Pharyngitis and Sinusitis

PHARYNGITIS AND SINUSITIS Study Notes

Objectives

  • Describe the symptoms and presentations of pharyngitis and sinusitis

  • Summarize treatments for pharyngitis and sinusitis

  • Learn concerning presentations of pharyngitis and sinusitis in primary care

  • Differentiate between viral and bacterial pharyngitis and sinusitis

Pharyngitis

  • Definition: Inflammation of the mucous membranes of the oropharynx; commonly referred to as a sore throat.

  • Differential Diagnoses:

    • Viral: Most common cause

    • Bacterial

    • Auto-immune

    • Non-infectious causes:

    • Gastroesophageal reflux disease (GERD)

    • Allergic rhinitis

    • Sinusitis

    • Smoking

    • Certain medications (e.g., ACE inhibitors)

  • Complications: Can arise if not appropriately managed.

Differential Diagnoses for Sore Throat

  • Strep Pharyngitis:

    • Caused by Group C and G Strep.

  • Other Causes:

    • Foreign body (FB) injury, referred pain, dental infection, otitis media, Mononucleosis (Mono), HIV, Herpes Simplex Virus (HSV), viral causes, Arcanobacterium haemolyticum, Neisseria gonorrhoeae, Corynebacterium diphtheriae (rare), Fusobacterium necrophorum, Lemierre syndrome.

Assessing for Airway Compromise

  • Key Indicators:

    • Voice changes: Muffled or "hot potato" voice

    • Hoarseness

    • Drooling or pooling of saliva

    • Stridor

    • Respiratory distress: Increased respiratory rate (RR) can be critical; check for retraction or dyspnea.

    • Tripod positioning: Indicates severe respiratory distress.

Concerning Symptoms

  • Signs to Note:

    • Severe pain

    • Patient appears toxic

    • Trismus (inability to open mouth)

    • Neck swelling

Viral Pharyngitis

Case Study: Sarah

  • Patient Profile: 35-year-old female with a sore throat and cold symptoms lasting 5 days.

  • Symptoms: Stuffy & runny nose, low-grade fever (100.6°F), headache, ear pressure, mild cough, body aches, and fatigue.

    • Denies nausea, vomiting, diarrhea, shortness of breath, and chest pain.

Vital Signs and Physical Exam (PE)

  • Vital Signs:

    • Temperature: 100.6°F

    • Pulse: 104

    • Blood Pressure: 110/76

    • Respiratory Rate: 18

    • Height: 5’6”

    • Weight: 160 lbs

  • General Appearance: Alert, moderately ill appearance

  • Throat Exam: Posterior pharynx redness, slight increase in tonsil size (2+), no exudate.

  • Tympanic Membranes (TMs): Grey and dull appearance, clear in all lobes (lungs).

  • Cervical Exam: Neck supple, no lymphadenopathy, cardiovascular examination (S1 S2 RRR, no murmurs).

Overview of Viral Pharyngitis

  • Incidence: Majority of pharyngitis is viral (50-80%).

    • Common Viruses:

    • Rhinovirus (20% of pharyngitis, 30-50% of URIs)

    • Other viruses include Adenovirus (usually presents with conjunctivitis), COVID-19, Epstein-Barr Virus, Influenza, Herpes Simplex Virus, Parainfluenza, Cytomegalovirus (CMV), Coronaviruses, Enteroviruses, Respiratory Syncytial Virus (RSV), HIV.

Common Presentation of Viral Pharyngitis

  • Symptoms:

    • Sore throat

    • Coughing

    • Rhinorrhea and nasal congestion

    • Conjunctivitis

    • Headache

    • Viral exanthem (skin rash)

Testing for Viral Pharyngitis

  • Testing Recommendations: Respiratory panels not routinely recommended in primary care unless using a “mini panel” with COVID, RSV, Influenza A/B. Exceptions include oncology patients, inpatient management, and concerns for other viral etiologies (HIV, EBV, etc.)

Treatment for Viral Pharyngitis

  • Options:

    • Ibuprofen or acetaminophen for pain relief

    • Throat lozenges, cough drops, hard candies

    • Gargling with salt water

    • Cool or warm drinks/snacks as per patient preference

    • Address other complaints

    • Consider the use of steroids?

    • Follow-up if symptoms persist or worsen.

Infectious Mononucleosis (Mono)

Case Study: Sally

  • Patient Profile: 20-year-old female with a persistent sore throat, low-grade fever, headache, and fatigue lasting for three weeks.

    • Attending classes at university, previously toured southern states.

Physical Exam Findings

  • Vital Signs:

    • Height: 5’7”, weight: 190 lbs

    • Blood Pressure: 120/70, pulse: 100, respiratory rate: 18

  • Appearance: Looks ill, potentially pale or in pain

  • Exams: Throat shows bilateral exudate, 3+ tonsils, neck supple with tender swollen bilateral posterior cervical nodes, abdomen soft and non-tender with active bowel sounds, no splenomegaly.

Overview of Mononucleosis

  • Cause: Most commonly caused by Epstein-Barr Virus (EBV), a type of herpes virus.

  • Symptoms:

    • Many remain asymptomatic; some develop infection known as mononucleosis (kind of mono).

    • Incubation Period: 4 to 7-8 weeks.

  • Transmission: Spread primarily through saliva (e.g., kissing, sharing utensils, etc.), can also spread sexually.

  • Oral shedding can occur for up to 18 months after the primary infection.

Common Presentation of Mono

  • Symptoms:

    • Headaches

    • Fever

    • Tonsillar hypertrophy

    • Lymphocytosis (increased lymphocytes) and atypical lymphocytes

    • Myalgia (muscle aches) and fatigue

    • Petechiae on the palate

    • Anterior or posterior cervical lymphadenopathy (posterior more common)

    • Assess for hepatomegaly or splenomegaly (~50% of patients).

Laboratory Findings in Mono

  • Findings:

    • White Blood Cell (WBC) count greater than 12,000 within 1-2 weeks of symptom onset.

    • Lymphocytosis: Absolute count > 4500/microL or a differential count > 50% on peripheral smear.

    • Monospot Test: Wait until 7-10 days after symptom onset for accuracy.

    • 85% sensitivity; 100% specificity, but less accurate in the first 2 weeks of clinical symptoms.

    • More Accurate Test: EBV specific panel.

Interpretation of EBV Testing

  • Testing outcomes:

    • No previous Infection/Susceptibility:

    • VCA-IgM: (-) VCA-IgG: (-) EBNA-IgG: (-)

    • Primary Infection (new or recent):

    • VCA-IgM: (+) VCA-IgG: (+) EBNA-IgG: (-)

    • Past Infection:

    • VCA-IgM: (-) VCA-IgG: (+) EBNA-IgG: (+)

Complications of Mono

  • Possible complications include:

    • Splenic rupture (rare but serious)

    • Airway obstruction

    • Hemolytic anemia or thrombocytopenia

    • Neurological complications (Guillain-Barré syndrome, meningitis, encephalitis)

    • Chronic EBV infection (very rare).

Treatment of Mono

  • Management:

    • Encourage fluids, rest, and humidification

    • Medications: Acetaminophen for fever and discomfort, NSAIDs as needed, steroids not routinely recommended.

    • Avoid contact sports for 4 weeks post-diagnosis and non-contact activities for 3 weeks.

Strep Pharyngitis

Case Study: Burt

  • Patient Profile: 28-year-old male with abrupt onset sore throat and fever.

    • Reports painful swallowing and diminished appetite with nausea (no vomiting).

Physical Examination Findings

  • Vital Signs:

    • Temperature: 101.8-102°F, Pulse: 128, Blood Pressure: 128/82, Weight: 165 lbs, Height: 5’11”

  • General Appearance: Ill-looking

  • Head and Neck Examination: No ear redness, nares normal, throat shows marked tonsillar, pharyngeal exudate, and anterior cervical lymphadenopathy.

  • Skin Assessment: Erythematous rash over trunk and forearms, resembling sandpaper.

Clinical Presentation of Strep

  • Symptoms:

    • Fever > 100.4°F

    • Sudden-onset sore throat

    • Tonsillopharyngeal or uvular edema

    • Patchy tonsillar or pharyngeal exudates

    • Tender cervical lymphadenitis

    • History of Group A Strep exposure, GI complaints (especially in children).

Diagnosis

  • Rapid Antigen Detection Test (RADT):

    • Generally sensitive within the 24 hours following the onset of symptoms.

    • Pros: Instant results, earlier diagnosis and treatment, inexpensive relative to cultures.

    • Gold Standard: Throat culture, with false positives being uncommon.

    • If RADT is negative, throat culture is recommended for children only if clinical suspicion remains high.

Centor Criteria for Strep Diagnosis

  1. Exudate present? (Yes: +1, No: 0)

  2. Tender swollen nodes? (Yes: +1, No: 0)

  3. Fever of 100.4°F? (Yes: +1, No: 0)

  4. Cough absent? (Yes: +1, No: 0)

    • Total Points: 4/5 (51-56% likelihood); treat if scoring points indicates need.

Treatment for Strep in Adults

  • Antibiotics:

    • Penicillin V 500 mg BID for 10 days

    • Amoxicillin 500 mg BID or 1 g daily for 10 days

    • PCN allergy alternatives: Cephalexin, Azithromycin, Clindamycin.

  • Symptomatic Relief: NSAIDs, acetaminophen, supportive treatment.

  • Return to Activities: Guidance on when patients can return to work or school.

Strep Carriers

  • Understanding Carriers: Presence of GAS in asymptomatic individuals, primarily children.

    • Low virulence means less likelihood of infecting others.

    • Distinguishing and management strategies for carriers when significant risks arise.

Complications of Strep Pharyngitis

  • Potential Issues:

    • Peritonsillar abscess

    • Retropharyngeal abscess

    • Rheumatic fever

    • Post-streptococcal glomerulonephritis

    • Prevention of these complications is the main reason for antibiotic treatment.

Peritonsillar Abscess

  • Presentation and Signs: Rapid tonsillar swelling (unilateral), increasing pain, dysphagia, and fever.

  • Treatment Protocols:

    • Airway management is crucial.

    • Administer pain relief, steroids, and antibiotics.

    • Referral to ED for I&D: Especially urgent cases.

Retropharyngeal Abscess

  • Symptoms: Stiff neck, difficulty swallowing, malaise.

  • Diagnostic Clues: Any URI can lead to retropharyngeal abscess. Requires urgent assessment and imaging.

  • Treatment: Emergency management required, including IV antibiotics.

Sinusitis

Overview

  • Definition: Inflammatory process in the paranasal sinuses; common in primary care.

  • Prevalence: 1 in 7 adults experience symptoms yearly; most cases are viral.

  • Classification:

    • Acute Sinusitis: Symptoms less than 4 weeks.

    • Subacute Sinusitis: 4-8 weeks.

    • Chronic Sinusitis: Symptoms lasting longer than 8 weeks.

    • Recurrent Acute Sinusitis: Three+ episodes per year with each episode lasting less than 2 weeks.

Case Study: Tucker

  • Patient Profile: 43-year-old male smoker with 3 weeks of cold symptoms, persistent nasal congestion, purulent discharge, headaches, low-grade fever, fatigue, slight sore throat, and cough.

Physical Exam Findings

  • PE: Ears with fluid but clear light reflex; nares hyperemic with purulent drainage; tenderness over maxillary sinuses; clear lung examination despite coughing.

Clinical Presentation of Sinusitis

  • Symptoms:

    • Maxillary toothache

    • Nasal congestion and obstruction

    • Purulent nasal discharge

    • Facial pain with bending

    • Abnormal trans-illumination findings

    • Poor response to decongestants

    • Localized facial tenderness

    • Additional symptoms: +/- fever, fatigue, cough, halitosis.

Criteria for Bacterial Sinusitis

  • Conditions to consider bacterial infection:

    • Severe: Temperature ≥ 102.2°F + facial pain/pressure + purulent discharge for 3 days or more.

    • Persistent: Purulent nasal drainage + facial pain/nasal obstruction that does not improve for ≥ 10 days.

    • Worsening: New or worsening symptoms after initial improvement (“double sickening”) following URIs lasting ≥ 7 days.

Antibiotic Stewardship in Sinusitis

  • Statistics: Nearly 50% of antibiotics prescribed for sinusitis are inappropriate due to either unnecessary use or the selection of the wrong agents.

  • Management Protocol:

    • If criteria for bacterial sinusitis are not met, provide symptomatic therapy only.

Treatment for Sinusitis

  • Medications:

    • Antibiotics: Most improve self-limiting, e.g., within 7 days, sometimes without treatment with antibiotics.

    • Decongestants: Oral or nasal (e.g., Afrin for a maximum of 3 days).

    • Antihistamines if indicated; increase fluid intake; Guaifenesin 600-1200 mg BID; inhaled nasal steroids, and nasal saline rinses

    • Fluticasone: An excellent choice for nasal spray.

Complications of Sinusitis

  • When to be concerned about complications?:

    • Look for severe headaches, periorbital edema, vision changes, abnormal extraocular movements, proptosis, cranial nerve palsies, altered mental status, painful eye movements, meningeal signs, and neck stiffness requiring immediate intervention (ER evaluation and CT).

Sinusitis Treatment Failure

  • Considerations: Rule out fungal causes in immunocompromised patients and address compliance with treatment; further imaging may be warranted if symptoms persist after the second course of treatment.

  • Differential Diagnoses: Consider other common conditions such as the common cold, allergic rhinitis, TMJ disorder, headaches, and dental infections as potential causes of similar symptoms.

References

  • Aronson, M. D., & Auwaerter, P. G. (2024, August 13). Infectious mononucleosis. In UpToDate.

  • Chow, A. W., & Doron, S. (2023, October 5). Evaluation of acute pharyngitis in adults. In UpToDate.

  • Pichichero, M. E. (2024, June 7). Treatment and prevention of streptococcal pharyngitis in adults and children. In UpToDate.

  • Wolford, R. W., Goyal, A., & Belgam Syed, S. Y. (2023, May 1). Pharyngitis. In StatPearls [Internet]. StatPearls Publishing.

  • Patel, Z. M., & Hwang, P. H. (2024). Acute sinusitis and rhinosinusitis in adults: Clinical manifestations and diagnosis. In UpToDate.

  • Patel, Z. M., & Hwang, P. H. (2024). Uncomplicated acute sinusitis and rhinosinusitis in adults: Treatment. In UpToDate.