs and castsUrinalysis with RBCs, WBCs and casts
  • 47. PoststreptococcalPoststreptococcal GlomerulonephritisGlomerulonephritis • DiagnosisDiagnosis – Clinical history, physical findings, andClinical history, physical findings, and confirmatory evidence of antecedentconfirmatory evidence of antecedent streptococcal infection (ASO or anti-DNAse B)streptococcal infection (ASO or anti-DNAse B) • TherapyTherapy – Penicillin to eradicate the nephritogenicPenicillin to eradicate the nephritogenic streptococci (erythromycin if allergic)streptococci (erythromycin if allergic) – Supportive care of complicationsSupportive care of complications
  • 48. DiphtheriaDiphtheria • Etiologic agent: CorynebacteriumEtiologic agent: Corynebacterium diphtheriadiphtheria – Extremely rare, occurs primarily inExtremely rare, occurs primarily in unimmunized patientsunimmunized patients – Gram positive rodGram positive rod – nonspore formingnonspore forming – strains may be toxigenic or nontoxigenicstrains may be toxigenic or nontoxigenic • exotoxin required for diseaseexotoxin required for disease
  • 49. Corynebacterium DiphtheriaeCorynebacterium Diphtheriae
  • 50. TONSILLITISTONSILLITIS Inflammation/Infection of the tonsilsInflammation/Infection of the tonsils  Palatine tonsilsPalatine tonsils → visible during oral exam→ visible during oral exam Also have pharyngeal tonsils (adenoids) and lingual tonsilsAlso have pharyngeal tonsils (adenoids) and lingual tonsils • HistoryHistory → sore throat, fever, otalgia, dysphagia→ sore throat, fever, otalgia, dysphagia • Physical ExamPhysical Exam → whitish plaques, enlarged/tender→ whitish plaques, enlarged/tender cervical adenopathycervical adenopathy • EtiologyEtiology → GAS, EBV – less commonly HSV→ GAS, EBV – less commonly HSV • TreatmentTreatment → same as for pharyngitis→ same as for pharyngitis
  • 51. TONSILLITISTONSILLITIS
  • 52. TONSILLITISTONSILLITIS
  • 53. LARYNGITISLARYNGITIS • Inflammation of the mucous membranesInflammation of the mucous membranes covering the larynx with accompaniedcovering the larynx with accompanied edema of the vocal cordsedema of the vocal cords  HistoryHistory →→ sore throatsore throat,, dysphoniadysphonia (hoarseness) or(hoarseness) or loss of voiceloss of voice, cough, possible, cough, possible low-grade feverlow-grade fever  Physical ExamPhysical Exam →→ cannot directly visualize larynx on standard PEcannot directly visualize larynx on standard PE must use fiberoptic laryngoscopy (not usuallymust use fiberoptic laryngoscopy (not usually necessary )necessary )
  • 54. LARYNGITISLARYNGITIS • ETIOLOGYETIOLOGY →→  AcuteAcute [<3wks duration]– Think infectious → most[<3wks duration]– Think infectious → most commonly viral – symptoms most commonly resolvecommonly viral – symptoms most commonly resolve in 7-10 daysin 7-10 days  ChronicChronic [>3wks duration]– Inhalation of irritant fumes,[>3wks duration]– Inhalation of irritant fumes, vocal misuse, GERD, smokersvocal misuse, GERD, smokers TreatmentTreatment → symptomatic care → complete→ symptomatic care → complete voice rest, avoid exposure to insulting agent,voice rest, avoid exposure to insulting agent, anti-reflux therapyanti-reflux therapy Prevailing dataPrevailing data does NOT supportdoes NOT support the use ofthe use of corticosteroids for symptomatic reliefcorticosteroids for symptomatic relief
  • 55. PERITONSILLAR ABSCESSPERITONSILLAR ABSCESS  Accumulation of pus in the tonsillar fossa → thought to be anAccumulation of pus in the tonsillar fossa → thought to be an infectious complication of inappropriately treatedinfectious complication of inappropriately treated pharyngitis/tonsillitispharyngitis/tonsillitis  HistoryHistory →→ Antecedent sore throat 1-2 wks prior - progressively worsensAntecedent sore throat 1-2 wks prior - progressively worsens DysphagiaDysphagia High feverHigh fever Ipsilateral throat, ear & possibly neck painIpsilateral throat, ear & possibly neck pain  Physical ExamPhysical Exam →→  Trismus – 67% of casesTrismus – 67% of cases  muffled voice (“Hot Potato”)muffled voice (“Hot Potato”)  Drooling &/or fetid breathDrooling &/or fetid breath  look for unilateral mass in the supratonsilar area with possible uvulalook for unilateral mass in the supratonsilar area with possible uvula deviationdeviation  fluctuant upon palpationfluctuant upon palpation
  • 56. PERITONSILLAR ABSCESSPERITONSILLAR ABSCESS  EtiologyEtiology →→ 90% of aspirated cultures grow bacterial pathogens90% of aspirated cultures grow bacterial pathogens  GAS – most common (approximately 30% of cases)GAS – most common (approximately 30% of cases)  Staphylococcus aureusStaphylococcus aureus  Anaerobes – most commonly Peptostreptococcal microbesAnaerobes – most commonly Peptostreptococcal microbes  TreatmentTreatment →→  Prompt ENT consultation forPrompt ENT consultation for needle aspirationneedle aspiration (*always(*always send cultures) or possible surgical drainagesend cultures) or possible surgical drainage  Systemic abx –Systemic abx – usually Clindamycinusually Clindamycin andand aa ββ-Lactam or-Lactam or 11stst generation cephalosporingeneration cephalosporin  Surgical tonsillectomy if:Surgical tonsillectomy if: 1)1) No improvement in 48 hoursNo improvement in 48 hours 2)2) H/O recurrent abscesses – 3 or more (controversial)H/O recurrent abscesses – 3 or more (controversial)
  • 57. Bilateral peritonsillar abscesses

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