SORE THROAT

Breaking down the orophraynx, nasopharynx, and larynx into anatomic components is not very valuable in developing a differential diagnosis of sore throat. What is useful is to use the mnemonic VINDICATE to establish the etiologies. Further analyzing the differential (because so many causes of sore throat are infectious), one may recall the inflammatory etiologies in a systematic fashion by starting with the smallest organism and working to the largest.

SORE THROAT, SYSTEMIC CAUSES

Let us begin with VINDICATE.

1. V—Vascular reminds one of blood dyscrasias such as leukemia, agranulocytosis of numerous causes, and Hodgkin disease.
2. I—Inflammatory diseases include the most common causes of sore throat, streptococcal or viral pharyngitis, but one must also consider the less frequent infectious diseases here. Beginning with the smallest organism and moving to the largest, one thinks of viral pharyngitis, particularly herpangina (due to Coxsackie virus), pharyngoconjunctival fever (due to eight or more viruses), and infectious mononucleosis. Viral influenza may begin with a sore throat. Moving to a larger organism, one should remember that Eaton agent (Mycoplasma) pneumonia might be associated with pharyngitis.

   Next, bacterial causes such as group A hemolytic Streptococcus (with or without scarlet fever), diphtheria, Listeria monocytogenes, and meningococcemia should be considered. Gonorrhea is increasingly a cause of sore throat. Tuberculosis should also be mentioned, although it is rare in contemporary affluent societies. Consider among bacterial causes sinusitis, tonsillar or peritonsillar abscess (quinsy), and retropharyngeal abscess: Staphylococcus organisms may cause these but they rarely cause the common sore throat.

   Moving to the next largest organisms, the spirochetes, think of syphilis and Vincent angina. Finally, remember the fungi, including thrush (moniliasis) and actinomycosis.

3. N—Neoplasm and carcinomas may include Hodgkin disease and leukemia. The Schmincke tumor is of particular interest here.
4. D—Degenerative diseases are an unlikely cause of sore throat, just as they are unlikely to cause pain anywhere.
5. I—Intoxication brings to mind chronic alcoholism and smoker’s throat. Agranulocytosis may also be included in this category, because it is so often drug-induced.
6. C—Congenital diseases are an infrequent cause of sore throat, but a hiatal hernia with reflux esophagitis may cause recurrent sore throat, because there may be reflux of gastric juice all the way to the posterior pharynx in the recumbent position. An elongated uvula may also be responsible.
7. A—Allergic diseases include angioneurotic edema of the pharynx or uvula and allergic rhinitis, otherwise, this category is a rare cause of sore throat.
8. T—Trauma brings to mind foreign bodies such as chicken bones and tonsilloliths.
9. E—Endocrine causes of sore throat should remind one of subacute thyroiditis; although the pain is really in the neck, the patient will report a “sore throat.”

Approach to the Diagnosis

In diagnosing the cause of sore throat, it has been traditional to do a throat culture and possibly a CBC and differential and start the patient on penicillin until the culture comes back. Now Abbott Laboratories (Abbott Park, IL, U.S.A.) has developed a rapid Streptococcus agglutination test on a throat swab. In resistant cases, repeated cultures (especially for diphtheria, gonorrhea, and Listeria organisms) and a monospot test will be useful. Because the titer for infectious mononucleosis may not be high initially, the differential test (Paul–Bunnell) or a repeated monospot test 1 to 3 weeks later may be necessary. Remember that subacute thyroiditis may present as a sore throat.

Book Source Details

• Book Title: Differential Diagnosis in Primary Care
• Author(s): R. Douglas Collins
• Year of Publication: 2007
• Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: Differential Diagnosis in Primary Care Authors: R. Douglas Collins Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-7817-6812-8

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