eMedicine Specialties > Emergency Medicine > Ear, Nose, & Throat
Pharyngitis: Differential Diagnoses & Workup
Updated: Aug 10, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Differential Diagnoses
Other Problems to Be Considered
Allergic rhinitis with postnasal drip
Airway obstruction
Head and neck neoplasias
Gastroesophageal reflux disease (GERD)
Peritonsillar cellulitis
Workup
Laboratory Studies
- GABHS rapid antigen detection test
Rapid antigen detection test for group A beta-hemolytic streptococci.
- This is the preferred method for diagnosing GAS infection in the emergency department because of difficulties with culture follow-up.
- Only patients with a high clinical likelihood of GAS pharyngitis should be tested. Patients with a Centor score of 0-1 should be treated symptomatically without testing.10
- Antigens are specific, but sensitivities vary. Children with a negative antigen test should have a follow-up culture unless the antigen being used in the office has been shown to be as sensitive as a culture.9
- Adults do not need follow-up culture after a negative antigen test because of the low incidence of GAS in this population.11
- Throat culture
- This is the criterion standard for diagnosis of GAS infection (90-99% sensitive). Although less expensive than the rapid antigen detection test, it is not be the best test to use in the emergency department because of difficulty with follow-up. The guidelines that recommend cultures for GAS screening are aimed at office-based practices and not the emergency department.
- Patients can be treated up to 9 days after onset of symptoms to prevent acute rheumatic fever, so immediate antibiotic therapy is not crucial if patients can be easily contacted for follow-up should a culture become positive.1
- Mono spot is up to 95% sensitive in children (less than 60% sensitivity in infants).
- Peripheral smear may show atypical lymphocytes in infectious mononucleosis.2
- Perform gonococcal culture, as indicated by history.
- A complete blood count (CBC), erythrocyte sedimentation rate (ESR), and C-reactive protein have a low predictive value and usually are not indicated.
Imaging Studies
- Imaging studies generally are not indicated for uncomplicated viral or streptococcal pharyngitis.
- Lateral neck film should be taken in patients with suspected epiglottitis or airway compromise.
- Soft tissue neck CT should be used if concern for abscess or deep-space infection exists.
Procedures
- The procedure for a throat swab is to vigorously rub a dry swab over the posterior pharynx and both tonsils, obtaining a sample of exudate. If any exudate is obtained, then transport it dry (not in a liquid medium).
More on Pharyngitis |
| Overview: Pharyngitis |
 Differential Diagnoses & Workup: Pharyngitis |
| Treatment & Medication: Pharyngitis |
| Follow-up: Pharyngitis |
| Multimedia: Pharyngitis |
| References |
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References
Alcaide AL, Bisno AL. Pharyngitis and epiglotittis. Infect Dis Clin North Am. 2006;21:449-469.
Twefik TL, Al Garni M. Tonsillopharyngitis: Clinical highlights. J of Otolaryngology. 2005;34.
Mostov PD. Treating the immunocompetent patient who presents with an upper respiratory infection: pharyngitis, sinusitis, and bronchitis. Prim Care. Mar 2007;34(1):39-58. [Medline].
Pichichero ME, Casey JR. Systematic review of factors contributing to penicillin treatment failure in Streptococcus pyogenes pharyngitis. Otolaryngol Head Neck Surg. Dec 2007;137(6):851-857. [Medline].
Gerber MA, Baltimore RS, Eaton CB, et al. Prevention of rheumatic fever and diagnosis and treatment of acute Streptococcal pharyngitis: a scientific statement from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee of the Council on Cardiovascular Disease in the Young, the Interdisciplinary Council on Functional Genomics and Translational Biology, and the Interdisciplinary Council on Quality of Care and Outcomes Research: endorsed by the American Academy of Pediatrics. Circulation. Mar 24 2009;119(11):1541-51. [Medline].
Centor RM, Allison JJ, Cohen SJ. Pharyngitis management: defining the controversy. J Gen Intern Med. Jan 2007;22(1):127-30. [Medline].
[Guideline] Bisno AL, Gerber MA, Gwaltney JM Jr, Kaplan EL, Schwartz RH. Practice guidelines for the diagnosis and management of group A streptococcal pharyngitis. Infectious Diseases Society of America. Clin Infect Dis. Jul 15 2002;35(2):113-25. [Medline].
Wagner FP, Mathiason MA. Using centor criteria to diagnose streptococcal pharyngitis. Nurse Pract. Sep 2008;33(9):10-2. [Medline].
Gerber MA. Diagnosis and treatment of pharyngitis in children. Pediatr Clin North Am. Jun 2005;52(3):729-47, vi. [Medline].
[Best Evidence] Tanz RR, Gerber MA, Kabat W, Rippe J, Seshadri R, Shulman ST. Performance of a rapid antigen-detection test and throat culture in community pediatric offices: implications for management of pharyngitis. Pediatrics. Feb 2009;123(2):437-44. [Medline].
Cooper RJ, Hoffman JR, Bartlett JG, et al. Principles of appropriate antibiotic use for acute pharyngitis in adults: background. Ann Emerg Med. Jun 2001;37(6):711-9. [Medline].
Patel NN, Patel DN. Acute exudative tonsillitis. Am J Med. Jan 2009;122(1):18-20. [Medline].
Del Mar CB, Glasziou PP, Spinks AB. Antibiotics for sore throat (Review). The Cochrane Collaboration. 2007;(1):1-41.
Tasar A, Yanturali S, Topacoglu H, Ersoy G, Unverir P, Sarikaya S. Clinical efficacy of dexamethasone for acute exudative pharyngitis. J Emerg Med. Nov 2008;35(4):363-7. [Medline].
Matthys J, De Meyere M, van Driel ML, De Sutter A. Differences among international pharyngitis guidelines: not just academic. Ann Fam Med. Sep-Oct 2007;5(5):436-43. [Medline].
Van Howe RS, Kusnier LP 2nd. Diagnosis and management of pharyngitis in a pediatric population based on cost-effectiveness and projected health outcomes. Pediatrics. Mar 2006;117(3):609-19. [Medline].
Pichichero ME. Pathogen shifts and changing cure rates for otitis media and tonsillopharyngitis. Clin Pediatr (Phila). Jul 2006;45(6):493-502. [Medline].
Pichichero M, Casey J. Comparison of European and U.S. results for cephalosporin versus penicillin treatment of group A streptococcal tonsillopharyngitis. Eur J Clin Microbiol Infect Dis. Jun 2006;25(6):354-64. [Medline].
Brook I. Overcoming penicillin failures in the treatment of Group A streptococcal pharyngo-tonsillitis. Int J Pediatr Otorhinolaryngol. Oct 2007;71(10):1501-8. [Medline].
Depdham D, Rao S, Hitchcock K. Should you treat carriers of pharyngeal group A strep?. J Fam Pract. 2008;57.
[Best Evidence] Altamimi S, Khalil A, Khalaiwi KA, Milner R, Pusic MV, Al Othman MA. Short versus standard duration antibiotic therapy for acute streptococcal pharyngitis in children. Cochrane Database Syst Rev. Jan 21 2009;CD004872. [Medline].
Further Reading
Keywords
pharyngitis, infection of pharynx, irritation of pharynx, infection of tonsils, irritation of tonsils, group A beta-hemolytic streptococcal infections, GABHS infections, bacterial pharyngitis, viral pharyngitis, acute rheumatic fever, acute glomerulonephritis, upper respiratory infections, heart valve damage, Streptococcus pyogenes, rhinovirus, adenovirus, peritonsillar abscess, toxic shock syndrome, Mycoplasma pneumoniae, Chlamydia pneumoniae, Arcanobacterium haemolyticus, rhinorrhea, gonococcal pharyngitis, coxsackievirus A, coxsackievirus B, herpes simplex, infectious mononucleosis, cytomegalovirus, CMV, odynophagia, tonsillopharyngeal petechiae, palatal petechiae, hand-foot-and-mouth disease, cervical lymphadenopathy, acute lymphoglandular syndrome, hepatosplenomegaly, scarlet fever, meningitis, endocarditis, subdural empyemas, Neisseria gonorrhoeae, Corynebacterium diphtheriae, Epstein-Barr virus, EBV, HIV-1, oral thrush, gastroesophageal reflux disease, GERD, endotracheal intubation, allergy, postnasal drip
