Pharyngitis

Question 1

____________
 Sore throat: common chief complaint
 Majority are non-bacterial/viral: part of the influenza
and common cold syndrome
 Uncommon in children < 1 yr
 Peak: 4-7 yrs
 May continue throughout childhood and into adult life

Answer 1

Pharyngitis

Question 2

What is the peak age of pharyngitis?

Answer 2

4-7 yo

Question 3

Response to antibiotics
 Complications of streptococcal infection (Number 1
most dreaded etiology)
 _______________
 Acute streptococcal pharyngitis: warrants accurate
diagnosis and therapy to prevent suppurative and nonsuppurative
complications.
 The life threatening infectious complications of
oropharyngeal infections warrant some discussion.

Answer 3

Rheumatic fever
 glomerolonephritis

Question 4

Tonsillitis/Epiglottitis
 Uvulitis
 Peritonsillar abscess __________-
 Retropharyngeal abscess ____________
 Ludwig angina___________-
 Vincent angina__________________

Answer 4

(Quinsy)

(prevertebral)

(submandibular)

(mixed anaerobic bacteria)

Question 5

What are the etiology of pharyngitis?

Answer 5

Infection
 Bacterial/Viral/Fungal
 Tonsillitis/Epiglottitis
 Uvulitis
 Peritonsillar abscess (Quinsy)
 Retropharyngeal abscess (prevertebral)
 Ludwig angina (submandibular)
 Vincent angina (mixed anaerobic bacteria)
2. Irritation
 Cigarette smoke/smog
 Inhaled irritants
 Reflux esophagitis
 Chemical toxins
 Dry hot air
 Hot foods, liquids
3. Others
 Tumors
 Granulomatosis
 Foreign body

Question 6

What are the viral etiologies?

Answer 6

Viral Etiology
 Parainfluenza (types1-4)
 Influenza
 Rhinovirus
 Coronavirus
 RSV
 Adenovirus
 Herpes simplex 1&2
 Epstein-Barr virus
 Adenovirus (types 2,4,7,14,21,others)
 Coxsackie A & B

 CMV
 HIV
 Human Herpesvirus6
 Measles
 Varicella
 Rubella

Question 7

What are the bacterial etiology?

Answer 7

Bacterial Etiology
 S. pyogenes (lives in throat, ↑ if stressed)
 Grp A-β hemolytic strep (GABHS)
 Grp C & G - β hemolytic strep
 Mixed aerobic/anaerobic organisms
 Neisseria gonorrheae
 Corynebacterium diphtheriae
 Yersinia enterocolitis
 Chlamydia pneumonia atypical pneumonia &
 Mycoplasma pneumonia pharyngitis
 Arcanobacterium hemolyticum
 Francisella tularensis

Question 8

 ___________________ (lives in throat, ↑ if stressed)

Answer 8

S. pyogenes

Question 9

Inflammatory mediators generated by viruses
 Bradykinin & Lysylbradykinin
 Stimulate pain nerve endings
 Direct invasion and colonization of the pharyngeal
mucosa
 Elaboration of virulence factors: exotoxins, hemolysins,
streptokinase, deoxyribonucleases, proteinases,
hyaluronidase – confer resistance to phagocytosis and
destruction.

Answer 9

Pharygitis pathophysio

Question 10

What are the pathological changes in viral infection?

Answer 10

Viral pharyngitis
 Edema, hyperemia ( increase blood flow) of tonsils and pharyngeal mucous
membrane
 Nasopharyngeal hyperplasia
 Vesiculation and mucosal ulceration
 Herpes simplex & Coxsackie A
 Inflammatory exudate
 Adenovirus & Epstein-Barr virus

Question 11

__________
 Intense inflammatory response : marked erythema (**redness of the skin)
 Edema of fauces and uvula
 Grayish yellow tonsillar exudate

Answer 11

Streptococcal

Question 12

__________ –drumstick appearance
 Fibrous pseudomembrane with necrotic epithelium,
leucocytes, bacterial colonies
 Dislodgement of pseudomembrane provokes bleeding and
aspiration
 Bull Neck ➡ due to swelling

Answer 12

Diphtheria

Question 13

This is a clinical feature of : ______________

 Mild to moderate pharyngeal discomfort
 Soreness, scratchiness, irritation
 Rhinorrhea and post nasal discharge
 Low to moderate temperature elevation (38.5C)
 Pharynx may appear normal or with mild edema and
erythema
 NO pharyngeal/tonsillar exudates
 Complaints subside over 3-4 days

Answer 13

Pharyngitis with the common cold

Question 14

This is a clinical feature of: ___________

 Sorethroat: major complaint
 Myalgia, headache, cough

 Coryzal (acute inflammation of the mucousmembrane of the nasal cavities; cold in the head.) symptoms and cough
 Fever - uncommon, if present:early defervescence ( abatement of fever)
 Edema/erythema of pharynx – mild
 NO exudates, NO painful cervical adenopathy

Answer 14

Pharyngitis with Influenza

Question 15

Pharyngoconjunctival Fever : _________________

 Marked sore throat with cough, malaise, myalgia,
headache, chills, dizziness
 High grade fever : 5-6 day duration
 Conjunctivitis: follicular type, bilateral
 Pharyngeal erythema, some exudates
 Cervical adenitis

Answer 15

Adenoviruses

Question 16

____________
-marked sore throat, erythematous pharynx, fever, rash
- red peritonsilar area
- Posterior pharynx ➡ Petechiae
** hand foot mouth disease— vesicles not seen in the mucosa

Answer 16

Pharyngitis due to Coxsackie Viruses

Question 17

What are the two syndromes of pharingitis of coxsackie?

Answer 17

2 syndromes:
1 Herpangina
2 HandFootMouth disease(

Question 18

1_______________: discrete(1-2mm across) painful graywhite
papulovesicular lesionson thesoft palate,uvula,
ant. tonsillar pillars x 7 days; lesions rupture - ulcerate

Answer 18

** Herpangina**

Question 19

____________): painful
vesicles in the oropharynx, ulcerative vesicles in the palms
and soles,trunk; not toxic looking; < 7days

Answer 19

2 HandFootMouth disease(CoxsackieA16

Question 20

_______________
 _______________– oral infections common during childhood and
adolescence
 high fever, gingivostomatitis which become ulcers -
anterior portion of mouth and lips, tongue, palate,
tonsils, pharynx; tender lymphadenopathy; Drooling,
refusal to eat/drink
 Resolves in 7-14 days, even if untreated

Answer 20

Pharyngitis and the Herpes simplex virus

HSV1

Question 21

________________
 “kissing disease”
 Epstein-Barr virus found in the oropharynx, spread by
person to person contact/blood transfusion
 Common among adolescents
 With hepatomegaly and splenomegaly ➡ avoid contact
sports
 Incubation: 4-7wks
 Prodome: 2-5 days: chills, sweats,feverishness, malaise
 Triad: Severe sore throat, high grade fever,
Lymphadenopathy– cervical,axillary,inguinal
 Tonsillitis in 70-90%; Tonsillar exudates in 30%
 Hepatomegaly in 10-15%;
 Splenomegaly in 50%
 Leucocytosis in 60-70%; lymphocytosis
 10% - atypical lymphocytes by 2nd wk of illness
 Self-limited, resolves in 3 wks
Diagnosis:
- Heterophil antibody test: IgM
85% of older children and adults are positive
2nd wk to illness – 6months
- atypical lymphocytes (periph smears) on 2nd wk of
illness
- specific antibody tests
- viral culture
- DNA PCR
Management: No need for antiviral drugs
- Avoid contact sports until pt is fully recovered and
spleen is not anymore palpable
- Do not give Ampicillin/Amoxicillin: may cause the
appearance of morbilliform rash
- Steroids only for those with airway obstruction,
massive splenomegaly, myocarditis, hemolytic anemia
Viral Pharyngitis
 Symptomatic Treatment
 Relieve pharyngeal discomfort
 Warm saline gargle
 Anesthetic sprays and lozenges (benzocaine)
 Rest, liquids
 Paracetamol/ibuprofen
CLINICAL FEATURE
MANAGEMENT
Infectious

Answer 21

Infectious Mononucleosis – Glandular Fever

Question 22

What is the triad in infectious mononucleosis?

Answer 22

Severe sorethroat

High grade fever

lymphadenopathy

Question 23

What is the mgt for viral pharyngitis?

Answer 23

Viral Pharyngitis
 Symptomatic Treatment
 Relieve pharyngeal discomfort
 Warm saline gargle
 Anesthetic sprays and lozenges (benzocaine)
 Rest, liquids
 Paracetamol/ibuprofen

Question 24

15% of all episodes of pharyngitis
 Prevention of sequelae : (acute rheumatic fever & acute
glomerulonephritis)depends on the timely diagnosis of
Strep pharyngitis and prompt antibiotic tx
 Incubation: 2-5 days; contact with respiratory
secretions of a person with strep pharyngitis
 Most common among school-aged & adolescent
 Associated with crowding, close contact in
school/military installations

Answer 24

Grp A Streptococcal pharyngitis

Question 25

Colonization of the pharynx : **results in asymptomatic carrier state**

Question 26

What is the major virulence factor of Group A strep?

Answer 26

 Acute infection  Major virulence factor: **M protein** – resistance to phagocytosis by PMNs  Type specific immunity to specific M serotype develops after infection

Question 27

 Scarlet fever – GABHS erythrogenic exotoxin (A,B,C)

Answer 27

Grp A Streptococcal pharyngitis

Question 28

**Sudden onset of feve**r and sore throat, **no cough**  Headache, malaise, **abdom pain**, nausea, **vomiting (in contrast to vira**l:**cough, rhinorrhea, conjunctivitis,** stridor, diarrhea, hoarseness)  Marked pharyngeal erythema  P**etechiae on palate(donut lesion**), enlarged tonsils with exudates, **strawberry tongue**, enlarged cervical lymph nodes

Answer 28

Group A Strep

Question 29

\_\_\_\_\_\_\_\_\_\_\_: Scarlet fever **- Not everybody gets scarlet fever!**  Pharyngitis with **fine diffuse red “sand paper” rash** that **blanches with pressure**; **desquamation follows after 1 wk**  **Circumoral pallor**: **red face with pallor around the mouth**  **Pastia’s lines**: accentuated erythema over flexor creases especially on the antecubital

Answer 29

\*\*Strep pharyngitis

Question 30

\_\_\_\_\_\_\_\_\_\_\_\_\_ Signs  Tonsillar & pharyngeal erythema and exudates  **Donut lesions – soft palate  Beefy red and swollen uvula**  Anterior cervical adenitis  **Scalatiniform rash** Symptoms  Sudden onset sore throat  Pain on swallowing  Fever  Headache  Abdominal pain  Nausea  Vomiting

Answer 30

GAS infection

Question 31

*signs*  **Conjunctivitis**  Stomatitis  Discrete ulcerative lesions *symptoms*  Coryza ** Hoarseness**  Cough  Diarrhea

Answer 31

Not GAS infection

Question 32

Diagnosis  Gold standard Group A strep: \_\_\_\_\_\_\_\_\_-

Answer 32

throat culture **NOTE : Gram stain- more practica**l (gm + in **chain/pair)**  Lab confirmation of **GrpA Strep (GAS) pharyngitis** **recommended** – because it is **not possible to clinically** **differentiate viral vs GAS pharyngitis**  Swab of tonsil and post pharynx for C/S – cannot distinguish carrier vs true infection

Question 33

What is being detected in rapid diagnostic test for group A strep?

Answer 33

 Rapid test: **detect grp A carbohydrate Ag** on the cell wall of

Question 34

GAS – latex agglutination test/ optical immunoassay/ chemiluminescent DNA probes \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ – Valid for **determining past infections**

Answer 34

 Strep Antibody Tests: (wks after onset)

Question 35

–Tool for evaluating possible post-strep illnesses \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Answer 35

ASO – antistreptolysin O  antiDNAse B  antihyaluronidase

Question 36

When to start treatment in Group A strep pharyngitis? \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Answer 36

Antibiotics should be started within 9th day of onset of Strep pharyngitis… NOTE:  to prevent **acute rheumatic fever**  To prevent the suppurative sequelae: i.e. **peritonsillar abscess**  To produce a rapid resolution of the signs and symptoms and to terminate contagiousness within 24 hrs (reduce transmission)  To shorten the clinical course of the disease

Question 37

What are the complications of Group A strep pharyngitis?

Answer 37

Complications  **Otitis media  Sinusitis  Acute Glomerulonephritis  Rheumatic Fever  Abscess Formation:** *-peritonsillar abscess -retropharyngeal abscess* **(both will require intensive antibiotic tx and drainage of the abscess)**

Question 38

 Etiologic agent: **GAS/anaerobes**  Occurs in the **potential space** between the **superior constrictor muscles and the tonsil**  Clinical manifestations: **preceded by acute pharyngitis with fever** **severe throat pain, trismus (lock jaw)**, difficulty swallowing or speaking, ***hot potato voice***, **torticollis ( also known as wry neck or loxia, is a dystonic condition defined by an abnormal, asymmetrical head or neck position)**, swollen inflammed tonsils, displaced uvula  Treatment: - Antibiotic therapy effective vs GABHS - Surgical drainage - Needle aspiration - Incision and drainage - Tonsillectomy

Answer 38

Peritonsillar Abscess

Question 39

Involves the s**pace between the posterior pharyngeal wall**and the**prevertebral fascia**:**has many lymph nodes** which **become infected and progress to suppuration**.  Clinical manifestations: **abrupt onset of high fever,** **difficulty feeding**, **severe distress with throat pain**, **hyperextension of head**, ***noisy gurgling respiration***, **stridor**, drooling, bulge on the posterior pharyngeal wall,cervical lymphadenopathy  Differential dx: epiglottitis/foreign body aspiration, meningitis, lymphoma, hematoma, vertebral osteomyelitis  Diagnosis: I&D with culture of abscessed node Soft tissue neck films/CT scan  Most often polymicrobial: GABHS, oropharyngeal anaerobes, Staph aureus, H.flu, Klebsiella Retropharyngeal Abscess  Treatment - IV antibiotics with or without surgical drainage - Surgical drainage: for patients in respiratory distress or unresponsive to IV antibiotics

Answer 39

**Retropharyngeal Abscess**

Question 40

What are the red flags associated with sore throat \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Answer 40

 Fever of \> 2 wks  Duration of sore throat \>2wks  Trismus, drooling, cyanosis  Hemorrhage  Assymetric tonsillar swelling  Respiratory distress (airway obstruction/pneumonia)  Apnea  Severe unremitting pain

Question 41

What is the DOC for sorethroat with red flags?

Answer 41

Drug of choice Child Adol Pen V BID/TID x10d PO 250mg 500MG Pen G OD IM 600,000 U 1.2M U \<25kg \>25kg

Question 42

Answer 42

Pseudomembrane of Diphteria

Question 43

Answer 43

Bull neck: Diptheria

Question 44

Answer 44

Herpangina: discrete(1-­‐‑2mm across) painful gray-­‐‑ white papulovesicular lesions on the soft palate, uvula, ant. tonsillar pillars x 7 days; lesions rupture -­‐‑ ulcerate

Question 45

Answer 45

HFMD

Question 46

Answer 46

Pharyngitis and the Herpes simplex virus • HSV1 – oral infections common during childhood and adolescence • high fever, gingivostomatitis which become ulcers -­‐‑ **anterior portion of mouth and lips, tongue, palate, tonsils, pharynx; tender lymphadenopathy;**Drooling, refusal to eat/ drink • Resolves in 7-­‐‑14 days, even if untreated

Question 47

Answer 47

Infectious Mononucleosis – Glandular Fever • Epstein-­‐‑Barr virus found in the oropharynx, spread by person to person contact/blood transfusion • Common among adolescents • Incubation: 4-­‐‑7wks • Prodome: 2-­‐‑5 days: chills, sweats,feverishness, malaise

Question 48

Answer 48

Strep Pharyngitis: Clinical Features • Sudden onset of fever and sore throat, no cough • Headache, malaise, abdom pain, nausea, vomiting (in contrast to viral: cough, rhinorrhea, conjunctivitis, stridor, diarrhea, hoarseness) • Marked pharyngeal erythema • Petechiae on palate, enlarged tonsils with exudates, strawberry tongue, enlarged cervical lymph nodesStrep Pharyngitis: Clinical Features • Sudden onset of fever and sore throat, no cough • Headache, malaise, abdom pain, nausea, vomiting (in contrast to viral: cough, rhinorrhea, conjunctivitis, stridor, diarrhea, hoarseness) • Marked pharyngeal erythema • Petechiae on palate, enlarged tonsils with exudates, strawberry tongue, enlarged cervical lymph nodesStrep Pharyngitis: Clinical Features • Sudden onset of fever and sore throat, no cough • Headache, malaise, abdom pain, nausea, vomiting (in contrast to viral: cough, rhinorrhea, conjunctivitis, stridor, diarrhea, hoarseness) • Marked pharyngeal erythema • Petechiae on palate, enlarged tonsils with exudates, strawberry tongue, enlarged cervical lymph nodesStrep Pharyngitis: Clinical Features • Sudden onset of fever and sore throat, no cough • Headache, malaise, abdom pain, nausea, vomiting (in contrast to viral: cough, rhinorrhea, conjunctivitis, stridor, diarrhea, hoarseness) • Marked pharyngeal erythema • Petechiae on palate, enlarged tonsils with exudates, strawberry tongue, enlarged cervical lymph nodesStrep Pharyngitis: Clinical Features • Sudden onset of fever and sore throat, no cough • Headache, malaise, abdom pain, nausea, vomiting (in contrast to viral: cough, rhinorrhea, conjunctivitis, stridor, diarrhea, hoarseness) • Marked pharyngeal erythema • Petechiae on palate, enlarged tonsils with exudates, strawberry tongue, enlarged cervical lymph nodesStrep Pharyngitis: Clinical Features • Sudden onset of fever and sore throat, no cough • Headache, malaise, abdom pain, nausea, vomiting (in contrast to viral: cough, rhinorrhea, conjunctivitis, stridor, diarrhea, hoarseness) • Marked pharyngeal erythema • Petechiae on palate, enlarged tonsils with exudates, strawberry tongue, enlarged cervical lymph nodesStrep Pharyngitis: Clinical Features • Sudden onset of fever and sore throat, no cough • Headache, malaise, abdom pain, nausea, vomiting (in contrast to viral: cough, rhinorrhea, conjunctivitis, stridor, diarrhea, hoarseness) • Marked pharyngeal erythema • Petechiae on palate, enlarged tonsils with exudates, strawberry tongue, enlarged cervical lymph nodesStrep Pharyngitis: Clinical Features • Sudden onset of fever and sore throat, no cough • Headache, malaise, abdom pain, nausea, vomiting (in contrast to viral: cough, rhinorrhea, conjunctivitis, stridor, diarrhea, hoarseness) • Marked pharyngeal erythema • Petechiae on palate, enlarged tonsils with exudates, strawberry tongue, enlarged cervical lymph nodesv

Question 49

Answer 49

Peritonsillar Abscess

Question 50

Answer 50

Retropharyngeal Abscess