Say Ahh: Acute Pharyngitis Diagnosis and Management

Jenna Herman, DNP, APRN, FNP-BC
Tuesday December 26, 2017

Upper respiratory infections (URIs) occur annually an average of 6 to 8 times for children and 2 to 4 times for adults. Acute sore throat, or pharyngitis, is a frequent presenting problem for clinicians as part of a URI or other condition.1 In 1 year, about 40% of children and 15% of adults recounted an episode of sickness with pharyngitis.2 These symptoms represent the 11th most prevalent reason to seek outpatient health care,3 or 1% to 2% of all visits.4,5 Nearly 10 million visits for children and more than 5 million visits for adults are made to clinics, urgent care centers, and emergency departments yearly for pharyngitis.2 The direct costs total nearly $1.2 billion annually.

Multiple structures in the mouth and pharynx are susceptible to inflammation, which can contribute to pain. A primary cause of this inflammation can be infection of the posterior oral pharynx lining. Pharyngitis is often produced through the grouping of 3 common signs and symptoms: fever, inflammation of the pharynx, and sore throat.1 Although these symptoms are easily recognizable, the precise mechanism behind them is not fully understood.2 Additional complexities develop because of the straightforward pharyngitis presentation, resulting in many variations in both practice and care guidelines.1 The root of this debate related to pharyngitis revolves around group A beta-hemolytic Streptococcus (GABHS), also known as strep throat.

ETIOLOGY/TRANSMISSION 

Acute pharyngitis is often triggered through development of inflammation in the pharynx, nasopharynx, and tonsillary area7 or the adjacent lymphoid tissue.4 Most pharyngitis cases are caused by viruses that may transpire because of the common cold1,3,7,8 and are often self-limited.2 One study estimated that the total causation may be as high as 80% to 90%,6 but contrasting studies provide a more realistic estimation that about half of all pharyngitis cases are viral.2,3,8 

The predominant viral cause is adenovirus, cited in about 10% to 25% of cases. Additional frequent sources consist of parainfluenza virus, enterovirus, rhinovirus, respiratory syncytial virus (RSV), human bocavirus, coronaviruses, and influenza A and B. Human herpes viruses, such as the human cytomegalovirus, Epstein-Barr virus, and herpes simplex virus, may also cause pharyngitis.2,3,5,8

In addition to organisms of viral origin, bacterial organisms can be causative agents of pharyngitis.4 Groups C and G streptococci are naturally occurring organisms in the oral cavity but may cause pharyngitis. Less common microbials include the gram-negative Fusobacterium necrophorum, N gonorrhoeae, atypical Mycoplasma pneumoniae and Chlamydia pneumonia,2,7 fungal pathogens, and diphtheria.1,8 The most well-known bacterial pathogen is Streptococcus pyogenes, which causes GABHS.2,7  

GABHS commonly afflicts both children and adolescents aged 5 to 15 years.1,3,8 Peak incidence is in winter and early spring.7 GABHS accounts for about 20% to 30% of pharyngitis cases in children and 5% to 15% in adults.1,9 The bacteria are spread by respiratory secretions,2 and GABHS symptoms arise after a brief incubation period of 2 to 4 days.8 However, asymptomatic carriers exist who will not develop infection, with numbers averaging 10% of the general population.

CLINICAL PRESENTATION 


Acute pharyngitis may present with myriad symptoms, but common identifiers are a triad of fever, sore throat, and inflammation of the pharynx with edema and erythema. Sometimes vesicles, ulcerations, or exudates may also occur.2,8 Pharyngitis itself is a symptom and is not always produced by a pathogen resulting in infection. By contrast, pathogens may be discovered in the oral cavity in asymptomatic individuals.

Typically, acute pharyngitis persists for 3 to 5 days. If symptoms continue beyond that characteristic time frame, the scope of differential diagnoses should be expanded. The oral cavity should be carefully checked for the presence of swelling, erythema, and exudates, in addition to symmetry. Thorough examination of the neck is also necessary to check for masses, tender or sensitive lymph nodes, and range of motion.

If viral pathogens are the cause of pharyngitis, patients will probably have temporal symptoms, such as a cough, conjunctivitis, rhinorrhea, coryza, hoarseness, diarrhea, and/or a rash.1-3 Findings of the pharyngeal examination of viral pharyngitis vary from mild erythema to quite red and edematous. Tonsillar hypertrophy may or may not be present.3 Cobblestoning in the posterior pharynx may signify postnasal drip, supporting a viral etiology.
 

If GABHS is suspected as the cause of pharyngitis, the focal point should be identification of any exposure to individuals with known GABHS infection during the preceding 2 weeks. GABHS patients generally have an abrupt onset of pharyngitis, fever, dysphagia, erythema, and/or exudates in the pharynx and anterior cervical lymphadenopathy.1,3 Throat discomfort may range from mild to severe, and throat erythema may be minimal to beefy red.3 Other symptoms associated with GABHS, such as headache, nausea, vomiting, abdominal pain, and the characteristic scarlatiniform rash (which feels like sandpaper), are not consistently present.2 However, similar to that of viral pharyngitis, actual presentation may differ. 
 

Some less common pathogens known to cause acute pharyngitis, such as groups C and G streptococci, are indistinguishable from GABHS symptoms based on examination, while others have suggestive symptoms. N gonorrhoeae occurs often with no symptoms as pharyngitis but occasionally produces tonsillar hypertrophy and a whitish-yellowish exudate.2 Scarlet fever causes a distinct diffuse erythematous exanthema. Mononucleosis may also trigger a maculopapular rash and posterior cervical lymphadenopathy.1 Dysphagia, voice changes, stridor, trismus, drooling, and/or ill appearance are red flags indicating more serious conditions that may prompt referral to an emergency department.
 

DIFFERENTIAL DIAGNOSIS 
 

Because pharyngitis can be nonspecific, it is essential to consider different causes. Both infectious and noninfectious conditions should be included in the differentials. Cardiac disease and thyroid disease may imitate pharyngitis. Influenza, diphtheria, mononucleosis,1 gastroesophageal reflux disease, URI, and allergic rhinitis should also be considered.
 

WORK-UP/LAB TESTS 
 

The clinical features of GABHS and viral pharyngitis are similar, making the physical diagnosis insufficient to differentiate between the 2 perspectives, so additional measures are needed.1 One way to determine the risk of GABHS is the Centor score. The most current Centor score is constructed based on several recognized factors of GABHS, each worth 1 point, for a maximum of 5 points. These criteria consist of age (3 to 14 years adds 1 point, 15 to 44 adds 0 points, and older than 45 subtracts 1 point), absence of cough, tonsillar hypertrophy or exudate, history of fever (specifically, greater than 38°C), and sore anterior cervical lymph nodes. The correlation is related to the greater the number, the higher the chance of the condition. Despite its widespread use, the Centor score has its limitations, as it has a high negative predictive value, meaning it is more effective for ruling out GABHS than diagnosing it.
 

In general testing for pharyngitis, the score is debatable, as it may be skewed because of the colonization of the organisms in asymptomatic patients.1 Respiratory virus detection can be completed through rapid antigen direct tests (RADTs), direct fluorescent antibody testing (DFA), and cultures.10 Often the preferred method to collect these samples is through a nasal wash or nasopharyngeal swab, both of which can be uncomfortable for the patient and require skill from the clinician.4 RADTs are simple to execute and produce results within 30 minutes for viral pharyngitis. However, results are restricted to RSV and the influenza A and B viruses. DFA can be completed within an hour for 8 known pharyngitis-causing viruses (RSV, influenza A and B, adenovirus, human metapneumovirus, and parainfluenza virus types 1, 2, and 3).10 Uncommon viral causes can be cultured from a respiratory panel, which can be expensive and may be beyond the scope of the retail health clinician. 
 

For GABHS, disease determination is usually completed through RADT or throat culture. RADTs are highly sensitive overall (90%) but depend on the knowledge and skill of the person(s) attaining the swab and performing the RADT.1,3,5,7 Treatment is indicated for a positive RADT.1 Throat cultures are considered the gold standard but have some disadvantages. The most significant delay is the time frame of receiving test results, which can be 18 to 24 hours.2,7 In addition, a throat culture is not necessarily needed for routine diagnosis of GABHS.
 

Because of the availability of common tests, most patients with acute pharyngitis do not require blood work to assist in risk stratification or diagnosis.1 Minimal evidence exists that tests such as a complete blood count and inflammatory markers such as C-reactive protein or erythrocyte sedimentation rate are useful in diagnosing viral pharyngitis or GABHS. However, it is important to contemplate other testing, if directed by the history and physical exam, for sexually transmitted diseases, for instance, or Monospot, if concern exists about mononucleosis.2,7 
 

COMPLICATIONS 
 

As viral pharyngitis is generally benign and self-limited, adverse outcomes rarely exist. GABHS complications such as acute rheumatic fever and acute glomerulonephritis are also uncommon, especially in the developed world.3,7 In addition to rheumatic fever and glomerulonephritis, possible problems include acute otitis media, acute sinusitis, quinsy, cervical lymphadenitis, mastoiditis,7 and peritonsillar abscess.1 Groups C and G streptococci also rarely cause complications, but reactive arthritis and subdural empyema have been reported.7 Little evidence supports adverse outcomes related to atypical pharyngeal-causing organisms M pneumoniae or C pneumoniae and fungal pathogens.
 

GENERAL TREATMENT

General treatment includes supportive care of antipyretics, analgesics, and gargles.1,5,8 Benzocaine lozenges and throat lozenges show some effectiveness.1,3 Acetaminophen (Tylenol) and nonsteroidal anti-inflammatory drugs are effective in decreasing acute pharyngitis symptoms in both children and adults.1,3,7,11 Conflicting results are present related to the efficacy of zinc gluconate, herbal treatments, and acupuncture.1 A short course of corticosteroids may benefit some patients,7 especially those with severe symptoms or who are unable to swallow.1,5 
 

ANTIBIOTICS

Clinicians must continue to self-reflect on the question related to patients with acute pharyngitis of whether antibiotics are necessary for treatment.1 More than half of children and nearly two-thirds of adults evaluated for pharyngitis get a prescription for antibiotics. Although there is no question as to how the patients who have received a diagnosis of GABHS should be treated, this prescription rate is much higher than the disease prevalence of GABHS.2 Evidence suggests overuse and inappropriate antibiotic prescribing are increasing resistance.3,6,9,10 
 

The first-line antibiotic treatment for GABHS is penicillin to confirm obliteration of the pathogen from the oral cavity.1,6,7 Penicillin may be given orally for 10 days or as a single intramuscular shot.1,4 No antibiotic resistance to penicillin has been documented for GABHS.1 However, penicillin does have the potential for some adverse effects, including anaphylaxis.5 Amoxicillin has comparable effectiveness to penicillin and again should be prescribed orally for 10 days.7 Both medications are also cheaper than alternatives.1

For patients with an identified allergy that is neither nonanaphylactic nor otherwise severe, an adequate alternate is cephalexin orally for 10 days. Those patients with a severe penicillin allergy may be prescribed clindamycin, azithromycin, or erythromycin. Sulfonamides and tetracyclines are not suggested because of high rates of antimicrobial resistance and treatment failure.
 

CONCLUSION

In today’s health care environment, especially in the retail health setting, there is great emphasis on convenience. Parents and patients may expect a prescription after a visit or describing symptoms over the phone. Although it may be tempting to write an antibiotic prescription, it should not be based on patient satisfaction or expectation. Appropriate education, including when antibiotics are necessary based on a clinician’s diagnosis, is key to overcoming the rising antibiotic resistance, especially because of conditions exhibited as acute pharyngitis.  
 


Jenna Herman, DNP, APRN, FNP-BC, is the family nurse practitioner program coordinator and an assistant professor at the University of Mary in Bismarck, North Dakota. Her clinical practice includes the Emergency Department of a level II trauma center, correctional medicine, and locum tenens in primary care clinics, nursing homes, and hospitals across rural North Dakota. 



References

1.     ESCMID Sore Throat Guideline Group, Pelucchi C, Grigoyan L, et al. Guideline for the management of acute sore throat. Clinical Microbiol Infect. 2012;18(suppl 1):1-28. doi: 10.1111/j.1469-0691.2012.03766.x.
2.     Hildreth AF, Takhar S, Clark MA, Hatten B. Evidence-based evaluation and management of patients with pharyngitis in the emergency department. Emerg Med Pract. 2015;17(9):1-16.
3.     Flores AR, Caserta MT. Pharyngitis. In: Bennet J, Dolin R, Martin J, eds. Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Disease. 8th ed. Philadelphia, PA: Elsevier Saunders; 2015. 
4.     Barton E, Spencer R. URTIs: recommended diagnosis and treatment in general practice. Prescriber. 2011;22(8):23-36.
5.     Giraldez-Garcia C, Rubio B, Gallegos-Braun JF, Imaz I, Gonzalez-Enriquez J, Sarria-Santamera A. Diagnosis and management of acute pharyngitis in a paediatric population: a cost-effectiveness analysis. Eur J Pediatr. 2011;170(8):1059-1067. doi: 10.1007/s00431-011-1410-0.
6.     Nicoteri JL. Adolescent pharyngitis: a common complaint with potentially lethal complications. J Nurse Pract. 2013;9(5):295-300.
7.     Salkind AR, Wright JM. Economic burden of adult pharyngitis: the payer’s perspective. Value Health. 2008;11(4):621-627. doi: 10.1111/j.1524-4733.2007.00286.x.
8.     Hong SY, Taur Y, Jordan MR, Wanke C. Antimicrobial prescribing in the USA for adult acute pharyngitis in relation to treatment guidelines. J Eval Clin Pract. 2011;17(6):1176-1183. doi: 10.1111/j.1365-2753.2010.01495.x. 
9.     Li L, Chen QY, Li YY, Wang YF, Yang ZF, Zhong NS. Comparison among nasopharyngeal swab, nasal wash, and oropharyngeal swab for respiratory virus detection in adults with acute pharyngitis. BMC Infect Dis. 2013;13:281. doi: 10.1186/1471-2334-13-281.
10.  Cox ED, Saluja S. Criteria-based diagnosis and antibiotic overuse for upper respiratory infections. Ambul Pediatr. 2008;8(4):250-254. doi: 10.1016/j.ambp.2008.02.005.
11.  Korb K, Scherer M, Chenot JF. Steroids as adjuvant therapy for acute pharyngitis in ambulatory patients: a systematic review. Ann Fam Med. 2010;8(1):58-63. doi: 10.1370/afm.1038.
12.  Sadeghirad B, Siemienik RAC, Brignardello-Petersen R, et al. Corticosteroids for treatment of sore throat: systematic review and meta-analysis of randomised trials. BMJ. 2017;358:j3887. doi: 10.1136/bmj.j3887.
13.  Ginocchio CC, McAdam AJ. Current best practices for respiratory virus testing. J Clin Microbiol. 2011;49(9):S44-S48. doi: 10.1128/JCM.00698-11.
 


 




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