Pharyngitis is an inflammatory illness of the mucous membranes and underlying structures of the throat. The clinical diagnostic category includes tonsillitis, tonsillopharyngitis, and nasopharyngitis; inflammation also frequently involves the uvula and soft palate. Illness usually is acute but also may be subacute or chronic. Establishing the diagnosis of pharyngitis requires objective evidence of inflammation (erythema, exudate, or ulceration). The symptom of sore throat invariably accompanies pharyngitis, but it should not be used as the sole criterion; sore throat is a common complaint of children with colds in whom no objective evidence of pharyngeal inflammation is present (see Chapter 7 ).
Although the clinical finding of pharyngitis suggests an almost exclusive group A streptococcal cause to many physicians, etiologic considerations should include a multitude of viruses, bacteria, and other infectious and noninfectious agents. Etiologically, pharyngitis is subdivided into two categories: illness with nasal symptoms (nasopharyngitis) and illness without nasal involvement (pharyngitis or tonsillopharyngitis). In acute illness, nasopharyngitis nearly always is of viral origin, whereas pharyngitis without nasal signs has diverse etiologic possibilities, including bacteria, viruses, fungi, and other unidentified causes. In this chapter, nasopharyngitis and pharyngitis without nasal involvement are considered separately.
History
Although throat inflammation undoubtedly has been a physical finding of disease throughout human existence, only in more recent years has attention been given to pharyngitis as a primary complaint. The throat findings of diphtheria were mentioned in the 3rd century ad , and Vincent angina was noted in the military before the Christian era, but group A streptococcal infection and pharyngitis were not clearly associated until World War II. Although Glover and Griffith mentioned streptococcal tonsillitis in 1931, the major reference to streptococci in the preantibiotic era was in association with scarlet fever, erysipelas, and suppurative processes.
In the early years of clinical virology large population studies of colds, pharyngitis, croup, bronchiolitis, and pneumonia were carried out. *
* References .
In more recent years, studies have been mainly related to new agents, and pharyngitis is an illness category that is frequently overlooked.Nasopharyngitis
Etiologic Agents
Etiologic agents of nasopharyngitis, categorized by type of lesion, frequency, season of occurrence, and duration of illness, are listed in Table 9.1 . The relative importance of nasal and pharyngeal manifestations also is presented. Although Table 9.1 shows three bacterial agents and one rickettsia, most occurrences of nasopharyngitis are caused by viral infections. The specific infectious agents are discussed fully in their respective sections of this book; only an overview is presented here.
| Etiologic Agent | TYPE OF PHARYNGEAL LESION a | RELATIVE IMPORTANCE OF NASAL AND PHARYNGEAL SYMPTOMS b | Frequency of Pharyngitis c | Main Season | Duration of Pharyngitis | |||
|---|---|---|---|---|---|---|---|---|
| Erythematous | Follicular | Exudative | Nasal | Pharyngeal | ||||
| Bacteria | ||||||||
| Corynebacterium diphtheriae | +++ | ++++ | + | +++ | + | Fall, winter, spring | Acute, subacute | |
| Haemophilus influenzae | ++ | ++ | ++ | + | Fall, winter, spring | Acute, subacute | ||
| Neisseria meningitidis | ++ | + | +++ | + | Fall, winter, spring | Acute, subacute | ||
| Viruses | ||||||||
| Adenoviruses | ++++ | ++++ | ++ | + | +++ | ++++ | All seasons | Acute |
| Enteroviruses | +++ | + | + | +++ | +++ | Summer, fall | Acute | |
| Influenza A, B, C | +++ | + | +++ | ++ | Fall, winter | Acute | ||
| Parainfluenza | ++ | + | +++ | + | ++ | Fall, winter, spring | Acute | |
| Respiratory syncytial | ++ | +++ | + | + | Fall, winter, spring | Acute | ||
| Coronavirus | + | + | ++ | + | Acute | |||
| Rhinoviruses | + | +++ | + | + | Fall, winter, spring | Acute | ||
| Human metapneumovirus | ++ | +++ | + | + | Fall, winter, spring | Acute | ||
| Human bocavirus | ++ | +++ | + | + | Fall, winter, spring | Acute | ||
| Rotaviruses | ++ | ++ | ++ | ++ | Fall, winter, spring | Acute | ||
| Rickettsia | ||||||||
| Coxiella burnetii | ++ | ++ | ++ | + | All seasons | Acute | ||
a Plus signs indicate the relative degree and severity of the lesion (++++, most marked; +, minimal).
c ++++, 76 % to 100 % ; +++, 51 % to 75 % ; ++, 26 % to 50 % ; +, 1 % to 25 % .
Adenoviruses are the most common cause of nasopharyngitis; types 1, 2, 3, 4, 5, 6, 7, 7a, 9, 14, and 15 account for most illnesses. Nasopharyngitis also commonly occurs with influenza and parainfluenza viral infections. †
† References .
Although rhinoviral, respiratory syncytial viral, human metapneumovirus, and human bocavirus infections are common occurrences in children and all always have nasal manifestations (coryza), the occurrence of objective pharyngeal manifestations is less common. ‡‡ References .
Respiratory symptoms with cough, nasal discharge, and pharyngitis frequently occur in children with rotaviral gastroenteritis.Epidemiology
Nasopharyngitis is a common illness of childhood. It tends to be most prevalent in young children in association with primary infections with respiratory viruses. Nasal symptoms with enteroviruses occur less frequently in school-aged children than in preschool-aged children. In contrast, older children rarely have pharyngitis with respiratory syncytial viral, parainfluenza viral, and rhinoviral infections. Nasopharyngitis caused by adenoviral infection is a particularly frequent occurrence in adolescents and young adults in military training.
Nasopharyngitis occurs more commonly during the cold-weather months (see Table 9.1 ). No apparent sex predilection has been found. The method of transmission is similar to that of other respiratory viral infections (see Chapter 7 ).
Pathophysiology
The pathophysiology of nasopharyngitis is discussed in Chapter 7 , in the pharyngitis section of this chapter, and in the chapters discussing the individual viral agents. In nasopharyngitis associated with Haemophilus influenzae and Neisseria meningitidis, the nasal symptoms may result from a concomitant respiratory viral infection.
Clinical Presentation
Because nasopharyngitis is caused by many different etiologic agents, a reasonable expectation is varied clinical manifestations. These differences are highlighted in Table 9.1 . Fever occurs in nearly all cases of nasopharyngitis. With adenoviral and influenza viral disease, the pharyngeal findings are most prominent; with the other respiratory viruses, coryza is more notable than are pharyngeal complaints. In adenoviral infections, follicular pharyngitis is the rule, and exudate is a common manifestation. In contrast, patients with the other respiratory viral infections usually present with pharyngeal erythema only. Nasopharyngitis of a viral etiology most often is an acute, self-limited disease lasting 4 to 10 days. Generally, adenoviral illnesses tend to be more prolonged than are illnesses resulting from the other respiratory viruses. Other symptoms in nasopharyngitis are related to the causative virus. Parainfluenza and respiratory syncytial viral infections also frequently have lower respiratory tract findings (laryngotracheitis, pneumonia, or bronchiolitis), and influenza is usually associated with more severe, generalized complaints.
Although respiratory symptoms in association with rotaviral gastroenteritis have been noted frequently, little careful clinical study of the respiratory manifestations has been performed. Lewis and associates, in a careful study observed a statistically significant occurrence of nasal discharge, cough, and red throat in children with rotaviral diarrhea compared with children with diarrhea caused by other agents.
Nasopharyngitis with H. influenzae or N. meningitidis infections has been noted mainly in patients with septicemia and meningitis. The nasal symptoms (coryza) usually preceded the pharyngitis and severe systemic disease by a few to several days. In Q fever, the predominant finding is pneumonia. With diphtheria, the exudative pharyngitis and constitutional symptoms are most prominent.
Pharyngitis, Tonsillitis, and Tonsillopharyngitis
Etiologic Agents
Etiologic agents of pharyngitis categorized by type of lesion, frequency of occurrence, and duration of illness are presented in Table 9.2 . Numerous diverse possibilities exist for the differential diagnosis of pharyngitis. The specific agents or factors are presented in their respective sections of this book, and only an overview is given here.
| Etiologic Agent or Factor | TYPE OF LESION a | Frequency of Occurrence b | Duration of Pharyngitis | ||||
|---|---|---|---|---|---|---|---|
| Erythematous | Follicular | Exudative | Ulcerative | Petechial | |||
| Bacteria | |||||||
| Streptococcus pyogenes | ++++ | ++ | +++ | +++ | ++++ | Acute | |
| Other streptococci (groups B, C, and G) | +++ | + | ++ | ++ | Acute | ||
| Brucella spp. | + | + | + | Subacute | |||
| Corynebacterium diphtheriae | +++ | ++++ | + | Acute | |||
| Corynebacterium pyogenes | ++++ | ++++ | + | Acute | |||
| Corynebacterium ulcerans | ++++ | +++ | + | Acute | |||
| Arcanobacterium haemolyticum | ++++ | ++ | +++ | + | Acute | ||
| Mixed anaerobes ( Prevotella spp., Peptostreptococcus, Fusobacterium spp.) | ++++ | + | ++++ | ++ | Subacute | ||
| Actinomyces spp. | + | + | + | Chronic | |||
| Helicobacter pylori | + | + | Chronic | ||||
| Francisella tularensis | ++++ | +++ | + | Acute, subacute | |||
| Haemophilus influenzae | ++ | ++ | Acute, subacute | ||||
| Legionella pneumophila | ++++ | + | Acute | ||||
| Neisseria meningitidis | ++ | + | ++ | Acute | |||
| Neisseria gonorrhoeae | ++ | + | + | Acute, subacute, chronic | |||
| Leptospira spp. | ++++ | + | Acute | ||||
| Treponema pallidum | + | + | + | + | Subacute | ||
| Borrelia spp. | ++++ | + | Acute | ||||
| Streptobacillus moniliformis | + | + | Acute | ||||
| Yersinia enterocolitica | ++++ | ++ | + | Acute | |||
| Yersinia pseudotuberculosis | + | + | Acute | ||||
| Streptococcus pneumoniae | + | + | + | Acute | |||
| Salmonella typhi | + | + | Acute | ||||
| Rothia dentocariosa | + | + | + | Acute | |||
| Mycobacterium tuberculosis | + | + | Chronic | ||||
| Chlamydia pneumoniae | ++++ | ++ | Acute | ||||
| Chlamydia trachomatis | ++ | + | + | + | Acute, recurrent | ||
| Viruses | |||||||
| Adenoviruses | ++++ | ++++ | ++ | ++++ | Acute | ||
| Influenza A, B, and C | +++ | +++ | Acute | ||||
| Parainfluenza | ++ | +++ | Acute | ||||
| Respiratory syncytial | ++ | + | Acute | ||||
| Enteroviruses | +++ | + | ++ | +++ | Acute | ||
| Epstein-Barr | +++ | + | ++++ | ++ | +++ | Acute, subacute | |
| Reoviruses | ++ | + | Acute | ||||
| Cytomegalovirus | + | + | Acute | ||||
| Herpes simplex | ++ | ++ | ++++ | ++ | Acute | ||
| Measles | +++ | + | ++ | Acute | |||
| Rubella | ++ | + | Acute | ||||
| Rhinoviruses | + | + | Acute | ||||
| HIV | ++ | Acute | |||||
| Mycoplasma | |||||||
| Mycoplasma pneumoniae | ++ | + | + | ++ | Acute | ||
| Mycoplasma hominis | + | + | + | Acute | |||
| Rickettsia | |||||||
| Coxiella burnetii | ++ | + | Acute | ||||
| Fungi | |||||||
| Candida spp. | + | ++++ | +++ | Acute, subacute, chronic | |||
| Parasites | |||||||
| Toxoplasma gondii | + | + | Acute | ||||
| Recognized Illnesses of Uncertain Etiology | |||||||
| Aphthous stomatitis | + | ++++ | ++ | Acute, recurrent | |||
| PFAPA | ++ | ++ | ++ | + | Acute, recurrent | ||
| Behçet syndrome | + | ++++ | + | Chronic, recurrent | |||
| Kawasaki disease | ++ | + | + | Acute | |||
| Stevens-Johnson syndrome | + | + | ++++ | + | Acute | ||
| Illness in which Host Factors or Therapeutic Agents are Primary Causes | |||||||
| Neutropenia, other immunodeficiencies, cancer, chemotherapeutic agents, generalized neoplastic disease | + | ++++ | ++ | Chronic | |||
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