Sore Throat

Cynthia R. Jacobstein, MD

Sore Throat - BASICS

Sore Throat - description

Sore throat or pain with swallowing is a common presenting complaint in the pediatric population. The majority of cases have an infectious etiology, with viral causes being the most common.

Sore Throat - DIAGNOSIS

Sore Throat - signs & symptoms

• General goal:
  • The majority of cases of sore throat have an infectious cause, with most (∼70–80%) of these having a viral etiology.
  • Once the life-threatening and/or noninfectious causes have been excluded, the goal is to determine if the pharyngitis is caused by group A โ-hemolytic Streptococci (GABS), which should be treated with antibiotics, or one of the many other infectious etiologies.
  • Phase 1: Use history and physical exam to separate infectious from noninfectious causes. If etiology seems infectious, consider testing for group A Streptococci infection.
• Clinical pearls:
  • The clinical appearance of GABS pharyngitis may be indistinguishable from pharyngitis of viral etiologies. The therapy for these illnesses is different:
    • Antibiotics for group A Streptococci versus symptomatic care for viral pharyngitis. The practitioner should perform diagnostic testing (i.e., rapid Strep antigen and/or culture) when GABS pharyngitis is considered.
    • In general, it is not recommended to treat pending the culture results; rather, wait until the GABS pharyngitis is confirmed with a positive antigen or culture before starting antibiotics.

Sore Throat - history

• Sore throat in association with fever, headache, and/or abdominal pain:
  • Common association of symptoms present in group A Streptococci pharyngitis
• Sore throat in association with fever, upper respiratory infection symptoms (cough, rhinorrhea, conjunctivitis):
  • More suggestive of viral pharyngitis
• Presence of drooling, voice changes:
  • Possibility of more severe infectious etiology, including retropharyngeal or peritonsillar abscess, epiglottitis
• Foreign body exposure:
  • Retained foreign body (e.g., fishbone) or laceration/irritation from foreign body
• Irritant exposure (e.g., dry air from heating or cooling system):
  • Pharyngeal mucosal drying
• Immunization status and travel history:
  • Possibility of diphtheria in the non- or incompletely immunized patient, especially if recent travel to countries of the former Soviet Union
• Sexual activity (including oral sex and possibility of abuse):
  • Gonococcal pharyngitis

Sore Throat - physical exam

• Pharyngeal erythema with or without exudate:
  • Suggestive of infectious etiology, though does not reliably differentiate viral from bacterial causes
• Tender cervical adenopathy:
  • Suggestive of infectious etiology; anterior cervical nodes described in classic GABS infection; posterior cervical nodes ± hepatosplenomegaly suggest possibility of Epstein-Barr virus (EBV)
• Concommitant pharyngitis and conjunctivitis:
  • Suggestive of adenovirus infection
• Stridor/Drooling:
  • Raises concern for etiologies that may cause airway obstruction
• Asymmetric enlargement of tonsillar pillar with deviation of uvula away from enlarged side +/− trismus:
  • Peritonsillar abscess
• Mild erythema with cobblestoning of posterior pharyngeal mucosa:
  • Suggests allergic or irritant etiology
• Vesicular or ulcerative lesions in oropharynx:
  • Suggestive of viral etiologies including herpes simplex (lesions commonly in anterior oropharynx) or coxsackievirus (lesions commonly in posterior oropharynx)
• Diffuse fine blanching erythematous popular rash:
  • Suggestive of scarlet fever, which is caused by GABS

Sore Throat - tests

Sore Throat - lab

• Throat swab for Strep antigen test with subsequent culture if antigen test is negative
  • Useful for definitive diagnosis of group A Streptococci infection. A negative antigen test should be followed by throat culture to improve sensitivity. The sensitivity of current rapid antigen tests ranges from 80–90%. The sensitivity of a correctly obtained throat culture swab ranges from 90–95%.
• CBC and Monospot if indicated:
  • Atypical lymphocytosis/presence of heterophil antibodies suggestive of EBV infection. EBV titers (if indicated) should be sent in those <4 years of age because of low sensitivity (∼50%) of Monospot in this age group.

Sore Throat - imaging

• Lateral neck x-ray:
  • Enlarged epiglottis suggests epiglottitis; widened prevertebral soft tissue space suggestive of retropharyngeal abscess
• CT scan of neck:
  • For diagnosis of retropharyngeal abscess in setting of suggestive lateral neck x-ray

Sore Throat - differencial diagnosis

• Infectious:
  • Pharyngitis/Tonsillitis
  • Viral: Adenovirus/Influenza/Parainfluenza, EBV, cytomegalovirus, human immunodeficiency virus
  • Bacterial: Group A β-hemolytic Streptococcus (Streptococcus pyogenes), groups C and G Streptococci, diphtheria, Neisseria gonorrhoeae, anaerobic bacteria, tularemia, Arcanobacterium haemolyticum
  • Stomatitis: Herpes simplex virus, coxsackievirus
  • Other infectious etiologies include peritonsillar cellulitis/abscess, retropharyngeal abscess, epiglottitis/supraglottitis
• Environmental:
  • Irritative pharyngitis: Exposure to smoke or dry air
• Trauma:
  • Foreign body: Either retained or causing laceration to posterior pharynx
  • Burns: Hot liquids/foods
  • Voice overuse
• Tumor:
  • Rare in pediatric population
• Allergic/Inflammatory:
  • Allergens causing chronic postnasal drip that leads to irritant pharyngitis
• Miscellaneous:
  • Kawasaki disease
  • PFAPA: Periodic fever, aphthous stomatitis, pharyngitis, adenitis
  • Psychogenic pain
  • Referred pain

Sore Throat - TREATMENT

Sore Throat - initial stabilization

• Factors that make sore throat an emergency include:
  • Airway compromise: Epiglottitis, retropharyngeal abscess, peritonsillar abscess, significant tonsillar hypertrophy, diphtheria
• The patient may present with toxic appearance, fever, drooling, voice change, and sitting in the sniffing position (to optimize airway). Make NPO, supplemental oxygen; consider airway adjuncts (e.g., nasal pharyngeal airway), IV access to facilitate airway management (if patient able to tolerate). Consider anesthesia consult for endotracheal intubation in most controlled setting.

Sore Throat - general measures

The treatment of viral pharyngitis is largely supportive care, including fluids and pain control.

Sore Throat - medication

Penicillin is the drug of choice for treatment of GABS pharyngitis. PO and IM regimens are available. Macrolide antibiotics (e.g. erythromycin), clindamycin, or some 1st-generation cephalosporins (provided no allergy in the form of immediate-type hypersensitivity to B-lactam antibiotics) may be used for those with penicillin allergy.

Sore Throat - FOLLOW UP

Sore Throat - disposition

Sore Throat - admission criteria

• Signs/symptoms of airway compromise: General toxicity, stridor, drooling. Patient may need emergency airway protection/stabilization
• Significant dehydration secondary to poor oral intake

Sore Throat - issues for referral

• Fluctuant peritonsillar abscess: Drainage may be done by otolaryngologist.
• Presence of foreign body: May need removal by otolaryngologist, or x-ray to look for air in retropharyngeal soft tissue.

Sore Throat - bibliography

1. Attia MW, Bennett JE. Pediatric pharyngitis. Pediatr Case Rev. 2003;3(4):203–210.
2. Bisno AL. Acute pharyngitis. N Engl J Med. 2001;344(3):205–211.
3. Bisno AL. Acute pharyngitis: Etiology and diagnosis. Pediatrics. 1996;97(6 pt 2):949–954.
4. Feder Jr. HM. Periodic fever, aphthous stomatitis, pharyngitis, adenitis: A clinical review of a new syndrome. Curr Opin Pediatr. 2000;12:253–256.
Fleisher GR. Sore throat. In: Fleisher GR, Ludwig S, eds. Textbook of Pediatric Emergency Medicine. Philadelphia: Lippincott Williams & Wilkins; 2000:581–585.
5. Gerber, MA. Diagnosis and treatment of pharyngitis in children. Pediatr Clin N Am. 2005;52:729–747.
6. Gerber MA, Tanz RR. New approaches to the treatment of group A streptococcal pharyngitis. Curr Opin Pediatr. 2001;13(1):51–55.
7. Schwartz B, et al. Pharyngitis—principles of judicious use of antimicrobial agents. Pediatrics. 1998;101(1 pt 2):171–174.
8. Shulman ST. Acute streptococcal pharyngitis in pediatric medicine: Current issues in diagnosis and management. Pediatr Drugs. 2003;5(suppl)1:13–23.

Sore Throat - CODES

Sore Throat - icd9

• 034.0 Streptococcal sore throat
• 054.79 Herpes pharyngitis
• 074.0 Coxacie pharyngitis
• 462 Acute sore throat, not otherwise specified

Sore Throat - FAQ

• Q: What is the incidence of group A Streptococci disease as the cause of pharyngitis?
• A: Group A Streptococci is the most common bacterial etiology of infectious pharyngitis. The incidence of this disease is ~15–30% of all cases of infectious pharyngitis.
• Q: When must antibiotic therapy begin in group A Streptococci pharyngitis in order to prevent rheumatic fever?
• A: Antibiotics should be started within 9 days from the onset of symptoms in order to prevent this nonsuppurative complication of group A Streptococci pharyngitis.

Book Source Details

• Book Title: The 5-Minute Pediatric Consult
• Author(s): M. William Schwartz MD; et al.
• Year of Publication: 2008
• Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.

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Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: The 5-Minute Pediatric Consult Authors: M. William Schwartz MD; et al. Publisher: Lippincott Williams & Wilkins Copyright: 2008 ISBN: 0-7817-7577-9

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