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. 17^th 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, 5^th 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.