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Sore Throat

Sore Throat: Excerpt from The Diagnostic Approach to Symptoms and Signs in Pediatrics

Sore throat refers to any painful sensationof the pharynx or surrounding tissues and is a common complaintin childhood and adolescence.

Principal Causes of Sore Throat

1. Infection
   1. Pharyngitis/tonsillitis
      1. Viral
      2. Bacterial
         1. Group A Streptococcus
         2. Other bacteria
   2. Peritonsillar, retropharyngeal, andlateral pharyngeal abscesses
2. Irritants
   1. Excessive dryness
   2. Dust
   3. Smoke
   4. Postnasal drip secondary to allergicrhinitis or sinusitis
3. Trauma
   1. Vocal abuse
   2. Thermal injury
4. Foreign body
5. Caustic substances
6. Psychogenic

Clinical Features and Diagnosis

Infection

Pharyngitis/Tonsillitis

Viral

Severalviruses may cause pharyngitis/tonsillitis, including parainfluenzaviruses, influenza viruses, rhinoviruses, coronaviruses, and respiratorysyncytial virus. Coryza and cough predominate, whereas fever isvariable finding. Nasal wash cultures are diagnostic but usuallyunnecessary for management.

Enteroviruses also may cause sore throatand fever, especially in summer months, but tonsillar exudate isunusual.

Herpanginais characterized by fever and painful vesicular lesions on pharynxand tonsils.

Coxsackie A16 is major cause of hand-foot-mouthdisease, which is characterized by vesicular lesions in the mouthand on hands and feet.

Herpes simplex virus produces acutegingivostomatitis with fever and painful vesicles usually confinedto anterior mouth. However, lesions may extend to anterior tonsillarpillars.

Epstein-Barr virus is common causeof sore throat in adolescents. Other characteristic findings ofinfectious mononucleosis include fever, malaise, fatigue, cervicalor generalized lymphadenopathy, and hepatosplenomegaly. >10% atypicallymphocytes are usually seen on blood smear. Positive mono spottest, which identifies immunoglobulin M (IgM) heterophile antibody,is diagnostic. When this test is negative, IgG and IgM antibodyagainst viral capsid antigen (VCA) should be determined. Presenceof IgM-VCA is associated with recent or current illness and confirmsdiagnosis, whereas IgG-VCA is present continuously after acute infection.

Adenovirus may cause pharyngoconjunctivalfever. Follicular hyperplasia of tonsils and exudate may be seen.

Bacterial

Group A Streptococcus

Most commonbacterial cause of pharyngitis/tonsillitis is group A Streptococcus.

Classic clinical presentation is school-agedchild with acute onset of fever and sore throat. Headache, abdominalpain, and vomiting also may occur. Rhinorrhea, cough, conjunctivitis,hoarseness, and diarrhea are unusual. Tonsils are enlarged and inflamed,with patches of exudate. Petechiae may sometimes be seen on palate.

Anterior cervical lymph nodes may beenlarged on 1 or both sides and are often tender.

Usual clinical dilemma is to distinguishbetween viral infection or group A streptococcal infection. Difficultto distinguish them clinically, except when typical erythematoussandpaper-like rash of scarlet fever occurs, which signifies infectionwith group A Streptococcus.

Rapid techniques are now availablefor detection of streptococcal antigen. Either rapid antigen testor throat culture should be performed if streptococcal pharyngitisis suspected. If antigen assay is negative, throat culture shouldbe obtained.

Other Bacteria

Pharyngitiscaused by group C or G Streptococcus is indistinguishable from that causedby group A Streptococcus.

A. hemolyticum produces illness similarto group A Streptococcus. Scarlet fever–like rash occursmost often in adolescents, but strawberry tongue and palatal petechiaehave not been described.

N. gonorrhoeae pharyngitis can occurin sexually active adolescents as consequence of oral-genital contact.Ulceration of pharynx and tonsils along with exudate may be seen.Its presence in younger children suggests sexual abuse.

M. pneumoniae is uncommon cause ofpharyngitis, whereas C. diphtheriae is rare cause of pharyngitis.With the latter infection, acute onset of fever and sore throatis followed in 1–2 days by grayish membrane over pharynxand tonsils, which may extend into larynx and trachea.

Positive throat culture confirms diagnosisof these pathogens.

Peritonsillar, Retropharyngeal, and Lateral Pharyngeal Abscesses

Generallydue to spread of infection from local sites.

Most common pathogens are aerobes (groupA Streptococcus, S. aureus, H. influenzae) and anaerobes (Peptostreptococcus,Fusobacterium, Prevotella, Porphyromonas species), although manyinfections are polymicrobial.

Peritonsillar abscess generally occursas complication of acute bacterial tonsillitis in older childrenand adolescents. Sore throat, fever, pain on swallowing, drooling,and trismus characterize this infection. Ipsilateral otalgia alsomay occur. Swollen inflamed tonsil has fluctuant quality and oftenpushes uvula across midline of oral cavity. Diagnosis is clinical,although specific pathogen can be cultured from infected tonsilor abscess drainage.

Although retropharyngeal abscess/cellulitisis uncommon cause of sore throat, it usually occurs in children <4yrs. Most children appear toxic and are in respiratory distress,but some complain of sore throat and painful swallowing early incourse. Often direct visualization is impossible and lateral neck radiographyshows bulge of posterior pharyngeal wall. If diagnosis is uncertain,CT can be performed.

Lateral pharyngeal abscess usuallypresents with fever and trismus as well as swelling and tendernessbelow mandible. CT is helpful in determining extent of abscess.

Irritants

Upon awakeningin morning, otherwise well child may have scratchy sore throat, whichusually improves over several hours. This sensation is usually dueto dryness of pharynx and frequently occurs with rhinitis, especiallyduring winter months when humidity is low and mouth breathing islikely because of nasal congestion.

Exposure to dust or smoke also maycause irritation of pharynx.

Postnasal drip secondary to allergicrhinitis or sinusitis also may cause pharyngeal irritation and mildsore throat.

Trauma

Excessiveuse of voice due to prolonged shouting or singing may cause sore throat.

Burn secondary to exposure of hot gasesor liquid also may cause pharyngeal pain.

Foreign Body

Foreignbody lodged in pharynx causes acute onset of choking, dysphagia,and sometimes upper airway obstruction.

Commonly, fish bone or chicken bonecan be seen in pharynx. Otherwise, neck radiography may be diagnostic.

Only symptom of retained foreign bodyin upper airway may be persistent stridor. In this circumstance,laryngoscopy is usually diagnostic.

Caustic Substances

Ingestionof caustic substances may cause inflammation of pharynx.

History and physical exam are diagnostic.

For suspected esophageal injury, esophagoscopyshould be performed.

Psychogenic

Sometimes there does not seem to be explanationfor sore throat after history, physical exam, negative throat culture,and normal neck radiographs. In this case, psychosocial historyis most valuable clinical tool.

Diagnostic Approach

Historyand physical exam provide important clues for proper diagnosis ofsore throat.

Most common clinical dilemma in childwith pharyngitis is whether pathogen is virus or group A Streptococcus.Tests to detect streptococcal antigen may be diagnostic, but ifresults of such tests are negative, throat culture should be performed.

Because many cases of pharyngitis aredue to viruses, antibiotic use should be guided by antigen detectiontests or culture. Presence of conjunctivitis, cough, rhinitis, andhoarseness suggests viral etiology. Infectious mononucleosis isalso a consideration, especially in older children and adolescents.

Neck radiography, flexible laryngoscopy,and CT are useful with suspected foreign body or retropharyngeal/lateralpharyngeal abscess.

References

1. Bisno AL. Acute pharyngitis: etiologyand diagnosis. Pediatrics 1996;97(suppl):949–954.
2. Feigin RD, Cherry JD, eds. Textbook of pediatric infectiousdiseases, 4th ed. Philadelphia: WB Saunders, 1998.
3. Fleisher GR. Sore throat. In: Fleisher GR, Ludwig S,eds. Textbook of pediatric emergency medicine, 4th ed. Philadelphia:Lippincott Williams & Wilkins, 2000:581–585.
4. Long SS, et al., eds. Principles and practice of pediatricinfectious diseases. New York: Churchill Livingstone, 1997.
5. Rudolph AM, ed. Rudolph's pediatrics, 20thed. Stamford, CT: Appleton & Lange, 1996.

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Book Source Details

• Book Title: The Diagnostic Approach to Symptoms and Signs in Pediatrics
• Author(s): Paul S. Bellet
• Year of Publication: 2006
• Copyright Details: The Diagnostic Approach to Symptoms and Signs in Pediatrics, Copyright © 2006 Lippincott Williams & Wilkins.

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More About This Book: Title: The Diagnostic Approach to Symptoms and Signs in Pediatrics Authors: Paul S. Bellet Publisher: Lippincott Williams & Wilkins Copyright: 2006 ISBN: 0-78172-899-1

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