Sore Throat

Sore throat is a common symptom. Many patients incorrectly believe that antibiotics improve the clinical course in all sore throats. Although the vast majority of sore throats are of viral origin and should be managed conservatively, an appropriate history and physical exam usually identify other causes of sore throat. Use of the clinical criteria listed below to determine the likelihood of strep pharyngitis will assist in making the work up more cost effective.

Differential Diagnosis

• Viral pharyngitis/laryngitis
  –Most common cause of sore throat
  –Associated with cough, low-grade fever, nasal congestion, and sneezing
  –Influenza occasionally causes sore throat with high fever, cough, severe myalgias
  –Rhino-, adeno-, coxsackie-, and herpesvirus
  –Acute HIV infection

• Mononucleosis
  –Associated with fever, headache, and excessive fatigue
  –Most common in teen and college ages
  –May have associated lymphadenopathy, splenomegaly, hepatitis, or encephalitis
• Streptococcal pharyngitis
  –May be associated with scarlatiniform rash, fever >101°F (>38.3°C), exudative pharyngitis, tender cervical lymphadenopathy, and absence of cough
  –More common in winter months, ages 5–10, and with history of group A Streptococcus exposure
• Allergic pharyngitis
• Gonococcal pharyngitis
• Fungal pharyngitis (e.g., Candida)
• Foreign body in throat
  –Most often occurs in smaller children
  –Associated with sudden onset of audible wheezing, stridor, drooling
• GERD
• Sore throat secondary to postnasal drip
• Irritation secondary to inhalants (e.g., cigarette smoke), chemicals (e.g., alcohol), hot foods
• Voice abuse (e.g., excessive screaming)
• Deep neck space infections (e.g., retropharyngeal abscess, peritonsillar abscess, Ludwig's angina)
• Epiglottitis/bacterial tracheitis
  –Occurs in children ages 2–7 and increasingly in adults
• Diphtheria
• Trauma
• Lymphadenitis (cervical)
• Cancer (e.g., tonsillar, tongue, laryngeal, esophageal)
• Caustic ingestions
• Thyroiditis
• Angina/acute coronary syndrome

Workup and Diagnosis

• History and physical exam often make the diagnosis
  –Consider exposure history, age, associated symptoms, past medical history (e.g. immunocompromise), use of inhaled steroids (e.g. with Candida pharyngitis), allergy history)
  –Focus on head and neck, lung, and abdominal examinations
• Streptococcal pharyngitis is often a clinical diagnosis
  –Presence of three out of four of the following criteria suggests the diagnosis: Exudative pharyngitis (not just a red throat); tender anterior lymphadenopathy; presence or history of fever; and absence of a cough; whereas if none or one of the criteria exists, group A β-hemolytic streptococcus is unlikely
  –Streptococcal culture is the gold standard (inexpensive; identifies group A and others; 1–2 days for results)
  –Rapid strep testing is more expensive and identifies only group A strep, but gives immediate results; very specific (95%) but less sensitive (60–70%), so consider culture if negative
• Monospot or CBC showing atypical lymphocytes is diagnostic for mononucleosis
• X-ray for foreign body; laryngoscopy if unable to verify
• Lateral neck X-ray may diagnose epiglottitis and retropharyngeal abscess
• Gonococcal and diphtheria cultures if necessary
• Barium swallow, upper GI series, or EGD for GERD

Treatment

• Viral pharyngitis: Treat symptomatically with hydration, decongestants, saline nasal spray, analgesics, and rest
• Strep pharyngitis: Appropriate antibiotics (e.g., penicillin, erythromycin) and symptomatic treatment with analgesics
• Mononucleosis: Symptomatic treatment with analgesics; limit contact sports if splenomegaly is present
  –Hospitalization in patients with encephalitis, airway compromise, or dehydration due to nausea/vomiting secondary to hepatitis
• Allergic pharyngitis: Antihistamines, nasal steroids
• Foreign body: Protect airway; removal by ENT doctor
• GERD: H2 blockers (e.g., ranitidine) or proton pump inhibitors (e.g., omeprazole), elevate head of bed, weight loss, small meals

Book Source Details

• Book Title: In a Page: Signs and Symptoms
• Author(s): Scott Kahan, Ellen G. Smith
• Year of Publication: 2004
• Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.

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Copyright Details: In a Page: Signs and Symptoms, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: In a Page: Signs and Symptoms Authors: Scott Kahan, Ellen G. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2004 ISBN: 1-4051-0368-X