Basics
Description
Throat pain with swallowing (odynophagia) or without swallowing may be a lone complaint or accompanied by a variety of other complaints. The most likely etiologies are self-limited but must rule out potentially life-threatening causes.
Epidemiology
- Sore throat is a common complaint year-round, but etiology depends on season and age of patient.
- In winter months, viral agents are more active.
- In spring and fall, postnasal drip from allergic rhinitis is a common cause of throat irritation.
General Prevention
- Careful hand washing and avoidance of respiratory secretions are key to minimizing spread of most infectious agents.
- Noninfectious etiology often triggered by specific exposure, so avoidance of that trigger would limit symptoms
Etiology
- Infectious
- Urgent/emergent: epiglottitis, peritonsillar cellulitis/abscess, retropharyngeal abscess, Lemierre syndrome
- Viral: adenovirus, influenza, coxsackie, parainfluenza, Epstein-Barr virus (EBV), cytomegalovirus (CMV), herpes simplex virus (HSV), human immunodeficiency virus
- Bacterial: group A ²-hemolytic Streptococcus (GAS, Streptococcus pyogenes), Mycoplasma pneumoniae, groups C and G streptococci, diphtheria, Neisseria gonorrhoeae, anaerobic bacteria, tularemia, Arcanobacterium haemolyticum
- Fungal: Candida
- Environmental
- Tobacco smoke or aerosolized irritant
- Trauma
- Foreign body: either retained or causing laceration to posterior pharynx
- Burns: hot liquids/foods
- Caustic ingestion
- Voice overuse
- Tumor
- Acute lymphocytic leukemia or T-cell lymphoma can rarely present as sore throat and fever.
- Allergic/inflammatory
- Postnasal drip from allergic rhinitis
- Miscellaneous
- Kawasaki disease
- PFAPA: periodic fever, aphthous stomatitis, pharyngitis, adenitis
- GERD
- Eosinophilic esophagitis
- Psychogenic pain
- Referred pain
Diagnosis
History
- Drooling, inability to swallow, rapid progression of symptoms, or respiratory distress may suggest more urgent/emergent problem: epiglottitis, peritonsillar abscess (especially with unilateral symptoms), or retropharyngeal abscess.
- Exposures, ingestions, foreign bodies: need to elicit whether patient was exposed to agent that could cause progression of symptoms
- Caustic ingestion burns may progress rapidly and require transfer to higher level of care.
- Foreign body ingestion may require removal or endoscopic visualization.
- Outbreaks in child care setting or school: GAS, influenza, and coxsackie can spread rapidly.
- Sexual activity or concern for sexual abuse: oral sex a risk factor for development of pharyngitis due to N. gonorrhoeae
- Children who are immunocompromised or children on chronic inhaled corticosteroids who are otherwise immune competent are at risk for esophageal candidiasis. Throat pain is often chronic and not responsive to other treatments.
- Associated symptoms
- Fever, headache (HA), stomach pain: Consider GAS.
- Fever, HA, rhinorrhea myalgias, fatigue: Consider influenza.
- Rhinorrhea, cough, conjunctivitis: more likely viral
- Runny nose, itchy nose, congestion: Consider postnasal drip from allergic rhinitis.
Physical Exam
- General
- Ill appearing, respiratory distress: epiglottitis, retropharyngeal abscess
- Pharynx and oral cavity
- Exudative tonsillitis: usually GAS but also present in EBV, N. gonorrhoeae, Arcanobacterium, HSV, adenovirus
- Vesicles or ulceration on tonsils, tonsillar pillars, or buccal mucosa; inflammation of gums: HSV, coxsackievirus, echovirus
- Posterior pharyngeal cobblestoning: postnasal drip from allergic rhinitis
- Asymmetry in tonsil size or deviation of uvula: peritonsillar abscess
- Burns on lips or tongue: hot liquid or caustic ingestion
- Eyes, ears, nose
- Conjunctivitis with sore throat: adenovirus
- Rhinorrhea: viral etiology most likely
- Boggy nasal turbinates, allergic shiners: postnasal drip from allergic rhinitis
- Lymph nodes
- Tender anterior cervical lymph nodes: classic for GAS
- Diffuse lymphadenopathy +/ ’ splenomegaly: EBV, less likely CMV
- Skin
- Scarlatiniform rash (diffuse, erythematous, fine-papular, "sand-papery " rash): scarlet fever from GAS pharyngitis but can be seen with infections due to A. haemolyticum and in Kawasaki disease
- Vesicular rash, particularly on palms, soles, and/or buttocks: coxsackievirus
Alert
- Although rare since the introduction of the vaccine for Haemophilus influenzae type b, patients may present with epiglottitis.
- Caution approaching a febrile, toxic-appearing patient who is unable to control secretions and exhibiting any respiratory distress. Defer exam or imaging until patient is in a setting where an emergent airway could be established if epiglottitis is suspected.
Diagnostic Tests & Interpretation
Lab
- Rapid antigen detection test
- Initial test of choice if GAS pharyngitis suspected
- High specificity ( ≥95%), variable sensitivity (55 " 90%)
- Need to confirm negatives with culture or DNA probe for GAS
- Heterophile antibody test (Monospot)
- Can be used to confirm EBV infection
- Not reliable under age 4 years
- Cultures for other bacteria (e.g., N. gonorrhoeae, A. haemolyticum) require special handling and specific medium for growth.
Imaging
- Lateral neck x-ray
- Thumb print sign: enlarged epiglottis. Do not get x-ray in unstable patient.
- Widened prevertebral soft tissue space suggestive of retropharyngeal abscess
- Chest x-ray if foreign body is suspected
- Must ensure object passes out of esophagus
- Look for free air indicating perforation
- CT scan of neck
- For diagnosis of retropharyngeal abscess in setting of suggestive lateral neck x-ray or peritonsillar abscess if suggested by physical exam
Treatment
The treatment of sore throat is primarily supportive, including fluids and pain control. Additional treatment depends on underlying etiology.
Medication
- Pain relievers such as ibuprofen or acetaminophen are generally sufficient to manage pain.
- Rarely, addition of codeine or other opioid may be warranted in patients who are unable to maintain sufficient PO intake.
- Use codeine with caution due to variability in metabolism by cytochrome P450 CYP2D6. Patients who are "ultra-rapid metabolizers " of codeine convert up to 15% (vs. 3%) of the drug to morphine, which can lead to toxicity.
- Alternatively, for less severe pain, topical treatments such as throat lozenges or throat sprays may provide additional comfort with fewer potential side effects.
- GAS pharyngitis: penicillin G benzathine IM (600,000 U <27 kg, 1.2 million U >27 kg) or penicillin V potassium PO (250 mg b.i.d. <27 kg, 500 mg b.i.d. >27 kg 10 days) or amoxicillin (50 mg/kg/day; max 1,000 mg) first line
- 1st-generation cephalosporin for penicillin-allergic patients with nonanaphylactic reactions
- Clindamycin for patients with type I hypersensitivity to penicillin
- Macrolides are also acceptable alternatives.
- Some studies have shown steroids (oral or IM) to be of benefit to patients with severe symptoms. However, they should be used only in limited circumstances due to side effects.
- Esophageal candidiasis: fluconazole (6 mg/kg 1, then 3 mg/kg daily; max 400 mg/day) or itraconazole (5 " 10 mg/kg/day divided daily or b.i.d.; max 600 mg/day) 14 " 21 days after resolution of symptoms
Issues for Referral
- Epiglottitis: Exam, airway stabilization, and ongoing management must be done in controlled setting.
- Peritonsillar abscess: often requires drainage either by needle aspiration, incision and drainage, or tonsillectomy
- Presence of foreign body: may need removal
Inpatient Considerations
Initial Stabilization
- Patients with signs of airway compromise or respiratory distress may require emergent airway management.
- Patients suspected to have epiglottitis must have airway stabilized prior to any other treatment or diagnostic testing.
- If no impending airway obstruction, can undertake diagnostic and therapeutic interventions, including IV placement for administration of IV fluids if patient is not tolerating PO, antibiotics for treatment of abscess or cellulitis, or anesthetic agents if endotracheal intubation becomes necessary
- Supplemental O2 as needed
- Make NPO if surgical intervention is required.
Admission Criteria
- Patients with conditions causing airway compromise require monitoring until they demonstrate response to treatment.
- Pain control or hydration: Patients with uncontrolled throat pain may be unable to take adequate PO to maintain hydration at home.
Additional Reading
- Galioto N. Peritonsillar abscess. Am Fam Physician. 2008;77(2):199 " 202. [View Abstract]
- Madadi P, Koren G. Pharmacogenetic insights into codeine analgesia: implications to pediatric codeine use. Pharmacogenomics. 2008;9(9):1267 " 1284. [View Abstract]
- Sadowitz PD, Page NE, Crowley K. Adverse effects of steroid therapy in children with pharyngitis with unsuspected malignancy. Pediatr Emerg Care. 2012;28(8):807 " 809. [View Abstract]
- Schwartz B, Marcy SM, Phillips WR, et al. Pharyngitis " principles of judicious use of antimicrobial agents. Pediatrics. 1998;101:171 " 174.
- Wing A, Villa-Roel C, Yeh B, et al. Effectiveness of corticosteroid treatment in acute pharyngitis: a systematic review of the literature. Acad Emerg Med. 2010;17(5):476 " 483. [View Abstract]
Codes
ICD09
- 462 Acute pharyngitis
- 784.1 Throat pain
- 034.0 Streptococcal sore throat
ICD10
- J02.9 Acute pharyngitis, unspecified
- R07.0 Pain in throat
- J02.0 Streptococcal pharyngitis
SNOMED
- 267102003 sore throat symptom (finding)
- 162397003 Pain in throat (finding)
- 43878008 Streptococcal sore throat (disorder)
FAQ
- Q: Are steroids effective adjuvant therapy for sore throat?
- A: There have been a number of good studies that have shown that giving steroids to patients with GAS pharyngitis has decreased time to improvement in symptoms on average about 5.2 hours. However, there was no significant difference in pain at 24 hours. In patients with non " GAS-associated sore throat, the results are more mixed. One study did show significant decrease in time to improvement in symptoms in patients with severe symptoms.
- Q: What is the risk of giving steroids to a patient with sore throat?
- A: None of the studies of steroid use in treatment of acute throat pain reported any significant side effects in the treatment groups. There were some reports of GI upset that often were attributed to concurrent use of antibiotics. However, sore throat and fever is rarely the presentation of acute lymphocytic leukemia (ALL), and it has been shown that steroid administration prior to the diagnosis of ALL has a significant adverse effect of the chance a patient will achieve complete remission. Current COG protocol may assign children with ALL who have received steroids prior to diagnosis to more intensive treatment groups depending on time of steroid administration.
- Q: Should antibiotics be given to children with sore throat based on physical exam findings that suggest GAS pharyngitis?
- A: No. Most cases of sore throat in children are due to viruses, and the rapid antigen detection test (RADT) is a widely available screening test that is easy to administer. The test has an excellent specificity, and patients with a positive RADT should be treated. Negative results should be sent for culture or DNA probe, which may delay treatment by 24 " 48 hours. However, the primary reason for treating GAS pharyngitis with antibiotics is to prevent rheumatic fever, which can be accomplished as long as antibiotics are administered within 10 days of onset of symptoms.