Pharyngitis differential diagnosis
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Venkata Sivakrishna Kumar Pulivarthi M.B.B.S [2]
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Overview
Pharyngitis should be differentiated from other infectious causes which mimic sore throat that includes oral thrush, infectious mononucleosis, epiglottitis and retropharyngeal abscess.[1]
Differentiating Pharyngitis from other Diseases
The major goal of the differentiating patients with sore throat or acute pharyngitis is to exclude potentially dangerous causes (e.g. Group A streptococcus), to identify any treatable causes, and to improve symptoms. Identifying the treatable causes is important because timely treatment with antibiotics helps prevent complications such as acute rheumatic fever, post streptococcal glomerulonephritis.[2]
| Variable | Pharyngitis | Oral thrush | Mononucleosis | Epiglottitis | Tonsilitis | Retropharyngeal abscess |
|---|---|---|---|---|---|---|
| Presentation |
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Dysphagia without odynophagia which will differentiate it from pharyngitis. | Usually presents with a classic triad of
|
Usually present with stridor and drooling; and other symptoms include difficulty breathing, fever, chills, difficulty swallowing, hoarseness of voice | Sore throat, pain on swallowing, fever, headache, cough | Neck pain, stiff neck, torticollis |
| Causes | Group A beta-hemolytic streptococcus. | candidal infection | Epstein-Barr virus | H. influenza type b, beta-hemolytic streptococci, Staphylococcus aureus, fungi and viruses. | Most common cause is viral including adenovirus, rhinovirus, influenza, coronavirus, and respiratory syncytial virus. Second most common causes are bacterial; Group A streptococcal bacteria,[5] | Polymicrobial infection. Mostly; Streptococcus pyogenes, Staphylococcus aureus and respiratory anaerobes (e.g. Fusobacteria, Prevotella, and Veillonella species)[3][4][5][6][7][8] |
| Physical exams findings | Inflammed pharynx with or without exudate | White plaques that reveal an erythematous base when scraped | Diffuse lymphadenopathy, particularly bilateral and posterior cervical,Splenomegaly in 50% of cases, Hepatomegaly in 10% of cases, Pharyngeal petechiae, Rash in 90% of patients will develop a pruritic, maculopapular rash after the use of ampicillin or amoxicillin | Cyanosis, Cervicallymphadenopathy, Inflammed epiglottis | Fever, especially 100°F or higher.Erythema, edema and Exudate of the tonsils.cervical lymphadenopathy, Dysphonia.[9][10][11][12] | Child may be unable to open the mouth widely. May have enlarged
cervical lymph nodes and neck mass. |
| Age commonly affected | Mostly in children and young adults,
with 50% of cases identified between the ages of 5 to 24 years.[13] |
Usually in immunocompromised patients, including those with advanced HIV/AIDS | Common in adolescents between 15-25 | Used to be mostly found in
pediatric age group between 3 to 5 years, however, recent trend favors adults as most commonly affected individuals with a mean age of 44.94 years.[14] |
Primarily affects children
between 5 and 15 years old.[15] |
Mostly between 2-4 years, but can occur in other age groups.[16][17] |
| Imaging finding | — | — | — | Thumbprint sign on neck x-ray | Intraoral or transcutaneous USG may show an abscess making CT scan unnecessary.[18][19][20] | On CT scan, a mass impinging on the posterior pharyngeal wall with rim enhancement is seen.[21][22] |
| Treatment | Antimicrobial therapy mainly penicillin-based and analgesics. | oral fluconazole | Supportive therapy
Glucocorticoids may be indicated in such cases of severe airway obstruction. |
Airway maintenance, parenteral Cefotaxime or Ceftriaxone in combination with Vancomycin. Adjuvant therapy includes corticosteroids and racemic Epinephrine.[23][24] | Antimicrobial therapy mainly penicillin-based and analgesics with tonsilectomy in selected cases. | Immediate surgical drainage and antimicrobial therapy. emperic therapy involves; ampicillin-sulbactam or clindamycin. |
References
- ↑ Vincent MT, Celestin N, Hussain AN (2004) Pharyngitis. Am Fam Physician 69 (6):1465-70. PMID: 15053411
- ↑ Del Mar CB, Glasziou PP, Spinks AB (2006) Antibiotics for sore throat. Cochrane Database Syst Rev (4):CD000023. DOI:10.1002/14651858.CD000023.pub3 PMID: 17054126
- ↑ Cheng J, Elden L (2013). "Children with deep space neck infections: our experience with 178 children". Otolaryngol Head Neck Surg. 148 (6): 1037–42. doi:10.1177/0194599813482292. PMID 23520072.
- ↑ Abdel-Haq N, Quezada M, Asmar BI (2012). "Retropharyngeal abscess in children: the rising incidence of methicillin-resistant Staphylococcus aureus". Pediatr Infect Dis J. 31 (7): 696–9. doi:10.1097/INF.0b013e318256fff0. PMID 22481424.
- ↑ Inman JC, Rowe M, Ghostine M, Fleck T (2008). "Pediatric neck abscesses: changing organisms and empiric therapies". Laryngoscope. 118 (12): 2111–4. doi:10.1097/MLG.0b013e318182a4fb. PMID 18948832.
- ↑ Brook I (2004). "Microbiology and management of peritonsillar, retropharyngeal, and parapharyngeal abscesses". J Oral Maxillofac Surg. 62 (12): 1545–50. PMID 15573356.
- ↑ Wright CT, Stocks RM, Armstrong DL, Arnold SR, Gould HJ (2008). "Pediatric mediastinitis as a complication of methicillin-resistant Staphylococcus aureus retropharyngeal abscess". Arch Otolaryngol Head Neck Surg. 134 (4): 408–13. doi:10.1001/archotol.134.4.408. PMID 18427007.
- ↑ Asmar BI (1990). "Bacteriology of retropharyngeal abscess in children". Pediatr Infect Dis J. 9 (8): 595–7. PMID 2235179.
- ↑ Tonsillitis. Medline Plus. https://www.nlm.nih.gov/medlineplus/ency/article/001043.htm. Accessed May 2nd, 2016.
- ↑ "Tonsillitis - NHS Choices".
- ↑ Stelter K (2014). "Tonsillitis and sore throat in children". GMS Curr Top Otorhinolaryngol Head Neck Surg. 13: Doc07. doi:10.3205/cto000110. PMC 4273168. PMID 25587367.
- ↑ "Tonsillitis - Symptoms - NHS Choices".
- ↑ Bennett, John (2015). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Elsevier/Saunders. ISBN 978-1455748013.
- ↑ Lichtor JL, Roche Rodriguez M, Aaronson NL, Spock T, Goodman TR, Baum ED (2016). "Epiglottitis: It Hasn't Gone Away". Anesthesiology. 124 (6): 1404–7. doi:10.1097/ALN.0000000000001125. PMID 27031010.
- ↑ Sharav, Yair; Benoliel, Rafael (2008). Orofacial Pain and Headache. Elsevier. ISBN 0723434123.
- ↑ Craig FW, Schunk JE (2003). "Retropharyngeal abscess in children: clinical presentation, utility of imaging, and current management". Pediatrics. 111 (6 Pt 1): 1394–8. PMID 12777558.
- ↑ Coulthard M, Isaacs D (1991). "Neonatal retropharyngeal abscess". Pediatr Infect Dis J. 10 (7): 547–9. PMID 1876473.
- ↑ Kawabata M, Umakoshi M, Makise T, Miyashita K, Harada M, Nagano H; et al. (2016). "Clinical classification of peritonsillar abscess based on CT and indications for immediate abscess tonsillectomy". Auris Nasus Larynx. 43 (2): 182–6. doi:10.1016/j.anl.2015.09.014. PMID 26527518.
- ↑ Nogan S, Jandali D, Cipolla M, DeSilva B (2015). "The use of ultrasound imaging in evaluation of peritonsillar infections". Laryngoscope. 125 (11): 2604–7. doi:10.1002/lary.25313. PMID 25946659.
- ↑ Fordham MT, Rock AN, Bandarkar A, Preciado D, Levy M, Cohen J; et al. (2015). "Transcervical ultrasonography in the diagnosis of pediatric peritonsillar abscess". Laryngoscope. 125 (12): 2799–804. doi:10.1002/lary.25354. PMID 25945805.
- ↑ Philpott CM, Selvadurai D, Banerjee AR (2004). "Paediatric retropharyngeal abscess". J Laryngol Otol. 118 (12): 919–26. PMID 15667676.
- ↑ Vural C, Gungor A, Comerci S (2003). "Accuracy of computerized tomography in deep neck infections in the pediatric population". Am J Otolaryngol. 24 (3): 143–8. PMID 12761699.
- ↑ Nickas BJ (2005). "A 60-year-old man with stridor, drooling, and "tripoding" following a nasal polypectomy". J Emerg Nurs. 31 (3): 234–5, quiz 321. doi:10.1016/j.jen.2004.10.015. PMID 15983574.
- ↑ Wick F, Ballmer PE, Haller A (2002). "Acute epiglottis in adults". Swiss Med Wkly. 132 (37–38): 541–7. PMID 12557859.