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.

Signs

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.

Treatment

 

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"

 

Aetiology

Commonest cause is viral

Bacterial cause suspected if lasting >3 days or systemic illness

Symptoms 

Sore throat 

Odynophagia & dysphagia

Earache (referred pain)

Cough

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)

Signs

Swollen/ erythematous tonsils 

Exudate on tonsils *

Cervical lymphadenopathy *

Stertor (not to be confused with stridor!)

Pyrexia *

* Signs suggestive of possible bacterial infection

Treatment

 

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.

 

Signs

 

Swollen pus filled tonsils

Cervical lymphadenopathy 

Hepatosplenomegaly 

Stertor (secondary to very enlarged tonsils)

 

Investigations 

 

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

 

Quinsy

 

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

 

Symptoms of tonsillitis

Unilateral pain

Progressive dysphagia

Trismus (reduced mouth opening)

"Hot potato" voice

 

Signs

 

Trismus

Peritonsillar swelling/ erythema

Erythematous/ swollen anterior arch of oropharynx

Deviation of the uvula to opposite side

Involved tonsil pushed medially 

 

 

 

 

 

 

 

 

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)

Right peritonsillar abscess (Quinsy)

 

Treatment

 

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;

- needle aspiration

- 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.

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)

  • Trismus

  • Neck stiffness

  • Airway compromise 

  • Stridor 

 

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.

 

Investigations 

 

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.

 

 

Additional resources

If you haven't done so already check out the following linked resources 

 

 

Linked tutorials