“IN THE NAME OF ALLAH

THE MOST BENEFICIAl,

THE MERCIFUL”
PRESENTED BY:
Dr. H. M. Yasir Farooq
(Lahore College of Pharmaceutical Sciences)
 TOPIC

PHARYGITIS
AND
TONSILLITIS
 PHARYNX
Pharynx is a fibro-muscular tube forming
upper part of air and food passages. It is 12-14
cm long and extends from base of the skull to
the lower border of cricoid cartilage.

DIVISIONS OF PHARYNX
Anatomically pharynx is divided into three
parts:
• Nasopharynx
• Oropharynx
• Hypopharynx / Laryngopharynx
 PHARYNGITIS
Pharyngitis = pharynx + itis (inflammation)

Pharyngitis is the painful inflammation of

pharynx. About 90% of cases are caused by viral
infection, with the remainder caused by bacterial
infection and, in rare cases, oral thrush (fungal
candidiasis e.g. in AIDS ). Some cases of
pharyngitis are caused by irritation from elements
such as pollutents or chemical substances.
Tonsillitis may occur simultaneously.
TYPES OF PHARYNGITIS

There are two types of Pharyngitis

• Acute Pharyngitis
• Chronic Pharyngitis
 ACUTE PHARYNGITIS
AETIOLOGY
Acute pharyngitis is very common and occurs
due to following aetiological factors:

VIRAL BACTERIAL FUNGAL MISCELLANEOUS

Influenza Streptococcus  Candida Toxoplasma

Para-influenza (Group A beta (parasite)
Herpes simplex hemolytic) Chlamydia

Measles Diphtheria
Chickenpox Gonococcus
Cytomegalo-
virus
Rhinovirus
CLINICAL FEATURES
Pharyngitis may occur in different grades of
severity.

Mild Infections:
• Discomfort in throat

• Malaise

• Low grade fever

• Congested pharynx but no lymphadenopathy.

Moderate to Severe Infections:

• Pain in throat

• Dysphagia

• Headache
 • Malaise and high grade fever
• Erythema and exudate in pharynx.
• Enlarged tonsils and lymphadenopathy.

Very Severe Infections:

• Edema of soft palate and uvula with
enlargement of cervical lymph nodes

It is not possible to differentiate viral

infections from bacterial ones on clinical
examination but, viral infections are generally
mild and are accompanied by rhinorrhoea and
hoarseness, while bacterial infections are
severe.
DIAGNOSIS
Throat swabs are taken and are subjected to
culture and sensitivity. Failure to get any bacterial
growth suggests viral infection.

TREATMENT
GENERAL MEASURES
 Bed rest
 Plenty of fluids
 Warm saline gargles
 Analgesics (Aspirin or Paracetamol) for fever and
pain.
SPECIFIC TREATMENT

 STREPTOCOCCAL PHARYNGITIS
 Penicillin G Benzathine

 Amoxicillin

 Amoxicillin + Clavulanic Acid

 Erythromycin

 DIPHTHERIA
 Diphtheria antitoxin

 Penicillin

 Erythromycin.
 GONOCOCCAL PHARYNGITIS
 Penicillin
 Oxytetracycline.

 FUNGAL INFECTIONS
 Nystatin.

 CHLAMYDIAL INFECTIONS
 Erythromycin
 Sulfonamides.
 CHRONIC PHARYNGITIS
It is a chronic inflammatory condition of
pharynx. There are two types of chronic
pharyngitis:
1. Chronic catarrhal pharyngitis
2. Chronic granular pharyngitis

AETIOLOGY
A large number of factors are responsible:

1. Persistent Infection in the Neighborhood

e.g., Chronic rhinitis
Chronic sinusitis
Chronic tonsillitis
Dental sepsis
Recurrent sore throat
2. Mouth Breathing
Breathing through the mouth exposes the
pharynx to air which has not been filtered,
humidified and adjusted to body temperature
thus making it more susceptible to infections.
Mouth breathing is due to:
• Obstruction in the nose by nasal polyp,
deviated septum, turbinate hypertrophy,
rhinitis or tumors
• Obstruction in the nasopharynx by adenoids

or tumors
• Protruding teeth which prevent apposition of

lips
• Habitual, without any organic cause
3. Chronic Irritants
Excessive smoking, chewing of tobacco and
pan, heavy drinking, highly spiced food can all
lead to chronic pharyngitis.

4. Environmental pollution
Smoky or dusty environment or irritant
industrial fumes may also be responsible for
chronic pharyngitis.

5. Voice Abuse
Some professions involve excessive use of
voice e.g. hawking. This may lead to chronic
pharyngitis.
SYMPTOMS
Severity of symptoms in chronic pharyngitis varies
from person to person
• Discomfort or pain in the throat, worst in the
morning.
• Foreign body sensation in the throat
• Tiredness of voice
• Cough

SIGNS
CHRONIC CATARRHAL PHARYNGITIS
• Congestion of pharyngeal wall

• Engorgement of vessels

• Increased mucus secretion

CHRONIC GRANULAR PHARYNGITIS
• Thick pharyngeal wall

• Congestion of pharynx

• Engorgement of vessels

• Reddish nodules on the posterior pharyngeal wall

• Lateral pharyngeal bands become hypertrophied

• Edema of the uvula

TREATMENT

 In all cases of chronic pharyngitis, the causative

agent must be found and treated
 Voice rest and speech therapy
 Warm saline gargles specially in morning
 Mandl’s paint may be applied to pharyngeal
mucosa
 Cautery of lymphoid granules may be done
under anesthesia by chemical or electro-cautery.
10 – 25 % silver nitrate is used for chemical
cautery.
 TONSILS
Aggregates of lymphoid tissue are scattered
throughout the pharynx, in its sub-epithelial layer
are known as TONSILS, forming a ring known
as WALDEYER’S RING. This consists of the
following:

• Nasopharyngeal tonsil or Adenoids

• Tubal tonsils
• Palatine tonsils
• Lingual tonsils
WALDEYER’S RING
ANOTHER VIEW OF WALDEYER’S RING
 TONSILLITIS
Tonsillitis = tonsil + itis (inflammation)

Tonsillitis is characterized by red, swollen

tonsils and causes, but not necessarily, a sore
throat and fever.
TYPES OF TONSILLITIS

There are 3 main types of tonsillitis:

• Acute Tonsillitis

• Subacute Tonsillitis

• Chronic Tonsillitis

ACUTE AND SUBACUTE TONSILLITIS

 Acute tonsillitis can last between 1-3 weeks and
often affects school-going children, but also affects
adults. It is rare in infants and in persons who are
above 50 years of age.
 Subacute tonsillitis can last between 3 weeks to 3
months.
AETIOLOGY
 Acute tonsillitis can either be bacterial or
viral in origin.
 Hemolytic streptococcus is the most
commonly infecting organism.
 Other causes of infection may be
staphylococci, pneumococci.
 These may primarily infect the tonsil or may
be secondary to a viral infection.
 Subacute tonsillitis is caused by bacterium
Actinomyces.
SYMPTOMS

The symptoms vary with severity of infection.

The predominant symptoms are as follows:

 Sore throat.
 Dysphagia (difficulty in swallowing due to local
pain.
 Fever (may vary from 100 – 104 °F and may be
associated with chills and rigors).
 Earache (referred pain from tonsil or due to otitis
media).
 Constitutional symptoms (headache, general
body aches, malaise).
 SIGNS
• Often the patient has foetid breath and coasted
tongue.
• There is hyperemia of pillars, soft palate and uvula.
• Tonsils are red and swollen with yellowish spots of
purulent material.
• There may be a membrane over the surface of
tonsils.
• The tonsils may be so much enlarged that they
meet in the midline.
• Jugulodiagastric lymph nodes are enlarged and
tender.
• These symptoms are generally mild in viral infection
and very severe in bacterial infection.
TREATMENT
GENERAL MEASURES
 Bed rest.
 Plenty of fluids.
 Warm saline gargles.
 Analgesics (Aspirin or Paracetamol) for fever and
pain.

SPECIFIC MEASURES

Antimicrobial Therapy
Most of the infections are due to streptococcus
and penicillin is the drug of choice. Patients allergic
to penicillin can be treated with erythromycin.
Antibiotics should be continued for 7 – 10 days.
COMPLICATIONS
 Chronic tonsillitis.
 Peri-tonsillar abscess.
 Parapharyngeal abscess.
 Cervical abscess due to suppuration of
jugulodiagastric lymph nodes in the neck.
 Acute otitis media.
 Rheumatic fever.
 Acute glomerulonephritis.
 Subacute bacterial endocarditis.
 CHRONIC TONSILLITIS
Chronic tonsillitis, which can last for long period
if not treated, is almost always bacterial.

AETIOLOGY
 It may be a complication of acute tonsillitis.
 Sub-clinical infections of tonsils without an acute
attack.
 Mostly affects children and young adults.
 Chronic infection in teeth and sinuses may be a
predisposing factor.
 SYMPTOMS
 Recurrent attacks of sore throat or acute
tonsillitis.
 Chronic irritation in throat with cough.
 Bad taste in mouth.
 Foul breath (halitosis) due to pus collection.
 Thick speech.
 Difficulty in swallowing.
 Choking spells at night (when tonsils are very
large and obstructive).
 SIGNS

 Tonsils may show varying degree of enlargement.

Sometimes they may meet in the midline.
 There may be yellowish beads of pus on the
surface of tonsils.
 Pressure on the anterior pillar may express pus or
cheesy material.
 Flushing of anterior pillars compared to the rest of
the pharyngeal mucosa.
 Enlargement of jugulodiagastric lymph nodes along
with tenderness.
 TREATMENT

CONSERVATIVE TREATMENT
 General health.
 Diet.
 Treatment of co-existent infections of teeth, nose
and sinuses.

SURGICAL TREATMENT
TONSILLECTOMY
Surgical removal of tonsils is known as
tonsillectomy.
INDICATIONS OF TONSILLECTOMY
 Hypertrophy of tonsils causing airway
obstruction, dysphagia and interference with
speech.
 Peri-tonsillar abscess.
 Tonsillitis causing febrile seizures.
 Recurrent throat infection.
CONTRAINDICATIONS OF TONSILLECTOMY
• Hemoglobin level less than 10 g/ dl.
• Children under 3 years of age.
• Presence of acute infection in upper respiratory
tract or tonsils.
• Bleeding disorders.
• Uncontrolled systemic disease e.g. diabetes,
hypertension or heart disease.
COMPLICATIONS OF CHRONIC TONSILLITIS

• Peri-tonsillar abscess.
• Parapharyngeal abscess.
• Intra tonsillar abscess.
• Tonsillolith.
• Focus of infection in rheumatic fever and acute
glomerulo-nephritis.
Drug Specifications
 Benzathine Penicillin G
Trade Name:
• Benzyl Penicillin ® PDH
Doses:
• For patients under 60 lbs: 600,000 units
once I/M
• For patients over 60 lbs: 1200,000 units
once I/M
Side Effects:
• Drowsiness, Convulsions, Confusion,
Rash, Electrolyte Imbalance,
Haemolytic Anemia, Acute Nephritis
Contraindications:
• Any known Hypersensitivity to Penicillin.
 Amoxicillin
Trade Name:
• Amoxil ® GSK
Doses:
• Adults: 250-500 mg Thrice a day
• Children: 125-250 mg Thrice a day
Side Effects:
• Convulsions, Confusion, Rash, Acute
Nephritis, serum sickness, Anxiety,
Nausea, Vomiting, Leukopenia,
Hallucination, Diarrhea
Contraindications:
• Any known Hypersensitivity to
Penicillin.
 Amoxicillin & Clavunaic Acid
Trade Name:
• Augmentin ® GSK
Doses:
• Adults:
Mild-Moderate infections: 375 mg Thrice a day
Severe Infections: 625 mg Thrice a day
• Children: 25 mg / kg / Day in divided
doses every 8 hrs.
Side Effects:
• Same as in Amoxicillin
Contraindications:
• Any known Hypersensitivity to
Penicillin.
 Erythromycin
Trade Name:
• Erythrocin ® Abbott
Doses:
• Adults: 250 mg every 6 hrs
• Children: 250 mg Twice a day
Side Effects:
• Gastrointestinal disturbances, Allergic
reactions, Mild burning & Irritation
Contraindications:
• Any known Hypersensitivity to any of
ingredients.
 Oxytetracylin
Trade Name:
• Terramycin ® Pfizer
Doses:
• Adults: 1-2 g divided in 4 equal doses
• Children: 25-50 mg / kg divided in 4
equal doses
Side Effects:
• Discoloration of teeth, Pericarditis,
Photosensitivity, Nausea, Vomiting,
Blurred Vision, Hepatotoxicity, Anorexia,
Pigmentation of nails
Contraindications:
• Any known Hypersensitivity to any of
ingredients.
 Nystatin
Trade Name:
• Nilstat ® Wyeth
Doses:
• Adults: 4-6 ml four times a day
• Children: 2 ml four times a day
(1 ml on each side of mouth)
Side Effects:
• Nausea, Vomiting, Diarrhea,
Gastrointestinal distress,
Contraindications:
• Any known Hypersensitivity to any of
ingredients.