02. Pharyngitis & Tonsillitis

DEFINITION
Tonsillopharyngitis is acute infection of the pharynx or palatine tonsils or both. Symptoms may include sore throat, dysphagia, cervical lymphadenopathy, and fever.

ETIOLOGY AND PATHOPHYSIOLOGY

The tonsils participate in systemic immune surveillance. In addition, local tonsillar defenses include a lining of antigen-processing squamous epithelium that involves B- and T-cell responses. Tonsillopharyngitis is usually viral, most often caused by the common cold viruses (adenovirus, rhinovirus, influenza, coronavirus, respiratory syncytial virus), but occasionally by Epstein-Barr virus, herpes simplex virus, cytomegalovirus, or HIV. In about 30% of cases, the cause is bacterial. Group A β-hemolytic streptococcus (GABHS) is most common  but Staphylococcus aureus, Streptococcus pneumoniae, Mycoplasma pneumoniae, and Chlamydia pneumoniae are sometimes involved. Rare causes include pertussis, Fusobacterium, diphtheria, syphilis, and gonorrhea. Tonsillopharyngitis of all varieties constitutes about 15% of all office visits to primary care physicians. Group A β-hemolytic streptococcus  (GABHS) occurs most commonly between ages 5 and 15 and is uncommon before age 3.

SYMPTOMS
- sore throat
- difficulty swallowing
- fever
- tender, swollen lymph nodes in the neck
- red, raw throat
Additional symptoms that may be associated with this disease:
- neck pain
- nasal discharge
- nasal congestion
- joint stiffness
- headache
- breath odor
SIGNS AND TESTS
- throat swab culture
- streptococcal screen

DIAGNOSIS

Pharyngitis itself is easily recognized clinically. However, its cause is not. Rhinorrhea and cough usually indicate a viral cause. Infectious mononucleosis is suggested by posterior cervical or generalized adenopathy, hepatosplenomegaly, fatigue, and malaise for > 1 wk; a full neck with petechiae of the soft palate; and thick tonsillar exudates. A dirty gray, thick, tough membrane that bleeds if peeled away indicates diphtheria.

Treatment Options      

Treatment Strategy

    Once strong suspicion or positive confirmation that a bacterial infection has caused the   pharyngitis, prescribe appropriate antibiotics. Pharyngitis that stems from a viral cause   has no specific treatment beyond bed rest and simple forms of self-treatment, such as   gargling and aspirin. Advise the patient to get plenty of rest.        

Drug Therapies

    Penicillin VK 250 mg tid, taken orally for 6 to 10 days, remains the drugof choice against   Group A streptococcal pharyngitis, primarily to prevent rheumatic fever. As an alternative,   intravenous penicillin G benzathine, or a first-generation cephalosporin. For patients   allergic to penicillin, erythromycin 300 to 400 mg tid makes a suitable substitute.  Suggest over-the-counter analgesics such as aspirin or an aspirin substitute to relieve the   pain of the sore throat. Take caution in prescribing aspirin for patients under 18. Patients   can relieve discomfort with throat lozenges and by gargling with 1/2 tsp. salt in a glass of   warm water several times daily. A soft or liquid diet including warm broths also helps to   avoid irritating the throat.        

Complementary and Alternative Therapies

    Established strep infection should be treated with antibiotics. Alternative treatments can   be effective in cases of acute, chronic, or recurrent pharyngitis. Begin with nutritional   support at the first sign of a sore throat. Use the tincture and/or the tea throughout the   course of infection. For mild or non-infectious pharyngitis, licorice ( Glycyrrhiza glabra) or   slippery elm (Ulmus fulva) in lozenges or teas to soothe irritation may be all that is   needed.          

Nutrition

      _... Zinc (30 mg/day or lozenges) boosts the immune system and relieves soreness.     _... Vitamin C (1,000 mg tid to qid) is needed, as bowel tolerates, for proper immune   function and to strengthen mucous membranes.     _... Beta-carotene (50,000 to 100,000 IU/day) restores integrity of mucous   membranes and supports immunity.

EXPECTATIONS (PROGNOSIS)
Pharyngitis most often clears up on its own.
COMPLICATIONS
- edema (swelling) of the larynx, a life-threatening condition
- rheumatic fever 

Courtesy:

Compiled and Shared By: Habib Anwar 

habib.anwar@hotmail.com