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Pharyngitis

Pharyngitis
Inflamed oropharynx: swollen and red.
Classification and external resources
Specialty Infectious disease
ICD-10 J02, J31.2
ICD-9-CM 462, 472.1
DiseasesDB 24580
MedlinePlus 000655
eMedicine emerg/419
MeSH D010612

Pharyngitis is the inflammation of the pharynx, a region in the back of the throat.[1] In most cases it is quite painful, and it is the most common cause of a sore throat.[2]

Like many types of inflammation, pharyngitis can be chronic or acute (quickly developing and temporary). Pharyngitis can result in very large tonsils, which cause trouble swallowing and breathing. Pharyngitis can be accompanied by a cough or fever, especially if caused by a systemic infection.

Most acute cases are caused by viral infections (40–80%), with the remainder caused by bacterial infections, fungal infections, or irritants such as pollutants or chemical substances.[2][3] Treatment of viral causes is mainly symptomatic, but bacterial or fungal causes may be treated with antibiotics and anti-fungal medicines respectively.

The word comes from the Greek word pharynx meaning "throat" and the suffix -itis meaning "inflammation."

Contents

  • Classification 1
  • Cause 2
    • Infectious 2.1
    • Non-infectious 2.2
  • Diagnostic approach 3
  • Management 4
    • Medications 4.1
    • Alternative 4.2
  • Epidemiology 5
  • References 6

Classification

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

If the inflammation includes tonsillitis, it maybe called pharyngotonsillitis.[4] Another sub classification is nasopharyngitis (the common cold).[5]

Cause

The majority of cases are due to an infectious organism acquired from close contact with an infected individual.

Infectious

Viral

These comprise about 40–80% of all infectious cases and can be a feature of many different types of viral infections.[2][3]

Bacterial

A number of different bacteria can infect the human throat. The most common is Group A streptococcus, but others include Streptococcus pneumoniae, Haemophilus influenzae, Bordetella pertussis, Bacillus anthracis, Corynebacterium diphtheriae, Neisseria gonorrhoeae, Chlamydophila pneumoniae, and Mycoplasma pneumoniae.[6]

Streptococcal pharyngitis
A case of strep throat

Streptococcal pharyngitis or strep throat is caused by group A beta-hemolytic streptococcus (GAS).[7] It is the most common bacterial cause of cases of pharyngitis (15–30%).[6] 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 and speed recovery.[8]

Fusobacterium necrophorum

Fusobacterium necrophorum is a normal inhabitant of the oropharyngeal flora and can occasionally create a peritonsillar abscess. In 1 out of 400 untreated cases, Lemierre's syndrome occurs.[9]

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"), submandibular space infection (Ludwig's angina), and epiglottitis.[10][11][12]

Fungal

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

Non-infectious

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.[13][14]

Diagnostic approach

Modified Centor score
Points Probability of Strep Management
1 or less <10% No antibiotic or culture needed
2 11–17% Antibiotic based on culture or RADT
3 28–35%
4 or 5 52% Empiric antibiotics

It is hard to differentiate a viral and a bacterial cause of a sore throat based on symptoms alone.[15] Thus often a throat swab is done to rule out a bacterial cause.[16]

The modified Centor criteria may be used to determine the management of people with pharyngitis. Based on 5 clinical criteria, it indicates the probability of a streptococcal infection.[8]

One point is given for each of the criteria:[8]

  • Absence of a cough
  • Swollen and tender cervical lymph nodes
  • Temperature >38.0 °C (100.4 °F)
  • Tonsillar exudate or swelling
  • Age less than 15 (a point is subtracted if age >44)

The McIsaac criteria adds to the Centor:[17]

  • Age less than 15: add one point
  • Age greater than 45: subtract one point

The Infectious Disease Society of America however recommends against empirical treatment and considers antibiotics only appropriate following positive testing.[15] 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.[15]

Management

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

Medications

Alternative

Alternative medicines are promoted and used for the treatment of sore throats.[23] However, they are poorly supported by evidence.[23]

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.[2]

References

  1. ^ "Pharyngitis". ClinicalKey. 
  2. ^ a b c d Marx, John (2010). Rosen's emergency medicine: concepts and clinical practice (7th ed.). Philadelphia, Pennsylvania: Mosby/Elsevier. Chapter 30.  
  3. ^ a b Acerra JR. "Pharyngitis". eMedicine. Retrieved 28 April 2010. 
  4. ^ Rafei K, Lichenstein R (2006). "Airway Infectious Disease Emergencies". Pediatric Clinics of North America 53 (2): 215–242.  
  5. ^ "www.nlm.nih.gov". 
  6. ^ a b Bisno AL (January 2001). "Acute pharyngitis".  
  7. ^ Baltimore RS (February 2010). "Re-evaluation of antibiotic treatment of streptococcal pharyngitis". Curr. Opin. Pediatr. 22 (1): 77–82.  
  8. ^ a b c Choby BA (March 2009). "Diagnosis and treatment of streptococcal pharyngitis". Am Fam Physician 79 (5): 383–90.  
  9. ^ Centor RM (2009-12-01). "Expand the pharyngitis paradigm for adolescents and young adults".  
  10. ^ "UpToDate Inc.".  (registration required)
  11. ^ Reynolds SC, Chow AW (Sep–Oct 2009). "Severe soft tissue infections of the head and neck: a primer for critical care physicians".  
  12. ^ Bansal A, Miskoff J, Lis RJ (January 2003). "Otolaryngologic critical care".  
  13. ^ "Mirapex product insert" (PDF). Boehringer Ingelheim. 2009. Retrieved 2010-06-30. 
  14. ^ "Mosby's Medical Dictionary, 8th edition". Elsevier. 2009. Retrieved 2010-06-30. 
  15. ^ a b c Shulman ST, Bisno AL, Clegg HW, Gerber MA, Kaplan EL, Lee G, Martin JM, Van Beneden C (Sep 9, 2012). "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 : an official publication of the Infectious Diseases Society of America 55 (10): e86–102.  
  16. ^ Del Mar C (1992). "Managing sore throat: a literature review. I. Making the diagnosis".  
  17. ^ Fine AM, Nizet V, Mandl KD (2012). "Large-Scale Validation of the Centor and McIsaac Scores to Predict Group A Streptococcal Pharyngitis.". Arch Intern Med 172.  
  18. ^ Baltimore RS (February 2010). "Re-evaluation of antibiotic treatment of streptococcal pharyngitis"". Current Opinion in Pediatrics 22 (Curr. Opin. Pediatr. 22 (1)): 77–82.  
  19. ^ Hayward G, Thompson M, Heneghan C, Perera R, Del Mar C, Glasziou P (2009). "Corticosteroids for pain relief in sore throat: systematic review and meta-analysis". BMJ 339: b2976.  
  20. ^ "Do steroids reduce symptoms in acute pharyngitis?". BestBets.org. Retrieved 2009-01-14. 
  21. ^ "LIDOCAINE VISCOUS (Xylocaine Viscous) side effects, medical uses, and drug interactions.". 
  22. ^ Del Mar CB, Glasziou PP, Spinks AB (2004). Del Mar, Chris, ed. "Antibiotics for sore throat".   - Meta-analysis of published research
  23. ^ a b "Sore throat: Self-care".  
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