Pharyngitis Explained

Pharyngitis should not be confused with laryngitis.

Pharyngitis
Synonyms:Acute sore throat
Field:Infectious disease
Symptoms:Sore throat, fever, runny nose, cough, headache, hoarse voice
Complications:Sinusitis, acute otitis media
Duration:3–10 days, depending on cause
Causes:Usually viral infection
Diagnosis:Based on symptoms, rapid antigen detection test, throat swab
Differential:Epiglottitis, thyroiditis, retropharyngeal abscess
Treatment:lidocaine
Frequency:~7.5% of people in any 3-month period

Pharyngitis is inflammation of the back of the throat, known as the pharynx. It typically results in a sore throat and fever. Other symptoms may include a runny nose, cough, headache, difficulty swallowing, swollen lymph nodes, and a hoarse voice.[1] Symptoms usually last 3–5 days, but can be longer depending on cause.[2] Complications can include sinusitis and acute otitis media. Pharyngitis is a type of upper respiratory tract infection.[3]

Most cases are caused by a viral infection. Strep throat, a bacterial infection, is the cause in about 25% of children and 10% of adults. Uncommon causes include other bacteria such as gonococcus, fungi, irritants such as smoke, allergies, and gastroesophageal reflux disease. Specific testing is not recommended in people who have clear symptoms of a viral infection, such as a cold. Otherwise, a rapid antigen detection test or throat swab is recommended. PCR testing has become common as it is as good as taking a throat swab but gives a faster result.[4] Other conditions that can produce similar symptoms include epiglottitis, thyroiditis, retropharyngeal abscess, and occasionally heart disease.[5]

NSAIDs, such as ibuprofen, can be used to help with the pain.[5] Numbing medication, such as topical lidocaine, may also help. Strep throat is typically treated with antibiotics, such as either penicillin or amoxicillin.[5] It is unclear whether steroids are useful in acute pharyngitis, other than possibly in severe cases, but a recent (2020) review found that when used in combination with antibiotics they moderately reduced pain and the likelihood of resolution.[6] [7]

About 7.5% of people have a sore throat in any 3-month period.[8] Two or three episodes in a year are not uncommon.[9] This resulted in 15 million physician visits in the United States in 2007.[10] Pharyngitis is the most common cause of a sore throat.[11] The word comes from the Greek word pharynx meaning "throat" and the suffix -itis meaning "inflammation".[12] [13]

Classification

Pharyngitis is a type of inflammation caused by an upper respiratory tract infection. It may be classified as acute or chronic. Acute pharyngitis may be catarrhal, purulent, or ulcerative, depending on the causative agent and the immune capacity of the affected individual. Chronic pharyngitis may be catarrhal, hypertrophic, or atrophic.

Tonsillitis is a subtype of pharyngitis.[14] If the inflammation includes both the tonsils and other parts of the throat, it may be called pharyngotonsillitis or tonsillopharyngitis.[15] Another subclassification is nasopharyngitis (the common cold).[16]

Clergyman's sore throat or clergyman's throat is an archaic term formerly used for chronic pharyngitis associated with overuse of the voice as in public speaking. It was sometimes called dysphonia clericorum or chronic folliculitis sore throat.[17]

Cause

Most cases are due to an infectious organism acquired from close contact with an infected individual.

Viral

These comprise about 40–80% of all infectious cases and can be a feature of many different types of viral infections.[11] [18]

rhinovirus, coronavirus, respiratory syncytial virus, and parainfluenza virus can cause infection of the throat, ear, and lungs causing standard cold-like symptoms and often pain.

Bacterial

A number of different bacteria can infect the human throat. The most common is group A streptococcus (Streptococcus pyogenes), but others include Streptococcus pneumoniae, Haemophilus influenzae, Bordetella pertussis, Bacillus anthracis, Corynebacterium diphtheriae, Neisseria gonorrhoeae, Chlamydophila pneumoniae, Mycoplasma pneumoniae, and Fusobacterium necrophorum.[19]

Streptococcal pharyngitis

See main article: Streptococcal pharyngitis. Streptococcal pharyngitis or strep throat is caused by a group A beta-hemolytic streptococcus (GAS).[20] It is the most common bacterial cause of cases of pharyngitis (15–30%).[19] Common symptoms include fever, sore throat, and large lymph nodes. It is a contagious infection, spread by close contact with an infected individual. A definitive diagnosis is made based on the results of a throat culture. Antibiotics are useful to both prevent complications (such as rheumatic fever) and speed recovery.[21]

Fusobacterium necrophorum

Fusobacterium necrophorum is a normal inhabitant of the oropharyngeal flora and can occasionally create a peritonsillar abscess. In one out of 400 untreated cases, Lemierre's syndrome occurs.[22]

Diphtheria

Diphtheria is a potentially life-threatening upper respiratory infection caused by Corynebacterium diphtheriae, which has been largely eradicated in developed nations since the introduction of childhood vaccination programs, but is still reported in the Third World and increasingly in some areas in Eastern Europe. Antibiotics are effective in the early stages, but recovery is generally slow.

Others

A few other causes are rare, but possibly fatal, and include parapharyngeal space infections: peritonsillar abscess ("quinsy abscess"), submandibular space infection (Ludwig's angina), and epiglottitis.[23] [24] [25]

Fungal

Some cases of pharyngitis are caused by fungal infection, such as Candida albicans, causing oral thrush.[26]

Noninfectious

Pharyngitis may also be caused by mechanical, chemical, or thermal irritation, for example cold air or acid reflux. Some medications may produce pharyngitis, such as pramipexole and antipsychotics.[27] [28]

Diagnosis

Probability of StrepManagement
1 or less<10%No antibiotic or culture needed
2 11–17%Antibiotic based on culture or rapid antigen detection test
3 28–35%
4 or 5 52%Empiric antibiotics
Differentiating a viral and a bacterial cause of a sore throat based on symptoms alone is difficult. Thus, a throat swab often is done to rule out a bacterial cause.[29]

The modified Centor criteria may be used to determine the management of people with pharyngitis. Based on five clinical criteria, it indicates the probability of a streptococcal infection.[21]

One point is given for each of the criteria:[21]

The Infectious Disease Society of America recommends against empirical treatment and considers antibiotics only appropriate following positive testing. Testing is not needed in children under three, as both group A strep and rheumatic fever are rare, except if they have a sibling with the disease.[30]

Management

The majority of the time, treatment is symptomatic. Specific treatments are effective for bacterial, fungal, and herpes simplex infections.

Medications

Alternative

See also: Alternative treatments used for the common cold. Gargling salt water is often suggested, but there is no evidence to support or discourage this practice.[10] Alternative medicines are promoted and used for the treatment of sore throats. However, they are poorly supported by evidence.[37]

Epidemiology

Acute pharyngitis is the most common cause of a sore throat and, together with cough, it is diagnosed in more than 1.9 million people a year in the United States.[11]

Notes and References

  1. Book: Oral and maxillofacial pathology. subscription. Elsevier. Neville. Damm. Douglas D.. Allen. Carl M.. Chi. Angela C.. 2016. 9781455770526. 4th. St. Louis, MO. 166. 908336985. 17 March 2020. 28 October 2021. https://web.archive.org/web/20211028081814/https://www.clinicalkey.com/ui-origin/master-1586/2-bundle.js. dead.
  2. Book: David A.Warrell . Timothy M. Cox . John D. Firth . Estée Török . Oxford textbook of medicine infection . 2012. Oxford University Press . Oxford. 9780191631733 . 280–281. live . https://web.archive.org/web/20161010214543/https://books.google.com/books?id=qkLibW2ZikYC&pg=PA280. 2016-10-10.
  3. Web site: Pharyngitis. National Library of Medicine. 4 August 2016. live. https://web.archive.org/web/20160520133301/http://www.nlm.nih.gov/cgi/mesh/2016/MB_cgi?mode=&term=Pharyngitis&field=entry#TreeC08.730.561. 20 May 2016. dmy-all.
  4. Web site: Acute pharyngitis - Symptoms, diagnosis and treatment BMJ Best Practice . bestpractice.bmj.com.
  5. Hildreth. AF. Takhar. S. Clark. MA. Hatten. B. Evidence-Based Evaluation And Management Of Patients With Pharyngitis In The Emergency Department.. Emergency Medicine Practice. September 2015. 17. 9. 1–16; quiz 16–7. 26276908.
  6. Principi. N. Bianchini. S. Baggi. E. Esposito. S. No evidence for the effectiveness of systemic corticosteroids in acute pharyngitis, community-acquired pneumonia and acute otitis media.. European Journal of Clinical Microbiology & Infectious Diseases. February 2013. 32. 2. 151–60. 22993127. 10.1007/s10096-012-1747-y. 7087613.
  7. de Cassan. Simone. Thompson. Matthew J.. Perera. Rafael. Glasziou. Paul P.. Del Mar. Chris B.. Heneghan. Carl J.. Hayward. Gail. 1 May 2020. Corticosteroids as standalone or add-on treatment for sore throat. The Cochrane Database of Systematic Reviews. 2020. 5. CD008268. 10.1002/14651858.CD008268.pub3. 1469-493X. 7193118. 32356360.
  8. Book: Jones. Roger. Oxford Textbook of Primary Medical Care. 2004. Oxford University Press. 9780198567820. 674. 4 August 2016. en.
  9. Book: Rutter. Paul Professor. Newby. David. Community Pharmacy ANZ: Symptoms, Diagnosis and Treatment. 2015. Elsevier Health Sciences. 9780729583459. 19. en. live. https://web.archive.org/web/20170908192747/https://books.google.com/books?id=NbjVCgAAQBAJ&pg=PA19. 8 September 2017. dmy-all.
  10. Weber. R. Pharyngitis.. Primary Care. March 2014. 41. 1. 91–8. 24439883. 10.1016/j.pop.2013.10.010. 7119355.
  11. Book: Marx, John . Rosen's emergency medicine: concepts and clinical practice . 7th . 2010 . Mosby/Elsevier . Philadelphia, Pennsylvania . 978-0-323-05472-0 . Chapter 30 .
  12. Book: Beachey. Will. Respiratory Care Anatomy and Physiology, Foundations for Clinical Practice,3: Respiratory Care Anatomy and Physiology. 2013. Elsevier Health Sciences. 978-0323078665. 5. en. live. https://web.archive.org/web/20170908192747/https://books.google.com/books?id=LBzD30OmrSwC&pg=PA5. 8 September 2017. dmy-all.
  13. Book: Hegner. Barbara. Acello. Barbara. Caldwell. Esther. Nursing Assistant: A Nursing Process Approach – Basics. 2009. Cengage Learning. 9781111780500. 45. en. live. https://web.archive.org/web/20170908192747/https://books.google.com/books?id=LopsCgAAQBAJ&pg=PA45. 8 September 2017. dmy-all.
  14. Web site: Tonsillitis. 4 August 2016. live. https://web.archive.org/web/20160325080921/http://www.nlm.nih.gov/cgi/mesh/2016/MB_cgi?field=uid&term=D014069. 25 March 2016. dmy-all.
  15. Rafei K, Lichenstein R . Airway Infectious Disease Emergencies . Pediatric Clinics of North America . 53 . 2 . 215–242 . 2006 . 16574523 . 10.1016/j.pcl.2005.10.001 .
  16. Web site: www.nlm.nih.gov . live . https://web.archive.org/web/20151117014738/http://www.nlm.nih.gov/cgi/mesh/2010/MB_cgi?field=uid&term=D014069 . 17 November 2015 . dmy-all .
  17. Broadwater . Kimberly . 2021 . Clergyman's Sore Throat . Journal of Singing . 78 . 1 . 113–117 . 10.53830/CNLB1302 . 239663449 . 2769-4046.
  18. Web site: Pharyngitis . Acerra JR . eMedicine . 28 April 2010 . live . https://web.archive.org/web/20100317130804/http://emedicine.medscape.com/article/764304-overview . 17 March 2010 . dmy-all .
  19. Bisno AL . Acute pharyngitis . . 344 . 3 . 205–11 . January 2001 . 11172144 . 10.1056/NEJM200101183440308 .
  20. Baltimore RS . Re-evaluation of antibiotic treatment of streptococcal pharyngitis . Curr. Opin. Pediatr. . 22 . 1 . 77–82 . February 2010 . 19996970 . 10.1097/MOP.0b013e32833502e7 . 13141765 .
  21. Choby BA . Diagnosis and treatment of streptococcal pharyngitis . Am Fam Physician . 79 . 5 . 383–90 . March 2009 . 19275067 . live . https://web.archive.org/web/20150208124744/http://www.aafp.org/afp/2009/0301/p383.html . 8 February 2015 . dmy-all .
  22. Centor RM . Expand the pharyngitis paradigm for adolescents and young adults . . 151 . 11 . 812–5 . 1 December 2009 . 19949147 . 10.7326/0003-4819-151-11-200912010-00011 . 10.1.1.669.7473 . 207535809 .
  23. Web site: UpToDate Inc. . live . https://web.archive.org/web/20090627030426/http://www.uptodate.com/online/content/topic.do?topicKey=pc_id%2F4421&selectedTitle=1~150&source=search_result . 27 June 2009 . dmy-all . (registration required)
  24. Reynolds SC, Chow AW . Severe soft tissue infections of the head and neck: a primer for critical care physicians . . 187 . 5 . 271–9 . Sep–Oct 2009 . 19653038 . 10.1007/s00408-009-9153-7 . 9009912 .
  25. Bansal A, Miskoff J, Lis RJ . Otolaryngologic critical care . . 19 . 1 . 55–72 . January 2003 . 12688577 . 10.1016/S0749-0704(02)00062-3 .
  26. Web site: Harvard Medical School . Sore Throat (Pharyngitis) . Harvard Health Publishing Harvard Medical School . Harvard Health Publishing . 3 December 2019.
  27. Web site: Mirapex product insert . 2009 . Boehringer Ingelheim . 30 June 2010 . live . https://web.archive.org/web/20100614020208/http://bidocs.boehringer-ingelheim.com/BIWebAccess/ViewServlet.ser?docBase=renetnt&folderPath=%2FPrescribing+Information%2FPIs%2FMirapex%2FMirapex.pdf . 14 June 2010 . dmy-all .
  28. Web site: Mosby's Medical Dictionary, 8th edition . 2009 . Elsevier . 30 June 2010.
  29. Del Mar C . Managing sore throat: a literature review. I. Making the diagnosis . . 156 . 8 . 572–5 . 1992 . 1565052 . 10.5694/j.1326-5377.1992.tb121422.x.
  30. Shulman ST, Bisno AL, Clegg HW, Gerber MA, Kaplan EL, Lee G, Martin JM, Van Beneden C . Clinical Practice Guideline for the Diagnosis and Management of Group A Streptococcal Pharyngitis: 2012 Update by the Infectious Diseases Society of America. . Clinical Infectious Diseases . 55 . 10 . e86–102 . 9 September 2012 . 22965026 . 10.1093/cid/cis629 . 7108032 . free .
  31. Re-evaluation of antibiotic treatment of streptococcal pharyngitis. February 2010. Curr. Opin. Pediatr. 22 (1). 77–82. 10.1097/MOP.0b013e32833502e7. 19996970. 22. Baltimore RS. Current Opinion in Pediatrics. 13141765.
  32. Hayward G, Thompson M, Heneghan C, Perera R, Del Mar C, Glasziou P . Corticosteroids for pain relief in sore throat: systematic review and meta-analysis . BMJ . 339 . b2976 . 2009 . 19661138 . 2722696 . 10.1136/bmj.b2976 .
  33. Web site: LIDOCAINE VISCOUS (Xylocaine Viscous) side effects, medical uses, and drug interactions. . live . https://web.archive.org/web/20100408065631/http://www.medicinenet.com/lidocaine_viscous/article.htm . 8 April 2010 . dmy-all .
  34. Kocher. JJ. Selby. TD. Antibiotics for sore throat.. American Family Physician. 1 July 2014. 90. 1. 23–4. 25077497.
  35. Spinks . Anneliese . Glasziou . Paul P. . Del Mar . Chris B. . 2021-12-09 . Antibiotics for treatment of sore throat in children and adults . The Cochrane Database of Systematic Reviews . 2021 . 12 . CD000023 . 10.1002/14651858.CD000023.pub5 . 1469-493X . 8655103 . 34881426.
  36. Urkin. J. Allenbogen. M. Friger. M. Vinker. S. Reuveni. H. Elahayani. A. Acute pharyngitis: low adherence to guidelines highlights need for greater flexibility in managing paediatric cases.. Acta Paediatrica. November 2013. 102. 11. 1075–80. 23879261. 10.1111/apa.12364. 24465793.
  37. Web site: Sore throat: Self-care . . 17 September 2007 . live . https://web.archive.org/web/20070929153814/http://www.mayoclinic.com/health/sore-throat/DS00526/DSECTION%3D10 . 29 September 2007 . dmy-all .

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