Casey Buitenhuys, MD, FACEP, and Stanley H. Inkelis, MD, FAAP
An 8-year-old girl has had a sore throat and fever for 2 days. She also has pain on swallowing, a headache, and a feeling of general malaise but no stridor, drooling, breathing difficulty, or rash. Other than the current illness, the girl is in good health. Although she has had sore throats in the past, she has never had one this severe. One week previously, her mother and father had sore throat and fever that resolved after 5 days with no medication.
The child has a temperature of 39.0°C (102.2°F). The physical examination is normal except for red tonsils with exudate bilaterally, palatal petechiae, and tender cervical lymphadenopathy.
1. What are the causes of sore throat in children?
2. What is the appropriate evaluation of the child with sore throat? What laboratory tests are necessary?
3. What is the appropriate management for the child with sore throat?
4. When should otolaryngologic consultation be obtained?
Sore throat, which is among the most common illnesses seen by the primary care physician, is a painful inflammation of the pharynx, tonsils, or surrounding areas. In most cases, children with sore throat have mild symptoms that require little or no treatment. However, sore throat may be the presenting symptom of a severe illness, such as epiglottitis or retropharyngeal abscess. Young children may not able to define their symptoms very well, which makes a careful history from parents or other caregivers and a good physical examination essential for correct diagnosis. Optimal management of sore throat, especially if group A β-hemolytic streptococcus (GABHS; Streptococcus pyogenes) is suspected, remains quite controversial.
In the United States, sore throat accounts for approximately 15 million outpatient physician visits each year, and approximately 5% of all pediatric emergency department visits are for pharyngitis. Sore throat is most common in children between 5 and 15 years of age. It is uncommon in infants younger than 1 year. Like other respiratory infections, sore throat occurs most often in the late fall and winter months. Approximately 11% of all school-age children receive medical care for pharyngitis. Twenty percent to 30% or more of cases of pharyngitis in these children are caused by GABHS. The estimated medical and nonmedical costs for GABHS pharyngitis are $205 per visit or approximately $224 million to $539 million per year, with much of the indirect costs related to parental loss of time from work.
The organisms that cause bacterial and viral pharyngitis are present in saliva and nasal secretions and are almost always transmitted by close contact. Spread between children in school is the common mode of transmission.
The clinical presentation of sore throat is variable and often depends on etiology (Box 89.1; also see Differential Diagnosis). Most children with sore throat present with sudden onset of pain and fever. The height of the fever is variable and is typically higher in younger children. In the older child, especially if the sore throat is associated with a common cold, fever is minimal or absent. The throat or tonsils are red, and the breath may be malodorous. Headache, nausea, vomiting, and abdominal pain may occur, especially if the child is febrile. Appetite may be decreased, and the child may be less active than usual.
In the child with the common cold, rhinorrhea and postnasal discharge are present. A pharyngeal and tonsillar exudate is not typical. Although the cervical lymph nodes may be enlarged, they are usually not very tender. In contrast, the child with streptococcal pharyngitis typically has high fever, pharyngeal and tonsillar exudate, and tender cervical lymph nodes.
Various bacteria and viruses produce sore throat symptoms by causing inflammation in the ring of posterior pharyngeal lymphoid tissue that consists of the tonsils, adenoids, and surrounding lymphoid tissue. This ring of tissue, called Waldeyer tonsillar ring, drains the oral and pharyngeal cavity and defends against infection of the mouth and throat. Other host defenses that protect against infection include the sneeze, gag, and cough reflexes; secretory immunoglobulin A; and a rich blood supply.
Viral sore throat may be acquired by inhalation or self-inoculation from the nasal mucosa or conjunctiva. The local respiratory epithelium becomes infected with the virus, and inflammation occurs. In some instances, inflammatory mediators may be responsible for the pain of sore throat. Group A β-hemolytic streptococcus and other bacterial organisms directly invade the mucous membranes. Enzymes produced by this organism, streptolysin O and hyaluronidase, aid in the spread of infection.
Box 89.1. Diagnosis of Sore Throat
•Pain in throat
•Erythema of pharynx or tonsils
•Follicular, ulcerative, exudative lesions of pharynx or tonsilsa
•Occipital or posterior cervical adenopathy
•Pain in throat, usually sudden onset
•Marked erythema of pharynx, tonsils, or uvula
•Headache, nausea, vomiting, abdominal pain
•Tonsillar and posterior pharyngeal wall exudate
•Tender, swollen cervical lymphadenopathy
•Absence of rhinorrhea or cough
•Positive rapid antigen test or throat culture result
•Distortion of natural anatomy
a Dependent on etiology (see Differential Diagnosis).
Although most children who present with sore throat have common viral or bacterial pharyngitis, other, less common disorders should be considered, such as infectious mononucleosis, acute HIV seroconversion syndrome, epiglottitis, retropharyngeal abscess, and peritonsillar abscess. See Box 89.2 for a list of causes of sore throat.
Viral infection, the most common cause of sore throat in children, is most often associated with an upper respiratory infection caused by a rhinovirus. Cough and rhinorrhea associated with a sore throat are suggestive of this etiology. Influenza virus infections may present with sudden onset of high fever, headache, cough, sore throat, and myalgia.
Adenovirus often results in exudative pharyngitis, frequently in children younger than 3 years. Pharyngoconjunctival fever, caused by adenovirus 3, is characterized by a high fever (temperature >39.0°C [>102.2°F]) for several days, conjunctivitis, and exudative tonsillitis.
Coxsackievirus and echovirus, both of which are enteroviruses, are the usual cause of herpangina. Vesicles and ulcers are generally apparent on the anterior tonsillar pillars and soft palate. They may also be found on the tonsils, pharynx, or posterior buccal mucosa. The child may have a high fever (temperature >39.0°C [>102.2°F]), be irritable, and refuse to eat or drink; dehydration may result. Coxsackievirus A16, coxsackievirus A6, and enterovirus 71 cause hand-foot-and-mouth disease, which is characterized by ulcerative oral lesions on the tongue and buccal mucosa and, less frequently, on the palate and anterior tonsillar pillars. Vesicular and papulove-sicular lesions are evident on the hands and feet and occasionally on other parts of the body, most commonly the knees and buttocks. It usually occurs in children younger than 5 years but can occur in older children as well. A more severe form of hand-foot-and-mouth disease is associated with coxsackievirus A6, a virus new to the United States in 2012. Enterovirus 71 is sometimes associated with severe central nervous system disease. Enteroviral infections typically occur in the late spring, summer, and early fall.
Box 89.2. Causes of Sore Throat
•HIV seroconversion syndrome
•Respiratory syncytial virus
•Corynebacterium diphtheriae (diphtheria)
•Francisella tularensis (tularemia)
•Group A β-hemolytic streptococcus
•Group B, C, and G β-hemolytic streptococci (non-GABHS)
•Haemophilus influenzae type B
•Treponema pallidum (syphilis)
•Abscess (peritonsillar or retropharyngeal)
•Allergic rhinitis with postnasal drip
•Cigarette smoke (including secondhand smoke)
Human herpesvirus may lead to pharyngotonsillitis but can be distinguished from most of the enteroviral infections because human herpesvirus almost always involves the anterior portion of the mouth and lips and is associated with gingivitis (ie, herpetic gingivostomatitis). The lesions often appear as whitish-yellow plaques with an erythematous base and are sometimes ulcerative. This illness is characterized by a high fever (temperature >39.0°C [>102.2°F]) for up to 7 to 10 days and frequent refusal to eat or drink because of the painful lesions. Dehydration may occur.
Epstein-Barr virus (EBV) may cause exudative pharyngotonsillitis alone or as part of the infectious mononucleosis syndrome that includes fever, malaise, lymphadenopathy, palatal petechiae, and hepatosplenomegaly. Fatigue, malaise, eyelid edema, organomegaly, and a maculopapular rash without the other characteristics of a scarlet fever rash help distinguish between infectious mononucleosis and GABHS infection.
Cytomegalovirus may cause an infectious mononucleosis syndrome similar to EBV but is less commonly associated with pharyngitis and splenomegaly.
HIV seroconversion syndrome may present with low-grade fever, myalgia, nonexudative pharyngitis, diffuse adenopathy, anorexia, and weight loss. Generally, onset of symptoms is approximately 1 week after exposure but may not appear until 1 month after exposure.
Group A β-hemolytic streptococcus is the most common cause of bacterial sore throat in children older than 3 years. The pharynx is typically very red and sometimes edematous, and the tonsils are red, enlarged, and covered with exudate. Occasionally, the uvula is quite inflamed as well. The child may also have dysphagia, fever, vomiting, headache, malaise, and abdominal pain. Swollen anterior cervical lymphadenopathy and petechiae on the soft palate and uvula are usually apparent. Additionally, the occurrence of a scarlatiniform rash, strawberry tongue, and Pastia lines (ie, petechiae in the flexor skin creases of joints) is indicative of scarlet fever, which is diagnostic of group A streptococcal infection (see Chapter 139). Sore throat from GABHS typically occurs in the winter and early spring. Rheumatic fever and glomerulonephritis are nonsuppurative complications of group A streptococcal infection.
Peritonsillar abscess or cellulitis and cervical lymphadenitis are suppurative complications of GABHS. Children with peritonsillar abscess often experience trismus and drooling and speak with a “hot
potato” voice. The abscess in the affected tonsil causes a bulge in the posterior soft palate and pushes the uvula away from the midline to the unaffected side of the pharynx. On palpation, the abscess may feel fluctuant. Peritonsillar cellulitis typically produces a bulge in the soft palate but does not cause deviation of the uvula.
Parapharyngeal and retropharyngeal abscesses that typically occur in children younger than 6 years are additional life-threatening complications of GABHS. Sore throat is associated with these conditions, but dysphagia is usually more evident when the child swallows. The child with a retropharyngeal or parapharyngeal abscess is toxic-appearing, also reports trismus, has a fever, has dysphonia, refuses to swallow, and drools. Additionally, the child may have meningismus and may be short of breath. A fluctuant mass may be palpated deep to the tonsils. The patient may have pain when the trachea is manipulated in a lateral direction. The neck may be stiff, and the patient may resist passive neck movements. Stridor may be present but usually is an ominous sign of impending airway compromise.
Group B, C, and G β-hemolytic streptococci (non-GABHS) have all been isolated from children with pharyngitis. Streptococcus pneumoniae and Arcanobacterium haemolyticum infrequently cause pharyngitis in children. The latter organism is associated with a scarlatiniform rash in some patients and is most common in adolescents and young adults. In contrast with scarlet fever, palatal petechiae and strawberry tongue are not present with the pharyngitis caused by this bacterium. Although Corynebacterium diphtheriae (diphtheria) rarely causes sore throat in immunized children, this organism should be considered in nonimmunized children or children from developing countries with exudative pharyngotonsillitis and a grayish pseudomembrane that bleeds when removal is attempted.
Chlamydia trachomatis may result in pharyngitis and tonsillitis in adolescents and young adults through sexual transmission. The role of Chlamydophila pneumoniae as a cause of sore throat in children remains unclear. Mycoplasma pneumoniae does not usually produce sore throat in children unless they have lower respiratory tract disease. Neisseria gonorrhoeae may cause sore throat in sexually active adolescents. Its occurrence in prepubertal children is often secondary to sexual abuse. The appearance of the throat is not characteristic, and diagnosis is made by cultures when the degree of suspicion is high. Tularemia is a rare cause of exudative pharyngitis in children but should be suspected if contact with wild animals has occurred.
Fusobacterium necrophorum is a gram-negative anaerobe that may cause an exudative pharyngitis, tender adenopathy, and fever. Untreated, it may progress to Lemierre syndrome or septic thrombosis of the internal jugular vein. Direct extension of the bacterial pharyngitis leads to perivenular inflammation and septic thrombosis of the internal jugular vein. The patient may present with fever, severe lateral neck pain, torticollis, and prominent internal and external jugular veins with erythema and induration. The patient may also present with additional signs and symptoms if septic emboli propagate, including acute neurologic signs (eg, central nervous system retrograde propagation), and shortness of breath as a result of multilobar pneumonia with or without cavitation (ie, pulmonary propagation). Paradoxical septic emboli may cause other symptoms if a right-to-left cardiac shunt is present.
Candida albicans may be responsible for sore throat in the infant or child who is immunocompromised or taking antibiotics. The child with oral candidiasis usually presents with whitish plaques on the labial or buccal mucosa that do not wipe off easily. When the pharynx and tonsils are involved, some discomfort or dysphagia, but usually not significant pain, may occur.
Epiglottitis (ie, supraglottitis) may present as sore throat. Prior to the Haemophilus influenzae type B (Hib) conjugate vaccine, epiglottitis typically affected children 2 to 7 years of age who would present with signs of toxicity, stridor, difficulty swallowing, and drooling. In the relatively well-appearing child with sore throat but no stridor, neither epiglottitis nor retropharyngeal abscess is a likely cause of sore throat. Historically, epiglottitis was almost always caused by Hib. With the widespread use of the Hib conjugate vaccine, however, this organism is now rarely the etiology, the prevalence of epiglottitis is diminished, and epiglottitis is rarely the cause of sore throat in children. Although rare in adolescents, epiglottitis may present with severe sore throat out of proportion to clinical findings. Other signs and symptoms include dysphagia, odynophagia, a muffled voice, and pain on palpation of the anterior neck around the hyoid bone. Streptococcus pneumoniae, Staphylococcus aureus, and group A, B, and C β-hemolytic streptococci are unusual but reported causative agents of epiglottitis.
The child with croup may have sore throat and stridor but does not usually appear toxic and does not have difficulty swallowing. Affected children are usually between 6 months and 3 years of age (see Chapter 71).
Odontogenic infections may cause localized infection, inflammation, and swelling of the submental and submandibular space. Significant infection of this space may present with Ludwig angina, which is characterized by difficulty with secretions, dyspnea, airway compromise, and elevated position of the tongue and “woody” induration and tenderness of the sublingual space.
Trauma from penetrating objects, burns, or exposure to caustic materials may cause sore throat in children. Household cigarette smoking, marijuana smoking, and vaping may also result in pharyngeal irritation. Additionally, allergic rhinitis with postnasal drip may result in sore throat. Tumor rarely causes sore throat in children but should be considered if a mass is present or pharyngeal inflammation persists. Persistent sore throat may also be a symptom of Kawasaki disease.
A thorough history often reveals the etiology of the sore throat (Box 89.3). Questions about duration, fever, headache, vomiting, pain on swallowing, rash, oral lesions, abdominal pain, and history of contact with other family members or classmates with similar symptoms suggest the most common causes of sore throat (eg, infections with viruses and GABHS). A history of rapid onset of fever, toxicity, difficulty swallowing, drooling, and respiratory distress is suggestive of epiglottitis and retropharyngeal abscess. Voice changes are suggestive of peritonsillar abscess or tonsillar hypertrophy associated with infectious mononucleosis (ie, EBV). Immunization history or history of immigration from a developing country is helpful in assessing the risk of diphtheria. Oral sexual activity suggests the possibility of a sexually transmitted infection. A history of allergies, trauma, and environmental smoke may help diagnose other causes of sore throat. Red eye or pinkeye with a rash, persistent fever (>5 days), and sore throat are suggestive of Kawasaki disease. A teenager with at-risk behavior and an influenza-like illness may be presenting with HIV seroconversion syndrome.
Box 89.3. What to Ask
•How long has the child had a sore throat?
•Does the child have fever, headache, or vomiting?
•How rapid was the onset of fever?
•Does the child have pain on swallowing?
•Are there any voice changes?
•Does the child have a rash or oral lesions?
•Does the child have abdominal pain?
•Does the child have any ill contacts?
•Are the child’s immunizations current?
•Is the child having any difficulty breathing?
•Does the child have a history of allergies?
•Has the child suffered any trauma to the throat or neck?
•Has the child been exposed to environmental smoke?
•For the sexually active adolescent or child with a history of sexual abuse with nonresponding sore throat, has there been any oral sexual activity? Any other risk-taking behavior?