Pharyngitis Overview

Pharyngitis

• Inflammation of pharyngeal mucous membranes and underlying structures, often due to infection.
• Peak incidence in late fall to early spring.
• Viral pharyngitis more common in young children during winter.
• Group A β-hemolytic streptococcus (GABHS) most prevalent in 5-15 year olds, also peaking in winter.

Pathogenesis (Viral)

• Adenovirus

• Influenza A & B

• Parainfluenza

• Epstein-Barr virus

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

• Enterovirus

• Herpes simplex virus

• Enterovirus and Coxsackie viruses commonly cause herpangina (vesicles and ulcers on anterior pillars).

• Coxsackie virus type 16 (hand, foot, and mouth disease) is associated with: tongue and buccal ulcers, papulovesicular rash on hands and feet, coryza, conjunctivitis, cough, diarrhea (spring, summer, and fall).

Pathogenesis (Bacterial)

• Group A β-hemolytic streptococcus (GAS)
• Group B, C, and G streptococci
• Corynebacterium diphtheriae
• Chlamydia trachomatis
• Neisseria gonorrhoeae
• Mycoplasma pneumoniae
• Other irritants (foreign body, chemical, referred pain)

Pharyngitis: Differential Diagnoses

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

Diagnosis (Viral)

• Gradual onset
• Cough
• Sore throat
• Fever
• Rhinorrhea
• Diarrhea
• Pharyngeal erythema
• Follicular, ulcerative, or exudative lesions

Diagnosis (Bacterial - GABHS or Streptococcal Pharyngitis)

• Rapid onset (incubation 2-4 days)
• Sore throat
• Fever
• Dysphagia
• Beefy-red, swollen pharynx; uvula and tonsils
• Enlarged, exudative tonsils (tonsillar exudate)
• Tender/swollen cervical/tonsillar lymph nodes
• Petechiae on soft palate, strawberry tongue
• Multiple GI symptoms (vomiting)
• Scarlatiniform rash (similar to scarlet fever)

Treatment

• Rapid strep test/throat culture.
• Antibiotics (e.g., amoxicillin) for bacterial infections.
• Increased fluid intake.
• Analgesics (acetaminophen, ibuprofen).
• Return to school after 24 hours of antibiotic treatment.
• Monitor for worsening symptoms (peritonsillar abscess).

Antibiotic Considerations (GABHS)

• Penicillin, ampicillin, amoxicillin, cephalosporins, macrolides, clindamycin are options.
• Avoid sulfonamides and tetracyclines due to high resistance rates.

Analgesics

• Systemic analgesics for moderate to severe pain.
• Acetaminophen, ibuprofen effective in reducing pain, fever, and inflammation.

Follow-up

• Routine re-culturing not always necessary; test of cure may be recommended for some patients.
• Assess for carrier state (common; low transmission risk).

Complications

• Acute rheumatic fever
• Poststreptococcal glomerulonephritis (children under 7 at higher risk).
• Pediatric autoimmune neuropsychiatric disorder associated with streptococcal infection (PANDAS).

Education

• Transmission via respiratory droplets.
• Medication adherence critical.
• Return to school/daycare after 24 hours with antibiotics.
• Separate personal items (toothbrushes, towels, cups) after starting treatment.

Scarlet Fever

• Hypersensitivity reaction to toxin produced by GABHS.
• May follow streptococcal pharyngitis or other streptococcal infections.
• Known as scarlatina.
• Erythemogenic toxin leads to widespread inflammation and vasodilation; characteristic scarlet rash.
• Incubation period: 1-7 days, rash usually appears on day 2.

Tonsillectomy/Adenoidectomy (T&A)

• Surgical removal of tonsils and adenoids.
• Common pediatric procedure.

Indications for T&A

• Frequently recurrent/chronic tonsillitis/adenoiditis (≥7 episodes/year, ≥5/yr for 2 years, or ≥3/yr for 3 years).
• Obstructive sleep apnea
• Peritonsillar abscess/cellulitis (≥1 event).
• Recurrent middle ear infections due to tonsil enlargement.
• Tonsillar obstruction affecting voice.
• Nasal obstruction .

Adenoid Hypertrophy

• Allergic (adenoidal) facial appearance (long face syndrome): Allergies may contribute to adenoid swelling, leading to a tired, droopy appearance.

T&A Procedure

• Preoperative assessment, informed consent.
• Anesthesia/IV access.
• Postoperative nausea and vomiting prevention (e.g., dexamethasone).
• Surgical removal (scissors, curettes, cautery, or harmonic scalpel).
• Bleeding control (e.g., bismuth subgallate, cautery).

T&A Complications

• Bleeding
• Dehydration
• Unresolved airway issues
• Infection
• Pneumonia
• Postoperative airway obstruction
• Laryngospasm/bronchospasm
• Oral mucosa burns
• TMJ issues
• Tongue/nerve numbness
• Remnants/regrowth
• Voice changes
• Nasal regurgitation (Rare)

Preoperative Care

• Explain the procedure to the child and family.
• Assess for active infections.
• Ensure informed consent.
• NPO status according to meal type before surgery.
• Assess for loose teeth.
• Use pain scale.

Postoperative Care

• Maintain airway patency and suction secretions.
• Hydration (after gag reflex returns); avoid straws.
• Pain management.
• Monitor vital signs, hydration, I&O.
• Frequent bleeding checks.
• Respiratory monitoring for stridor/obstruction.
• Monitor drooling, restlessness, agitation.
• Avoid codeine/tramadol post-op.
• Highest bleeding risk 7-10 days after surgery emphasized

Pertussis

• Infection caused by Bordetella pertussis.
• Droplet precautions.
• Significant morbidity in children, especially infants.
• More prevalent during summer and fall months.
• Prevention through dTap or Tdap vaccination (depending on age).

Pertussis Disease Progression

• Catarrhal (flu-like): rhinorrhea, malaise, sneezing, dry cough (may be absent in infants), and mild fever.
• Paroxysmal (rapid coughing): coughing spasms followed by post-tussive emesis, exhaustion, inspiratory whoop, and thick mucus.
• Convalescent (reduced coughing): increased susceptibility to other respiratory infections.