Departemen T.H.T.K.

L
Fakultas kedokteran
Universitas Padjadjaran

P H A R Y N G ITIS

IN TR O D U C TIO N
Pharyngitis is an inflammatory disease of the mucosal and submucosal

structures of the Pharynx.

40 million visits by adults to medical facilities per year
More prescription written for pharyngitis than any other

respiratory infection
Inflamation of the Pharynx can cause by Infection or non infection
Most pharyngitis are diagnosed by clinical evaluation and usually

respond to treatment.

Anatom y ofthe Pharynx

Continuation of the digestive tract

from the oral cavity

Funnel-shaped fibromuscular tube
Approximately 15 cm long
Common route for air and food

Anatom y

Histology of PHARYNX
The features of the pharynx seen in a low-magnification image include:
1. Stratified squamous non-keratinized epithelium (black arrows)
2. Lamina propria (White bracket), including of a dense band of elastic fibers (green
bracket)
3. Muscularis (purple bracket) consisting of skeletal muscle

lume
n

Innervation
ofthe Pharynx

Innervation
Pharyngeal plexus of nerves
Run along the lateral aspect of the

pharynx in the buccopharyngeal fascia

Formed by CN X and IX and sympathetic
fibers from the stellate ganglion
Motor fibers from cranial root of CN XI
fibers carried by CN X
Exception - stylopharyngeus

Blood Supply
Blood supply
Branches of the external carotid artery
Ascending pharyngeal
Dorsal branches from the lingual artery
Tonsillar branches of the facial artery
Palatine branches from the maxillary

artery

Blood Supply

H istory
Chief complain
Scratchy or burning throat
Dysphagia, Odynophagia
Referred otalgia
Throat clearing
Halitosis
Cough
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

Family History, Allergy, Risk Factor,Medication

Smoking

Physicalexam ination
Complete ENT Examination
Use proper equipment
Tongue depressor
Head lamp
Laryngeal mirror
Endoscopy : Nasopharynx and Hypopharynx

Describe color of Mucosa

Reddish compare with surrounding structure
Supuration,Debris,Plaque,

Exudate,Petechie,Secrete,Membrane/Pseudome
mbrane

Laboratory Test
Blood Test : CBC
Swab and culture
Strep Test
X-Ray :
Sub Mento-vertex
Neck Lateral soft tissue AP-Lateral

D iff
erentialdiagnosis of
pharyngitis
Pharyngeal exudates:
S. pyogenes
C. diphtheriae
EBV

D iff
erentialdiagnosis of
pharyngitis
Skin rash:
S. pyogenes
HIV
EBV

D iff
erentialdiagnosis of
pharyngitis
Conjunctivitis:
Adenovirus

Suppurative Com plications ofG roup A

StreptococcalPharyngitis

Otitis media
Sinusitis
Peritonsillar and retropharyngeal

abscesses
Suppurative cervical adenitis

N onsuppurative Com plications ofG roup 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

Infectious causes ofpharyngitis

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

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.

Corynebacterium Diphteriae
Treponema palidum
Mycoplasma pneumoniae
Arcanobacterium haemolyticum
Neisseria gonorrhea
Chlamydia pneumoniae

 Viruses
Most common agents in pharyngitis are

the rhinovirus and coronavirus

Both single stranded, +sense RNA
picornaviruses
Grow best at 33 degrees Celsius
Approximates the temperature of the
nasopharynx

EBV
Early infections in life are mostly

asymptomatic
Clinical disease is seen in those with
delayed exposure (young adults)
Defined by clinical triad
Fever, lymphadenopathy, and

pharyngitis combined with +heterophil

antibodies and atypical lymphocytes

 Other clinical findings

Splenomegaly 50%
Hepatomegaly 10%
Rash 5%

EBV PETECH IE

EBV D iagnosis
By Clinical presentation
CBC with differential (atypical
lymphocytes T
lymphocytes)
Detection of heterophil antibodies
(Monospot test)
IgM titers

Treatm ent
Supportive management
Rest
Avoidance of contact sports (?-

>splenic rupture?)
Glucocorticoids (severe cases)

M easles

Paramyxovirus
Highest incidence in children sparing

those
under 6 months
Decline in recent decade from
immunization programs

M easles
Clinical manifestations

Symptoms 9-11 days after exposure

Cough, coryza, conjunctivitis, fever
Kopliks spots (3 days after onset)
Pinpoint gray-white spots surrounded
by erythema
Appear on mucous membranes
Common on buccal mucosa

M easles
Kopliks Spot
Rash Appear 1 day

Later
Starts on head then to
torso and extremities
Persists for 3-5 days
then fades
Treatment
Suportive
Self limited
Vaccine ( Prevention)

H IV
Pharyngitis

Usually opportunistic infection

HSV
CMV
Candida

Viral particles have been detected in

lymphoepithelial tissues of the

pharynx

BACTERIA

Streptococcus
Group A streptococcus most
common
Streptococcus pneumoniae
Group C streptococcus
No proven benefit of treating nongroup A streptococcal pharyngitis

Streptococcus
Reasons for treating Group A

streptococcus
1) relief of symptoms related to
infection
2) prevent rheumatic fever
3) prevent suppurative sequelae
4) prevent further spread of group
A streptococcus in the community

Streptococcus
Clinical characteristics

Sore throat
Erythema of the involved tissues with
or without purulent exudate
Petechiae of the soft and hard palate

Streptococcus

D iagnosis
G roup A Streptococcus

All patient with suspected group A

streptococcal pharyngitis should be
test for the organism.
Methods include
rapid antigen detection tests
(RADT) 10min,
slide-culture test using a bacitracin
disk - overnight
Blood agar culture - overnight

Treatm ent G ABH S

Treatment
Penicillin V for 10 days drug of choice

Erythromycin second line

Amoxicillin and Ampicillin better
absorption
No proven benefit
Possible rash from ampicillin Rx, if
EBV is the cause

N eisseria gonorrhea
Gram-negative diplococci

Two pathogenic types of Neisseria

N. gonorrhea causes pharyngitis
with exudate
Diagnosis requires high index of
suspicion in patients with suggestive
sexual history

D iagnosis
Diagnosis

Gram-stain from swab

95% sensitive
50% specific
Culture should always be done
Grows on chocolate agar with high
CO2
Rapid nucleic acid probe tests now
available

N eisseria gonorrhea
Treatment
125 mg single IM dose of

Ceftriaxone and
Doxycycline, 100 mg PO Bid X 7 days

Corynebacterium D iphteriae
Causative organism of diphtheria
Gram-negative bacillus
Produces exotoxin at site of infection
Travels to heart and nervous system
Spread by close contact via droplets or

contaminated articles
Humans are the sole carriers of the organism
More common in children < 10 years
Rare occurrence today because of routine
vaccination

C.D iphteriae
Clinical manifestations
Systemic symptoms from exotoxin
Fatigued
Lethargic
Tachycardic
toxic

 Clinical characteristics
Pharynx
grayish membrane (composed of

fibrin,leukocytes, and cellular debris)

extends from pharynx to larynx
Extensive cervical lymphadenopathy
(bull neck)

D iphtheria
Etiologic agent: Corynebacterium

diphtheria
Extremely rare, occurs primarily in

unimmunized patients
Gram positive rod
nonspore forming
strains may be toxigenic or nontoxigenic
exotoxin required for disease

D iphteriae

Bullneck

D iagnosis
Diagnosis
Isolation of the organism
Culture from local lesion
Grows on selective media containing

potassium tellurite
Notify microbiology lab if diphtheria
suspected

Corynebacterium D iphtheriae

Treatm ent

Started before culture confirmation

Airway
Resuscitation
Skin test for allergy to horse serum
Administer diphtheria antitoxin
Have epinephrine available
Antibiotics (erythromycin, penicillin

G, rifampin, or clindamycin) used to

eradicate carrier state

 Prevention
Vaccine
Trivalent vaccine diphtheria toxoid,

tetanus toxoid and pertussis (DTP)

6 weeks of age, 2 more 4-8 weeks
intervals, and 6-12 months later

FungalPharingitis
Causes of candidiasis (monilia)

Increase relative proportion

long term antibiotics
Compromise of general immune capacity of host

Leukopenia
Corticosteroid therapy
T lymphocyte dysfunction
AIDS
Medications cyclosporin
leukemia
Diabetes mellitus

 Clinical manifestations
White, cheesy plaque
Loosely adherent to mucosa
Painless
Painful if removed

Candidiasis

D iagnosis

Usually made clinically

Exudates or epithelial scrapings may
be examined by KOH prep or G-stain
- Demonstration of budding yeast
associated with hyphae and
pseudohyphae is diagnostic

Candidiasis
Treatment

- Oropharyngeal (thrush)
Nystatin suspension: 10-15 cc mouth

rinses 5X/day for as long as the patient

is susceptible
More severe forms with laryngeal or
esophageal involvement fluconazole
400mg PO bid X 14 days
Disseminated candidiasis
Amphotericin B

N on Infection Pharyngitis
Etiology
Irritation
Chemical
Polutan Smoking
Dry Air
Radiotherapy
Allergy
Trauma
Post Operative sore throat Intubation

Sym ptom s
Not Specific Sore Throat
Search for Risk factor :
Smoking, snoring, Allergy, Gastic reflux
Radiation

Treatm ent
Symptomatic
Analgetics NSAID
Steroids
Gargle

Eliminate etiology

Terim a Kasih