viral pharyngitis



Overview

Definition

Viral pharyngitis is an inflammatory disease of the pharyngeal mucosa, submucosal tissues and lymphoid tissues caused by viral infection [1].

The pharynx is divided from top to bottom into 3 parts: nasopharynx, oropharynx and laryngopharynx. The oropharynx is the posterior continuation of the oral cavity and is located between the plane of the soft palate and the upper edge of the epiglottis, which is usually referred to as the pharynx.

The oropharynx communicates anteriorly with the oral cavity via the pharyngeal isthmus, and the lateral wall of the pharynx consists of the lingual palatine arches, the pharyngeal palatine arches, and the (palatine) tonsils. Behind the palatine arch on each side are longitudinal strips of lymphoid tissue called lateral pharyngeal cords.

The so-called pharyngeal isthmus is a circumferential narrowing of the upper uvula and free edge of the soft palate, the lower dorsum of the tongue, and the lingual and palatal arches and pharyngeal palatal arches on both sides [2].

It usually resolves in 7 to 10 days, but complications can lead to a prolonged course [3].

Typology

The main types of viruses that cause pharyngeal infections are: coxsackievirus, adenovirus, parainfluenza virus, rhinovirus, influenza virus, coronavirus, EBV, and herpes simplex virus infections.

Coxsackie virus infection

The virus causes acute upper respiratory tract infections and pharyngitis after infection through the respiratory and digestive tracts. When it occurs in the pharynx, tonsils, and soft palate, it is often characterized by herpes of the pharynx and soft palate with fever, sore throat, and swelling. Coxsackievirus A-16 infection is also an important cause of HFMD outbreaks and infections.

Adenovirus infection

The virus is mainly transmitted via the fecal-oral route, but can also be transmitted via the respiratory tract. The disease may occur with diarrhea along with respiratory symptoms such as pharyngitis and cough, or milder symptoms of fever and vomiting. Sore throat symptoms are more severe than in the common cold. Childhood patients often present with conjunctivitis, also known as pharyngoconjunctival fever.

Parainfluenza virus infection

This group of viruses belongs to the family Paramyxoviridae, while influenza viruses belong to the family Mucoviridae. The two types of viruses are not the same, hence the name parainfluenza virus. There are four types of parainfluenza viruses.

Infections occur mostly in the dry and cold seasons of winter and spring, and are spread through the respiratory tract, mainly through airborne droplets. Certain types are susceptible at ages 2 to 5 years, with a more pronounced onset in summer and fall, and a tendency to become prevalent once every other year, and are prone to cause common colds characterized by pharyngitis.

Rhinovirus infection

30%~60% of viral pharyngitis in adults is caused by the common cold, and rhinovirus infection is the main cause of the common cold, accounting for 1/2~2/3 of the causes of the cold, with an incubation period of 2~4 days. The infection often presents with a mild degree of sore throat, and most patients are accompanied by nasal symptoms such as nasal congestion and runny nose.

Influenza virus infection

Influenza viruses are categorized into three types: A (A), B (B) and C (C). The viruses can also cause illness in humans and a variety of animals, appearing as human influenza, avian influenza, swine influenza, and so on.

Human influenza is mainly caused by influenza A and influenza B viruses, which are mainly transmitted through airborne droplets, contact between susceptible and infected persons or contact with contaminated objects. The fall and winter seasons are the high incidence period.

After infection, obvious systemic symptoms such as high fever, chills or chills, malaise, dizziness and headache, and generalized aches and pains, as well as milder upper respiratory symptoms such as cough, runny nose, nasal congestion, and sore throat, can be manifested [4].

Coronavirus infection

Since the worldwide outbreaks of Severe Respiratory Syndrome 2002 (SARS) and Crown Pneumonia Nova 2019 (COVIS-19), new variants of human coronaviruses have attracted great attention as respiratory viral infection pathogens.

Early data on clinical symptoms of human respiratory coronavirus infections from a 2001 cohort showed pharyngitis in 30%, rhinitis in 36.6%, and laryngitis in 3.3%.

Data from more than 1.54 million adult COVIS-19 cases in the UK in 2022 showed that when the alpha and delta strains evolved to the omicron subtype variants BA.1 and BA.2, all patients presented with symptoms of pharyngitis such as sore throat and hoarseness [5].

EBV infection

EBV (Epstein-Barr virus) belongs to the Herpesviridae family. The virus is commonly latent in human B-lymphocytes and intermittently replicates in oropharyngeal epithelial cells to facilitate salivary transmission. The main cause of pharyngeal infection is infectious mononucleosis (IM).

The route of initiation of infection is through lymphoid tissue and pharyngeal epithelial cells. The initial incubation period is 3 to 7 weeks. Mild general malaise and fever precede symptoms for 1 to 2 weeks followed by significant sore throat, fever, and lymph node enlargement.

Herpes simplex virus infection

Contact with oral secretions is the primary mode of transmission. Pharyngeal infections are primarily caused by herpes simplex virus (HSV) type 1 and are sometimes accompanied by gingivostomatitis, enlarged lymph nodes, herpes-like lesions in the oral cavity or oropharynx, and superficial ulcers.

Morbidity

Acute viral pharyngitis and chronic pharyngitis develop acutely as a result of viral infection, often during the fall-winter and winter-spring seasons.

Pathogens can be transmitted by droplets and close contact, but also by contact with contaminated hands and utensils. Transmission between family members, in kindergartens, schools or confined workplaces is a prominent feature of the epidemiology of these viral infections.

Healthy people can also carry susceptible viruses, and the body’s immunity to their infection is weak and short-lived, and there is no cross-immunity between the viruses, so the disease can recur.

In young children, acute viral pharyngitis is often the precursor or concomitant symptom of acute infectious diseases, such as measles, influenza, rubella, etc. In adults and older children, acute viral pharyngitis is often the precursor or accompaniment of acute infectious diseases. In adults and older children, it often follows acute rhinitis and acute tonsillitis. Cold, fatigue, excessive smoking and alcohol, and decreased systemic resistance are all triggers of the disease.

Sore or itchy throat accounts for approximately 50% of acute viral pharyngitis due to rhinoviruses, 80% in parainfluenza virus infection and 50% in influenza A [6]. It is almost 100% in epidemics of the Omicron subtype variant of the new coronavirus [5].

Etiology

Causes of disease

Coxsackieviruses, adenoviruses, parainfluenza viruses, rhinoviruses, influenza viruses, coronaviruses, EBVs, and herpes simplex virus infections are common causative agents in the development of viral pharyngitis.

Under the condition of sound body immune function, the virus is protected by the immune barrier and may not develop. Viral pharyngitis occurs when the protective barrier is destroyed by various triggers, resulting in a decrease in the body’s resistance.

Triggering factors

In the case of rain, cold, fatigue, irregular life, mental stress, excessive smoking and alcohol, and suffering from systemic immune deficiency diseases, it is easy to be infected by viruses and triggered by pharyngitis.

Chronic pharyngitis, chronic tonsillitis, adenoid hypertrophy, sinusitis, chronic rhinitis and other peripheral inflammation of the wave, long-term open-mouth breathing and other bad habits, can also be induced by the pharyngeal immune defenses decline, which leads to viral invasion of disease.

In the high temperature or cold, dry climate, inhalation of harmful dust, smoke, pharynx by toxic substances or allergens after the stimulation, can also trigger the pharynx is in a susceptible state, become a viral pharyngitis attack triggers.

Such as endocrine disorders, autonomic nervous system dysfunction, diabetes, vitamin deficiency, tumor chemotherapy or application of immunosuppressants, can also make the body present neurohumoral immune disorders, easy to induce viral infections.

Pathogenesis

Inflammation of the pharynx and lymphatic tissues is mainly caused by direct viral invasion of the pharyngeal mucosa, submucosa and lymphatic tissues, as well as inflammation triggered by the immune response of the body’s immune system. If secondary bacterial infection occurs, it can cause suppurative inflammation and swelling of the cervical lymph nodes.

Symptoms

Main Symptoms

The main symptoms of viral pharyngitis include dryness of the pharynx, burning of the pharynx, itching of the pharynx, sore throat, and hoarseness.

Other symptoms

Fever, usually not high and not long lasting in adults, but the temperature fluctuates in children patients with a wide range of 37.5 ℃ to 40 ℃. Headache, general malaise, muscle aches and pains, accompanied by generalized discomfort such as loss of appetite, nausea and vomiting.

Complications

Acute otitis media

If the inflammation develops to the nasopharynx and spreads to the Eustachian tube, it causes changes such as fluid in the tympanic chamber and negative pressure in the middle ear.

Symptoms such as ear stuffiness, tinnitus and ear pain are common, and sometimes hearing loss can also be caused.

Acute sinusitis

Nasal congestion, runny nose, impaired sense of smell, rhinorrhea.

Chilliness, fever, peripheral discomfort, constipation, insomnia, etc.

Acute cervical lymphadenitis

Swelling and hardening of cervical lymph nodes, conscious pain or pressure.

There may be high fever, chills, headache, generalized weakness.

Tracheitis and bronchitis

Manifested as coughing, coughing up sputum, wheezing or shortness of breath. Those with obvious wheezing may be accompanied by bronchial asthma and bronchospasm, and may have varying degrees of chest tightness and shortness of breath.

Seek medical attention

Most respiratory viral infections resolve spontaneously in 5-7 days. If symptoms are not severe, home care and symptomatic treatment are recommended. If the symptoms are severe or prolonged, or if the patient has serious underlying medical conditions, he/she should go to the hospital for further treatment.

Department of Medicine

Otorhinolaryngology

If you experience dryness of the throat, burning of the throat, itching of the throat, sore throat, hoarseness, etc., it is recommended that you consult the ENT department promptly.

Emergency Department

If you have difficulty breathing, a high fever that won’t go away, are unconscious, or have other cardiovascular problems, it is recommended that you go to the Emergency Department as soon as possible or call the 120 emergency number.

Preparation for medical treatment

Preparation for medical consultation: registration, preparation of information, common problems

Tips for seeking medical treatment

Children are too young to express themselves accurately. Parents can observe and record their children’s symptoms so that they can give more reference to the doctor.

Preparation List

Symptom list

Pay special attention to the time of onset of symptoms and special manifestations.

Is there any dryness in the throat? When did it occur?

Is there burning in the throat?

Is there pharyngeal itching?

Is there a sore throat?

Is there a fever?

Is there a headache?

Any generalized discomfort?

Are there any other symptoms such as thirst, constipation, nausea, or vomiting?

Under what circumstances are the symptoms aggravated or relieved?

Medical History Checklist

Has there been rain, cold, fatigue, irregular life, mental stress, excessive smoking or drinking before the appearance of these symptoms?

Any chronic pharyngitis, chronic tonsillitis, adenoid hypertrophy, sinusitis, chronic rhinitis, etc.?

Are you in a hot or cold, dry environment?

Do you inhale harmful dust and smoke?

Are you suffering from endocrine disorders, autonomic dysfunction, diabetes mellitus, vitamin deficiency and other systemic diseases?

Checklist

Examination results of the last six months, which can be brought to the doctor’s office

Indirect laryngoscopy

Laboratory tests: blood test, throat swab, and specific antigen, antibody and viral nucleic acid test

Fiberoptic (electronic) nasopharyngolaryngoscope

Imaging: Chest X-ray and CT examination

Medication List

Medication used in the last 3 months, if available in boxes or packages, bring with you to the doctor’s office

Antivirals: ribavirin, acyclovir

Glucocorticoids: budesonide suspension, prednisone, dexamethasone

Topical medications: Borax Gargle, Chlorhexidine Gargle

Antipyretic and analgesic drugs: ibuprofen, acetaminophen

Proprietary Chinese medicines: Clearing Throat Drops Pills, Golden Voice Pills, Liu Shen Pills, Golden Voice Pills, Clearing Throat Granules

Container tablets: iodine throat tablets, watermelon cream throat tablets, lysozyme tablets

Diagnosis

Diagnosis

Medical history

Recent history of rain, cold, fatigue, irregular life, mental stress, excessive smoking and drinking.

There may be history of chronic pharyngitis, chronic tonsillitis, adenoid hypertrophy, sinusitis, chronic rhinitis.

Epidemiologic onset of winter and spring has a history of contact with infectious agents, especially kindergartens, schools and confined workplaces.

Clinical symptoms

Common pharyngeal dryness, burning, itching, sore throat and other symptoms, may be accompanied by fever, headache and general discomfort.

Indirect laryngoscopy

Observe the hypopharynx and larynx.

Exclude acute epiglottitis, pediatric acute laryngitis and other ENT emergencies that can cause choking.

No fasting is required, but the patient must cooperate by sticking out his tongue and making a long “coat” sound to fully expose the observation area.

Laboratory Tests

Blood tests

Can indicate whether the infection is viral or bacterial and help in the initial determination of the condition.

Increased white blood cells and neutrophils may indicate bacterial infection; normal or slightly elevated white blood cell count and elevated lymphocyte count may indicate viral infection.

Fasting is not required before the test.

Pharyngeal swab and specific antigen, antibody and nucleic acid tests

Specific types of causative viruses can be identified, which can help to define the cause and extent of the disease and guide systematic and standardized treatment.

Assisted fiberoptic (electronic) nasopharyngeal examination when necessary

Nasopharyngeal and laryngeal conditions can be observed.

Imaging examination

Including chest X-ray and CT examination. Suitable for patients with persistent cough and sputum and wheezing.

Rule out bronchial and pulmonary disorders for comprehensive disease management.

Differential Diagnosis

Many respiratory viral infectious diseases and bacterial infections of the pharynx are indistinguishable from viral pharyngitis in terms of early prodromal symptoms and clinical signs, but with the development of the disease, the following disease-specific symptoms, signs and laboratory tests will gradually appear.

Measles

Similarities: both may have symptoms such as sore throat, fever and malaise.

Differences: Measles is characterized by oral measles mucous membrane spots and maculopapular rash all over the body, with bran-like exfoliation and hyperpigmentation after the rash recedes. In addition, measles is often accompanied by conjunctivitis symptoms.

Scarlet fever

Similarity: Both may have symptoms such as sore throat and fever.

Differences: Scarlet fever is more common in children. Early on, there may be chills, high fever, typical prune tongue and scarlet fever-like rash. Group A hemolytic streptococcus can be detected by throat swab culture.

Influenza

Similarities: Both may have symptoms such as sore throat, fever and malaise.

Differences: Influenza is highly contagious, with obvious systemic symptoms of toxicity, while the pharyngeal symptoms are less severe, and can be differentiated by pathogenetic examination.

Infectious mononucleosis

Similarity: both can have fever, sore throat symptoms.

Differences

Sore throat is mild, tonsils are enlarged, grayish-white secretion can be seen on the surface, which can be easily swabbed away.

Leukocytes decrease in the early stage and increase in the later stage, monocytes increase (60%~80%), and anisotropic lymphocytes are greater than 10%.

Serum heterophilic agglutination test is positive.

Although the disease is due to EBV infection, it is not specific and cannot be used as a differential.

Granulocytopenic pharyngitis

Similarity: both may have fever, sore throat and other manifestations.

Differences

Ulceration of tonsils and surrounding tissues with brown necrotic material may occur.

Decrease in white blood cells, neutrophils, platelets, and accelerated erythrocyte sedimentation rate (ESR).

Fanshawe pharyngitis

Similarities: both may have symptoms such as sore throat and fever.

Differences

The tonsils are covered with gray or yellow pseudomembrane, which can be easily swabbed off, and the ulcerated surface can be seen underneath.

Clostridium difficile and Spirochaetes fanshawe can be found on smear of pharyngeal swab.

Novel coronavirus infection

Similarities: both may have symptoms such as sore throat, dry throat and fever.

Differences: Cough and muscle aches are obvious, and nucleic acid and viral antigen tests are positive.

Treatment

Aim of treatment: Relieve symptoms and avoid complications.

Treatment principle: adequate rest, drinking plenty of water, symptomatic treatment, antiviral treatment for severe cases.

General treatment

Adequate rest and adequate water intake are recommended; eat a light, liquid diet or soft food (may be more appropriate for those who have difficulty swallowing due to pain or enlarged tonsils), and abstain from smoking, alcohol (including second-hand smoke) and other respiratory irritants. Avoid acidic foods and beverages (especially in those with oral or pharyngeal ulcers) [7-8].

Actively treat local diseases such as chronic tonsillitis, adenoid hypertrophy, sinusitis, chronic rhinitis, and other relevant underlying diseases of the whole body such as endocrine disorders, autonomic dysfunction, diabetes mellitus, and vitamin deficiency.

Make child patients quiet, avoid crying, reduce physical exertion, try to delay the progress of dyspnea aggravation.

Avoid staying up late, exertion, increase sleep and maintain emotional stability.

Stay away from adverse conditions that may continue to aggravate the condition or stimulate discomfort.

Topical treatments

Containing tablets

This topical treatment can be used to relieve throat discomfort when there are no systemic symptoms or when the symptoms are mild.

Commonly used drugs are lysozyme tablets, iodine throat tablets, watermelon cream tablets and so on.

Mouthwash

Local application of mouthwash which has the effect of cleansing and sterilizing the oral cavity can be used.

Commonly used are compound borax gargle, compound furacilin gargle, compound chlorhexidine gargle and so on.

Posterior pharyngeal wall coating

The swollen lymphoid follicles in the posterior pharyngeal wall can be coated to play the role of anti-inflammatory, astringent, as well as to improve local blood circulation and promote the secretion of glands.

Commonly used 1%~3% iodized glycerin, 2% silver nitrate, etc.

Nebulization therapy

Ultrasonic nebulization inhalation can be used to make the drugs act directly on the pharynx, which is conducive to anti-inflammation and swelling, dilute the viscous secretion in the pharynx, and reduce the pain and discomfort in the pharynx.

Budesonide suspension is commonly used.

Systemic treatment

Anti-infection treatment

Due to the phenomenon of influenza virus drug resistance caused by current drug abuse, antiviral drugs are generally not necessary for patients without fever, with normal immune function, and with onset of illness of no more than 2 days [9].

Antivirals can be administered by oral or intravenous routes. Amantadine or amantadine ethylamine significantly reduces the duration of symptoms, and the neuraminidase inhibitors zanamivir and oseltamivir have similar effects. Acyclic guanosine and valacyclovir, famciclovir, and phosphonoform are effective in ulcerative oropharyngeal herpesvirus infections in immunocompromised individuals.

They can be used early and routinely in immunodeficient individuals. Oseltamivir and ribavirin have a broader antiviral spectrum, with strong inhibitory effects against influenza virus, parainfluenza virus, and respiratory syncytial virus, which may shorten the duration of illness.

Antipyretic and analgesic drugs

For those with fever and headache, NSAIDs with anti-inflammatory, antipyretic and analgesic effects can be chosen to help relieve symptoms.

Ibuprofen and acetaminophen are commonly used, and aspirin is also available for adults.

Parents of pediatric patients must be reminded that children recovering from viral infections (e.g., chicken pox, flu, and colds) should not take salicylic acid-based antipyretics, such as aspirin. They are prone to serious adverse drug reactions called Reye’s syndrome and have a high mortality rate.

Proprietary Chinese Medicine

Chinese medicine believes that viral pharyngitis is mostly caused by wind-heat, and treatment should be based on the principle of dispersing wind-heat to improve symptoms such as sore throat, dry throat, and discomfort in swallowing.

Commonly used proprietary Chinese medicines: Cold and Flu Punch, Zheng Chaihu Drink, Xiao Chaihu Punch, Banlangen Punch, Yin Qiao Xie Tu Tablet, as well as Liushen Pill and Golden Throat Pill. Compound Chaihu injection is also effective in viral pharyngitis [10].

Prognosis

Cured

Untreated

Those with mild systemic symptoms due to viral pharyngitis and no complications are usually cured within 1 week.

Chronic viral pharyngitis can be exacerbated or recurrent with repeated episodes or in the presence of adverse physicochemical factors.

When the inflammatory reaction spreads to the ear, nose, trachea, bronchus and other systems of the body, corresponding complications can occur, such as otitis media, sinusitis, tracheitis, etc.

After treatment

The prognosis of acute viral pharyngitis is generally good after timely and reasonable treatment.

Harmfulness

If the treatment is not complete, it is easy to recur.

Acute viral pharyngitis can lead to acute otitis media, acute sinusitis, acute nephritis, rheumatic fever, as well as trachea, bronchus and pneumonia and other complications.

Pediatric patients with acute viral pharyngitis, such as downward spread, triggered by pediatric acute laryngitis, often due to the rapid progression of the disease, when the failure to get timely and effective treatment, there will be respiratory difficulties, or even suffocation, can be life-threatening.

Daily

Daily Management

Dietary management

Those with fever should increase water intake appropriately to keep the throat moist.

Choose light, vitamin-rich and easy-to-digest food with sufficient calories.

Avoid spicy and irritating foods such as chili peppers, as well as fried, deep-fried, oily and sweet foods, such as cakes and fried fast foods, to avoid aggravating the discomfort.

Children with pharyngeal discomfort can be fed with “small meals”.

Life management

The less symptomatic patients should rest appropriately, and the more serious or elderly should mainly rest in bed.

Keep the child quiet and minimize crying, as this may aggravate the hypoxia.

Ventilate the room regularly and keep it moist; the indoor temperature should not be too high to avoid cold and flu.

Avoid exposure to harmful gases and dust, and avoid contact with allergens.

Rinse the mouth after eating or give oral care on time to prevent oral infection.

Tableware, spittoon and other supplies used by patients should be sterilized in time according to regulations [11].

Follow-up examination

Patients should follow the doctor’s instructions for timely review. If the original symptoms do not improve or worsen, or new symptoms appear, they should consult the doctor in time.

Prevention

Regular life, combination of work and rest.

Adhere to regular and appropriate physical activities to enhance physical fitness and resistance.

Ventilate the room by opening the windows and keeping the indoor air circulating.

Avoid triggering factors such as exposure to cold and excessive fatigue.

Avoid going to crowded public places during the peak season.

Improve the living and occupational environment to avoid long-term inhalation of dust and harmful gases.

Take appropriate measures to avoid the spread of the disease and prevent cross-infection.

Pay attention to personal hygiene and wash hands frequently.