Pharyngitis, Tonsillitis & Sore Throat
Pharyngitis - inflammation of the pharyngeal mucosa
This is simply inflammation of the pharynx. It come in two main forms: acute and chronic. In the acute form the cause is almost always a virus (e.g. rhinovirus, herpes simplex, Epstein-Barr, RSV). The chronic form is different in this regard. Here, chronic irritation by smoke, stomach acid, irritant foods or alcohol are the common causative agents.
These are often very subtle. Some erythema of the pharyngeal mucosa will be seen in acute cases and there may be an exudate. However, bacterial pharyngitis will usually produce a greater amount of exudate.
Depending upon the infecting virus you may see vesicles (HSV), enlargement of the tonsils with exudate (Epstein-Barr), and signs in other areas affected by the virus such as in the nose or eyes.
Simple acute pharyngitis can be treated initially with good analgesia, fluids and rest.
If other conditions are associated with it then treatment should be directed at those as well. For example, steroids may needed in a case of Epstein-Barr infection (Glandular fever / infectious mononucleosis) or antivirals for HSV.
In chronic pharyngitis treatment is directed at the underlying cause. Stop smoking, manage reflux, improve hygiene at work and changing diet can all help.
Tonsillitis - inflammation of the tonsillar tissues
Commonest cause is viral
Bacterial cause suspected if lasting >3 days or systemic illness
Odynophagia & dysphagia
Earache (referred pain)
Usually, self limiting, however systemic illness and dehydration can follow if oral intake is reduced.
Systemic features include pyrexia, tachycardia & other signs of sepsis
Airway compromise is very rare, more commonly seen in the complications from tonsillitis (see below)
Swollen/ erythematous tonsils
Exudate on tonsils *
Cervical lymphadenopathy *
Stertor (not to be confused with stridor!)
* Signs suggestive of possible bacterial infection
Simple uncomplicated tonsillitis can be treated initially with good analgesia.
Antibiotics are reserved for patients where a possible bacterial cause is suspected. A prolonged illness may suggest a superimposed bacterial infection.
In severe cases or where the patient is unable to eat and drink and/or is systemically unwell a brief admission for IV antibiotics, steroids and fluid rehydration may be needed. Patients can often be discharged when able to manage oral intake after a few hours of IV treatment.
Caution advised in immunocompromised patients e.g. diabetics. These patients are at higher risk of complications.
Please see the ABMU ENT departmental guidelines below for more information and a treatment algorithm.
Glandular fever (infectious mononucleosis)
Caused by the Epstein-Barr virus (EBV), which is transmitted via the infected patient's saliva through coughing, sneezing and kissing hence the term "kissing disease".
Symptoms are similar to those found in tonsillitis, however, are often more severe and prolonged. Pyrexia of >38, marked fatigue (often prolonged) are common complaints.
Other symptoms include abdominal discomfort and systemic illness.
Swollen pus filled tonsils
Stertor (secondary to very enlarged tonsils)
GF is a clinical diagnosis. Bloods tests do exist including a monospot test, however, these tests are unreliable and are used as an aid only.
Treated the same way as tonsillitis, however, advise on avoidance of contact sports and abdominal trauma for at least 6 weeks must be given. Traumatic splenic rupture and airway compromise and potentially lethal complications if not safety netted against.
Complications of tonsillitis
A complication of tonsillitis is seen in a "peritonsillar abscess" or "quinsy". Classically presenting a few days after the onset of tonsillitis with worsening symptoms.
Symptoms of tonsillitis
Trismus (reduced mouth opening)
"Hot potato" voice
Peritonsillar swelling/ erythema
Erythematous/ swollen anterior arch of oropharynx
Deviation of the uvula to opposite side
Involved tonsil pushed medially
Right peritonsillar abscess (Quinsy)
Unilateral peritonsillar erythema in the absence of above can be described as a peritonsillar cellulitis or an early quinsy.
(note unilateral tonsillar swelling is not a quinsy, asymmetrical tonsils are common)
IV antibiotics and steroids as with severe tonsillitis are key. In addition to this drainage of the quinsy should be conducted.
Drainage can be performed in two main ways under local anaesthetic;
- incision and drainage (usually reserved for recurrent quinsy)
This often provides instant relief and patients can often be discharged a few hours later if symptoms have improved.
The image shows one method of draining quinsy, by using a stab incision over the abscess itself and then stretching open the cut with forceps or scissors.
Other Causes of Sore Throat
Soreness in the throat may signify a number of conditions apart from those mentioned above. Particularly important are life-threatening conditions such as epiglottitis, supraglottitis, and a deep neck space abscess. These often present with significant systemic illness and disproportionate pain with a normal appearing oropharynx. Other signs & symptoms of such conditions include;
Significant dysphagia (even to their own saliva)
These conditions require emergency referral to the ENT department!
Head and neck malignancy
Malignancy in the oropharynx, larynx or pharynx are an important differential diagnosis and must be considered in cases of persisting pain. Pain is unlikely to be the only symptom in cases of malignancy. Please see the page on red flags for further information.
In cases of persisting throat pain a good history is essential. Have suspicion that a malignancy is present if no other cause can be found and perform a neck, oral and laryngeal examination.
If a malignancy is found CT/MRI, CXR and ultrasound examinations will follow and a biopsy will be required.
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