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You are in: eMedicine Specialties > Emergency Medicine > Ear, Nose, And Throat

Pharyngitis
Last Updated: April 21, 2005

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AUTHOR INFORMATION

Section

Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Bibliography

Author: A Antoine Kazzi, MD, Chief of Service, Department of Emergency Medicine, Medical Direct
Emergency Unit, American University of Beirut
Coauthor(s): Jeannine Wills, MD, Staff Physician, University of California at Irvine College of Medic
A Antoine Kazzi, MD, is a member of the following medical societies: American Academy of Emerge
American Medical Association, California Medical Association, and Society for Academic Emergency
Editor(s): Jerry Balentine, DO, Professor of Emergency Medicine, New York College of Osteopathic
Medical Director, Saint Barnabas Hospital; Francisco Talavera, PharmD, PhD, Senior Pharmacy E
Mark W Fourre, MD, Program Director, Department of Emergency Medicine, Maine Medical Center
Professor, Department of Surgery, University of Vermont School of Medicine; John Halamka, MD, C
Officer, CareGroup Healthcare System, Assistant Professor of Medicine, Department of Emergency
Israel Deaconess Medical Center; Assistant Professor of Medicine, Harvard Medical School; and Wi
MD, Program Director, Internship Training, Associate Professor, Department of Emergency Medicine
Southern California
Disclosure

INTRODUCTION

Section 2 of

Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Bibliography

Background: Pharyngitis is defined as an infection or irritation of the pharynx and/or tonsils. The eti
infectious, with 40-60% of cases being of viral origin and 5-40% of cases being of bacterial origin. Ot
allergy, trauma, toxins, and neoplasia.

The main ED concerns with pharyngitis are to rule out more serious conditions, such as epiglottitis o
abscess, and to diagnose group A beta-hemolytic streptococcal (GABHS) infections. GABHS infectio
sequelae and represent approximately 15% of all ED pharyngitis visits.

Pathophysiology: In infectious pharyngitis, bacteria or viruses may directly invade the pharyngeal m
local inflammatory response. Other viruses, such as rhinovirus, cause irritation of pharyngeal mucos
nasal secretion.

Streptococcal infections are characterized by local invasion and release of extracellular toxins and p
addition, M protein fragments of certain serotypes of GABHS are similar to myocardial sarcolemma a
linked to rheumatic fever and subsequent heart valve damage. Acute glomerulonephritis may result f
antigen complex deposition in glomeruli.
Frequency:

In the US: It has been estimated that children in the US experience over 5 upper respiratory i
year and an average of one streptococcal infection every 4 years. The occurrence in adults is
rate. The most significant bacterial agent causing pharyngitis in both adults and children is GA
(Streptococcus pyogenes), and the most significant viruses are rhinovirus and adenovirus. GA
prevalent in late fall through early spring.

Internationally: The incidence is higher internationally. Antibiotic resistance may be more pre
countries because of overprescription of antibiotics. In Japan, a 60% resistance rate to erythro

Mortality/Morbidity:

One in 400 cases of untreated GABHS infections can be expected to result in acute rheumati

Other sequelae of a streptococcal pharyngitis include acute glomerulonephritis, peritonsillar a

shock syndrome.

Mortality from pharyngitis is rare but may result from one of its complications. For the ED phys
obstruction is a concern.

Age: Pharyngitis occurs with much greater frequency in the pediatric population. GABHS also is mo

school-aged children. GABHS causes 15% of all adult pharyngitis and about 30% of pediatric cases.

The peak incidence of bacterial and viral pharyngitis occurs in the school-aged child aged 4-7

Pharyngitis, especially GABHS infection, is rare in children younger than 3 years.

Mycoplasma pneumoniae, Chlamydia pneumoniae, and Arcanobacterium haemolyticus peak

in people in the teen years through the young adulthood years.

CLINICAL

Section 3 of

Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Bibliography

History: A clinical diagnosis of GABHS infection results in an overestimation of incidence by as muc

bacterial and viral cases of pharyngitis can be indistinguishable on clinical grounds. However, the cla
are described below.

GABHS infection most commonly occurs in those aged 4-7 years.

Sudden onset is consistent with a GABHS pharyngitis. Pharyngitis following several days of c
rhinorrhea is more consistent with a viral etiology.

Person recently has been in contact with others diagnosed with GABHS or rheumatic fever.

Headache is consistent with GABHS or mycoplasma infection.

Cough is not usually associated with GABHS infection.

Vomiting is associated with GABHS infection but may be present in other types of pharyngitis

A history of recent orogenital contact suggests the possibility of gonococcal pharyngitis.

o

A history of rheumatic fever is important when considering treatment.

Physical:

Airway patency must be addressed first.

Temperature

Fever is usually absent or low-grade in viral pharyngitis, but this is not specific enough
and bacterial etiologies.

Fever can be as high as 106F with coxsackievirus A, coxsackievirus B, herpes simple

HIV-1, infectious mononucleosis, and cytomegalovirus (CMV).

Hydration status: Oral intake usually is compromised because of odynophagia; therefore, vari
dehydration result.

HEENT
o

Conjunctivitis may be seen in association with adenovirus.

Scleral icterus may be seen with infectious mononucleosis.

Rhinorrhea usually is associated with a viral cause.

Tonsillopharyngeal/palatal petechiae are seen in GABHS infections and infectious mon

A tonsillopharyngeal exudate may be seen in streptococcal infectious mononucleosis a

M pneumoniae, C pneumoniae, A haemolyticus, adenovirus, and herpesvirus infection
exudate does not differentiate viral and bacterial causes.

Oropharyngeal vesicular lesions are seen in coxsackievirus and herpesvirus. Concomi

hands and feet are associated with coxsackievirus (hand-foot-and-mouth disease).

Lymphadenopathy: Tender anterior cervical nodes are consistent with streptococcal infection,
adenopathy is consistent with infectious mononucleosis or the acute lymphoglandular syndrom

Cardiovascular: Murmurs should be documented in an acute episode of pharyngitis to monito

rheumatic fever.

Pulmonary: Pharyngitis and lower respiratory tract infections are more consistent with M pneu
pneumoniae, particularly when a persistent nonproductive cough is present.

Abdomen: Hepatosplenomegaly can be found in infectious mononucleosis infection.

Skin

Causes:

A sandpapery scarlatiniform rash is seen in GABHS infection (see Scarlet Fever).

Maculopapular rashes are seen with various viral infections and with infectious mononu
treated with penicillin.

Bacterial pharyngitis
o

Group A beta-hemolytic streptococci (15% of all pharyngitis)

The classic clinical picture includes a fever of greater than 101.5F, tonsillophary
exudate, swollen tender anterior cervical adenopathy, elevated WBC count, hea
children, palatal petechiae, midwinter to early spring season, and absent cough
are associated with viral pharyngitis.
A scarlatiniform rash also is associated with GABHS infection (scarlet fever), ie,
erythematous rash over the trunk and extremities with circumoral pallor and a st

Group C, G, and F streptococci (10%) may be indistinguishable clinically from GABHS

cause the immunologic sequelae of GABHS infection. They may be associated with foo
Group C streptococci have been reported to cause meningitis, endocarditis, and subdu

Arcanobacterium (Corynebacterium) haemolyticus (5%) is more common in young adu

similar to GABHS infection, including a similar scarlatiniform rash. Patients often have
outbreaks have been reported.

Mycoplasma pneumoniae in young adults presents with headache, pharyngitis, and low
symptoms. Approximately 75% of patients have a cough, which is distinctive from GAB

Chlamydia pneumoniae (5%) has a clinical picture similar to that of M pneumoniae. Ph

precedes the pulmonary infection by about 1-3 weeks.

Neisseria gonorrhoeae is a rare cause of pharyngitis. A careful history is important sinc

follows orogenital contact. It may be associated with severe systemic infection.

Corynebacterium diphtheriae is rare in the United States. A foul smelling gray-white ph

may result in airway obstruction.

Unusual bacteria that could present with pharyngitis include Borrelia species, Francise
Yersinia species, and Corynebacterium ulcerans.

Viral pharyngitis
o

Adenovirus (5%): The distinguishing feature of an adenovirus infection is conjunctivitis

pharyngitis (pharyngoconjunctival fever). It is the most common etiology in children you

Herpes simplex (< 5%): Vesicular lesions (herpangina), especially in young children, ar
older patients, pharyngitis may be indistinguishable from GABHS infection.

Coxsackieviruses A and B (< 5%): These infections present similarly to herpes simplex
vesicles. If vesicles are whitish and nodular, it is known as lymphonodular pharyngitis.
cause hand-foot-and-mouth disease, which presents with 4- to 8-mm oropharyngeal ul
the hands and feet, and, occasionally, on the buttocks. The oropharyngeal ulcers and v

within one week.

Epstein-Barr virus (EBV): Clinically known as infectious mononucleosis, it is extremely

distinguish from GABHS infection. Exudative pharyngitis is prominent. Distinctive featu
retrocervical or generalized adenopathy and hepatosplenomegaly. Atypical lymphocyte
peripheral blood smear. Viral cultures from washings are about 20% sensitive in adults

CMV: Presentation of CMV is similar to the presentation of infectious mononucleosis. P

older, are sexually active, and have higher fever and more malaise. Pharyngitis may no
complaint.

HIV-1: This is associated with pharyngeal edema and erythema, common aphthous ulc
exudates. Fever, myalgia, and lymphadenopathy also are found.

Other causes of pharyngitis

o Oral thrush is due to candidal species, usually in patients who are immunocompromise
common in young children and presents with whitish plaques in the oropharynx.
o Other causes include dry air, allergy/postnasal drip, chemical injury, gastroesophageal
(GERD), smoking, neoplasia, and endotracheal intubation.
DIFFERENTIALS

Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Bibliography

Candidiasis
Diphtheria
Epiglottitis, Adult
Gonorrhea
Herpes Simplex
Mononucleosis
Pediatrics, Croup or Laryngotracheobronchitis
Pediatrics, Epiglottitis
Pediatrics, Hand-Foot-and-Mouth Disease
Pediatrics, Pharyngitis
Pediatrics, Scarlet Fever
Peritonsillar Abscess
Pharyngitis
Pneumonia, Mycoplasma
Retropharyngeal Abscess
Rheumatic Fever
Other Problems to be Considered:
Allergic rhinitis with postnasal drip
Airway obstruction

Section 4 of

Head and neck neoplasias

Gastroesophageal reflux disease (GERD)
Peritonsillar cellulitis

WORKUP
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Bibliography

Lab Studies:

GABHS rapid antigen detection test

o

This is the preferred method for diagnosing GABHS infection in the ED because of diffi

A throat swab should follow a negative result.

Rapid antigen detection is not sensitive for Group C and G streptococci or other bacter

Throat culture
o

This is the criterion standard for diagnosis of GABHS infection (90-99% sensitive).

Positive cultures are clinically important only in patients with a related clinical illness les

Antistreptolysin-O (ASO) is a highly sensitive test but it is not practical in the ED because of th

Mono spot is up to 95% sensitive in children (less than 60% sensitivity in infants).

Peripheral smear may show atypical lymphocytes in infectious mononucleosis.

Perform gonococcal culture, as indicated by history.

Routine labs usually are not available for A hemolyticus, M pneumoniae, or C pneumoniae.

Fluorescent monoclonal antibody test exists for C pneumoniae.

A complete blood count (CBC), erythrocyte sedimentation rate (ESR), and C-reactive protein
indicated.

Imaging Studies:

Imaging studies generally are not indicated for uncomplicated viral or streptococcal pharyngiti

Lateral neck film should be taken in patients with suspected epiglottitis or airway compromise

A chest x-ray can elucidate pneumonia in M pneumoniae or C pneumoniae infection or in othe

Procedures:

The procedure for a throat swab is to vigorously rub a dry swab over the posterior pharynx an

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