Viral Pharyngitis

Viral pharyngitis is inflammation of the pharynx caused by viruses (rhinovirus, adenovirus, coronaviruses, influenza, parainfluenza, enterovirus, Epstein Barr virus, cytomegalovirus, HIV, herpes simplex), accounting for most sore throats in adults and children. It is self limiting, usually settling in 3 to 7 days.

• Spread by droplets and contact.
• Peaks in cold and rainy seasons and in school going children.

Sore throat, scratchy throat, hoarseness, cough, rhinorrhoea, conjunctivitis, mild fever, malaise, with diffusely erythematous pharynx and sometimes vesicles; tonsillar exudate is less common and lymph nodes mildly enlarged.

• Cough, coryza and conjunctivitis point towards a viral cause; severe pain with exudate and tender nodes without cough suggests streptococcal infection.
• Differential diagnosis: streptococcal pharyngitis, infectious mononucleosis, acute HIV infection, diphtheria, peritonsillar abscess, epiglottitis, herpangina, hand foot and mouth disease, gonococcal pharyngitis, candidiasis, reflux, allergic rhinitis, thyroiditis.
• Complications: dehydration, secondary bacterial sinusitis or otitis media, post viral cough, peritonsillar abscess, rarely airway obstruction.

Clinical.

• Rapid antigen detection test or throat culture when streptococcal infection is possible (a negative test supports a viral cause); monospot or EBV serology and full blood count (atypical lymphocytes) in persistent fever with fatigue and posterior cervical nodes.
• HIV test in suspected acute infection; swab for diphtheria where grey adherent membrane is present.
• Viral PCR is not routinely required.

Symptomatic care; antibiotics do not help.

• Supportive: rest, oral fluids, warm salt water gargles (half a teaspoon in a glass of warm water), throat lozenges for adults, humidified air, soft diet, avoid smoking.
• Pharmacological: paracetamol 1 g every 6 hours (children 15 mg/kg every 6 hours), ibuprofen 400 mg every 8 hours (children 10 mg/kg every 8 hours); benzydamine 0.15 percent gargle every 3 hours; single dose dexamethasone 10 mg orally for severe pain in adults. Do not give amoxicillin or ampicillin if infectious mononucleosis is possible (rash). Oseltamivir 75 mg twice daily for 5 days only for influenza in severe or high risk patients.
• Procedures: none.
• Special groups: pregnancy, paracetamol and gargles; children under 12 years, avoid aspirin; HIV, test for acute infection; diabetes, monitor glucose; elderly, hydrate carefully.
• Red flags: drooling, stridor, inability to swallow saliva, trismus, muffled voice, neck swelling, unilateral tonsillar bulge, grey membrane, high fever beyond 5 days, dehydration.
• Follow-up: review in 3 to 5 days if not improving; return urgently for airway symptoms.