Acute Pharyngitis

1. Phar yngitis:
Assessment and
Management
Amy McAllister
December 2014

2. Case 1
 22 year old Caucasian female with 2
days of sore throat, cough, headache,
rhinorrheoa. No PMH/FH.
 Examination:
 HR 105, BP 120/80, Temp 37.9, Sats
99% RA, RR 14

3. Case 1

4. Case 1
 Likely diagnosis?
 Centor criteria?
 Investigations?
 Management?
 - Steroids?
 - Antibiotics?

5. Case 2
 26 year old Indigenous male from Northern
Territory with 2 days of sudden onset of sore
throat and pain on swallowing without cough or
coryza.
 PMH: Diabetic
 FH: Mother and sister have Rheumatic heart
disease
 Obs: HR 125, BP 90/50, Temp 38.5, sats 96%
RA, RR 19
 O/E: Looks septic, salivary pooling

6. Case 2

7. Case 2
 Likely diagnosis?
 Centor criteria?
 Investigations?
 Management?
 - Steroids?
 - Antibiotics?

8. Epidemiology
 12 million presentations of pharyngitis annually in US
 Mostly late winter or early spring
 Group A strep accounts for 5-15% of adults
presenting with pharyngitis
 However, antibiotics are prescribed in more than 60%

9. Causes
Infectious
*Mostly viral*
 Influenza
 Infectious mononucleosis
 Herpes simplex
 Primary HIV

10. Causes
Infectious
Bacterial
 Group A Streptococcus (GAS)
 Also Group C and G
 Epiglottitis
 Quinsy
 Retropharyngeal abscess
 HIB
 N.Gonorrhoeae
 Fusobacterium necrophorum
 Mycoplasma pneumonia
Fungal
 Candida

11. Causes
Other
 Allergy
 Trauma
 Toxins
 Smoking
 Cancer
 GORD
 Thyroiditis

12. Group A Strep (GAS)
 Most important treatable agent of pharyngitis
 Clinical features:
 Centor criteria (1point each)
 Tonsillar exudate
 Fever
 Tender cervical lymphadenitis
 Absent cough or rhinorrheoa

13. Modified Centor criteria
 3-14 years old = add 1 point
 15-44 years old = 0 points
 > 44 years old + = subtract a point
 Studies – 57% of 206,870 people with 4
centor criteria tested positive for GAS

14. Complications of GAS
Suppurative
 Sinusitis
 Peritonsillar abscess
 Retropharyngeal abscess
Non-suppurative
 Acute Rheumatic fever
 Post-strep glomerulonephritis
 Scarlet fever
 Toxic shock

15. Acute Rheumatic Fever
Modified Jones criteria:
Major criteria
 Polyarthritis
 Carditis
 Subcutaneous nodules
 Erythema marginatum
 Sydenham's chorea

16. Acute Rheumatic Fever
 Minor:
 Fever
 Arthralgia
 Raised ESR or CRP
 Leukocytosis
 ECG showing features of heart block
 Previous episode of rheumatic fever or inactive
heart disease

17. Excluding dangerous conditions (1)
 Sore throat or odonophagia
 Fever
 Muffled voice
 Drooling
 Stridor
 Respiratory distress
 Hoarseness
 Severity of pain out of proportion of exam

18. Epiglottitis

19. Excluding dangerous conditions (2)
 Severe, usually unilateral sore throat
 Fever
 “Hot potato” voice
 Drooling/ pooling of saliva
 Trismus

20. Peritonsillar abscess

21. Excluding dangerous conditions (3)
 Sore throat
 Fever
 Dysphagia/Odynophagia
 Neck pain
 Dyspnea/ stridor
 Cervical lymphadenopathy
 Drooling
 Torticollis
 Trismus

22. Retropharyngeal abscess

23. Excluding dangerous conditions (4)
 Fever, chills, malaise
 Mouth pain
 Stiff neck
 Dysphagia
 Leans forward
 Absent trismus
 Muffled voice or unable to speak
 Tender “woody” induration or crepitus in
submandibular area

24. Ludwig's angina

25. Excluding dangerous conditions (5)
 Fever
 Malaise and severe fatigue
 Pharyngitis
 Lymphadenopathy
 Splenomegaly
 Guillain-Barre syndrome
 Deranged LFTs

26. Infectious Mononucleosis

27. Investigations
 RADT
 Throat culture
 Monospot
 Gonococcal culture
 Lateral neck film
 Soft-tissue neck CT
 Bloods?

28. Management
 ABCs!
 ?Airway obstruction
 Hydration
 Analgesia
 Antibiotics
 ENT referral

29. Analgesia - options
 OOTC lozenges/gargles
 Paracetemol
 Aspirin
 NSAIDs
 Steroids

30. Dose of Dex?
 Cochrane review
 8 trials, 743 participants (children and
adults)
 Patients taking steroids were x3 times
more likely to have complete resolution
by 24 hours vs placebo

31. Dose of Dex?
 However…
 different steroids used
 different doses and routes
 antibiotics co-administered
 sample size too small to assess for adverse effects
 Useful in cases of airway obstruction

32. Antibiotics – why?
 Reduces duration and severity of
symptoms and complications
 Most useful within first 2 days
 Reduces by 1 day
 Reduces incidence of rheumatic fever
within 9 days following onset of symptoms
 Reduces transmission; patient no longer
contagious after 24hours

33. Evidence
 Cochrane review July 2013
 27 trials, 12,835 cases of pharyngitis (adults and
children)
 Reduced sore throat and fever by half
 Reduced symptoms by 16 hours on average
 Less suppurative complications vs placebo
 Reduced ARF by over 2/3 within 1 month

34. Antibiotics – which?
 Penicillin – no clinical isolate has
demonstrated resistance
 Oral penicillin V for 10 days
 Amoxicillin
 IM Penicillin G Benzathine
 First generation Cephalosporins
 Macrolides

35. Antibiotics – who?
 High incidence of acute rheumatic fever
e.g. indigenous
 Existing rheumatic disease or Scarlet
fever
 Immunosuppressed

36. Risks
 Drug side effects
 Patient expectations

37. Summary
 Most cases of adult pharyngitis are viral, and
rheumatic disease is very rare in WA
 Use modified Centor criteria if GAS suspected
 Antibiotics if scoring 2 or more, or high risk group
 Steroids if severe odynophagia
 Otherwise analgesia and supportive care
 Consider different diagnosis than GAS if symptoms
lasting over 7 days

38. References
 http://www.guideline.gov/content.aspx?id=38416
 http://www.rhdaustralia.org.au/sites/default/files/guideline_ http://www.thecochranelibrary.com/details/browseReviews/ http://www.uptodate.com/contents/evaluation-of-acute-