Pharyngitis and Laryngitis

Key Points

1.
Infections are the most common cause of pharyngitis. Viral infections are more common than bacterial, with 50% to 60% of cases caused by common viruses.
2.
The AAO-HNS Clinical Practice Guideline for Tonsillectomy in Children from 2018 strongly recommends watchful waiting for recurrent throat infections if there have been <7 episodes in the past year, <5 episodes per year in the past 2 years, or <3 episodes per year in the past 3 years.
3.
Group A streptococcal pharyngitis should be treated with antibiotics to prevent potential complications of rheumatic fever. Treatment should be initiated within 10 days of symptoms.
4.
Any patient with chronic laryngitis for over 2 weeks, those with worrisome symptoms, or those with a high risk history of cancer should be evaluated by an otolaryngologist to rule out the presence of other causes of symptoms, including malignancy.

Pearls

1.
Pediatric autoimmune neuropsychiatric disorder associated with streptococcal infection (PANDAS) is a self-limited condition associated with increased tics and obsessive mannerisms that correlate with elevated ASO titers.
2.
Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) is a condition characterized by high fever that lasts 3 to 7 days and recurs every 3 to 6 weeks. The cause of PFAPA is unknown but it is thought to be either immune related or infectious.
3.
The majority of patients who receive amoxicillin to treat infectious mononucleosis will develop a diffuse rash due to hypersensitivity. This is often confused with penicillin allergy.

Questions

1 What is pharyngitis?

Pharyngitis, simply stated, is inflammation of the pharyngeal mucosa and submucosa. Classically, a clinical diagnosis of pharyngitis includes inflammation of the tonsils. This is often referred to as pharyngotonsillitis.

2 What is laryngitis?

Laryngitis is acute or chronic inflammation of the laryngeal mucosa.

3 Why are these conditions important?

“Sore throat” is one of the most common chief complaints seen in the primary care setting. Acute or chronic inflammation of the pharynx, tonsils, and/or larynx leads to difficulty in phonation, swallowing, and breathing. This inflammation is often associated with significant discomfort, and certain conditions can lead to acute upper airway compromise. Pharyngitis and tonsillitis account for over 14 million visits per year to clinics, urgent care centers, and emergency departments. The economic burden of these conditions in the United States has been estimated to be over $1.2 billion. Half of this cost could be saved by adherence to current clinical guidelines and avoidance of overprescribing antibiotics.

4 What is the most common cause of pharyngitis?

Infections are the most common cause of pharyngitis. Viral infections are more common than bacterial infections, with 50% to 60% of cases caused by common viruses. Viral causes include rhinovirus, coronavirus, adenovirus (associated with conjunctivitis), herpes simplex virus, Epstein-Barr virus (EBV), coxsackievirus, HIV, and cytomegalovirus. Typically, viral infections have a less severe course with lower fever and symptoms of an upper respiratory infection (cough, runny nose, and sneezing). The majority of bacterial cases are caused by group A streptococcus (10% of all adult cases of pharyngitis and 30% of cases in children). Other bacterial causes include syphilis, pertussis, gonorrhea, diphtheria, and Fusobacterium . Fungal pharyngitis, typically caused by Candida albicans , is uncommon, except in select populations such as immunocompetent infants and the immunocomprised.

Other causes of pharyngitis include postnasal drip, irritants (smoking, dust, dry heat, chemicals), laryngopharyngeal reflux, chronic mouth breathing, voice abuse, granulomatous diseases, chronic allergies, and connective tissue disorders. Malignancy should be a part of the differential diagnosis of atypical presentations or courses of pharyngitis.

5 How does one diagnose group A streptococcal (GAS) pharyngitis? What is the treatment of this infection?

The symptoms of GAS pharyngitis include high fever, headache, palatal/tonsillar petechiae, exudative tonsillitis, and tender cervical lymphadenopathy. Cough and rhinorrhea are not usually observed. However, clinical features alone do not readily distinguish between GAS pharyngitis and viral pharyngitis. Swabbing the throat to test for GAS pharyngitis with a rapid antigen detection test (RADT) and/or culture should be performed for diagnosis. A negative RADT should be followed with a culture in children, given that the sensitivity of the test can be as low as 70%. It is over 95% specific; thus a positive test should not be followed by a culture. It is not recommended that a negative test in adults be followed routinely by a culture due to the low incidence of GAS pharyngitis in adults and the low risk of developing rheumatic fever. Children under the age of 3 years are routinely not tested unless they have an older sibling with GAS pharyngitis because the risk of GAS infection and rheumatic fever is very low in this population.

GAS pharyngitis should be treated with antibiotics to prevent the potential complications of rheumatic fever. Treatment should be initiated within 10 days of symptom onset. Other benefits of treatment include a shorter duration of symptoms and cessation of contagious status after 24 hours of treatment.

Oral penicillin or amoxicillin for 10 days is the recommended treatment for GAS pharyngitis. Alternatively, a single dose of intramuscular benzathine penicillin G may be administered. For patients with a penicillin allergy, treatment with an oral cephalosporin, a macrolide, or clindamycin is indicated. The treatment duration should be 10 days, unless azithromycin is used. The treatment course for azithromycin is only 5 days.

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