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Acute pharyngitis should be treated according to the etiologic agent. The most common causes of pharyngitis are:
Acute pharyngitis should be treated according to the etiologic agent. The most common causes of pharyngitis are:
=====Viral infections=====
=====Viral infections=====
Most common cause of infection in children. The most common viral infection are ''[[Adenovirus]]'', ''[[rhinovirus]]'', ''[[influenza A and B]]'', ''[[parainfluenza]]'' 1,2,3. Most of them a self limiting however a few may need antivirals in the immunocompromised.<ref name="Bisno-1996">{{Cite journal  | last1 = Bisno | first1 = AL. | title = Acute pharyngitis: etiology and diagnosis. | journal = Pediatrics | volume = 97 | issue = 6 Pt 2 | pages = 949-54 | month = Jun | year = 1996 | doi =  | PMID = 8637780 }}</ref>
As viral infections are the most common causes of pharyngitis in children, most patients do not require treatment and only need supportive care.<ref name="Bisno-1996">{{Cite journal  | last1 = Bisno | first1 = AL. | title = Acute pharyngitis: etiology and diagnosis. | journal = Pediatrics | volume = 97 | issue = 6 Pt 2 | pages = 949-54 | month = Jun | year = 1996 | doi =  | PMID = 8637780 }}</ref>
<ref name="Bisno-1996">{{Cite journal  | last1 = Bisno | first1 = AL. | title = Acute pharyngitis: etiology and diagnosis. | journal = Pediatrics | volume = 97 | issue = 6 Pt 2 | pages = 949-54 | month = Jun | year = 1996 | doi =  | PMID = 8637780 }}</ref>
<ref name="Bisno-1996">{{Cite journal  | last1 = Bisno | first1 = AL. | title = Acute pharyngitis: etiology and diagnosis. | journal = Pediatrics | volume = 97 | issue = 6 Pt 2 | pages = 949-54 | month = Jun | year = 1996 | doi =  | PMID = 8637780 }}</ref>


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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Chetan Lokhande, M.B.B.S [2]

Overview

The majority of cases of pharyngitis are self-limited and only require symptomatic therapy.

Medical Therapy

Acute pharyngitis should be treated according to the etiologic agent. The most common causes of pharyngitis are:

Viral infections

As viral infections are the most common causes of pharyngitis in children, most patients do not require treatment and only need supportive care.[1] [1]

Bacterial infections

They usually require antibiotics as group A beta-hemolytic streptococcus (GAS) is the most common . If bacteria are recovered from throat culture they do not need antibiotics as they dont cause pharyngitis .

Allergic infection

Treat allergic infection with systemic or topical anti-histaminics.

There are three types of treatment: symptomatic, remedial and preventive. Symptomatic treatments are aimed at reducing pain and symptoms. Remedial treatments attempt to cure pharyngitis by reducing its spread and speeding up the healing process. Preventive treatments attempt to block the start of an infection.

Remedial treatments are mostly effective for bacterial infections such as streptococcal infections. For viral infections, even with treatment, most cases of pharyngitis will still settle spontaneously within a few days. Hence the most popular method of treatment is symptomatic. Many preventive treatments are also remedial, thus those two treatments will be listed in the same section.

Twenty-two non-antibiotic managements for sore throat have been studied in controlled trials.[2]Analgesics are among the most effective, but there are many simple measures that can also be used.

Symptomatic treatments

  • Analgesics such as NSAIDs can help reduce the pain associated with a sore throat.[2]
  • Throat lozenges (cough medicine) are often used for short-term pain relief.
  • Avoid foods and liquids highly acidic in nature, as they will provoke temporary periods of intense pain.
  • Warm tea (true or Tisane) or soup can help temporarily alleviate the pain of a sore throat.
  • Cold beverages, popsicles and ice cubes numb the nerves of the throat somewhat, alleviating the pain for a brief time.
  • Mouthwash (when gargled) reduces the pain but only for a brief time.
  • Drinking heavy amounts of liquid reduces the pain for a short time.
  • Peppermint candy might help with some cases as well as other hard candies. It will reduce the pain for a short time.
  • Yogurt has been shown to help alleviate the pain temporarily by coating the affected area. Milk also has the same effect.
  • Gargling with warm saline solution may help reduce mucus. [3] While it is a popular household remedy, there is little evidence that it provides any long-term benefit.

Remedial and preventive treatments

Performing remedial treatments early when a patient's throat begins to feel scratchy may help the infection from spreading to the rest of the throat and back of the mouth, which can result in difficulty in swallowing. Treatment should begin the first or second day of the illness, however if the patient has a cold or the flu, the infection may still continue to spread to other areas such as the ears through the eustachian tube (causing an earache) and to the lungs through the trachea (causing a cough). Healthy people who will be in frequent contact with someone with pharyngitis may also try the measures below, of which some can be also be preventive, to help inhibit the start of an infection.

  • The use of antibiotics is a helpful remedial treatment when a bacterial infection is the cause of the sore throat. For viral sore throats, antibiotics have no effect.
  • Honey has long been used for treating sore throats due to its antiseptic properties.[4]
  • Swallowing a couple teaspoons of raw lemon or lime juice several times a day may help destroy microorganisms in bacteria-related throat infections.[5] Research also shows that lemon juice may destroy some viruses such as HIV.[6] This remedy should be started during the first or second day of sickness because citric acid can irritate a patient's throat tissues after pharyngitis becomes too widespread. If this is the case, the patient may try a diluted solution of lemon, honey and tea (or lemon with hot water).

Medical treatment for Acute Pharyngitis

Topical therapy

Oral rinses were more effective in treating conditions affecting oral cavity and base of the tongue whereas sprays were more effective in coating the posterior pharynx and hence they were used to treat posterior pharynx conditions.[7]

Oral rinses
  • Salt water gargles which have been used since a long time have not shown any benefit in releiving throat pain . It is still used as it has minimal side effects.
  • Lidocaine, Diphenhydramine and Maalox (Aluminium hydroxide, magnesium hydroxide and simethicone) have shown to be helpful. This combination can be used to treat Coxsackie A or B infection or herpes simplex. Avoid using the lidocaine over its recommended use.[8][9]
  • Benzydamine hydrochloride rinses have shown to be help reduce the pain in a few cases. However, they are used more frequently to treat radiation mucositis.[10][11][12][13][14]
Sprays
  • Topical anesthetic sprays have been used in the past to treat pharyngitis , however their effect is not signigficant . They may also cause a few allergic reactions and side effects like methemoglobinemia and hence should not be used in children.
  • Chlorhexidine /benzydamine sprays are more effective in alleviating symptoms of acure viral pharyngitis and group A streptococcal pharyngitis.[15][16]
Lozenges
  • Medical throat lozenges help reducing the duration of symptoms and also provide with some sympotomatic relief. They do come with a few side effects similiar to sprays like methemoglobinemia. They are not recommended for children as there is a risk of choking Lozenges containing antisepotics, menthol , anesthetics and antiflammatory agents have been used.[17][18][19]

Systemic Therapy

Analgesics

Analgesics are prescribed for moderate to severe pain. Acetaminophen , Nonsteroidal antiinflammatory drugs (NSAID) have shown to decrease pain symptoms. They may also help in reducing fever and inflammation.[20][21][22][23][24][25]Aspirin should be avoided in children as it may cause Reye's syndrome .Only for severe pain codeine may be added to the NSAID.

Glucocorticoids

They may alleviate pain , and may also be beneficial in patients of Group A streptococcal pharyngitis. No benefits were obtained by adding single dose glucocorticoid to antimicrobial therapy in children.[26][27][28][29][30][31][32][33]Since there are safer and more effective alternatives than glucocorticoids for pain relief and their long term use come with a few side effects they not recommended for symptomatic relief of throat pain.However in a few conditions like infectious mononucleosis a short term may be help in alleviating pain.

Antibiotic therapy

  • Antibiotics should be used with caution in patients of pharyngitis as all patients do not necesarily need it . They may also cause some undesired complications or side effects. The rationale behind prescribing antibiotics is to prevent complications and secondary infections.[20][34].It may also allow for rapidly resuming usual activities and prevent spread to family, classmates, and other close contacts.[35]
  • Antibiotics are only needed or prescribed prophylactically for Group A beta-hemolytic streptococci (GAS) .Antibiotics may help in decreasing the duration of symptoms but a few studies have shown that analgesic have the a similiar or better effect .[20][36]
  • Antibiotics are prescribed for streptococcal pharyngitis to prevent suppurative infections like peritonsillar abscess, cervical lymphadenitis, mastoiditis and other invasive infections and non suppurative disorders like acute rheumatic fever and post streptococcal glomerulonephritis.
  • Inappropriate or overzealous use of antibiotics for treatment of pharyngitis is the major cause to antibiotic resistance.[37][38][39]
Antimicrobial Regimens
  • Diphtherial pharyngitis[40]
  • Preferred regimen (1): Erythromycin (PO or by IV) for 14 days (40 mg/kg per day with a maximum of 2 g/d)
  • Preferred regimen (2): Procaine penicillin G given IM for 14 days (300,000 U/d for patients weighing <10 kg and 600,000 U/d for those weighing >10 kg).
  • Preferred regimen (2): Erythromycin
  • Preferred regimen (3): Rifampin
  • Preferred regimen (4): Clindamycin
  • Acute
  • Children:
  • Preferred regimen: Penicillin V PO 250 mg twice daily or 3 times daily
  • Adolescents and adults:
  • Preferred regimen (1): Penicillin V PO 250 mg 4 times daily or 500 mg twice daily for 10 days
  • Preferred regimen (2): Amoxicillin 50 mg/kg once daily (max = 1000 mg) alternate:25 mg/kg (max = 500 mg) twice daily for 10 days
  • Preferred regimen (3): Benzathine Penicillin G I.M 27 kg: 600 000 U; ≥27 kg: 1 200 000 U 1 dose only
  • Preferred regimen (4): Cephalexin PO 20 mg/kg/dose twice daily (max = 500 mg/dose)for 10 days
  • Alternative regimen (1): Cefadroxil PO 30 mg/kg OD (max = 1 g) for 10 days
  • Alternative regimen (2): Clindamycin PO 7 mg/kg/dose 3 times daily (max = 300 mg/dose) for 10 days
  • Alternative regimen (3): AzithromycinPO 12 mg/kg once daily (max = 500 mg) for 5 days
  • Alternative regimen (4): Clarithromycin PO 7.5 mg/kg/dose twice daily (max = 250 mg/dose) for 10 days

Chronic Carriers of Group A Streptococci

Antimicrobial therapy is not indicated for majority of chronic carriers. A few conditions where antibiotics are recommended are:

  1. An outbreak of rheumatic fever, acute poststreptococcal glomerulonephritis or invasive GAS infection .
  2. Closed community outbreak of GAS pharyngitis.
  3. Family history of acute rheumatic fever.
  4. Excessive anxiety about rheumatic fever
  5. If tonsillectomy in considered because of carriage.

Antimicrobial Regimens

  • Chronic carriers of group A streptococci
  • Preferred regimen (1): Clindamycin 20–30 mg/kg/d in 3 doses (max = 300 mg/dose) for 10 days
  • Preferred regimen (2): Penicillin AND Rifampin; Penicillin V: 50 mg/kg/d in 4 doses × 10 d (max = 2000 mg/d) ;rifampin: 20 mg/kg/d in 1 dose × last 4 d of treatment (max = 600 mg/d) for 10 days AND Amoxicillin–Clavulanate 40 mg amoxicillin/kg/d in 3 doses (max = 2000 mg amoxicillin/d) for 10 days
  • Preferred regimen (3): Benzathine penicillin G IM 600 000 U for <27 kg and 1 200 000 U for ≥27 kg single dose AND Rifampin PO 20 mg/kg/d in 2 doses (max = 600 mg/d) for 4 days

References

  1. ↑ 1.0 1.1 Bisno, AL. (1996). "Acute pharyngitis: etiology and diagnosis". Pediatrics. 97 (6 Pt 2): 949–54. PMID 8637780. Unknown parameter |month= ignored (help)
  2. ↑ 2.0 2.1 Thomas M, Del Mar CB, Glasziou P. (2000). "How effective are treatments other than antibiotics for acute sore throat?" (PDF). Br J GP. 50 (459): 817–820. PMID 11127175.
  3. ↑ "Sore throat: Self-care - MayoClinic.com". Retrieved 2007-09-17.
  4. ↑ Ramoutsaki I, Papadakis C, Ramoutsakis I, Helidonis E (2002). "Therapeutic methods used for otolaryngological problems during the Byzantine period". Ann. Otol. Rhinol. Laryngol. 111 (6): 553–7. PMID 12090712.
  5. ↑ "USE OF CITRIC ACID AS ANTIMICROBIAL AGENT OR ENHANCER OR AS ANTICANCER AGENT - SHANBROM TECH LLC".
  6. ↑ "Lemon juice may kill AIDS virus: research - ABC News (Australian Broadcasting Corporation)".
  7. ↑ Patel, SK.; Ghufoor, K.; Jayaraj, SM.; McPartlin, DW.; Philpott, J. (1999). "Pictorial assessment of the delivery of oropharyngeal rinse versus oropharyngeal spray". J Laryngol Otol. 113 (12): 1092–4. PMID 10767923. Unknown parameter |month= ignored (help)
  8. ↑ Hess, GP.; Walson, PD. (1988). "Seizures secondary to oral viscous lidocaine". Ann Emerg Med. 17 (7): 725–7. PMID 3382075. Unknown parameter |month= ignored (help)
  9. ↑ Gonzalez del Rey, J.; Wason, S.; Druckenbrod, RW. (1994). "Lidocaine overdose: another preventable case?". Pediatr Emerg Care. 10 (6): 344–6. PMID 7899121. Unknown parameter |month= ignored (help)
  10. ↑ Turnbull, RS. (1995). "Benzydamine Hydrochloride (Tantum) in the management of oral inflammatory conditions". J Can Dent Assoc. 61 (2): 127–34. PMID 7600413. Unknown parameter |month= ignored (help)
  11. ↑ Passàli, D.; Volonté, M.; Passàli, GC.; Damiani, V.; Bellussi, L. (2001). "Efficacy and safety of ketoprofen lysine salt mouthwash versus benzydamine hydrochloride mouthwash in acute pharyngeal inflammation: a randomized, single-blind study". Clin Ther. 23 (9): 1508–18. PMID 11589263. Unknown parameter |month= ignored (help)
  12. ↑ Wethington, JF. (1985). "Double-blind study of benzydamine hydrochloride, a new treatment for sore throat". Clin Ther. 7 (5): 641–6. PMID 3902241.
  13. ↑ Epstein, JB.; Silverman, S.; Paggiarino, DA.; Crockett, S.; Schubert, MM.; Senzer, NN.; Lockhart, PB.; Gallagher, MJ.; Peterson, DE. (2001). "Benzydamine HCl for prophylaxis of radiation-induced oral mucositis: results from a multicenter, randomized, double-blind, placebo-controlled clinical trial". Cancer. 92 (4): 875–85. PMID 11550161. Unknown parameter |month= ignored (help)
  14. ↑ Kim, JH.; Chu, FC.; Lakshmi, V.; Houde, R. (1986). "Benzydamine HCl, a new agent for the treatment of radiation mucositis of the oropharynx". Am J Clin Oncol. 9 (2): 132–4. PMID 3521255. Unknown parameter |month= ignored (help)
  15. ↑ Cingi, C.; Songu, M.; Ural, A.; Erdogmus, N.; Yildirim, M.; Cakli, H.; Bal, C. (2011). "Effect of chlorhexidine gluconate and benzydamine hydrochloride mouth spray on clinical signs and quality of life of patients with streptococcal tonsillopharyngitis: multicentre, prospective, randomised, double-blinded, placebo-controlled study". J Laryngol Otol. 125 (6): 620–5. doi:10.1017/S0022215111000065. PMID 21310101. Unknown parameter |month= ignored (help)
  16. ↑ Cingi, C.; Songu, M.; Ural, A.; Yildirim, M.; Erdogmus, N.; Bal, C. (2010). "Effects of chlorhexidine/benzydamine mouth spray on pain and quality of life in acute viral pharyngitis: a prospective, randomized, double-blind, placebo-controlled, multicenter study". Ear Nose Throat J. 89 (11): 546–9. PMID 21086279. Unknown parameter |month= ignored (help)
  17. ↑ Bisno, AL. (2001). "Acute pharyngitis". N Engl J Med. 344 (3): 205–11. doi:10.1056/NEJM200101183440308. PMID 11172144. Unknown parameter |month= ignored (help)
  18. ↑ Watson, N.; Nimmo, WS.; Christian, J.; Charlesworth, A.; Speight, J.; Miller, K. (2000). "Relief of sore throat with the anti-inflammatory throat lozenge flurbiprofen 8.75 mg: a randomised, double-blind, placebo-controlled study of efficacy and safety". Int J Clin Pract. 54 (8): 490–6. PMID 11198725. Unknown parameter |month= ignored (help)
  19. ↑ "Flurbiprofen: new indication. Lozenges: NSAIDs are not to be taken like sweets!". Prescrire Int. 16 (87): 13. 2007. PMID 17323518. Unknown parameter |month= ignored (help)
  20. ↑ 20.0 20.1 20.2 20.3 Thomas, M.; Del Mar, C.; Glasziou, P. (2000). "How effective are treatments other than antibiotics for acute sore throat?". Br J Gen Pract. 50 (459): 817–20. PMID 11127175. Unknown parameter |month= ignored (help)
  21. ↑ Gehanno, P.; Dreiser, RL.; Ionescu, E.; Gold, M.; Liu, JM. (2003). "Lowest effective single dose of diclofenac for antipyretic and analgesic effects in acute febrile sore throat". Clin Drug Investig. 23 (4): 263–71. PMID 17535039.
  22. ↑ Schachtel, BP.; Thoden, WR. (1993). "A placebo-controlled model for assaying systemic analgesics in children". Clin Pharmacol Ther. 53 (5): 593–601. PMID 8491069. Unknown parameter |month= ignored (help)
  23. ↑ Bertin, L.; Pons, G.; d'Athis, P.; Lasfargues, G.; Maudelonde, C.; Duhamel, JF.; Olive, G. (1991). "Randomized, double-blind, multicenter, controlled trial of ibuprofen versus acetaminophen (paracetamol) and placebo for treatment of symptoms of tonsillitis and pharyngitis in children". J Pediatr. 119 (5): 811–4. PMID 1941391. Unknown parameter |month= ignored (help)
  24. ↑ Benarrosh, C. "[Multicenter double blind study of tiaprofenic acid versus placebo in tonsillitis and pharyngitis in children]". Arch Fr Pediatr. 46 (7): 541–6. PMID 2688592.
  25. ↑ Eccles, R.; Loose, I.; Jawad, M.; Nyman, L. (2003). "Effects of acetylsalicylic acid on sore throat pain and other pain symptoms associated with acute upper respiratory tract infection". Pain Med. 4 (2): 118–24. PMID 12873261. Unknown parameter |month= ignored (help)
  26. ↑ Olympia, RP.; Khine, H.; Avner, JR. (2005). "Effectiveness of oral dexamethasone in the treatment of moderate to severe pharyngitis in children". Arch Pediatr Adolesc Med. 159 (3): 278–82. doi:10.1001/archpedi.159.3.278. PMID 15753273. Unknown parameter |month= ignored (help)
  27. ↑ O'Brien, JF.; Meade, JL.; Falk, JL. (1993). "Dexamethasone as adjuvant therapy for severe acute pharyngitis". Ann Emerg Med. 22 (2): 212–5. PMID 8427434. Unknown parameter |month= ignored (help)
  28. ↑ Bulloch, B.; Kabani, A.; Tenenbein, M. (2003). "Oral dexamethasone for the treatment of pain in children with acute pharyngitis: a randomized, double-blind, placebo-controlled trial". Ann Emerg Med. 41 (5): 601–8. doi:10.1067/mem.2003.136. PMID 12712025. Unknown parameter |month= ignored (help)
  29. ↑ Marvez-Valls, EG.; Stuckey, A.; Ernst, AA. (2002). "A randomized clinical trial of oral versus intramuscular delivery of steroids in acute exudative pharyngitis". Acad Emerg Med. 9 (1): 9–14. PMID 11772663. Unknown parameter |month= ignored (help)
  30. ↑ Roy, M.; Bailey, B.; Amre, DK.; Girodias, JB.; Bussières, JF.; Gaudreault, P. (2004). "Dexamethasone for the treatment of sore throat in children with suspected infectious mononucleosis: a randomized, double-blind, placebo-controlled, clinical trial". Arch Pediatr Adolesc Med. 158 (3): 250–4. doi:10.1001/archpedi.158.3.250. PMID 14993084. Unknown parameter |month= ignored (help)
  31. ↑ Niland, ML.; Bonsu, BK.; Nuss, KE.; Goodman, DG. (2006). "A pilot study of 1 versus 3 days of dexamethasone as add-on therapy in children with streptococcal pharyngitis". Pediatr Infect Dis J. 25 (6): 477–81. doi:10.1097/01.inf.0000219469.95772.3f. PMID 16732143. Unknown parameter |month= ignored (help)
  32. ↑ Wing, A.; Villa-Roel, C.; Yeh, B.; Eskin, B.; Buckingham, J.; Rowe, BH. (2010). "Effectiveness of corticosteroid treatment in acute pharyngitis: a systematic review of the literature". Acad Emerg Med. 17 (5): 476–83. doi:10.1111/j.1553-2712.2010.00723.x. PMID 20536799. Unknown parameter |month= ignored (help)
  33. ↑ Hayward, G.; Thompson, MJ.; Perera, R.; Glasziou, PP.; Del Mar, CB.; Heneghan, CJ. (2012). "Corticosteroids as standalone or add-on treatment for sore throat". Cochrane Database Syst Rev. 10: CD008268. doi:10.1002/14651858.CD008268.pub2. PMID 23076943.
  34. ↑ 34.0 34.1 Spinks, A.; Glasziou, PP.; Del Mar, CB. (2013). "Antibiotics for sore throat". Cochrane Database Syst Rev. 11: CD000023. doi:10.1002/14651858.CD000023.pub4. PMID 24190439.
  35. ↑ Lindbaek, M.; Francis, N.; Cannings-John, R.; Butler, CC.; Hjortdahl, P. (2006). "Clinical course of suspected viral sore throat in young adults: cohort study". Scand J Prim Health Care. 24 (2): 93–7. doi:10.1080/02813430600638227. PMID 16690557. Unknown parameter |month= ignored (help)
  36. ↑ Bradley, CP. (2000). "Taking another look at the acute sore throat". Br J Gen Pract. 50 (459): 780–1. PMID 11127165. Unknown parameter |month= ignored (help)
  37. ↑ Linder, JA.; Bates, DW.; Lee, GM.; Finkelstein, JA. (2005). "Antibiotic treatment of children with sore throat". JAMA. 294 (18): 2315–22. doi:10.1001/jama.294.18.2315. PMID 16278359. Unknown parameter |month= ignored (help)
  38. ↑ Linder, JA.; Chan, JC.; Bates, DW. (2006). "Evaluation and treatment of pharyngitis in primary care practice: the difference between guidelines is largely academic". Arch Intern Med. 166 (13): 1374–9. doi:10.1001/archinte.166.13.1374. PMID 16832002. Unknown parameter |month= ignored (help)
  39. ↑ McCaig, LF.; Besser, RE.; Hughes, JM. (2002). "Trends in antimicrobial prescribing rates for children and adolescents". JAMA. 287 (23): 3096–102. PMID 12069672. Unknown parameter |month= ignored (help)
  40. ↑ The first version of this article was adapted from the CDC document "Diphtheria - 1995 Case Definition" athttp://www.cdc.gov/epo/dphsi/casedef/diphtheria_current.htm. As a work of an agency of the U.S. Government without any other copyright notice it should be available as a public domain resource.
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