Pharyngitis Overview and Causes

Pharyngitis

• Inflammation of the pharynx and tonsil tissues, most often caused by infection.
• Peak incidence occurs in late fall and early spring.
• Younger children are more prone to viral pharyngitis during winter.
• Bacterial pharyngitis (GABHS) predominantly affects children aged 5-15, with winter peaks.

Pathogenesis of Pharyngitis

Viral Causes

• Adenovirus

• Influenza A & B

• Parainfluenza

• Epstein-Barr virus

• Coxsackie virus (causing herpangina, hand, foot, and mouth disease)

• Enterovirus

• Coxsackie virus (hand, foot, and mouth disease) characteristically presents with oral ulcers, hand/foot rash (vesicles/papules) in spring, summer, and fall, often with associated coryza, conjunctivitis, cough, and diarrhea.

• Enterovirus and coxsackievirus often cause herpangina, marked by oral blisters and ulcers on the anterior pillars.

Bacterial Causes

• Group A β-hemolytic streptococcus (GABHS)
• Group B, C, and G streptococci (non-GABHS)
• Corynebacterium diphtheriae
• Chlamydia trachomatis
• Neisseria gonorrhoeae
• Mycoplasma pneumonia
• Other: Mucosal irritation, foreign bodies, chemical exposure, referred pain

Pharyngitis Differentials

• Allergic rhinitis
• Postnasal drip
• Fungal infections
• Tonsillar abscess
• Retropharyngeal abscess
• Epiglottitis

Diagnosis of Pharyngitis

Viral Pharyngitis

• Gradual onset
• Cough
• Sore throat
• Fever
• Rhinorrhea
• Diarrhea
• Erythematous pharynx (redness)
• Follicular, ulcerative, or exudative lesions in the pharynx

Bacterial Pharyngitis (GABHS)

• Rapid onset (incubation 2-4 days)
• Sore throat
• Fever
• Difficulty swallowing
• Beefy-red, swollen pharynx, uvula, and tonsils
• Tonsillar exudate (pus) and enlarged tonsils
• Swollen and tender cervical and tonsillar lymph nodes
• Petechiae on soft palate, "strawberry" tongue (coated)
• Possible multiple GI symptoms (e.g., vomiting)
• Scarlet fever-like rash

Treatment of Pharyngitis

• Rapid strep test/throat culture needed for diagnosis.
• Antibiotics (e.g., amoxicillin) for bacterial infection, crucial to prevent complications like rheumatic fever and glomerulonephritis.
• Increase fluid intake.
• Analgesics for pain.
• Return to school/daycare 24 hours after antibiotic initiation.
• Inform parents/guardians to watch for signs of worsening symptoms (e.g. peritonsillar abscess).

Antibiotics for Pharyngitis

• Penicillin (and related agents like ampicillin and amoxicillin), cephalosporins, macrolides, and clindamycin are suitable treatments for GAS pharyngitis.
• Sulfonamides and tetracyclines are generally avoided due to resistance risks.

Analgesic and Corticosteroid Treatment

• Systemic analgesics (e.g., acetaminophen, ibuprofen) can reduce throat pain and fever in cases of pharyngitis and tonsillitis.

Follow-up Care for Pharyngitis

• Routine follow-up cultures are not usually needed but a test of cure can be recommended in some instances.
• Assessment of carrier state may be considered, especially given a low risk of transmission and complications.

Complications of Pharyngitis

• Acute rheumatic fever
• Post-streptococcal glomerulonephritis (especially children <7 years old)
• Pediatric autoimmune neuropsychiatric disorder associated with strep (PANDAS), possibly presenting as OCD, ADHD, tics, or worsening of existing behaviors, following or coinciding with a strep infection

Education Regarding Pharyngitis

• Transmission occurs via respiratory secretions.
• Adherence to prescribed medications is essential.
• Children can return to school 24 hours after antibiotic initiation, but sharing of personal items should be avoided.

Scarlet Fever

• Hypersensitivity reaction caused by toxin from GABHS.
• Often follows streptococcal pharyngitis, but other strep infections can cause it too.
• Characterized by a scarlet-colored rash and inflammatory process in the tonsils and pharynx.
• Incubation period: 1-7 days, rash usually appears on day 2.

Tonsillectomy & Adenoidectomy (T&A)

• Surgical removal of tonsils and/or adenoids.
• A common pediatric surgery.

Indications for T&A

• 7+ episodes of recurrent or chronic infection in last year, OR 5+ per year for 2 years, OR 3+ per year for 3 years with relevant clinical findings (fever, adenopathy, exudate, positive strep test)
• Obstructive sleep apnea
• Peritonsillar abscess/cellulitis (more than 1 infection)
• Recurrent middle ear infections due to enlargement
• Vocal alterations from obstruction
• Nasal obstruction

Adenoid Hypertrophy

• Allergic (adenoidal) face (long face syndrome) due to swollen adenoids (behind nose and throat).

T&A Procedure

• Pre-op verification, child receives general anesthesia, IV access secured.
• Pre-procedure use of dexamethasone may be indicated for post-op nausea/vomiting.
• Tonsils and adenoids resected using various techniques, bleeding controlled.

T&A Complications

• Bleeding
• Dehydration
• Failure to improve sleep apnea, nasal obstruction
• Infection
• Pneumonia
• Post-op airway obstruction/laryngospasm/bronchospasm
• Oral burns
• TMJ problems
• Tongue numbness
• Regrowth of tonsil tissue
• Nasal regurgitation (rare)

Pre-Treatment Care for T&A

• Explanation of procedure, informed consent, lab tests (clotting, blood type, crossmatch).
• Prohibitation from aspirin/NSAIDs close to surgery.
• Information provided regarding post-op pain and fluids
• Assessment of loose teeth.

Post-Treatment Care for T&A

• Prevent airway obstruction, suction, encourage liquids when gag reflex returns.
• Avoid straws initially.
• Pain management, assess and monitor regularly.
• Monitoring of blood, respiration, hydration, intake/output, drooling; assess for indications of bleeding, respiratory issues

Pertussis (Whooping Cough)

• Infection caused by Bordetella pertussis.
• Droplet precautions necessary.
• Often milder in adults; more serious in children and infants.
• Higher prevalence during summer (June) and fall (September).
• Immunization (dTap/Tdap).

Disease Progression of Pertussis

• Initial stage (catarrhal): cold-like symptoms, low fever

• Paroxysmal stage: rapid coughs followed by vomiting/exhaustion, whooping sound

• Convalescent stage: gradual reduction in coughing but susceptibility to other infections

• Usual source is an unrecognized infection in a family member. Infants present with unique findings.

This quiz explores the inflammation of the pharynx, commonly known as pharyngitis, highlighting its viral and bacterial causes. It covers peak incidence periods, particularly among children, and features details about associated pathogens. Test your knowledge on the pathogenesis and symptoms of this condition.