Chapter 30 Sore Throat (Case 2)
Patient Care
History
• Sore throat with itchy, watery eyes and rhinorrhea without fever and following a seasonal pattern suggests allergy.
• A morning sore throat improved by midday suggests an irritant such as warm dry air from a home heater.
• Foreign body ingestion is suggested by history of eating small bones (fish) or ingesting small objects such as a staple.
Physical Examination
• Tachypnea or irregular respirations with increased work of breathing suggests possible respiratory failure with upper airway obstruction.
• Asymmetric tonsils, a fluctuant pharyngeal bulge, and a uvula deviated contralaterally may indicate peritonsillar abscess.
Tests for Consideration
• Rapid respiratory panel: Detects influenza, parainfluenza, adenovirus, human metapneumovirus, rhinovirus, and respiratory syncytial virus (RSV) $325
Imaging Considerations
→ Neck radiograph—Anteroposterior (AP) and lateral views: Foreign body or retropharyngeal abscess $250
Clinical Entities: Medical Knowledge
| Viral Pharyngitis | |
|---|---|
| Pϕ | Many viruses cause pharyngeal inflammation and sore throat: rhinovirus, coronavirus, RSV, adenovirus, influenza, parainfluenza, coxsackievirus, and herpes simplex (HSV). Spread occurs by direct contact with secretions and inhalation of droplets containing virus. |
| TP | All ages are affected and present with mild sore throat, cough, rhinorrhea, and possibly fever. Associated symptoms such as diarrhea support the diagnosis. Conjunctivitis suggests the pharyngoconjunctival fever syndrome of adenovirus. Summer is peak time for coxsackievirus, which presents with painful papules and vesicles in the posterior pharynx or as part of hand-foot-and-mouth disease with vesicles in the mouth and on palms and soles. |
| Dx | Diagnosis is clinical. Specific viral testing may be done in select cases. |
| Tx | Treatment is supportive with particular attention to pain control and hydration. See Nelson Essentials 103. |
| Group A Streptococcal Pharyngitis | |
|---|---|
| Pϕ | Sore throat is caused by local invasion of the posterior pharynx with the help of streptokinase and hyaluronidase and release of exotoxins causing pain and fever. M protein, the major virulence factor of GAS, acts by preventing activation of complement, protecting the organism from phagocytosis. Spread occurs via direct contact with secretions and inhalation of bacteria-containing droplets. |
| TP | Abrupt onset of sore throat and fever with headache and abdominal pain is typical. Classic examination findings include red inflamed tonsils with exudates, a red swollen uvula, palatal petechiae, and tender anterior adenopathy. In addition, the fine sandpapery maculopapular rash and strawberry tongue may occur, and 5- to 11-year-olds are most commonly affected. |
| Dx | Perform a throat swab for GAS antigen, with culture performed if the rapid point of care test is negative. Diagnosis can be confusing in GAS “carriers.” |
| Tx | Oral penicillin or amoxicillen for 10 days is the treatment of choice. For penicillin allergic children who have had mild (non-type I hypersensitivity) reactions to penicillins, a 10-day course of a first-generation cephalosporin is appropriate. For children with immediate (type I) hypersensitivity reactions to penicillins, a 10-day course of clindamycin or a 5-day course of azithromycin are alternative regimens. Treatment will shorten the course and reduce incidence of peritonsillar or retropharyngeal abscess, cervical adenitis, and rheumatic fever. See Nelson Essentials 103. |
| Peritonsillar Abscess (PTA) | |
|---|---|
| Pϕ | PTA is a suppurative complication of GAS pharyngitis, infectious mononucleosis, or viral pharyngitis. Usually unilateral and located near the superior pole of the tonsil, the most likely organisms are GAS, other streptococci, staphylococci including Staphylococcus aureus, or anaerobes. |
| TP | Adolescents are more commonly affected and present with fever, sore throat, painful and difficult swallowing, difficulty opening the mouth (trismus), drooling, and a muffled “hot potato” voice. On examination there is an asymmetric posterior pharynx with a unilaterally enlarged tonsil and contralateral deviation of the uvula, with possible peritonsillar fluctuance. |
| Dx | Diagnosis is clinical. Cultures of the abscess fluid following drainage may identify the organism(s) and allow targeted treatment. |
| Tx | Initial treatment is with intravenous antibiotics. Clindamycin will cover GAS, most methicillin-resistant S. aureus (MRSA), and many anaerobes and is a reasonable first-line therapy. Ampicillin/sulbactam is another option but does not cover MRSA. Otolaryngology consultation is obtained for drainage. Adequate hydration and analgesia should be maintained. See Nelson Essentials 135. |
| Retropharyngeal Abscess | |
|---|---|
| Pϕ | Retropharyngeal abscess may follow acute pharyngitis. The fluid collection accumulates between the wall of the posterior pharynx and the prevertebral fascia. Responsible organisms are similar to PTA. |
| TP | Toddlers and young children are usually affected. Signs and symptoms include those of PTA, and, in addition, these children often resist movement of their neck and prefer a hyperextended position, mimicking meningismus. There may be stridor and respiratory distress in severe cases with airway obstruction. |
| Dx | Anterior bulging of the posterior pharyngeal wall may be appreciated. A lateral neck radiograph in the hyperextended position demonstrates a widened prevertebral space at the level of C2. Normally, the prevertebral space is less than half the width of the vertebral body. CT scan of the neck with contrast will delineate the collection and aid in the decision regarding need for surgical intervention. |
| Tx | As in PTA above. See Nelson Essentials 135. |
| Infectious Mononucleosis | |
|---|---|
| Pϕ | IM is most commonly due to Epstein-Barr virus (EBV); spread is via close contact with saliva. Lymphocytes are infected, which can produce multiple-system involvement, but acute pharyngitis is most common. Viral shedding can persist for months after symptom resolution. |
| TP | The typical patient is an older child presenting with sore throat, headache, fever, and fatigue. Examination reveals exudative pharyngitis, palatal petechiae, and tender cervical lymphadenopathy. Splenomegaly is common, and there may be hepatomegaly. Although the sore throat, headache, and fever usually resolve within 1 to 3 weeks, the fatigue may persist for 8 weeks or longer. Co-infection with GAS is not uncommon. Occasionally, a morbilliform rash may develop after amoxicillin given for GAS. This classic reaction may be related to an elevated level of benzylpenicilloyl-specific IgM antibodies in patients with IM and should not be considered an allergy. |
| Dx | Diagnosis is made by history, examination, along with supportive laboratory data. CBC demonstrates atypical lymphocytosis greater than 10%, which along with a positive heterophile antibody or Monospot is diagnostic. Monospot may be negative under 4 years of age, and serologic testing for EBV is also available; the IgM against viral capsid antigen may be most helpful in these cases. |
| Tx | Treatment is supportive. Spleen size should be monitored by the pediatrician, and contact sports avoided until the spleen is no longer palpable, because of the risk for life-threatening rupture. Corticosteroids may be helpful if there are severe symptoms, including airway compromise or massive splenomegaly. There is no evidence to support use of corticosteroids in uncomplicated cases. There is a theoretical risk that corticosteroid therapy may contribute to eventual development of EBV-associated malignancies, so they should be used only after careful consideration of risk and benefit. See Nelson Essentials 99. |
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