Clinical Manifestations

Symptoms of pharyngitis depend on the etiology. Sore throat is the most common symptom associated with pharyngitis and represents the third most common complaint encountered in office-based medicine (2,3). Dysphagia, odynophagia, ear pain, fever, and malaise are other associated symptoms. Airway obstruction presents less commonly. Noninfectious inflammatory conditions may cause a similar constellation of symptoms without fever and malaise. Less frequently encountered symptoms include globus sensation, voice changes, snoring, nasal congestion, and frequent throat clearing (4). Neoplasms occurring within the

TABLE 1 Etiology of Pharyngitis/Adenotonsillitis

I. Infection

A. Bacterial

1. Streptococcus

2. Arcanobacterium haemolyticum

3. Neisseria gonorrhea

4. Corynebacterium diphtheriae

5. Bordetella pertussis

6. Treponema pallidum

7. Fusobacterium necrophorum

8. Mycobacterium (tuberculosis, avium, intracellulare, kansasii, scrofulaceum)

9. Other bacterium (Mycoplasm, Francisella, Chlamydia, Anaerobes)

B. Viral

1. Adenovirus

2. "Common cold" viruses (rhinovirus, coronavirus, parainfluenza virus, and influenza virus)

3. Epstein-Barr virus

4. Cytomegalovirus

5. Coxsackie virus

6. Herpes simplex virus

7. Measles

8. Human immunodeficiency virus

9. Other viruses

C. Fungal

1. Candidiasis

2. Aspergillosis

3. Other mycosis

II. Neoplasms

A. Hematological cancer

B. Epithelial cell cancer

C. Salivary cancer

III. Inflammatory/autoimmune disease

A. Wegener's granulomatosis

B. Sarcoidosis

C. Crohn's disease

D. Extraesophageal reflux disease

E. Pemphigus

F. Bullous pemphigoid

G. Cicatricial pemphigoid

H. Epidermolysis bullosa

I. Stevens-Johnson syndrome J. Behgefs disease

IV. Iatrogenic

A. Radiation

B. Medications

V. Nutritional

A. Vitamin deficiency

B. Dehydration pharynx produce similar symptoms but complaints are typically unilateral, in contrast to infectious or inflammatory conditions, which are bilateral. Dehydration and acute weight loss secondary to dysphagia occur with pharyngitis of any cause. Chronic progressive weight loss over several months is common in neoplastic etiologies. Cervical lymphadenopathy may be present with either infectious or neoplastic etiologies.

Erythema of the pharyngeal mucosa is the hallmark physical exam finding of pharyngitis. Tonsillar enlargement in patients with recurrent pharyngitis may be present.

FIGURE 1 Normal adenoid tissue in the nasopharynx.

Tonsil size is commonly graded on a scale of one to four, with grade 1 tonsils being contained within the tonsillar pillars and grade 4 tonsils touching at the midline of the oropharynx (Fig. 2). Normal tonsils are often cryptic and may contain debris within the crypts, called tonsilliths. The adenoid bed may also be enlarged when viewed with mirror examination or through nasal endoscopy. The adenoid tissue contains more folds than crypts when compared with the palatine tonsils. A whitish-gray exudate covering the pharyngeal mucosa may result from sloughing epithelial cells (Fig. 3). Mucosal changes such as ulceration, petechiae, or maculopapules are common in noninfectious etiologies and warrant further examination.

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