Sore Throat
Esther K. Chung
INTRODUCTION
Sore throat is one of the most common reasons children are brought to medical attention. Most often, this complaint is part of an upper respiratory tract infection. Because children experience an average of five to seven upper respiratory tract infections per year, health care providers must be familiar with the evaluation and treatment of sore throat. In addition, misdiagnosis or inadequate treatment of a sore throat caused by certain bacterial pathogens can result in serious complications.
DIFFERENTIAL DIAGNOSIS LISTInfectious Causes
Nasopharyngitis
Pharyngitis
Peritonsillar abscess or cellulitis
Retropharyngeal abscess or cellulitis
Parapharyngeal abscess
Tonsillitis
Laryngitis
Uvulitis
Epiglottitis
Lemierre syndrome
Laryngotracheobronchitis (croup)
Herpangina
Herpetic gingivostomatitis
Hand-foot-and-mouth disease
Cervical adenitis (referred pain)
Acute otitis media (referred pain)
Dental abscess (referred pain)
Scarlet fever
Kawasaki disease
Tularemia (Francisella tularensis infection)
Toxic Causes
Caustic or irritant ingestions (e.g., acid, lye)
Inhaled irritant (e.g., tobacco smoke)
Neoplastic Causes
Leukemia
Lymphoma
Rhabdomyosarcoma
Traumatic Causes
Foreign body
Intraluminal tear
Gastroesophageal reflux disease
Vocal abuse (e.g., shouting)
External neck trauma (e.g., strangulation, child abuse)
Congenital or Vascular Causes
Branchial cleft cyst
Thyroglossal duct cyst
Inflammatory Causes
Autoimmune disorders
Allergy
Postradiation
Psychosocial Causes
Psychogenic pain (globus hystericus)
Miscellaneous Causes
Cyclic neutropenia
Periodic fever, aphthous stomatitis, pharyngitis, cervical adenitis (PFAPA) syndrome
Vitamin deficiency—A, B-complex, C
Dehydration
Pharyngeal irritation from breathing dry, heated air
DIFFERENTIAL DIAGNOSIS DISCUSSION
Nasopharyngitis
Etiology
Most cases of nasopharyngitis, also known as the common cold or upper respiratory tract infection, are caused by viral agents. There are more than 200 serologically different causative agents. The most common are rhinoviruses, coronaviruses, parainfluenza virus, enteroviruses (coxsackievirus A and B, echovirus, and polio virus), adenovirus, influenza virus A and B, and respiratory syncytial virus.
Clinical Features
The clinical picture typically includes fever, runny nose, sneezing, and nasal congestion with clear or purulent nasal secretions, a sore throat lasting for several days, and a self-limited clinical course of 4 to 10 days. Infection caused by group A beta hemolytic Streptococcus (GABHS) may present as a seromucoid rhinitis in toddlers.
Associated symptoms may include irritability, restlessness, muscle aches, cough, eye discharge, vomiting, or diarrhea, depending on the causative agent. Otitis media with effusion, laryngotracheobronchitis, or bronchiolitis may be present.
Complications are typically attributable to bacterial superinfection and include sinusitis, cervical adenitis, mastoiditis, peritonsillar and periorbital cellulitis, acute otitis media, and pneumonia.
Evaluation
The patient or parent should be asked about associated symptoms and about ill contacts at home, school, or child care. A complete physical examination should be performed, paying particular attention to the patient’s overall appearance and hydration status.
Treatment
The treatment of nasopharyngitis consists of bed rest, increased intake of fluids, and the administration of acetaminophen or ibuprofen for pain and fever. Because of the risk of Reye syndrome with influenza infection, aspirin and aspirin-containing products should be avoided. Oral decongestants (e.g., pseudoephedrine), oral antihistamine agents, and phenylephrine drops may be used for children who are greater than or equal to 6 years old. Saline drops and nasal suctioning are appropriate for infants with nasal obstruction. Humidifiers and vaporizers may be useful to prevent drying of secretions.
Pharyngitis
Etiology
Most cases of acute pharyngitis are caused by viruses—most commonly, adenoviruses. Other viral causes include influenza viruses A and B; parainfluenza viruses 1, 2, and 3; Epstein-Barr virus (EBV); cytomegalovirus; human herpesvirus 6; human immunodeficiency virus; human metapneumovirus; and enteroviruses. Bacterial causes include GABHS (15% to 30% of all acute pharyngitis in children), group C streptococci, group G streptococci, Mycoplasma pneumoniae, Corynebacterium diphtheriae, Arcanobacterium haemolyticum, Neisseria gonorrhoeae, N. meningitides, Yersinia enterocolitica, Y. pestis, and F. tularensis.
Clinical Features
Viral pharyngitis (caused by viruses other than EBV) is characterized by the gradual onset of a sore throat, fever, hoarseness, and halitosis (in some patients), and an erythematous throat with or without exudate. Follicular and ulcerative lesions, mild cough, rhinorrhea, conjunctivitis, diarrhea, enanthem, or exanthem suggest a viral cause. Cervical adenopathy (tender or nontender) and poor intake of solid foods and decreased appetite are seen. The clinical course is selflimited and lasts 1 to 5 days.
Although infectious mononucleosis is rare before 4 years of age, young children may experience pharyngitis caused by EBV. Clinical features include fever and a sore and erythematous throat with or without exudate. Palatal petechiae, poor intake of solid foods, posterior cervical and generalized adenopathy, hepatosplenomegaly, and fatigue may be seen.
Many experts consider pharyngitis caused by GABHS and rheumatic fever to be uncommon in children >3 years, but GABHS has been isolated in symptomatic infants as young as 3 months. It may present with the sudden onset of a sore throat, a fever as high as 104 °F (40 °C), erythematous tonsils with or without exudate, petechiae on the soft palate, and headache. Nausea, vomiting, and stomach ache are often associated symptoms. Tender, anterior cervical adenopathy, and a fine sandpaper-like rash may be noted on physical examination. Complications include acute otitis media, sinusitis, peritonsillar and retropharyngeal abscesses, acute glomerulonephritis, rheumatic fever, and suppurative cervical adenitis.
Evaluation
The parent should be asked about associated symptoms and whether the child has had contact with anyone at home or at school with a sore throat, mononucleosis, strep throat, scarlet fever, or rheumatic fever.
The tonsils, pharynx, soft palate, skin, neck, lymph nodes, liver, spleen, and pulses should be examined, and the patient’s general appearance and overall respiratory status and hydration status should be assessed.
A rapid strep test, also known as a rapid antigen detection test, should be obtained, if available, for all patients with an inflamed throat on physical examination; and if the rapid strep test is negative, a throat culture for GABHS should be sent.
TABLE 72-1 Clinical Findings Useful in the Diagnosis of Streptococcal Pharyngitis | |||
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