Viral Pharyngitis Treatment & Management

Treatment strategies for patients with acute pharyngitis are based on epidemiologic factors, signs and symptoms, and results of laboratory tests.^[1] Rest, oral fluids, and salt-water gargling (for soothing effect) are the main supportive measures in patients with viral pharyngitis.^[2]

Analgesics and antipyretics may be used for relief of pain or pyrexia. Acetaminophen is the drug of choice. Traditionally, aspirin has been used, but it may increase viral shedding. Aspirin should not be used in children or adolescents, especially with influenza, because of its association with Reye syndrome. One study proved that ibuprofen was superior to acetaminophen for symptomatic relief in children aged 6-12 years. A double-blind randomized study involving adult patients from 27 study centers in Latin America found that 5 days of treatment with celecoxib 200 mg once daily is as effective as diclofenac 75 mg twice daily in the symptomatic treatment of viral pharyngitis.^[3]

Anesthetic gargles and lozenges, such as benzocaine, may be used for symptomatic relief. Hospitalization for intravenous hydration may be necessary when odynophagia is intense.

Antibiotics do not hasten recovery or reduce the frequency of bacterial complications. The risks of prescribing antibiotics in patients with viral pharyngitis include the common side effects of antibiotics (diarrhea, rashes, candidiasis, unplanned pregnancy secondary to oral-contraceptive failure) and the rare occurrence of anaphylaxis.^[4]

Specific treatment of viral infections is available for only a few viruses.

Influenza

Beginning treatment with one of the adamantanes (amantadine or rimantadine) within 48 hours of the onset of illness decreases the duration of symptoms in influenza A infection.^[5] However, both agents lack activity against influenza B infection, which is usually mild.

Adamantanes can be used in cases of presumed influenzal pharyngitis occurring during a known influenza type A epidemic. The major advantage of rimantadine is a low-risk risk of central nervous system effects, such as lightheadedness, difficulty concentrating, nervousness, and insomnia, which can be a significant problem with amantadine, particularly in elderly patients.

Ribavirin has helped patients severely ill with influenza A or B infections.

Newer neuraminidase inhibitors (inhaled zanamivir, oral oseltamivir) started within 30 hours of the onset of influenza can shorten the duration of symptoms.^[6] It was previously thought that oseltamivir reduces the risk of complications of influenza, such as such as pneumonia. However, the authors of the 2006 Cochrane review on this topic conceded in 2009 that the ability of oseltamivir to reduce postinfluenza complications in healthy adults was unknown due to their lack of ability to obtain original data.^{[7, 8]} Subsequently, this review was withdrawn from The Cochrane Library Issue 3, 2011. A new Cochrane protocol^[9] was recently developed to systematically review published and unpublished clinical study reports on effectiveness and harms of neuraminidase inhibitors for influenza in all age groups.

Updated information about influenza activity and antiviral resistance can be found on the Web sites of the US Centers for Disease Control and Prevention^[10] and the World Health Organization.^[11]

EBV infectious mononucleosis

Specific antiviral therapy with acyclovir, ganciclovir, and interferon alfa reduces viral shedding but does not improve clinical outcome.

Corticosteroids may improve the symptoms, but they are generally not recommended because infectious mononucleosis is usually benign and self-limited.

However, corticosteroids are indicated if the patient has massive tonsillar hypertrophy that threatens to obstruct the airway.

Herpes simplex virus

In an immunocompetent host, oral acyclovir, famciclovir, and valacyclovir decrease the duration of symptoms and viral shedding.

In an immunocompromised host, these drugs decrease pain and viral shedding and accelerate healing of lesions. These drugs are helpful in severely afflicted patients.

Acute retroviral syndrome

Several unique considerations favor antiretroviral therapy during this phase of HIV infection. Treatment may limit the extent of viral dissemination throughout the body, attenuate the progress of HIV infection by lowering the plasma viral RNA set point, and limit the extent of viral genetic variability, which is responsible for drug resistance.

Treatment may also allow salvage of a CD4 T-cell–specific immune response that may be important in the immune control of HIV infection.

Drinking large amounts of fluid is recommended. No specific dietary restrictions are needed. Soft, cold foods (eg, ice cream, popsicles) are more easily tolerated.

No restriction in activity is required.