PHARYNGITIS DR AARYA SERIN

ACUTE PHARYNGITIS

AETIOLOGYOccurs due to varied aetiological factors like viral, bacterial, fungal or othersViral causes are more commonAcute streptococcal pharyngitis (due to Group A beta haemolytic streptococci) has received more importance because of its aetiology in rheumatic fever and post-streptococcal glomerulonephritis.

Viral Bacterial FungalMiscellaneo

us•Rhinoviruses •Influenza •Parainfluenza •Measles and chickenpox •Coxsackie virus •Herpes simplex •Infectious mononucleosis •Cytomegalovirus

•Streptococcus (Group A, beta-haemolyticus) •Diphtheria •Gonococcus

•Candida albicans •Chlamydia trachomatis

•Toxoplasmosis (parasitic, rare)

CLINICAL FEATURES Milder infections present with discomfort in the throat, some malaise and low grade fever.Pharynx in these cases is congested No lymphadenopathy. Moderate and severe infections present with pain in throat, dysphagia, headache, malaise and high fever. Pharynx in these cases shows erythema, exudate and enlargement of tonsils and lymphoid follicles on the posterior pharyngeal wall.

Very severe cases show oedema of soft palate and uvula with enlargement of cervical nodes.

DIAGNOSISCulture of throat swab is helpful in the diagnosis of bacterial pharyngitis. It can detect 90% of Group A Streptococci. Diphtheria is cultured on special media. Swab from a suspected case of gonococcal pharyngitis should be cultured immediately without delay.

Failure to get any bacterial growth suggests a viral aetiology.

TREATMENT General measures Bed rest, plenty of fluids, warm saline gargles or pharyngeal irrigations and analgesics form the mainstay of treatment. Local discomfort in the throat in severe cases can be relieved by lignocaine viscous before meals to facilitate swallowing.

Specific treatment Streptococcal pharyngitis (Group A, beta-haemolyticus) is treated with Penicillin G, 200,000 to 250,000 units orally four times a day for 10 days or

benzathine penicillin G, 600,000 units once i.m. for patient <60 lb in weight and 1.2 million units once i.m. for patient >60 lb.

In penicillin-sensitive individuals, erythromycin, 20 to 40 mg/kg body weight daily, in divided oral doses for 10 days is equally effective.

Diphtheria is treated by diphtheria antitoxin and administration of penicillin or erythromycin Gonococcal pharyngitis responds to conventional doses of penicillin or tetracycline

VIRAL INFECTIONS CAUSING PHARYNGITIS

Herpangina It is caused by Group A coxsackie virus and mostly affects children. Characteristic features include fever, sore throat and vesicular eruption on the soft palate and pillars. Vesicles are small and surrounded by a zone of erythema. Infectious mononucleosis It is caused by Epstein-Barr virus. It is characterised by fever, sore throat, exudative pharyngitis, lymphadenopathy, splenomegaly and hepatitis.

Cytomegalovirus It mostly affects immunosuppressed transplant patients. It mimics infectious mononucleosis but heterophil antibody test is negative. Pharyngoconjunctival fever It is caused by an adenovirus It is characterised by sore throat, fever and conjunctivitis. There may be pain in abdomen, mimicking appendicitis.

Acute lymphonodular pharyngitis It is usually caused by a coxsackie virus It is characterised by fever, malaise and sore throat. White-yellow, solid nodules appear on the posterior pharyngeal wall in this type of pharyngitis. Measles and chickenpox also cause pharyngitis Measles is characterised by the appearance of Koplik's spots (white spots surrounded by red areola) on the buccal mucosa opposite the molar teeth. The spots appear 3-4 days before the appearance of rash.

FUNGAL PHARYNGITIS Candida infection of the oropharynx can occur as an extension of oral thrush. It is seen in patients who are immunosuppressed, debilitated or taking high doses of antimicrobials. Nystatin is the drug of choice.

MISCELLANEOUS CAUSES OF PHARYNGITIS Chlamydia trachomatis infection causes acute pharyngitis and can be treated by erythromycin or sulphonamides. Toxoplasmosis is caused by Toxoplasma gondii, an obligate intracellular parasite.

CHRONIC PHARYNGITIS

It is a chronic inflammatory condition of the pharynx. Pathologically, it is characterised by hypertrophy of mucosa, seromucinous glands, subepithelial lymphoid follicles and even the muscular coat of the pharynx. Chronic pharyngitis is of two types: 1. Chronic catarrhal pharyngitis 2. Chronic hypertrophic (granular) pharyngitis.

AETIOLOGY 1. Persistent infection in the neighbourhood In chronic rhinitis and sinusitis, purulent discharge constantly trickles down the pharynx and provides a constant source of infection. This causes hypertrophy of the lateral pharyngeal bands.

2. Mouth breathing Breathing through the mouth exposes the pharynx to air which has not been filtered, humidified and adjusted to body temperature thus making it more susceptible to infections.

Mouth breathing is due to: (i) Obstruction in the nose (ii) Obstruction in the nasopharynx (iii) Protruding teeth which prevent apposition of lips, (iv) Habitual, without any organic cause.

3. Chronic irritants Excessive smoking, chewing of tobacco and pan, heavy drinking, highly spiced food 4. Environmental pollution Smoky or dusty environment or irritant industrial fumes 5. Faulty voice production Excessive use of voice or faulty voice production seen in certain professionals or in "pharyngeal neurosis" where person resorts to constant throat clearing, hawking or snorting, and that may cause chronic pharyngitis, especially of hypertrophic variety.

SYMPTOMS 1. Discomfort or pain in the throat This is especially noticed in the mornings. 2. Foreign body sensation in throat Patient has a constant desire to swallow or clear his throat to get rid of this "foreign body". 3. Tiredness of voice Patient cannot speak for long and has to make undue effort to speak as throat starts aching. The voice may also lose its quality and may even crack. 4. Cough Throat is irritable and there is tendency to cough. Mere opening of the mouth may induce retching or gagging.

SIGNSChronic catarrhal pharyngitis •congestion of posterior pharyngeal wall with engorgement of vessels; faucial pillars may be thickened•increased mucus secretion which may cover pharyngeal mucosa. Chronic hypertrophic (granular) pharyngitis •Pharyngeal wall appears thick and oedematous with congested mucosa and dilated vessels. •Posterior pharyngeal wall may be studded with reddish nodules. These nodules are due to hypertrophy of subepithelial lymphoid follicles normally seen in pharynx•Lateral pharyngeal bands become hypertrophied. •Uvula may be elongated and appear oedematous

GRANULAR PHARYNGITIS. NOTE: REDDISH NODULES ON THE POSTERIOR PHARYNGEAL WALL

TREATMENT 1. In every case of chronic pharyngitis, aetiological factor should be sought and eradicated. 2. Voice rest and speech therapy is essential for those with faulty voice production. Hawking, clearing the throat frequently or any other such habit should be stopped. 3. Warm saline gargles, especially in the morning, are soothing and relieve discomfort. 4. Mandl's paint may be applied to pharyngeal mucosa. 5. Cautery of lymphoid granules is suggested. Throat is sprayed with local anaesthetic and granules are touched with 10-25% silver nitrate.

ATROPHIC PHARYNGITIS

It is a form of chronic pharyngitis often seen in patients of atrophic rhinitis. Pharyngeal mucosa along with its mucous glands shows atrophy. Scanty mucus production by glands leads to formation of crusts which later get infected giving rise to foul smell. Clinical Features Dryness and discomfort in throat are the main complaints. Hawking and dry cough may be present due to crust formation. Examination shows dry and glazed pharyngeal mucosa often covered with crusts.

TREATMENT Aim is to remove the crusts and promote secretion. The crusts can be removed by spraying the throat with alkaline solution, or pharyngeal irrigation. Mandl's paint applied locally has a soothing effect. Potassium iodide, 325 mg, administered orally for a few days helps to promote secretion and prevents crusting.

KERATOSIS PHARYNGITIS It is a benign condition characterised by horny

excrescences on the surface of tonsils, pharyngeal wall or lingual tonsils appearing as white or yellowish dots. These excrescences are the result of hypertrophy and keratinisation of epithelium. They are firmly adherent and cannot be wiped off. The disease may show spontaneous regression and does not require any specific treatment except for reassurance to the patient.