ACUTE PHARYNGEAL INFECTIONS.

Acute pharyngitis is common, causing about 200 physician visits per 1,000 people every year in the United States. [1] Although the majority are self-limiting viral infections, serious and sometimes life-threatening sequelae do occur. Our complex goal in treating acute pharyngitis is symptom alleviation, decreasing infectivity, and preventing--or providing early treatment for--serious sequelae while practicing cost-effective medicine and not contributing to antibiotic resistance.

If a patient with acute pharyngitis has symptoms suggesting infection with group A [beta]-hemolytic streptococci (fever, no cough, no hoarseness, no rhinorrhea, no myalgias), a rapid screen for streptococcus is appropriate. Although this test cannot differentiate between acute viral pharyngitis in a chronic streptococcal carrier and acute streptococcal pharyngitis, treatment is recommended when positive. If negative, throat culture is prudent, yielding results in 18 to 48 hours. The physician may wait for positive results before beginning antibiotics, or may start antibiotic therapy, discontinuing it if the culture is negative. Penicillin remains effective treatment, though the current national shortage of aqueous penicillin may dictate another antibiotic choice. Most other patients with pharyngitis do not benefit from antibiotics (unless specific features are present, suggesting the few other bacterial causes of pharyngitis, such as diphtheria or gonorrhea).

Among the myriad viral causes of pharyngitis (adenovirus, coxsackievirus, rhinovirus, herpes simplex virus, parainfluenza, respiratory syncytial virus, ECHO viruses, influenza, measles, rubella, cytomegalovirus), Epstein-Barr virus (infectious mononucleosis [IM]) and primary HIV infection are two in which Precise diagnosis can improve patient outcome. In severe IM, close observation for airway compromise, with hospitalization, antiviral medications, steroid therapy, and airway support may be beneficial. Since ampicillin causes a pruritic rash in IM, avoidance is prudent. For primary HIV infection, prompt initiation of appropriate antiretroviral medication may improve long-term outcome.

Although chronic sore throat is a more common presentation of oropharyngeal or hypopharyngeal cancers than acute sore throat, thorough visualization of the upper airway is recommended when acute pharyngitis symptoms persist beyond 2 weeks, especially in adult smokers. Laryngopharyngeal reflux can also present as acute sore throat. Dual probe pH testing, barium swallow, and/or esophagogastroscopy can confirm this diagnosis. Acute thyroiditis is also sometimes described by patients as a "sore throat."

In the United States, 50 years of treating acute pharyngitis with antibiotics has made the once-common sequelae (acute rheumatic fever, scarlet fever, glomerulonephritis) relatively rare. The suppurative sequelae (peritonsillar abscess, retropharyngeal abscess, mastoiditis) are also less common than in the preantibiotic era, making them more difficult to recognize when they do occur.

Uncommon but potentially catastrophic sequelae in patients with recent acute pharyngitis symptoms include abscess formation (peritonsillar, parapharyngeal, retropharyngeal), airway compromise with supraglottitis (epiglottitis), and septic emboli with multiple organ system failure in Lemierre's syndrome. Patients with any of these sequelae usually appear toxic. Typically, they are febrile, with marked dysphagia and odynophagia. There is usually a history of a preceding pharyngitis. Frequently, the patient's symptoms worsen despite appropriate outpatient antibiotic therapy. If trismus is present, a peritonsillar abscess should be suspected. Intraoral examination usually shows an asymmetric, erythematous soft palate, with the uvula pushed away from the abscess side. Bilateral occurrence is rare. Needle aspiration via the anterior tonsillar pillar usually yields pus. The decision about inpatient vs outpatient treatment is based the need for parenteral antibiotics, adequacy of hydration, and effective pain contro l.

Patients with the less common retropharyngeal or parapharyngeal abscesses may not have continuing dysphagia or odynophagia. Typical neck posture is a clue to retropharyngeal abscess, confirmed by computed tomography (CT). Parapharyngeal abscess may follow acute pharyngitis, or may come from subclinical dental infections, without preceding sore throat. Neck pain, asymmetry, and sometimes tenderness suggest the diagnosis; CT confirms it.

Classic supraglottitis in children has a short time (6 to 12 hours) from onset of pharyngitis symptoms to airway symptoms. In adults, there is often a more indolent course (several days or more) to the preceding pharyngitis. Specifically questioning a patient about air hunger often elicits symptoms of early airway inadequacy. Gentie transnasal fiberoptic laryngopharyngoscopy reveals beefy-red edematous supraglottic mucosa. Since airway collapse can occur quickly, these patients are hospitalized, appropriate antibiotic/antiviral therapy is begun, and the airway is monitored closely. The adult's larger airway usually allows avoidance of endotracheal intubation or tracheotomy, which are done if needed.

Lemierre's syndrome differs from other suppurative sequelae in its time course. The neck pain from internal jugular vein thrombosis, fever, and sepsis typically begin a week or more after the pharyngitis, and the pharyngitis symptoms may not be reported unless specifically sought in the history. As detailed in the case presentation in this issue, prompt antibiotic and supportive therapy is required to prevent disseminated sepsis and death.

In summary, acute pharyngitis is common, nearly always self-limited, and only occasionally benefits from antibiotic therapy. Nevertheless, the practitioner must be able to recognize the disorder in its potentially life-threatening presentations.

Karen H. Calhoun, MD

Department of Otolaryngology

University of Texas Medical Branch at Galveston

301 University Blvd

Galveston, TX 77555-0521

Reference

(1.) Bisno AL: Acute pharyngitis. N Engl J Med 2001; 344:205-211