This document provides information about pharyngitis (inflammation of the pharynx). It discusses the different causes of pharyngitis including bacterial (e.g. Streptococcus pyogenes), viral (e.g. rhinovirus), and fungal. It provides details on symptoms, diagnosis, treatment, and complications of various types of pharyngitis. It also discusses other conditions that can cause pharyngeal inflammation like diphtheria, tuberculosis, and mononucleosis.

1. DR. B. P. SHAH
ASSISTANT PROFESSOR
DEPARTMENTOF ORL and HNS
BPKIHS

3.  Definition – inflammation of
the mucous membranes and
submucosal structures of
the pharynx
 TYPE:
1. Acute- bacterial, viral,
fungal
2. Chronic nonspecific
3. Chronic specific

4.  Bacterial
▪ Group A beta-hemolytic
streptococci (S. pyogenes)*
▪ most common bacterial cause of
pharyngitis
▪ 15-30% of cases in children and
5-10% in adults.
▪ Mycoplasma pneumoniae
▪ Arcanobacterium haemolyticum
▪ Neisseria gonorrhea
▪ Chlamydia pneumoniae
 Viral >90%
▪ Rhinovirus , Coronavirus –
common cold
▪ Adenovirus –
pharyngoconjunctival
fever;acute respiratory illness
▪
▪ Parainfluenza virus – common
cold; croup
▪ Coxsackievirus – herpangina
▪ EBV – infectious mononucleosis
▪ HIV

5.  Spread by contact with respiratory secretions
 Peaks in winter and spring
 School age child (5-15 y)
 Communicability highest during acute infection
 Patient no longer contagious after 24 hours of antibiotics
 If hospitalized, droplet precautions needed until no longer
contagious

6.  Classic symptoms → Fever,
throat pain, dysphagia
VIRAL → Most likely
concurrent URI symptoms of
rhinorrhea, cough, hoarseness,
conjunctivitis & ulcerative
lesions
STREP → Look for associated
headache, and/or abdominal
pain
Fever and throat pain are usually
acute in onset

7.  VIRAL
EBV –White exudate covering
erythematous pharynx and tonsils,
cervical adenopathy,
Subacute/chronic symptoms
(fatigue/myalgias)
 transmitted via infected saliva
Adenovirus/Coxsackie –
vesicles/ulcerative lesions present on
pharynx or posterior soft palate
Also look for conjunctivitis

8.  Bacterial
GAS – look for whitish exudate covering
pharynx and tonsils
▪ tender anterior cervical adenopathy
▪ palatal/uvular petechiae
▪ scarlatiniform rash covering torso and
upper arms
Spread via respiratory particle droplets
 NO school attendance until 24 hours after
initiation of appropriate antibiotic therapy
▪ Absence of viral symptoms (rhinorrhea,
cough, hoarseness)

9.  Vesiculation & Ulceration HSV
Gingivostomatitis Coxsackievirus
 Cnonjunctivitis Adenovirus
 Gray-white fibrinous pseudomembrane
With marked cervical lymphadenopathy Diphteria
 Macular rash Scarlet fever
 Hepatosplenomegally &Rash
&Fatigue &Cervical lymphadenitis EBV

10.  Pharyngeal exudates:
 S. pyogenes
 C. diphtheriae
 EBV
 Skin rash:
 S. pyogenes
 HIV
 EBV

11.  Strep:
Throat culture(Gold stndard)
Rapid Strep. Antigen kits
 Infectious Mono.:
CBC(Atypical lymphocytes)
Spot test (Positive slide
agglutination)
 Mycoplasma:
Cold agglutination test

12. VIRAL –
Supportive care only – Analgesics, Antipyretics,
Fluids
 use of oral or intramuscular corticosteroids for pain relief
EBV – infectious mononucleosis
activity restrictions – mortality in these pts most commonly
associated with abdominal trauma and splenic rupture

13.  (Antibiotic ,Acetaminophen ,Warm salt gargling)
 Strep: Penicillin ,Erythromycin , Azithromycin
 Carrier of strep:
Clindamycin ,Amoxicillin clavulanic
 Retropharyngeal abscesses:
Drainage + Antibiotics
 Peritonsilar abscesses:
penicillin + Aspiration

14.  Prevention of ARF if treatment started within
9 days of illness
 Reduce symptoms
 Prevent local suppurative complications
BUT
Does not prevent the development of the post
streptococcal sequel of acute
glomerulonephritis

15.  Clinical diagnosis of scarlet fever
 Household contact with documented strep.
Pharyngitis
 Past history of ARF
 Recent history of ARF in a family member

16.  Peritonsillar cellulitis or abscess
 Parapharyngeal abscess
 IM with severe dysphagia
 Severe uncomplicated tonsillitis with dysphagia and dehydration
 Sore throat asso with stridor or resp difficulty (absolute)

17.  Suppurative
 Otitis media
 Sinusitis
 Peritonsillar and
retropharyngeal
abscesses
 Suppurative cervical
adenitis
 Nonsuppurative
 Acute rheumatic fever
 follows only streptococcal
pharyngitis (not group A strep skin
infections)
 Acute glomerulonephritis
 May follow pharyngitis or
skin infection (pyoderma)
 Nephritogenic strains

18.  Occurs most commonly in
association with pharyngitis
 Strawberry tongue
 Rash
▪ Generalized fine, sandpapery
scarlet erythema with
accentuation in skin folds
(Pastia’s lines)
▪ Circumoral pallor
▪ Palms and soles spared
 Treatment same as strep
pharyngitis

19.  Glandular fever , Kissing disease
 IP= 5-7 wks
 Acute follicular tonsillitis
 Psudomembrane
 Tender cervical adenopathy, periorbital
oedema, mono or poly neuropathies
 Systemic menifestations
 Diagnosis- Paul Bunnell and monospot
tests, IgM ab against EBV viral capsid ag
(gold standard), atypical lymphocytes

20.  supportive
 Antivirals- famciclovir, maribavir
 Avoid ampicillin --rubelliform rash
 Steroids- for threatened upper airway obstr
NEWER MODALITIES:
1. Infusion of leukocyte associated antigen
matched EBV cytotoxicT-cells

21.  Etiologic agent: Corynebacterium
diphtheria
 Extremely rare, occurs primarily in
unimmunized patients
 Gram positive rod
 nonspore forming
 strains may be toxigenic or
nontoxigenic
▪ exotoxin required for disease
 POI-through infected secretions from the nose,
throat, eyes, or skin lesions

22.  gray-black pseudomembrane
 Bleeds on attempts to remove
 "bull-neck”, airway obstruction.
 myocarditis, neuritis, and acute tubular necrosis
 Myocarditis -2 weeks after onset
 Peripheral neuritis -3 to 7 weeks later. Motor rather
than sensory nerves. Commonly affects the soft palate
and pharyngeal muscles.
 Definitive diagnosis -pseudomembrane to be cultured
in Loeffler's,Tellurite, and blood agar media
 Chinese character" appearance –Albert stain

23.  Treatment - antitoxin and antibiotics
 Booster vaccination should be given during the recovery period and serial
electrocardiograms should be obtained for early detection of cardiac
complications. Disease eradication should be documented by two
negative cultures after completing treatment.
 Diphtheria toxoid booster injection - recommended every 10 years in
adults

24. Clinically
 Pallor of the mucosa
 Typical ulcers
Painful
Superficial
Shallow
Undermined edge
Caseous floor
Etilogy:
Secondary to Pulmonary
Tuberculosis
 Inv- sputum Z-N staining, phenol auramine
stain, PCR
 Except for Rx for with ATT, no specific Rx
needed for pharyngeal TB

25. Secondary :
-Hyperaemic mucosa
-Mucous patches
-Snail track ulcers
Primary :Chancre, rare in
the pharynx
Tertiary: Gumma
Pinkish rubbery swellings
--►typical ulcer
Single painless
indurated papule
Deep punched
out edge
Necrotic dirty
yellow floor

26.  Inflammation of the mucous membranes covering the
larynx with accompanied edema of the vocal cords
 Acute [<3wks duration]–Think infectious → most
commonly viral – symptoms most commonly resolve in 7-
10 days
 Chronic [>3wks duration]– Inhalation of irritant fumes,
vocal misuse, GERD, smokers

27. A. Acute infection B. Chronic infection
 Acute simple laryngitis  Chronic laryngitis
 Acute epiglottitis Tuberculosis
Viral LTB  Scleroma
 Bacterial LTB  Candidiasis
 Spasmodic croup  Sarcoidosis
C. Laryngeal edema
D. Laryngo-pharyngeal reflux disease (LPRD)

28.  Etiology
 Viral infection (common cold)
 Vocal abuse
 Allergy / smoking / environmental pollution
 Gastro esophageal reflux disease
 Thermal / chemical burn due to inhalation
 Use of asthma inhalers
 Laryngeal trauma (endotracheal intubation)
 Undue physical or psychological stress

29.  History of upper respiratory tract infection
 Hoarseness: high pitched husky voice
 Dry, paroxysmal cough, mainly at night
 Sore throat worsened by talking; fever,
malaise
 Laryngoscopy: red, swollen supraglottic
mucosa; mild erythema / swelling of true
vocal cords; inspissated secretions b/w vocal
cords

30.  Prevention: avoidance of cold fluids, cold air, smoking,alcohol
consumption
 Absolute voice rest
 Tincture Benzoin steam inhalation & mucolytics
 Anti-tussives: dextromethorphan, codeine
 Pantoprazole for GERD; analgesics for pain
 Antibiotics: for secondary bacterial infections
 Steroid: for laryngeal edema

32. Synonym: Acute Supraglottitis , Supraglottic laryngitis
Definition: Rapidly developing inflammation of epiglottis &
adjacent tissues, due to bacterial infection, may cause life-
threatening airway obstruction
Causative agents: Haemophilus influenzae type b (Hib),
Streptococcus pyogenes, Streptococcus pneumoniae,
Staphylococcus aureus

33.  Distress (respiratory)
 Dysphagia
 Drooling (due to inability to swallow)
 Severe sore throat / odynophagia
 Muffled voice
 Sudden onset & rapid progression in children (in
hours); Indolent course in adults (in days)

34.  Simply depressing child's
tongue with tongue depressor
or indirect laryngoscopy may
visualize enlarged, cherry red
epiglottis in some situations
 These procedures may
precipitate complete airway
obstruction, hence avoided

35.  Pt appears anxious
 Leans forward with
support of both
forearms
 Extends neck in an
attempt to maintain an
open airway

36. 1. Flexible laryngoscopy: carried out only in
ICU or OT with intubation / tracheostomy
set ready
2. Post-intubation direct laryngoscopy
3. Plain x-ray soft tissue of neck lateral view
4. Culture from epiglottis during intubation:
+ve in 15% cases of H. influenzae
5. Blood culture: +ve in 15% cases of H.
influenzae

37.  Inflamed cherry-red
epiglottis
 Thickened
aryepiglottic folds
 Edematous arytenoid
cartilages

38. Lateral view taken in erect position only
 Enlargement of epiglottis (thumb sign)
 Absence of well defined vallecula (Vallecula sign)
 Thickening of aryepiglottic folds (cause for stridor)
 Circumferential narrowing of subglottic portion of
trachea during inspiration (25% cases)
 Ballooning of hypopharynx

40.  Red arrow = enlarged epiglottis
 Yellow arrow = thickened ary-epiglottic folds

42.  Hospitalization, careful monitoring & isolation
 Hydration + humidification + oxygen tent therapy
 Secure airway in acute stridor → Mechanical
ventilation till swelling + inflammation subside
 IV Ceftriaxone: 100 mg/kg/d in 2 divided doses
 Hydrocortisone: 100 mg IV stat & 25 mg Q8H
 Rifampicin prophylaxis for household contacts

43.  Endotracheal intubation
 Trans-nasal: preferred
 Trans-oral
 Percutaneous trans-laryngeal ventilation by needle
cricothyrotomy
 Tracheostomy: last resort for acute stridor

44.  Hib vaccination for all children
 Rifampicin prophylaxis (20 mg/kg /day; max. 600 mg) for 4
days should be given to all household contacts if:
a. child in household < 4 years, not received
appropriate doses of Hib vaccine
b. immuno-compromised child, despite vaccination
 Children > 2 years with epiglottitis do not need vaccination
as disease provides immune protection

45.  Commonest infective cause of stridor in children
 Mean age for presentation = 18 months
 Causative agents:
 Parainfluenza virus type I, II, III
 Influenza virus
 Respiratory syncytial virus
 Rhinovirus
 Measles

46.  Gradual onset preceeded by URTI of > 48 hrs
 Hoarseness
 Biphasic stridor, mainly at night
 Dry cough (like barking of seal)
 Low grade fever (< 102 F)
 Child prefers to lie down, but is restless
 Dysphagia & drooling absent

47.  Plain X-ray soft tissue neck, AP view
a. Church steeple or pencil-point sign: squared
appearance of subglottic area replaced by cone shaped
narrowing just below vocal cords
b. Ballooning of hypopharynx
 Flexible laryngoscopy: narrowed subglottic area

51.  Hospitalization
 Humidification & mucolytic drugs
 Hydration with IV fluid
 Hydrocortisone: 100 mg IV stat & 25 mg Q8H
 Oxygen tent: es bronchospasm & pulm. edema
 Antibiotic (IV Ceftriaxone): 100 mg/kg/day
 Racemic adrenaline (1:1000) nebulization
 Intubation /Tracheostomy for acute stridor

52. Synonym: pseudo-membranous croup
More severe than viral LTB
Causative agent: Staphylococcus aureus
Pathology: sloughing of respiratory epithelium
C/F: Hoarseness, biphasic stridor, dry cough, high grade fever
(> 102F), child supine but restless
X-ray neck, AP view: church steeple sign
Rx: moist air + oxygen + antibiotics

53.  Synonym: spasmodic croup
 Etiology: unknown (? Influenza virus infection)
causing subglottic mucosal edema
 C/F: Child below 3 years with rapid onset of biphasic
stridor + barking cough + low grade fever
(< 102 F). Dysphagia & drooling are absent.
 X-ray neck, AP view: church steeple sign
 Rx: Moist air + oxygen + supportive treatment. Rarely
endotracheal intubation. Avoid sedatives.

54. Acute
epiglottitis
Viral croup Bacterial
croup
Spasmodic
croup
R.P.
abscess
Age (yr) 3-7 1-3 1-8 1-3 1-3
Voice Normal or
muffled
Hoarse Hoarse Hoarse Hoarse
Cough Absent Barking
seal-like
Barking
seal-like
Barking
seal-like
Absent
Stridor Inspiratory Biphasic Biphasic Biphasic Inspiratory
Dysphagia
+ drooling
Severe Absent Absent Absent Severe
Fever > 102 F < 102 F > 102 F < 102 F > 102 F
Posture Quiet,
sitting
Restless,
supine
Restless,
supine
Restless,
supine
Restless,
sitting

55. Definition: Chronic non-specific inflammation causing
irreversible changes of laryngeal mucosa
Etiology of chronic laryngitis:
 Viral infection (common cold)
 Vocal abuse
 Allergy / smoking / environmental pollution
 Gastro esophageal reflux disease
 Thermal / chemical burn due to inhalation
 Laryngeal trauma (endotracheal intubation)
 Undue physical or psychological stress

56. Hoarseness (worse in morning) + dry cough for > 3 wk
Persistent clearing of throat
H/o previous URTI / GERD may be present
Laryngoscopy: hyperemic laryngeal mucosa
with sub-mucosal edema
Treatment:Voice test + medicated steam inhalation +
systemic antibiotic. Avoidance of alcohol & tobacco.
Reversible within few weeks.

58. Hoarseness (worse in morning) + dry cough for > 3 wk
Persistent clearing of throat
H/o previous URTI / GERD may be present
Laryngoscopy:
▪ Mild congestion of laryngeal mucosa
▪ Patches of epithelial thickening
▪ Broad based polypoid lesions

59. Kleinsasser’s classification:
 Grade I: simple squamous cell hyperplasia
or keratosis
 Grade II: squamous cell hyperplasia + atypia (mild
to moderate dysplasia)
 Grade III: carcinoma in situ with intact basal
membrane

60. Absolute voice rest for 48 hours
Systemic antibiotic
Tincture Benzoin steam inhalation
Analgesics & anti histamine-decongestant
Micro-laryngoscopic excision of lesion & HPE
 Grades I & II: no further treatment
 Grade III: total excision of lesion / radiotherapy

61.  Avoid breathing polluted air
 Avoid tobacco in any form (chewing, smoking)
 Avoid recreational drugs like marijuana
 Avoid alcohol consumption
 Avoid talking or shouting at noisy places
 Avoid continuous throat clearing
 Avoid whispering loudly

62.  Commonly associated with pulmonaryTB
 Posterior commissure arytenoids, vocal cords, ventricular
bands & epiglottis mainly affected
 Method of spread:
 Bronchogenic: contact of larynx with sputum
containing tubercular bacilli
 Hematogenous

63. 1. Exudation + hyperemia in subepithelial layers
2. Mono-nuclear round cell infiltration of subepithelial layers
causing pseudo-edema
3.Tubercle formation: granuloma with epithelioid cells +
Langhans giant cells + caseation necrosis
4. Ulceration: shallow ulcers with undermined edges involving
arytenoids & epiglottis (moth eaten or mouse nibbled
appearance)
5. Cicatrization: ulcers heal by fibrosis

64.  History of pulmonaryTB
 Weakness of voice followed by hoarseness
 Cough with hemoptysis
 Throat pain
 Referred earache
 Dysphagia & odynophagia due to perichondritis

65.  Impairment of vocal cord adduction (first sign)
 Areas affected commonly are inter-arytenoid
area, posterior vocal cords + false cords +
epiglottis
 Congestion of these areas with surrounding
pallor
 Pseudo-edema  mamillated appearance of
interarytenoid area + turban-shaped epiglottis
 Shallow, undermined ulcers
 Vocal cord palsy + perichondritis

66.  Diagnosis
 Direct laryngoscopy & biopsy
 Chest X-ray, P.A. view
 Sputum for A.F.B.
 Treatment
 Anti-tubercular medication for 9 months

67.  Drinking lot of fluids - Drink 7-9 glasses of water per day; also good are
herbal tea and chicken soup.
 maintaining good general health - Exercise regularly.
 Avoiding smoking -They are bad for the heart, lungs and vocal tract.
 Eating a balanced diet - Include vegetables, fruits and whole grain
foods.
 Avoid dry, artificial interior climates.
 Do not eat late at night - may have problems when stomach acid backs
up on the vocal cords.
 Use a humidifier to assist with hydration.

69.  Infections with acute or chronic lymphadenitis
 Tumors
 Congenital
 Thyroglossal cyst
 Epidermoid cyst
 Branchial cyst or fistula
 Lymphangioma
 Haemangioma and arterio-venous malformations

70. Definition:
Congenital epithelial cysts, which arise on the
lateral part of the neck due to failure of
obliteration of the second branchial cleft in
embryonic development.

71.  Branchial anomalies result
from improper development
of the branchial apparatus
 Branchial apparatus develops
2nd-6th week
 Neck is shaped like a hollow tube
with circumferential ridges =
Arches (mesoderm)
 Ridges between arches = Clefts
and Pouches
▪ Clefts = outside (ectoderm)
▪ Pouches = inside (endoderm)
▪ “CAP”

72.  Many theories

 congenital
i. Branchial apparatus theory
ii. Cervical sinus theory
 The cervical lymph nodes cystic
transformation ( inclusion
)theories.

73.  Solitary, painless mass in the
neck of a child or a young
adult.
 History of intermittent
swelling and tenderness of the
lesion during upper respiratory
tract infection may exist.
 Discharge if associated with a
sinus tract.
 May present with locally
compressive symptoms.
 + family history.

74.  Primary lesion: Branchial cysts are
smooth, nontender, fluctuant
masses, along the upper one third of
the anteromedial border of the
sternocleidomastoid muscle
between the muscle and the
overlying skin.
 Secondary lesion: tender if
secondarily inflamed or infected.
When associated with a sinus tract,
mucoid or purulent discharge onto
the skin or into the pharynx may be
present.

75.  Branchiogenic carcinoma
 Tuberculous adenitis
 Lipoma
 Metastatic malignant neoplasms (SCCA from a primary site in the
aerodigestive tract)
 Cystic hygroma (lymphangioma)
 Carotid body tumors
 Lymphomas
 Hemangiomas
 Thyroid cysts
 Ectopic thyroid
 Cervical thymic cysts
 Thyroglossal duct cyst
 Parotid cystic tumors

76.  Cyst arising from lateral neck and having lymphoepithelial
characteristics should be regarded as a branchial cyst.

 Usually occur in the 2nd or 3rd decade of life.
 Most commonly found in the anterior triangle of the neck
anterior to the upper third of the sternomastoid.
 A cyst occupying the posterior triangle is extremely rare.
 Hence they should be suspected in all the cystic swellings of
the neck except the median ones.

77. • Ultrasound
• Round mass with uniform low
echogenicity and lack of
internal septations
• Advantages: No radiation, no
sedation for children, low
cost
• Not typically ordered alone

78.  Well defined, low density
unilocular mass with a thin
uniformly enhancing rim
• More radiation, higher cost,
may require sedation
(children)

79.  MRI allows for finer
resolution during
preoperative
planning.The wall
may be enhancing on
gadolinium scans.

80.  Antibiotics
 Should cover respiratory flora and Staph aureus (broad
spectrum)
 Cover 2-4 weeks
 Abscess
 Consider needle aspiration to drain
▪ May work without causing as much scaring as I&D
 I&D if needle aspiration doesn’t work
 Once infection cleared, operate

81.  Complete surgical excision of tract and cyst is
treatment of choice in most cases
 1st cysts
 Must identify facial nerve as tract is usually associated
with it
 If possible, wait till 2 years of age
▪ Mastoid tip defined
▪ Facial nerve larger and deeper
▪ Controversy: waiting can lead to more infections  more scar 
more difficult surgery
 Lacrimal probes can help locate tract

83.  3rd and 4th cysts
 Must identify the recurrent laryngeal nerve as
closely associated (will be deep to tract)
 Removal of ipsilateral thyroid lobe is advocated to
ensure complete removal of tract
 Perform DL to examine pyriform sinus
▪ Fogarty vascular catheter can be placed through the
sinus tract

84.  foramen caecum - site of
the development of the
thyroid at the base of
tongue.
 tongue develops, the
thryroid diverticulum
descends in the neck,
maintaining its connection
to the foramen caecum
 A cyst can be located
anywhere along the
migratory tract if it fails to
become obliterated.

85.  located in the midline at or just
below the hyoid bone.
 Due to communication with the
mouth via the foramen caecum
the cyst can become infected.
 The cyst is smooth, soft and
non-tender.
 Owing to its attachment to the
foramen caecum, the cyst does
move upwards when the tongue
protrudes.

86.  May contain thyroid
tissue
▪ Potentially the only
functioning thyroid
 Perform U/S or CT to
look for thyroid and to
assess lesion
 May contain cancer
▪ 1%
▪ Papillary carcinoma

87.  Early surgical excision to avoid the
complications of infection
 Surgery entails complete excision of the cyst
and its tract upward to the base of the tongue
(Sistrunk Operation)

88.  congenital malformations of lymph tissue
- result from the failure of lymph spaces
to connect to the rest of the lymphatic
system.
 present as a soft, smooth, nontender
mass that is compressible and can be
transilluminated.
 Depending on the size and location, there
might be respiratory compromise and
difficulty in feeding.

89.  Goals: Improvement of cosmetic appearance,
relieve of impaired breathing and eating.
 Big lesions causing respiratory embarrassment
might need urgent intubation at birth.
 Surgery is difficult because of the infiltrative nature
of these lesions.
 Preferred treatment : infiltration with Bleomycin,
alcohol or other sclerosing agents.

90.  benign tumors of the
capillary vessels of the skin
 occur anywhere, but are
common in the face and
neck
 Typical growth, stationary
and involutionary phase

 Treatment : conservative
(wait and see); excision or
sclerosation