Society for Pediatric Urgent Care

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Society for Pediatric Urgent Care

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Sore Throat

ALERTS

  • Peritonsillar abscess
  • Retropharyngeal abscess – <4yrs
  • Epiglottitis
  • Foreign body
  • Trauma

AGE CONSIDERATIONS

  • Strep pharyngitis risk – >2yrs
    Gonococcal & Chlamydial pharyngitis – Adolescents

DIFFERENTIAL DIAGNOSIS

  • Viral pharyngitis
  • Herpangina
  • Coxsackie
  • GABHS pharyngitis
  • EBV
  • Post-nasal drip
  • Gonococcal pharyngitis
  • Chlamydia pharyngitis
  • Peritonsillar abscess/cellulitis
  • Retropharyngeal abscess
  • GERD
  • Epiglottitis
  • PFAPA syndrome (Periodic fever, Aphthous ulcers, Pharyngitis, & cervical adenitis)
  • Pharyngeal Foreign Body
    Trauma

EVALUATION

HISTORY

  • Onset and quality of pain, associated fever, timing, URI s/sx, malaise, headache, abdominal pain/vomiting, associated neck pain

PHYSICAL EXAM

  • HEENT: otoscopic findings, oropharynx, neck, lymph nodes
  • Abdomen
  • Skin

DIAGNOSTIC FINDINGS

  • Pharynx: erythema, edema, exudate, uvular positioning, lesions, strawberry tongue, palatal petechiae, trismus
  • Neck/Lymph: ROM, lymphadenopathy
  • Abdomen: tenderness, assess for splenomegaly
    Skin: rash

CONCERNING FINDINGS

  • Peritonsillar/Retropharyngeal abscess: assymetry, uvular deviation, trismus, drooling
  • EBV: splenomegaly, ill appearing
  • Epiglotitis: tongue protruding, drooling, tripod-sit, ill appearing, anxious
  • Foreign body: airway compromise,
    Trauma: bleeding, airway compromise, shock

DIAGNOSTIC TESTS

LAB TESTS

  • Rapid strep
  • Throat culture
  • Viral throat culture
  • Monospot, EBVserology (IgG, IgM)
  • CBC

IMAGING

  • Lateral neck xray
  • CT – neck

MANAGEMENT

TRANSFER/ADMISSION CONSIDERATIONS

  • Significant tonsillar edema with concern for progression to airway compromise
  • Peritonsillar or Retropharyngeal abscess
  • Dehydration
  • Foreign body
  • Epiglotitis
  • Trauma

COMPLICATIONS

  • Peritonsillar and retropharyngeal abscess
  • Uvulitis
  • Cervical lymphadenitis
  • Otitis Media/Mastoiditis
  • Acute rheumatic fever, acute post-streptococcal glomerulonephritis, and acute post-streptococcal arthritis – with Group A strep
  • EBV-induced reactive arthritis
  • Vascular injury (trauma)

PEARLS AND PITFALLS

  • Tonsillar lymphoma – asymmetrical enlarged tonsils without signs of infection
  • Small tears in penetrating oral trauma usually do not require repair but prophylactic antibiotics are needed
  • Oral daily penicillin used to prevent recurrent acute rheumatic fever
  • Frequency of tonsillitis needed for tonsillectomy are >6 in the previous year, >5 in the 2 preceding years or 3 episodes per year for 3 years

VIRAL PHARYNGITIS

TREATMENT

Supportive

  • Fever and pain reliever
  • Push fluids

Complementary & Alternative Therapies

  • Salt water or Listerine gargles

Surgery / Other Procedures

FOLLOW UP

Anticipatory Guidance

  • Pain reliever
  • Typical duration of sore throat is 7-10 days
  • Typical duration of fever is 3-5 days

Signs and Symptoms to return

  • Persistent fever, sore throat, fatigue/malaise
  • Decreased urine output
  • Increasing pain
  • Trismus, drooling

Activity, Diet

  • Activity as tolerated
    Increase fluids

PROGNOSIS, COMPLICATIONS

  • Typically self-resolves
  • Can progress to peritonsillar or retropharyngeal abscess

GABHS PHARYNGITIS

TREATMENT

First Line

  • Penicillin VK
  • Amoxicillin (40-50 mg/kg divided BID for 10 days)
  • IM Penicillin G

Second Line

  • Erthromycin/Azithromycin
  • Cephalexin (5% cross reactivity with PCN allergy)
  • Clindamycin

Supportive

  • Fever and pain reliever
  • Push fluids

Complementary & Alternative Therapies

  • Salt water or listerine gargles

Surgery / Other Procedures

  • Tonsillectomy if recurrent infections

FOLLOW UP

Anticipatory Guidance

  • Pain reliever
  • May take 48-72 hours for pain and fever to stop

Signs and Symptoms to return

  • Persistent fever, sore throat, fatigue/malaise
  • Persistent vomiting, decreased urine output
  • Increasing pain
  • Trismus, drooling

Activity, Diet

  • No school/work until 24 hours on antibiotics
  • Activity as tolerated
  • Increase fluids

PROGNOSIS, COMPLICATIONS

  • Typically responds well to antibiotics
  • Can progress to peritonsillar or retropharyngeal abscess
  • Can progress to acute rheumatic fever if untreated

REFERENCES

  1. Hayden GF, Turner RB. Acute pharyngitis. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 17th ed. Philadelphia, PA: Saunders Elsevier, 2004.
  2. Pantell R. Pharyngitis: Diagnosis and Management. Pediatr. Rev., Aug 1981; 3: 35 – 39.
  3. Pichichero M. GroupA Beta-hemolytic Streptococcal Infections. Pediatr. Rev., Sep 1998; 19: 291 – 302
  4. Yellon R, McBride T, and Davis H. Otolaryngology. In: Zitelli B and Davis H. Atlas of Pediatric Physical Diagnosis, 5th ed.Philadelphia, PA: Mosby Elsevier, 2007:921-925

ADDITIONAL RESOURCES

  1. Paradise J, Bluestone C, Colborn DK, Bernard B, Rockette H, and Kurs-Lasky M. Tonsillectomy and Adenotonsillectomy for Recurrent Throat Infection in Moderately Affected Children. Pediatrics, Jul 2002; 110: 7 – 15
  2. Tanz R, Gerber M, Kabat W, Rippe J, Seshadri R, and Shulman S.
    Performance of a Rapid Antigen-Detection Test and Throat Culture in Community Pediatric Offices: Implications for Management of Pharyngitis. Pediatrics, Feb 2009; 123: 437 – 444.