Acute pharyngitis, chronic pharyngitis, Chronic catarrhal pharyngitis, Chronic hypertrophic (granular) pharyngitis, Pakistan ,

1. Pharyngitis
BRIG ANWAR UL HAQ
ENT Specialist
CMH Lahore
03018513303

2. 2
Acute pharyngitis
Definition*:
Acute inflammation of pharyngeal mucosa and submucosa,
mostly involved in pharyngeal lymphoid tissue.

3. Pharyngitis
• Inflammation of the pharynx
secondary to an infectious
agent
• Most common infectious
agents are group A
streptococcus and various
viral agents
• Often co-exists with tonsillitis

4. Etiology
• Strep.A
• Mycoplasma
• Strep.G
• Strep.C
• Corynebacterium diphteriae
• Toxoplasmosis
• Gonorrhea
• Tularemia
• Rhinovirus
• Coronavirus
• Adenovirus
• Cmv
• Ebv
• Hsv
• Enterovirus
• Hiv

5. Acute pharyngitis
•Etiology
• Viral >90%
• Rhinovirus – common cold
• Coronavirus – common cold
• Adenovirus – pharyngoconjunctival fever;acute respiratory illness
• Parainfluenza virus – common cold; croup
• Coxsackievirus - herpangina
• EBV – infectious mononucleosis
• Hiv

6. Acute pharyngitis
•Etiology
•Bacterial
• Group A beta-hemolytic streptococci (S. Pyogenes)*
• Most common bacterial cause of pharyngitis
• Accounts for 15-30% of cases in children and 5-10% in adults.
• Mycoplasma pneumoniae
• Arcanobacterium haemolyticum
• Neisseria gonorrhea
• Chlamydia pneumoniae

7. Pharyngitis
•History
•Classic symptoms → fever, throat pain, dysphagia
VIRAL → most likely concurrent URI symptoms of
rhinorrhea, cough, hoarseness, conjunctivitis & ulcerative
lesions
STREP → look for associated headache, and/or abdominal
pain
Fever and throat pain are usually acute in onset

8. Clinical features
• Different grades of severity.
• Milder infections (symptoms)
• Discomfort in the throat
• Malaise
• Low grade fever.
• Milder infections (signs)
• Congested
• No lymphadenopathy.

9. Clinical features
• Moderate and severe pharyngitis (symptoms)
• Pain in throat
• Dysphagia
• Headache
• Malaise
• High fever.
• Moderate and severe pharyngitis (signs)
• Erythema
• Exudate
• Enlargement of tonsils
• Lymphoid follicles on the posterior pharyngeal wall
• Oedema of soft palate and uvula
• Enlargement of cervical nodes.

10. Clinical features
• Not possible on clinical examination to differentiate
• Viral from bacterial infections
• Viral infections
• Generally mild and are accompanied by
• Rhinorrhea
• Hoarseness
• Bacterial - Severe.
• Gonococcal Pharyngitis
• Mild and may even be asymptomatic

11. Pharyngitis
• Viral
EBV –
white exudate covering erythematous pharynx and tonsils
cervical adenopathy,
Subacute/chronic symptoms (fatigue/myalgias)
 Transmitted via infected saliva
Adenovirus/coxsackie –
Vesicles/ulcerative lesions present on pharynx or posterior soft palate
Also look for conjunctivitis

12. Epidemiology of streptococcal pharyngitis
• Spread by contact with respiratory secretions
• Peaks in winter and spring
• School age child (5-15 y)
• Communicability highest during acute infection
• Patient no longer contagious after 24 hours of
antibiotics
• If hospitalized, droplet precautions needed until no
longer contagious

13. Pharyngitis
• Physical exam
• Bacterial
GAS – look for whitish exudate covering pharynx and tonsils
• Tender anterior cervical adenopathy
• Palatal/uvular petechiae
Spread via respiratory particle droplets – NO school attendance
until 24 hours after initiation of appropriate antibiotic therapy
• Absence of viral symptoms (rhinorrhea, cough,
hoarseness)

14. Suppurative complications of group A
streptococcal pharyngitis
• Otitis media
• Sinusitis
• Peritonsillar and retropharyngeal abscesses
• Suppurative cervical adenitis

15. Nonsuppurative complications of group A
streptococcus
• Acute rheumatic fever
• Follows only streptococcal pharyngitis (not group A strep skin
infections)
• Acute glomerulonephritis
• May follow pharyngitis or skin infection (pyoderma)
• Nephritogenic strains

16. Pharyngitis

17. Pharyngitis

18. Pharyngitis

19. Pharyngitis

20. Clinical manifestation
(strep.)
• Rapid onset
• Headache
• GI symptoms
• Sore throat
• Erythma
• Exudates
• Palatine petechiae
• Enlarged tonsils
• Anterior cervical adenopathy
&tender
• Red& swollen uvula

21. Clinical manifestation
(viral)
• Gradual onset
• Rhinorrhea
• Cough
• Diarrhea
• Fever

23. Diagnosis
• Strep:
Throat culture(gold stndard)
Rapid strep. Antigen kits
• Infectious mono.:
Cbc(atypical lymphocytes)
Spot test (positive slide agglutination)
• Mycoplasma:
Cold agglutination test

24. Treatment
(antibiotic ,acetaminophen ,warm salt gargling)
• Strep: penicillin, erythromycin, azithromycin
• Carrier of strep:
Clindamycin, amoxicillin clavulanic
• Retropharyngeal abscesses:
Drainage + antibiotics
• Peritonsilar abscesses:
Penicillin + aspiration

25. Pharyngitis
• Treatment
VIRAL – supportive care only – analgesics, antipyretics,
fluids
No strong evidence supporting use of oral or
intramuscular corticosteroids for pain relief → few
studies show transient relief within first 12–24 hrs after
administration
EBV – infectious mononucleosis
Activity restrictions – mortality in these pts most commonly
associated with abdominal trauma and splenic rupture

26. Pharyngitis
•Treatment → do so to prevent ARF (acute rheumatic fever)
Gas →
Oral penicillin– treatment of choice
10 day course of therapy
Im benzathine penicillin – 1.2 million units x 1
Azithromycin, clindamycin, or 1st generation cephalosporins -
allergy

27. Group A beta hemolytic streptococcus

29. Chronic pharyngitis
• Pathologically
• Characterised by hypertrophy of
• Mucosa
• Seromucinous glands
• Subepithelial lymphoid follicles
• Muscular coat of the pharynx.

30. Types of chronic pharyngitis
• 1. Chronic catarrhal pharyngitis
• 2. Chronic hypertrophic (granular) pharyngitis.

31. Aetiology
• A large number of factors are responsible:
1. Persistent infection in the neighbourhood
• Ch ronic rhinitis
• Sinusitis
• Purulent discharge
• Constantly trickles down the pharynx and
• Provides a constant source of infection.
• Causes hypertrophy of the lateral pharyngeal bands.
2. Chronic tonsillitis
3. Dental sepsis
4. Mouth breathing

32. Aetiology
5. Breathing through the mouth
• Neither filtered
• Nor humidified
• Obstruction in the nose
• Nasal polypi
• Allergic rhinitis
• Vasomotor rhinitis
• Turbinate hypertrophy
• Deviated septum
• Tumours
6. Nsopharyngeal causes
• Adenoids
• Tumours
7. Habitual
• Without any organic cause.

33. Aetiology
8. Chronic irritants.
• Excessive smoking
• Chewing oftobacco and pan
• Heavy drinking,
• Highly spiced food
9. Environmental pollution
• Smoky
• dusty environment
• Irritant industrial
10. Faulty voice production
• Excessive use of voice
• Faulty voice production seen in certain professionals or in
• "Pharyngeal neurosis”
• Throat clearing
• Hawking
• Snorting

34. Symptoms
• 1. Discomfort or pain in the throat.
• 2. Foreign body sensation in throat.
• 3. Tiredness of voice.
• 4. Cough.
• Throat is irritable
• Tendency to cough
• 5. Retching or gagging.

35. Signs
• Chronic catarrhal pharyngitis
• Congestion of posterior pharyngeal wall with
• Engorgement of vessels
• Faucial pillars may be thickened.
• Increased mucus secretion which may cover pharyngeal mucosa.

36. Signs
• Chronic hypertrophic (granular) pharyngitis
• Pharyngeal wall appears thick
• Pharyngeal wall oedematous
• Congested mucosa
• Dilated vessels.
• Posterior pharyngeal wall may be studded with reddish nodules (hence the
term granular pharyngitis).
• These nodules are due to hypertrophy of subepithelial lymphoid foll icles
normally seen in pharynx
• Lateral pharyngeal bands become hypertrophied.
• Uvula may be elongated and appear oedematous.

37. Treatment
• Aetiological factor should be sought and eradicated
• Voice rest
• Speech therapy is essential for those with
• Faulty voice production. Hawking, clearing the throat
• Frequently or any other such habit should be stopped.
• 3warm saline gargles.
• 4. Mandl's paint
• 5. Cautery of lymphoid granules
• 10-25% silver nitrate.
• Electrocautery or

38. Atrophic pharyngitis
• It is a form of chronic pharyngitis often seen in patients of atrophic
rhinitis.
• Pharyngeal mucosa along with its mucous glands shows atropl1y.
• 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.
• Hawki ng and dry cough may be present due to crust formation.
• Examination shows dry and glazed pharyngeal mucosa often
covered with crusts.

39. Atrophic pharyngitis
Treatment
• This is the same as for co-existent atrophic rhinitis.
• Aim is to remove the crusts and promote secretion.
• The crusts can be removed by spraying the throat with alkaline
solution ,pharyngeal irrigation.
• Mandl's paint applied locally has a soothing effect.
• Potassium iodide, 325 mg

40. Keratosis Pharyngitis
• Benign condition characterized by horny excrescences on the
• Surface of tonsils
• Pharyngeal wall
• Lingual tonsils
• Appearing as white or yellowish dots.
• These excrescences are the result of
• Hypertrophy
• Keratinisation of epithelium.
• They are firmly adherent and cannot be wiped off.

41. Keratosis pharyngitis
• No accompanying inflammation
• Constitutiona l symptoms thus
• Differential diagnosis
• Acute follicular tonsillitis.
• Spontaneous regression
• Does not require any specific treatment
• Reassurance to the patient.