Pharyngitis and laryngitis are inflammatory conditions affecting the upper airway. The majority of these inflammatory conditions are viral in origin and self-limiting. In adults, cigarette smoking and gastroesophageal reflux are major causes of chronic laryngitis, whilst in infants and children gastroesophageal reflux and viral and bacterial infections play the major role in etiology.
Symptoms that occur secondarily to the pathologic features of mucosal inflammation and submucosal edema include hoarseness, sore throat, cough, pain, or difficulty in swallowing or, occasionally, airway obstruction.
Diagnostic tests, depending on the presumptive diagnosis, may include bacterial culture and serology, histopathologic biopsy, barium radiography, or pH studies. Management may include avoidance or treatment of the underlying cause with viral conditions managed symptomatically, some bacterial infections treated with antibiotics and for more serious conditions such as epiglottitis (supraglottitis) and diphtheria occasionally requiring endotracheal intubation or tracheotomy.
Laryngitis is an inflammation of the larynx, which frequently results in hoarseness or loss of the voice. Laryngitis may be acute or chronic and the most common form associated with a viral upper respiratory tract infection is self-limiting although bacterial infection may also cause laryngitis in association with bronchitis or pneumonia. Chronic laryngitis is frequently seen in smokers, and also in adults with gastroesophageal reflux disease (GERD). In children acute laryngotracheobronchitis (croup) and epiglottitis (supraglottitis) can lead to severe or even fatal respiratory obstruction.
Pharyngitis is an inflammatory condition of the pharynx accompanied by a sore throat and occasionally difficulty in swallowing. It is usually viral but may be caused by bacterial or fungal infection. GERD or particularly extraesophageal reflux (EER) can also cause an acid pharyngitis in adults and children. Serious complications of pharyngitis may include peritonsillar abscess or retropharyngeal abscess, airway obstruction with infectious mononucleosis or rheumatic fever, glomerulonephritis, or bacteremia from group A beta hemolytic streptococcus (GABHS) infection.
Historically, laryngitis and pharyngitis have been known since the earliest medical writings but it is only in the last two centuries that visualization of the larynx has been achieved. The incidence of epiglottitis (supraglottitis) and diphtheria with severe airway obstruction and the need for urgent tracheotomy has declined precipitously since the introduction of vaccinations for both of these conditions.
Pharyngitis and laryngitis are relatively common conditions, especially those spread by viruses, and are more common in late winter and spring as is laryngotracheobronchitis (croup). Three to five per cent of children have at least one episode of croup and it reoccurs in about 5% of these cases. The majority of episodes occur between the ages of 6 months and 4 years, and boys are affected twice as commonly as girls.
It has been estimated that prior to the introduction of the Haemophilus influenzae (Hib) vaccine, there were between 3.2 and 8.6 cases of epiglottitis (supraglottitis) per 10 000 pediatric hospital admissions.
The major etiologic causes of laryngitis are shown in bullet list 1and include infective, allergic, and traumatic causes.
Bullet list 1: Etiology of laryngitis
- Common cold virus
- Influenza virus
- Parainfluenza virus
- Respiratory syncytial virus
- Herpes simplex viruses
- Haemophilus influenzae
- Candida albicans
- Vocal cord abuse
The great majority of cases of laryngitis, both acute and chronic, are caused by infective agents and GERD in children and adults, as well as cigarette smoking in adults. Vocal cord abuse in both age groups is another common cause of laryngitis. Viral croup covers a group of infections caused by viruses, including laryngotracheitis, laryngotracheobronchitis, and spasmodic croup. The organisms involved include adenoviruses, influenza viruses, parainfluenza virus, rhinovirus, and respiratory syncytial viruses. In addition, there are other factors that predispose a child to croup, including cold temperatures, low humidity, pollution, and passive smoking, as well as EER. In pediatric patients, epiglottitis (supraglottitis) is almost always caused by H. influenzae infection although Streptococcus pneumoniae, Streptococcus group A, B, and C, Staphylococcus aureus, Pseudomonas aeruginosa, Candida, and Herpes simplex viruses have been implicated in less than 1% of cases in this age group and usually in immunocompromised patients.
Diphtheria remains endemic in many developing countries although it has virtually disappeared from most developed countries with the introduction of diphtheria toxoid and immunization programs. The causative organism is Corynebacterium diphtheriae.
GERD and, in particular, EER affect the larynx giving a high incidence of hoarseness, excessive throat clearing, chronic cough, and other otolaryngologic complaints with little in the way of esophagitis. The larynx and pharynx do not have protective mechanisms to prevent mucosal injury, while the esophagus demonstrates a mucosal barrier, bicarbonate production, and peristaltic clearance.
Pharyngitis includes inflammation of the structures of the nasopharynx, oropharynx, and laryngopharynx (see bullet list 2).
- Common cold virus
- Influenza virus
- Infective mononucleosis (Epstein–Barr virus)
- Human immunodeficiency virus
- Group A streptococcus
- Corynebacterium diphtheriae
- Neisseria gonorrhoea
- Haemophilus influenzae
- Borrelia vincentii
- Ludwigs cellulitis
- (Anaerobic fusobacteria and spirochetes)
- Candida albicans
- Cigarette abuse
- Alcohol abuse
- Kawasaki disease
Nasopharyngitis is common during winter months with adenovirus, influenza virus, parainfluenza viruses, and enterovirus being the most common etiologic factors. Ninety per cent of pharyngotonsillitis is related to GABHS, adenoviruses, influenza viruses, parainfluenza viruses, enteroviruses, Epstein–Barr virus, and mycoplasma infection.
Group A beta hemolytic streptococcus (GABHS) is the most common and serious bacterium causing pediatric pharyngitis. There is a small risk of rheumatic fever (0.3%) and acute glomerulonephritis (10–15% of those infected with nephritogenic strains). Infectious mononucleosis is caused by Epstein–Barr virus, a member of the herpes virus family, and is a major cause of pharyngitis in adolescents and young adults. EER may cause an acid pharyngitis and has been implicated in sinus and middle ear disease.
Viral croup occurs when the causative virus spreads from the nose and pharyngeal airway to the larynx and trachea. Local cellular defenses are impaired and the ciliary function is inhibited resulting in edema and infiltration of inflammatory cells producing narrowing of the subglottis. Secondary bacterial infection may occur causing purulent secretions, which may compromise the airway.
Epiglottitis (supraglottitis) is caused by H. influenzae B bacterium, which is a mesomorphic Gramnegative organism capable of both anaerobic and aerobic growth. The type B strain is unique in that it possesses an antigenic capsule and is capable of invading mucosal tissue. The organism may be spread hematogenously and blood cultures may be positive. Invasion of the supraglottic structures results in an intense inflammatory and infective reaction and occasionally microabscess formation in the region that causes the epiglottis to swell and compromise the airway.
Diphtheria caused by C. diphtheriae Gram-positive bacillus affects the respiratory passages with an exotoxin released after 2–4 days of incubation causing tissue necrosis and exudate. This exudate eventually can develop into an adherent gray membrane of fibrinous nature, which may cause edema and airway obstruction.
EER causes laryngeal and pharyngeal erythema with edema of the vocal cords and false vocal cords, larynx, and pharynx. Because of the lack of protective factors mentioned earlier, less acid or pepsin exposure is needed to cause mucosal damage to the pharynx and larynx.
Tonsillitis may be viral or bacterial, particularly with group A beta hemolytic streptococcus (GABHS). Chronic tonsillitis where there is cryptic debris secondary to bacterial interaction with undigested food may also show bacterial biofilm formation within the crypts. Peritonsillar and retroesophageal abscesses occur when bacterial organisms proliferate in between the tonsillar capsule and tonsillar bed and the retropharyngeal tissues and the prevertebral fascia, respectively.
Chronic laryngitis in adults is often related to cigarette abuse and may be aggravated by alcohol consumption and EER. Pathologically, there is edema of the submucosa and epithelial changes that may undergo malignant transformation.
General features Major symptoms are a sore throat, usually of sudden onset, accompanied by pain and difficulty in swallowing, and fever. In cases of viral pharyngitis there will be rhinitis, conjunctivitis, diarrhea, or cough, which will be absent in ‘strep throat’, caused by GABHS. Fever, headache, and swollen cervical lymph nodes may accompany ‘strep throat’. Gastroesophageal reflux in infants may be normal and in small quantities but persistent reflux may be accompanied by excessive vomiting during the first few weeks of life, forceful vomiting, chronic cough, wheezing, apnea or brief breath holding spells, and excessive crying. In more severe cases, there may be weight loss or slow weight gain. In adults, GERD symptoms may include heartburn, particularly at night, belching, nausea and vomiting, and regurgitation of food with some hoarseness, sore throat, difficulty in swallowing, and occasionally cough or wheezing.
Signs of pharyngitis include erythematous pharynx including the tonsils and soft palate on occasion with a coating or membrane. There may be accompanying cervical lymph node enlargement and tenderness. Classically, streptococcal pharyngitis shows a red pharynx with exudate on the tonsils and petechiae on the soft palate. It may be accompanied by scarlet fever with a red rash on the trunk primarily with a strawberry tongue and pallor around the mouth. The main sign of gastroesophageal reflux in infants and children is diffuse erythema of the oropharynx, unaccompanied by exudate or fever.
If a diagnosis of strep pharyngitis is suspected then throat culture or an antigen detection test should be performed. The throat culture is 90–95% sensitive while the rapid strep test is less sensitive but as specific as the throat culture. Culture must be taken prior to starting antibiotic treatment. There is a 10% false-positive rate in patients who are carriers of GABHS without clinical symptoms. Testing for infectious mononucleosis is indicated if there is generalized lymphadenopathy together with a membrane over the pharynx. If there is suspicion of other infections such as gonorrhea or HIV, then these should be tested for using the appropriate swab or serologic testing.
Gastroesophageal reflux may be tested for using a barium swallow examination or esophageal pH monitoring. Intraluminal impedance testing is a new modality for assessing GERD. An endoscopy may be necessary to demonstrate ulceration or inflammation of the esophageal walls or obtain biopsies of the mucosa. In adults, esophageal manometry is used to demonstrate abnormal sphincter pressure.
Acute tonsillitis presents with fever, sore throat, and odynophagia and usually in the absence of acute coryzal symptoms. Chronic tonsillitis is less well defined but may present with chronic sore throat, halitosis, malaise, and coughing up of cryptic debris.
The tonsils are usually enlarged, erythematous, and with an exudate on the medial surface, accompanied by tender cervical lymph nodes. The chronically infected tonsil may show dilated surface vessels and it may be possible to express cryptic debris with compression of the tonsil.
Throat cultures may show GABHS on testing surface swabs while full blood counts, monospot, or Epstein–Barr virus serology will differentiate infectious mononucleosis from other conditions.
Laryngitis may be accompanied by an upper respiratory tract infection or have a history of a recent infection. There is often hoarseness. In the acute form, there will be fever and a possible cervical lymphadenopathy. Chronic laryngitis will have a history of months to years of hoarseness, possible cough or accompanying heartburn and there may be a history of cigarette or alcohol abuse.
Laryngotracheobronchitis (croup) often is associated with a mild upper respiratory tract infection with a ‘seal bark’ type cough. This may progress to inspiratory stridor and labored breathing. There may be signs of chest retraction and on auscultation of the chest there may be decreased breath sounds, wheezing, or prolonged inspiration or expiration. Epiglottitis (supraglottitis) presents with a sore throat, difficulty in swallowing, drooling, and difficulty in breathing with a crowing inspiratory stridor. There may be hoarseness, fever, chills, and occasionally cyanosis.
Apart from an accompanying upper respiratory tract infection, the larynx may show a diffusely erythematous larynx with swelling of the vocal cord. It is critical in adults with a long smoking history for a careful mirror or fiber-optic examination of the larynx to rule out carcinoma of the larynx. With epiglottitis (supraglottitis), it is contraindicated to examine the larynx with a tongue blade as this may cause an acute laryngospasm and obstruction.
In adult smokers with persistent hoarseness, a microlaryngoscopy examination under anesthesia may be necessary for diagnosis and biopsy purposes to rule out carcinoma of the larynx. Radiography of the neck may reveal a classical ‘rat-tail’ appearance of the subglottis in croup. Epiglottitis (supraglottitis) with airway obstruction is an emergency situation and requires careful assessment and investigation under controlled conditions. Neck X-rays, which might show an enlarged epiglottis, may well be academic and pose a danger of obstruction while the patient is in the radiology suite. A blood or throat culture may show H. influenzae or other bacteria and a full blood count may indicate elevated white blood cell levels.
Pediatric esophageal reflux and EER is increasingly being diagnosed with a range of symptoms from postprandial vomiting through to failure to thrive and airway manifestations. GERD in children is generally defined using four categories:
- Physiologic reflux. This is usually largely asymptomatic with infrequent emesis in children.
- Functional reflux. This is silent or asymptomatic and can be confirmed by pH monitoring.
- Pathologic gastroesophageal reflux. This can interfere with growth and cause respiratory complications.
- Secondary GERD. This is related to a secondary disorder such as neurologic or anatomic abnormality of the esophagus. Respiratory complications of reflux include recurrent bronchitis, pneumonia, croup, and chronic asthma and it may complicate or possibly cause laryngeal contact granulomas and ulcers.
Management and Current Therapy
Gastroesophageal Reflux in Children and Adults
There are three phases for treatment of EER in children, which include lifestyle modifications, pharmacologic treatment, and antireflux surgery; the severity of the reflux determines the level of treatment. Conservative measures including elevating the head when in bed, frequent small feeds, thickening of milk, and fasting before bedtime are useful. Adjuncts for conservative management of EER may include H2 receptor blockers, prokinetic agents, or protein pump inhibitors. Conservative measures, antacids, and H2 antagonists are the treatment of choice for mild reflux and in the more severe cases prokinetic agents or protein pump inhibitors are suggested. Surgical intervention includes Nissen fundoplication, which has a 90% success rate in symptom control and a low mortality rate. Management of adults with gastroesophageal reflux is similar to that in children but particular attention should be paid to weight reduction.
The majority of cases of viral laryngitis correspond to conservative management with voice rest, humidification, and anesthetic lozenges. Croup of mild degree can be managed at home with a cool air nebulizer and symptomatic therapy. Occasionally, oral or inhaled steroids are necessary. Serious illness requires hospitalization with aerosolized racemic epinephrine, oxygen, humidification, and consideration of antibiotic therapy for bacterial infections. Infrequently, intubation is necessary. Epiglottitis (supraglottitis) requires hospitalization, usually in the intensive care unit, and endotracheal intubation may be required and, occasionally, emergency tracheotomy. Intravenous fluids, systemic steroids, and antibiotics are often required. Family members should be treated in view of the contagious nature of the infections.
Viral pharyngitis is treated symptomatically but GABHS pharyngitis is managed with penicillin V for 10 days. There are concerns about the length of the regimen and bacteriologic treatment failures occur in up to 35% of young patients. Cephalosporins are an alternative treatment to penicillin therapy. The new generation macrolides such as azithromycin and chlorithromycin are effective in penicillin-resistant patients although there appears to be increasing GABHS resistance to this group of antibiotics. Clindamycin may be used in cases of GABHS carrier states or failure with other antibiotics. Bacterial biofilm in tonsillar crypts may mitigate against effective antibiotic therapy for the chronic tonsillitis states. Bacterial replacement therapy utilizing probiotic bacteria, particularly Streptococcus salivarius, may be applied to prevention of streptococcal pharyngitis.
Tonsillectomy is indicated for severe recurrent tonsillitis where there are three or more tonsillar infections per year despite adequate medical therapy that are accompanied by fever, dysphagia, cervical adenopathy, or positive GABHS culture and tonsillar exudates. Other indications for tonsillectomy include quinsy (peritonsillar abscess) as well as hypertrophy causing obstructive sleep disorder. If chronic tonsillitis does not respond to a 3–6 week therapeutic trial of clindamycin or amoxicillin clavulanate, then tonsillectomy may need to be considered.
Facets of Treatment
Although vaccination for diphtheria and Hib has significantly decreased the presentation of these diseases, a high index of suspicion should still be exercised. There may be compliance problems with a 10 day penicillin treatment for GABHS pharyngitis but a 5-day course of azithromycin or macrolides, in view of the high rate of failure with these agents, must be regarded with caution. Recurrent croup may require further investigation to rule out coexisting anatomical abnormalities such as subglottic stenosis. Adults with chronic laryngitis who persist in smoking require regular follow-up to detect malignant change in the larynx.
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