Children with complaints of mouth and/or throat pain may have infections that range from mild and self-limited in nature to severe and life threatening. With the advent of childhood immunizations and the increased availability of effective antimicrobials, we have seen improved outcomes and decreased incidence of many serious, life-threatening infections.^1-4 Despite this, infections of the neck and oral cavity remain a significant cause of childhood morbidity and reason for admission to the hospital. This chapter focuses on common oral cavity and neck infections that result in hospitalization or have potential for serious complications.

BACKGROUND

Stomatitis is the term used to describe inflammatory lesions of the oral mucosa, usually presenting as small, shallow, painful ulcerations. It has infectious and noninfectious causes. The location of lesions and accompanying findings from the history and physical exam can help to identify the underlying cause and guide further management. Most cases of stomatitis are isolated, benign, and self-limited. However, some cases can cause significant morbidity that require inpatient treatment and others may be a sign of an underlying systemic condition.

CLINICAL PRESENTATION

Three of the most common causes of stomatitis in children are recurrent aphthous ulcers, herpangina, and herpetic gingivostomatitis. These can usually be distinguished based on clinical findings alone.

Recurrent Aphthous Ulcers

Commonly referred to as “canker sores,” recurrent aphthous ulcers are the most common cause of inflammatory ulcerations of the oral mucosa.⁵ They typically present as small (<5 mm), round, painful ulcerations with clearly defined and erythematous borders on the mucosal surface of the inner lip or buccal mucosa. Lesions heal spontaneously within 10 to 14 days of onset without any scarring, but commonly recur. Familial tendencies have been noted, but the cause remains unknown. There are hypotheses that there may be a relation to alterations in local cell-mediated immunity, trauma, emotional stress, and possibly nutritional deficiencies. Other systemic symptoms, such as fever, are usually absent.

Herpangina

This condition, usually caused by group A coxsackieviruses, is found commonly in young children during the summer and early fall. It presents with sore throat and mouth pain, occasionally accompanied by fever, with clusters of small vesicles that progress to small ulcerations. Mucosal involvement characteristically involves the hard palate, tongue, buccal mucosa, and gums. Involvement of the hands and feet is characteristic, and lesions favor the lateral aspects on the fingers and toes as well as periungual (Figure 100-1). Lesions may also appear in other areas, particularly the buttocks and knees. While these lesions typically will heal spontaneously over 3 to 5 days, oral intake can be markedly decreased during the illness due to severe odynophagia and lead to dehydration.

Herpetic Gingivostomatitis

Gingivostomatitis is the most common manifestation of herpes simplex virus (HSV) infection in childhood, with primary herpetic gingivostomatitis typically occurring between 6 months and 5 years of age. It is primarily due to HSV type 1,⁶ resulting from direct exposure to oral secretions or lesions present in close contacts. Symptoms typically begin with a viral prodrome of low-grade fevers, malaise, and decreased appetite. Lesions begin as small vesicles on the gingiva that subsequently rupture to form painful ulcerations. The gingiva becomes very red, edematous, bleeds easily, and may become covered with a thick, black crust. Most lesions are anterior and involve the lips and gingiva, although lesions on the tongue, hard palate, and pharynx can occur (see Figure 100-2). Spread of the infection beyond the oral mucous membranes is sometimes seen with spread to the perioral skin, fingers (herpetic whitlow), or eyes (HSV keratitis).

DIFFERENTIAL DIAGNOSIS

In addition to HSV and coxsackieviruses described above, other viruses such as varicella, human immunodeficiency virus (HIV), and other enteroviruses can cause stomatitis. Infections with Candida albicans are common in infants and older patients who are immunocompromised and can cause erythematous and painful oral lesions, but are accompanied by white plaques. Traumatic ulcers can be due to mechanical, chemical, or thermal injuries. Patients receiving certain chemotherapy regimens are at high risk for severe mucositis, requiring immediate recognition and supportive care. Some systemic illnesses can present with oral ulcerations in association with other systemic signs and symptoms, including Crohn’s disease, Behçet’s disease, systemic lupus erythematosus, and reactive arthritis. Cyclical occurrences of stomatitis can also be seen in children with cyclic neutropenia or PFAPA (periodic fever with aphthous stomatitis, pharyngitis, and adenitis). In toxic-appearing patients with hemorrhagic oral lesions and discoloration of of oral mucosa, Stevens-Johnson syndrome should be considered.

DIAGNOSTIC EVALUATION

Diagnosis can usually be made on historical and clinical grounds alone. Further testing is only necessary when the cause is unclear. When necessary, HSV and many other viruses can be identified using viral polymerase chain reaction (PCR) (preferred), culture, serology, or immunofluorescence. For patients with reduced oral intake and possible dehydration, consideration should be given to checking serum electrolytes. If patients are ill-appearing or secondary bacterial infections are suspected, blood cultures and complete blood count (CBC) should be considered as well.

MANAGEMENT

Pain control and hydration are the primary focus when managing patients with stomatitis. Pain is often well controlled with acetaminophen or ibuprofen. Another option includes topical application of “magic mouthwash.” There are dozens of variations of these cocktails which can be used in either “swish and spit” or “swish and swallow” applications. A common combination consists of an equal-parts mixture of Maalox, 2% viscous lidocaine, and diphenhydramine. Due to concern for toxicity due to systemic absorption of lidocaine, however, this should be avoided in younger patients.⁷ A protective emollient, such as Orabase, with or without the addition of a corticosteroid or topical anesthetic, can also be effective in treatment of painful aphthous ulcers.⁵ In patients with HSV gingivostomatitis, if given within 3 to 4 days of disease onset, acyclovir may be able to decrease the duration of pain, fever, and viral shedding.^7-9

ADMISSION CRITERIA

Most patients with stomatitis can be managed in an outpatient setting. Admission should be considered for patients with severe pain despite oral medications, dehydration, or concern for secondary bacterial infection or other serious conditions such as Stevens-Johnson syndrome. In addition, immunocompromised patients and children with mucositis related to chemotherapy often require admission for supportive care and close monitoring.

PREVENTION

When infectious causes are suspected, patients and families should be encouraged to practice good hand hygiene and reduce contact with oral secretions to minimize the spread of infection. Hospitalized patients can be placed in isolation according to the standards of the admission facility.

BACKGROUND

With an estimated 15 million visits to healthcare providers annually in the United States, sore throat is one of the most common complaints that cause children to seek care from a healthcare provider.¹⁰ Pharyngitis in children is most frequently caused by viral infections.¹¹ However, bacterial causes are not uncommon, with group A β-hemolytic streptococcus (GABHS) comprising 15% to 30% of all cases of pediatric pharyngitis.¹² Clinicians are often challenged with deciding which children have benign, self-limited conditions and which require further evaluation to prevent serious complications and spread of infection.

CLINICAL PRESENTATION

Nearly every child with pharyngitis will present with pharyngeal erythema and a history of sore throat. When secondary to a viral infection, other findings on presenting history may include rhinitis, cough, stridor, conjunctivitis, hoarseness, oral ulcerations, or diarrhea. Bacterial causes of pharyngitis often present with an acute onset of symptoms that include headaches, nausea, vomiting, or abdominal pain in absence of the previously mentioned viral symptoms. Exudative pharyngitis can be seen in both bacterial and viral infections. Some findings often associated with infection by GABHS specifically include palatal petechiae, sandpaper-like rash, and anterior cervical lymphadenopathy, but these are nonspecific findings. GABHS infections peak between 5 and 11 years of age, with symptoms typically lasting 3 to 5 days.¹¹ Pharyngitis in infants and children are most likely to be due to viral infections, and symptoms may be slightly more prolonged, lasting >5 days. Both GABHS and viral pharyngitis are common in the colder months between the winter and early spring.¹¹

Arcanobacterium haemolyticum classically causes pharyngitis and rash in adolescents. The rash typically appears several days after the onset of pharyngitis but current development of pharyngitis and rash occasionally occurs. The rash is pruritic and may appear urticarial, maculopapular, or scarlitinoform. It typically begins on the extensor surfaces of the extremities and spreads centrally to affect the trunk over several days; the face and buttocks are typically spared.

DIFFERENTIAL DIAGNOSIS

Viral infections are the most common etiology of pharyngitis in children. However, aside from GABHS, there are several other bacterial causes to consider as well. Noninfectious causes of pharyngitis are less common, but should also be considered in the proper context. Table 100-1 lists the various causes of pharyngitis in children. The presenting history and physical exam is critical to help determine the most likely cause in each individual patient.

DIAGNOSTIC EVALUATION

The goal of diagnosis is to identify treatable causes of pharyngitis and prevent complications and transmission of illness to others. If symptoms are consistent with uncomplicated viral pharyngitis, monitoring the patient without further workup may be reasonable. However, if GABHS is suspected, further testing is usually needed due to the lack of specific findings to make a clinical diagnosis. Evaluation for GABHS infection should begin with a throat swab sent for a rapid antigen detection test (RADT).¹⁰ Testing is not necessary if there are overt signs of viral infection present (e.g. rhinorrhea, conjunctival infection) and usually should not be done in children under 3 years of age unless other risk factors are present. Because RADTs are highly specific but have a sensitivity of only 70% to 90%,¹⁰ children with positive tests should be treated as having a GABHS infection, but negative RADT tests warrant culture for confirmation; while most clinical microbiology laboratories routinely perform cultures on throat swab specimens with a negative RADT for GABHS, it is important to verify whether your laboratory uses this approach or requires a separate test order. Care must be taken to distinguish a positive test for GABHS in patients with an acute infection versus those who have a viral pharyngitis but are colonized with GABHS. Some estimates have placed the colonization rate as high as 20%.¹⁰ Pharyngeal swabs can also be sent for culture of bacteria other than GABHS, such as Neisseria gonorrhoeae, Archanobacterium haemolyticum, or Fusobacterium necrophorum.

Rapid diagnostic tests are also available for various viral pathogens, including respiratory syncytial virus (RSV), influenza A and B, and heterophile antibody spot (Monospot) tests for Epstein-Barr virus (EBV). However, unless management will change, these tests may not be necessary. Serologic tests can also be ordered in certain cases but are generally not indicated.