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PHARYNGITIS

(Module)

Departement of Otorhinolaryngology HNS


Dr. Hasan Sadikin General Hospital
Bandung ~ May 2010

INTRODUCTION

Pharyngitis is an inflammatory disease of the mucosal


and submucosal structures of the throat
Infection or non-infection
Affected tissues ; oropharynx, nasopharynx,
hypopharynx, tonsils, and adenoids
High concentrations of lymphoid tissue prone to
reactive changes, especially in response to pathogenic
organisms

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Most pharyngitis are diagnosed by clinical evaluation


and usually respond to treatment with antibiotics

Onset : acute and chronic pharyngitis

Acute : infectional causes are more common

Chronic : non-infectional more common, infection with


involvement of biofilm

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ANATOMY

The pharynx is the common chamber of the respiratory


and digestive tracts

It forms from the endodermal primitive foregut

12- to 14-cm musculomembranous tube that extends


from the base of the skull and the back of the nose and
mouth to the level of the 6th CV becomes
continuous with the esophagus

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ANATOMY

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ANATOMY

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Physiology of pharynx

The laryngo-pharynx functions as a "timeshare" for respiration and deglutition


The most basic function of larynx is airway
protection
Some herbivores and infants breathe and
swallow simultaneously; whereas adults must
interrupt respiration (usually during expiration)
to swallow
During deglutition bolus must be moved
completely through the pharynx while the
glottis is closed
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The normal swallow; three phases :


1. The oral phase; prepares the food for delivery to the
pharynx; mastication, addition and mixing of saliva,
control of bolus tongue, lips, buccinator, palate,
selection and verification of safety of bolus
2. The pharyngeal phase; moves the bolus quickly (<1
second), past the closed glottis and through UES into the
esophagus; nasopharyngeal, cessation of respiration
(usually during expiration), glottic closure, bolus
propulsion, laryngeal elevation and pharyngeal shortening,
epiglottic rotation, relaxation of m.cricopharyngues
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3.

Esophageal phase ; conveys bolus to the stomach


(3-6 seconds)

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Waldeyers Ring
Palatina tonsil (faucial)
Pharingeal tonsil (adenoid)
Lingual tonsils
Lateral pharyngeal band
Soliter noduls of posterior pharingeal wall

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PHARYNGITIS
1.
2.
3.
4.
5.
6.
7.
8.

Bacterial Infection.
Viral Infection.
Fungal Infection.
Parasitic Infection.
Infectious Granulomatous Disease.
Non Infectious Granulomatous Disease.
Integumental and Connective Tissue Disorders.
Idiopathic Pharyngitis.

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BACTERIAL INFECTION
1.
2.
3.
4.
5.
6.
7.
8.
9.

Streptococcal Infection.
Scarlet Fever.
Staphylococcal Infection.
Diphteri.
Haemophillus Infection.
Pertussis.
Gonorrhea
Syphillis.
Rhinoscleroma.

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STREPTOCOCCAL INFECTION

Etiology: Group A beta-hemolytic Streptococcus,


Streptococcus pneumonia.
World wide problem (WHO : related to increasing
rheumatic hd and glomerulonephritis)

incubation period : 12 hours to 4 days

Clinical : sore throat, dysfagia, fever, and cervical


lymphadenopathy

Diagnosis : culture

Therapy : antibiotic. , chronic /carrier ? L R - AX

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http://www.guideline.gov/summary/

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SCARLET FEVER

Clinical : a rash (red, punctate, spreads to cover


virtually the entire body ), the strawberry tongue.

Diagnosis : culture.

Treatment : antibiotic
cephalosporins).

Rarely affects infants : maternal antibodies.

Complications : rheumatic fever, rheumatic heart


disease, and acute poststreptococcal glomerulonephritis.

(penicillins,

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SCARLET FEVER

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STAPHYLOCOCCAL INFECTION

Cause of : S. aureus or S. salivarius.

Clinical : mucopurulent drainage, mucosal erythema,


edema, and pustules.

Treatment : antibiotics based on culture and sensitivity


results.

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STAPHYLOCOCCAL INFECTION

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DIPHTEROID INFECTION

Cause of: C. diphtheriae (gram positive, rod ), C.


ulcerans
Upper respiratory tract membranous pharyngitis
(pseudo-membrane may cause respiratory obstruction
Fever, enlarged anterior cervical lymph nodes and
oedema of soft tissues ("bull neck" appearance)
Incubation : 2 to 4 days.
Exotoxins :
tissue necrosis and inflammation, a gray-black
membrane
Treatment :
Antitoxin, Antibiotic.
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DIPHTEROID INFECTION

http://www.dipnet.org/general.public.php
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Diphtheria Hotspots 1997 - 2006 from cases


reported to the WHO

http://www.dipnet.org/general.public.php
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PERTUSSIS
(whooping cough)

Cause of : Bordetella pertussis (gram-negative


coccobacillus )

The incubation period : 1 week.

Clinical stages : the catarrhal stage, the paroxysmal


stage (whooping cough, fever ( - ), convalescent stage.

Treatment : self-limiting.

Immunization.

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PERTUSSIS

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Pertussis world map WHO 2002


/100.000 inhabitans

http://www.who.int/entity/healthinfo/statistics/bodgbddeathdalyestimates.xls
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HAEMOPHILLUS INFECTION

Cause of : H. influenzae type B ( coccobacillary gramnegative).

Symptoms : sore throat, fever, and dysphagia.

Clinical : red epiglottis is seen.

Histopathologic examination : acute inflammatory


process.

Treatment : secure airway and antibiotic.

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GONORRHEA

A pyogenic gram-negative diplococcus.

Asymptomatic, sore throat, tonsillar hypertrophy,


cervical adenopathy.

Identification : cultured on appropriate media ( chocolate


agar).

Treatment : penicillin, cephalosporins, or quinolones.

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SYPHILLIS

The clinical stages : primary, secondary, tertiary, and


congenital

Incubation period : 30 to 90 days (median, 3 weeks)

Primary stage : painless solitary chancre, ulcerates,


indurated margins.

Microscopically : plasma cells, histiocytes, lymphocytes,


and polymorphonuclear leukocytes.

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SYPHILLIS

Secondary stage : multiply and disseminate from the


primary lesion.

Pharyngotonsillitis
erosions.

One third : spontaneous remission, one third : latent


disease, and one third progress to tertiary syphilis.

Tertiary stage : slowly progressive, involving the central


nervous system.

mucous

patches

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SYPHILLIS

Gummas histologically : consisting of central


coagulative necrosis surrounded by palisading
macrophages and fibroblasts.

Serologic tests : nonspecific nontreponemal antibody


tests (VDRL, RPR) and specific treponemal antibody
tests (FTA-ABS), Darkfield, Whartin Starry staining.

Treatment : penicillin, tetracycline or erythromycin.

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RHINOSCLEROMA

Caused by Klebsiella rhinoscleromatis .


Three phases : rhinitic phase (mucopurulent discharge
hyperplastic mucosae), florid phase (, nasal obstruction),
sclerotic phase ( resolution).
Histopathologic : submucosal polymorphous, Mikuliczs
cells.
Identifiable by Grams stains or Warthin - starry
Treatment : antibiotic.

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VIRAL INFECTION
1.
2.
3.
4.
5.
6.
7.

Measles.
Herpes Simplex Virus.
Varicella Zoster.
Cytomegalovirus.
Epstein-Barr Virus.
Human Imunodeficiency Virus.
Hand, Foot, and Mouth disease.

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MEASLES

Morbilli virus.

Clinical : coryza, conjunctivitis, Kopliks spots,


lymphoreticular
hyperplasia,
and
cutaneous
erythematous rash.

Pharyngeal area : follicular hyperplasia of all lymphoid


tissue with Warthin-Finkeldey cells.

Treatment : symptomatic, self-limiting.

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HERPES SIMPLEX VIRUS

Subtypes: type 1 (usually oral) and type 2 (usually


genital).
Transmission : saliva.
The incubation period : 2 to 12 days.
Primary HSV infection :gingivostomatitis, acute
pharyngitis.
Pharynx : lesions (bleed easily, a black crust or a gray
exudate).
Disseminated infection: malnutrition, immunodeficiency,
immunosuppressive therapy, and malignancy.

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HERPES SIMPLEX VIRUS

The diagnosis : tissue culture, cytologic examination,


electron microscopy, fluorescent antibody, ELISA.

Histopathologic : multinucleated
intranuclear inclusions.

giant

cells

and

Management : symptomatic.

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VARICELLA ZOSTER VIRUS

Varicella zoster virus is a member of the herpesvirus


family and is neurotropic.

Although it occurs in a variety of clinical settings,


pharyngeal involvement by this virus is rare.

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EPSTEIN-BARR VIRUS

Infects B-lymphocyte (infectious mononucleosis).


IM : sore throat, fever, and malaise, lymphadenopathy,
splenomegaly , and hepatomegaly
Diagnosis of IM : clinical manifestations, laboratory,
serum heterophile antibodies
Microscopic : proliferation of immunoblasts, plasma
cells, Reed-Sternberg-like cells, and lymphocytes.
Therapy is supportive, including rest and fluids.

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CYTOMEGALOVIRUS

Has several antigenically strains, cause of congenital


and acquired infections.
Transmission : contact with saliva, semen, and by
infusion.
Clinical : asymptomatic, except in immunocompromised
patients.
Detected through : viral isolation, serology, or PCR.
Characteristic : intranuclear or cytoplasmic inclusion.

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HUMAN IMUNODEFICIENCY
VIRUS

Association with
syndrome (AIDS).

acquired

immunodeficiency

Pharyngitis can be seen : abnormalities in the


tonsils.

Test : PCR and immunohistochemical analysis.

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Hand, Foot, and Mouth Disease


(Singaporean Flu)

Is a human syndrome caused by intestinal viruses,


Picornaviridae family the most common strains:
Coxsackie A virus and Enterovirus 71 (EV71)
Often confused with foot-and-mouth (hoof-andmouth) disease cattle, sheep, and swine;
different viruses (Apthoviruses)
Spread: direct contact, infectious virus in the nose
and throat secretions, saliva, blister fluid, and stool
most contagious during the first week, summer,
autumn

http://www.cdc.gov/ncidod/dvrd/revb/enterovirus/hfhf.htm
http://www.infeksi.com/articles.php?lng=in&pg=44
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Recorded outbreaks

http://wwwnc.cdc.gov/travel/content/outbreak-notice/hand-foot-mouth-disease-china-2010.aspx
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Course of disease

Incubation periode:3-7 days


Early symptoms : fever, sore throat, poor appetite,
general malaise
1-2 days after fever : painful sores in the mouth and/or
throat small red spots blister ulcers
A non-itchy skin rash develops over 12 days (flat or
raised red spots, blisters) located on the palms of the
hands and soles of the feet, buttocks and/or genitalia

http://humanenterovirus71.wordpress.com/

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Self limiting disease 7-10 days


Diagnosis : Clinical manifestation and virus isolation, Tzanck
smear (-)
DD : Herpes simplex, varicella zoster
Tzanck cells (+)
Treatment :
Bed rest
Symptomatic (acateminophen, ibuprofen)
Complications: Meningitis, encephalitis ( bulbar, myocarditis
(Coxsackie Virus Carditis) or pericarditi, acute flaccid
paralyse akut(Polio-like illness)

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FUNGAL INFECTION
1.

Candida Infection.

2.

Deep Seated Mycoses.

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CANDIDA INFECTION

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CANDIDA INFECTION

Invasion of the mucosal surfaces can occur, causing pain


or dysphagia.

Lesions : cheesy or creamy mucosal plaques.

Identification : Grams stain or PASstain or by culture


on Sabourauds agar.

Histologically : budding yeasts and pseudohyphae with


an associated inflammatory infiltrate.

Treatment : topical nystatin, oral ketoconazole,


fluconazole, amphotericin B.

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DEEP SEATED MYCOSES

Fungi can infect a variety of head and neck sites.

These mycoses include Cryptococcus neoformans,


Rhinosporidiosis seeberi, Histoplasma capsulatum,
Blastomyces dermatitidis, and Paracoccidiodomycosis
brasiliensis.

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PARASITIC INFECTION

Parasitic infections of the pharyngeal region are rare.

The parasites that may infect the pharynx are


Leishmania
braziliensis,
Toxoplasma
gondii,
Clinostomum complanatum, and Mammomonogamus
laryngeus.

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INFECTIOUS GRANULOMATOUS
DISEASES
1.

Tuberculosis.

2.

Leprosy

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TUBERCULOSIS

Etiologi : Mycobacterium tuberculosis.

Clinical : sore throat, cervical adenopathy, and pulmonary


symptoms. Examination : erythematous granular, ulcerated mucosa.

The clinical workup : chest radiograph, tuberculin skin test, and


microbiologic cultures.

Microscopic : necrosis surrounded by epithelioid histiocytes,


inflammatory cells, and giant cells.

Treatment : medications

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LEPROSY

Etiologi : Mycobacterium leprae.

Transmission : skin-to-skin contact, the upper respiratory tract.

Classification : lepromatous or tuberculoid .

The Mitsuda reaction : for classifying the clinical forms of leprosy, as


a prognostic tool.

The histopathologic : tuberculoid leprosy (noncaseating


granulomatous process) , lepromatous leprosy (proliferation of foamy
macrophages)

Treatment : chemotherapy (dapsone, clofazimine, and rifampin).


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NON INFECTIOUS GRANULOMATOUS


DISEASES

1.
2.
3.

Wegeners Granulomatosis.
Chrons Disease.
Sarcoidosis.

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WEGENERS
GRANULOMATOSIS
Idiopathic,
multisystem disorder.
Characterized : necrotizing, granulomatous inflammation
and a vasculitis.
Diagnosis : the antineutrophil cytoplasmic antibody
(ANCA).
Treatment : prednisolone, cyclophosphamide, and other
immunosuppressant agents.

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CHRONS DISEASE

Unknown etiology that primarily affects the small and


large intestines.

Pharyngeal involvement by Crohns disease may be seen


in 9% of patients.

Resolution may follow treatment of the intestinal


disorder.

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SARCOIDOSIS

Unknown etiology.
Presents with hilar lymphadenopathy and pulmonary and
cutaneous involvement.
Pharyngeal involvement : inflammatory process, and
tonsillar hyperplasia.
The diagnosis : clinical, radiologic, and pathologic
findings (Schaumann bodies).
Treatment : corticosteroid therapy.

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INTEGUMENTAL
AND
CONNECTIVE TISSUE DISORDERS

1.
2.

Steven Johnsons Syndrome.


Pemphigus.

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STEVENS JOHNSONS
SYNDROME

Exudative erythema multiforme, cause is unknown.

Lesion : erythematous, vesiculobullous lesion.

Histologically
:
liquefaction
degeneration,
intraepithelial vesicles and subepidermal bullae .

Treatment : self-limited, symptomatic (maintenance of


fluid and electrolyte balance, treatment of secondary
infections).

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PEMPHIGUS

Types : vulgaris, vegetans, foliaceus, erythematosus,


herpetiformis, drug-induced, IgA and paraneoplastic .

Lesion : vesicles, bullae (bleed easily, painful),


Nikolskys sign (-), remissions and exacerbations.

Histologically : intraepithelial vesicles and bullae,


acantholysis, Tzanck cells, nuclear swelling and
hyperchromasia.

Treatment : immunosuppressive agents, and antibiotics.

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Others Cause of
Pharyngitis
Reflux Pharyngitis
GERD, hiatal hernia, and positive gastrytis
Helicobacter pylor
Hoarsness, sore throat, chronic cough, globus
sensation, halitosis, cervikal dyphagia, laryngeal and
esophageal malignancy
Mild pharyngeal erytheme, interarythenoid edeme
Treatment : PPI, behavioral

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Marshall syndromes (PFAPA)


Etilogy ?
1948, Raimann et al periodic disease
Marshall et al 1987 FAPA (Fever (>40,5oc), Apthous
stomatitis, Pharyngitis, cervical Adenitis), 1989
PFAPA
Periodic fever syndrome, 5 days
Recurrent 2-12 weeks

Berlucchi Marco and Dr Piero Nicolai. Marshalls syndrome or PFAPA (periodic fever, aphthous stomatitis,
pharyngitis, cervical adenitis) syndrome. 2004.
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Pharyngitis

& stomatitis (75%), cervical


adenophaty (66,6%), minor symptoms :
headache, nausea, vomiting, malaise
Treatment : Antibiotics (penicillin,
sephalosporin, macrolides, and sulfonamide)
NSAIDs (acetaminophen, ibuprofen),
acyclovir, acetylsalicylic acid, and colchicines

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Radiation Pharyngitis
Radiotherapy 16 - 22 cGy mucosal atropy
Low saliva (effects on major dan minor salivary
glands) predisposes superinfection of
bacterial/fungal of pharynx
Symptomatical therapy
Sucralfat, dyphenhydramin, antibacterial agent, and
topical steroid
Pylocarpin

Bailey Byron J.and Jonas T. Johnson. Head and Neck Surgery Otolaryngology, 4 th edition. Volume 1.
Philadelphia: Lippincot, William and Wilkins, 2006.
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IDIOPATHIC PHARINGITIS

Pharyngeal pain without an obvious explanation.

Possible predisposing factors : dietary and personal habits,


certain medications can also irritate the throat, persitent
infection in the neighbourhood, mouth breathing, chronic
irritant (excessive smoking, chewing of tobacco), environment
pollution, self-induced causes of pharyngitis (Munchausen
syndrome), emotional or psychiatric disturbances.

Difficult to diagnose and treat (symptomatic medications,


consultations)

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Chronic pharyngitis
Hypertophy of mucosa, seromucinous glands,
subepithelial lymphoid follicles, muscular coat of the
pharynx
Treatment :

Etiological factors
Stop habits ; hawking,
throat clearing freuquently

Granular pharyngitis
Cauter: 10-25% silver nitrate
, electrocautery/diathermy
Atrophic pharyngitis
pharyngeal irrigation
Potassium iodide orally; promote secretion, prevents crusting

Bailey Byron J.and Jonas T. Johnson. Head and Neck Surgery Otolaryngology, 4th edition. Volume 1. Philadelphia:
Lippincot, William and Wilkins, 2006.
Dhingra P.L. Disease of Ear, Nose and Throat, 4th edition. Noida-India: Elsevier, 2007.
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HIGHLIGTHS
Pharyngitis is one of the most common disorders affecting
the head and neck.
Causes of pharyngitis include infection, inflammation, and
congenital disorders.
Diagnosis of pharyngitis is based on a careful history and
physical examination.
Aerobic and anaerobic bacterial cultures may be required to
establish a diagnosis of bacterial infection.

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HIGHLIGTHS
Viral cultures are uncommonly justified in managing patients with
pharyngitis.
Mycoses are uncommon causes of pharyngitis and require special
stains and cultures for diagnosis.
Granulomatous inflammation may result from infectious agents,
systemic diseases (Wegeners granulomatosis), foreign material, or
neoplasms.
Persistent symptoms of pharyngitis may result from postnasal
drainage or reflux esophagitis.

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HIGHLIGTHS
Effective treatment of any pharyngeal lesion requires
establishing a correct diagnosis.
Failure of a pharyngeal lesion to resolve with empiric
therapies requires appropriate cultures or biopsy.
Major complications of pharyngitis include uncontrolled
sepsis, hemorrhage, or airway obstruction.

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Thank You

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