Angina: Pharyngitis and Tonsillitis

Neck pain, one of the most common symptoms of angina in medical practice, both in adults and in children, generally arises due to a frame of pharyngitis and/or tonsillitis.



Pharyngitis is the name given to inflammation of the pharynx. Tonsillitis is the inflammation of the tonsils. Both have as their main symptom a sore throat. As they are anatomically close, it is very common for the pharynx and tonsils to ignite simultaneously, a framework called tonsillitis. Although they ignite together, some people have predominantly tonsillitis, while others, pharyngitis. Throughout the text I will differentiate the terms pharyngitis and tonsillitis, but what goes for one, also serves to the other.

Before we begin, study the diagram on the right to learn what structures are being described. All of them can be seen by opening your mouth in front of a mirror.

Pharyngitis can be caused by bacterial or viral infections. Most cases are of viral origin. Several types of viruses can lead to pharyngitis and / or tonsillitis. Influenza is a common example of a sore throat of viral origin.

The viral pharyngitis is benign processes that resolve spontaneously, unlike bacterial pharyngitis or tonsillitis that can lead to complications such as abscesses and rheumatic fever. A sore throat caused by bacteria should always be treated with antibiotics (I'll explain why below).


The more correct way is by collecting material from throat swabs or swab with a cotton stick on the tip to collect material from the inflamed area for further laboratory evaluation. The analysis of the collected material by the swab can identify the infectious agent is a bacterium or a virus.

Despite help from the swab, there is a practical problem: the identification of the infectious agent takes at least 48-72h. Therefore, doctors often choose to start treatment based on clinical findings. As laboratory tests are now faster to identify bacteria, but it's not always easy to collect and send the material for analysis.

We explain below how to distinguish a viral sore throat from a bacterial pharyngitis by only clinical elements.


Symptoms of tonsillitis / pharyngitis are:

• Prostration
• Sore throat
• Pain in the body
• Fever
• Headache

All the above symptoms are common in both bacterial and viral infections. Other elements, therefore, are needed to distinguish between them.

Usually viral pharyngitis is accompanied by other signs of respiratory infection such as coughing, sneezing, nasal cold, conjunctivitis and / or hoarseness. Respiratory viral infections do not usually cause symptoms restricted to the pharynx or tonsils. Another tip is that the viral pharyngitis, although the throat becomes very inflamed, pus is unusual.

Having tonsillitis caused by bacteria not present with respiratory symptoms described above, usually causes spots of pus on the tonsils and swollen lymph nodes (glands) in the neck. The bacterial pharyngitis can also cause swelling of the uvula and petechiae (bleeding points) on the palate. The fever of bacterial infection is usually higher than in viral, but this is not a rule, since there are cases of influenza and high fever.

The presence of pus and swollen glands in the neck speaks strongly in favor of a bacterial pharyngitis. However, some viral infections such as infectious mononucleosis may also be present with these findings.

Mononucleosis is caused by the Epstein-Barr virus and usually goes with fever, purulent tonsillitis and swollen lymph nodes in the back of the neck (unlike bacterial tonsillitis that has swollen lymph nodes in the anterior neck). Other signs and symptoms are the possible increase in spleen weight loss, and extreme fatigue signals hepatitis. The picture of mononucleosis can be easily confused with a bacterial pharyngitis. The prescription of antibiotics such as amoxicillin in patients with mononucleosis may lead to the development of allergy with red spots appearing all over the body.

As can be seen, the distinction between viral and bacterial pharyngitis is important, since the treatment is different. If you suspect viral pharyngitis, rest and hydration are indicated. If the frame suggests bacterial pharyngitis, we should start antibiotics in order not only to accelerate the healing process, but also to prevent complications and transmission to other family members, especially those with intimate and prolonged contact.


Among the complications of bacterial pharyngitis, the main is rheumatic fever, which occurs mainly in children and young people.

Scarlet fever is a disease caused by Streptococcus bacteria. It presents as pharyngitis, with fever and diffuse rash.

The post-streptococcal glomerulonephritis is a kidney injury also caused by the same bacterium Streptococcus. Usually it's present with hypertension, blood in the urine and acute renal failure.

There is a type of psoriasis, called guttate psoriasis, which is related to the Streptococcus pharyngitis. They are skin lesions that arise whenever there is a throat infection, which disappears after the cure.


To avoid the complications of bacterial tonsillitis described above, treatment should always be done with antibiotics. In most cases, at 48h, there is already a dramatic improvement in symptoms.

Treatment with antibiotics derived from penicillin and amoxicillin (Amoxil) should be done for 10 days. In patients allergic to penicillin azithromycin (Zithromax) is an option for 5 days. In those patients with marked edema of the pharynx, who can not swallow tablets, or those who do not want to take medication for several days, an option is intramuscular injection of benzathinepenicillin, the famous one-time Benzetacil.

If the symptoms of a bacterial pharyngitis are very strong, while waiting for the effect of antibiotics anti-inflammatory drugs can be used to relieve the inflammation of the throat. But you should remember that the anti-inflammatory drugs are only symptomatic, they do not treat the bacterial infection.

The viral pharyngitis usually lasts only four or five days and resolves on its own. The use of antibiotics is not necessary. If the symptoms are very uncomfortable, anti-inflammatory can be used by two or three days. Moreover, rest and proper hydration are necessary.

Alternative treatments:

• Honey: There is no job that has failed to demonstrate benefits of honey.
• Propolis: It has a small anti-inflammatory effect. It works much less as any common anti-inflammatory remedy.
• Papain: Besides not improving, in large quantities can aggravate the inflammation.
• There are no studies that prove the effectiveness of homeopathy or herbal medicine in the treatment of pharyngitis. Disease duration and incidence of complications is equal to placebo.

Who wants symptomatic relief without taking many drugs, the ideal is to perform various daily gargling with warm water and a pinch of salt.

The removal of the tonsils (tonsillectomy) is an option in children who present more than six episodes of strep throat every year. As the incidence of complications is much lower in adults in this group the indication for tonsillectomy is more controversial, as there is a possibility of no improvement, just making sure the patient had bouts of tonsillitis and possibility to have bouts of pharyngitis, which ultimately is the same.

Patients with throat infections repetition may form crypts (small hole) in the tonsils. They accumulate caseous (or caseum), a yellowish substance, like pus, which is actually debris of old inflammatory cells. The caseous can cause a bad breath in people with tonsillitis / chronic pharyngitis.