Distinguish potentially life-threatening (epiglottitis, peritonsillar, and retropharyngeal abscess) and benign (uncomplicated pharyngitis) conditions.
Use a scoring system to guide management of pharyngitis.
Suspected group A β-hemolytic streptococcus (GABHS) infections can be confirmed by performing a rapid antigen screening test or a throat culture.
Antibiotic treatment is used to prevent suppurative and nonsuppurative (immune-mediated) complications GABHS.
Sore throat is a common complaint seen in the emergency department (ED). Pharyngitis is inflammation of the throat and is usually the cause of sore throat. Inflammation of the tonsils (ie, tonsillitis) may also be present. The goal of the initial evaluation of patients with a complaint of sore throat is to exclude the most serious conditions (eg, abscess, epiglottitis).
Infectious pharyngitis involves direct invasion of the pharyngeal mucosa by bacteria or viruses leading to a local inflammatory response. Viruses are the most common cause of pharyngitis and include adenovirus, parainfluenza, influenza A and B, Coxsackie, rhinovirus, coronavirus, and Epstein-Barr virus (EBV).
Group A β-hemolytic streptococcus (GABHS) is the most common bacterial cause of pharyngitis. It accounts for 15–30% of cases of pharyngitis in children and 5–15% in adults. The peak age group is 5–15 years old. Most cases are seen in the winter and spring. GABHS pharyngitis is rare in patients younger than 2 years. Antibiotics are used to treat GABHS and to prevent suppurative and nonsuppurative complications. Suppurative complications include abscess formation. Nonsuppurative complications include scarlet fever, acute rheumatic fever (ARF), poststreptococcal glomerulonephritis, and streptococcal toxic shock syndrome. Scarlet fever, presenting with pharyngitis and a diffuse erythematous rash, is the result of the skin’s reactivity to the release of pyrogenic exotoxin by GABHS. ARF is a delayed sequela and can present with arthritis, carditis, chorea, erythema marginatum, and subcutaneous nodules. Poststreptococcal glomerulonephritis is caused by nephritogenic strains of GABHS. Children <7 years of age are at the highest risk. Streptococcal toxic shock syndrome is a severe GABHS infections presenting with shock and multisystem organ failure. The pharynx, skin, mucosa, and vagina can be portals of entry for GABHS resulting in streptococcal toxic shock syndrome.
Epiglottitis is an infection of the epiglottis and adjacent supraglottic structures that can result in respiratory arrest and death if swelling is severe enough to airway occlusion. The widespread use of Haemophilus influenzae type B (HIB) conjugate vaccine in young children has dramatically changed the epidemiology of epiglottitis, and the incidence has decreased. Epiglottitis is currently more often seen in adolescents and adults. Common organisms include Streptococcus pneumoniae, Staphylococcus aureus, nontypeable H. influenza, and β-hemolytic streptococcus.
Retropharyngeal abscess is a deep space neck infection involving the lymph nodes that drain the nasopharynx, adenoids, posterior paranasal sinuses, and middle ear. The disease can start as an infection in these nodes (adenitis) leading to a suppurative adenitis, phlegmon formation, and finally, a retropharyngeal abscess. Incidence peaks between 2 and 4 years of age, as the retropharyngeal lymph nodes are prominent in young children but atrophy before puberty.
Peritonsillar abscess (PTA) is a collection of pus between the tonsillar capsule and the palatopharyngeal muscle. It is usually preceded by pharyngitis or tonsillitis with progression from cellulitis to phlegmon, and then abscess. It is the most common deep neck infection in children and adolescents. Infections are polymicrobial and include anaerobic and aerobic organisms (GABHS, S. aureus, fusiform, and bacteroides).
Most patients with pharyngitis will complain of sore throat and fever. Symptoms are acute in onset with GABHS pharyngitis. There is also pain on swallowing (odynophagia) or difficulty swallowing (dysphagia). Young children may not localize the pain to the throat and will complain of headache and/or abdominal pain instead of sore throat. Nausea and vomiting may also be present. Toddlers can present with fever, fussiness, or refusal to take liquids and solids.
Coryza, conjunctivitis, and hoarseness are symptoms suggestive of viral illness. Pharyngitis with fever, red eyes, and rash prompts concern for Kawasaki disease (mucocutaneous lymph node syndrome). Fatigue and anorexia are associated with infectious mononucleosis.
Drooling and the inability to handle oral secretions are seen is patients with epiglottitis, peritonsillar, or retropharyngeal abscess. Increased work of breathing (tachypnea, retractions, and stridor) is seen in patients with epiglottitis. Severe unilateral throat pain and inability to open the mouth (trismus) is seen in patients with a peritonsillar abscess. A muffled or “hot potato” voice can be heard in patients with a peritonsillar abscess, but is also present with epiglottitis and retropharyngeal abscess. Children with a retropharyngeal abscess may also have neck stiffness and pain with extension of the neck.
Airway patency must be assured, and impending airway compromise needs to be rapidly identified. Evaluate the hydration status, focusing on findings that have been correlated with dehydration in children. Signs and symptoms include a general “ill” appearance, the absence of tears with crying, dry mucous membranes, decreased skin turgor, tachycardia, and delayed capillary refill (>2 seconds). Auscultate the heart and document murmurs that might suggest the presence of acute rheumatic fever.
Patients with epiglottitis will be “toxic” appearing, showing signs of respiratory distress with stridor. The patient may prefer to sit in the “sniffing position” with the neck extended. Drooling, respiratory distress, and hyperextension of the neck are seen in patients with retropharyngeal abscess. Anterior bulging of the posterior pharyngeal wall may be visualized on examination. Those with a peritonsillar abscess may have trismus, “hot potato” muffled voice, and drooling with a fluctuant bulge in the posterior aspect of soft palate with contralateral deviation of the uvula (Figure 53-1A). Classic findings in GABHS pharyngitis are fever, tender cervical adenopathy, tonsillar erythema, exudates, and hypertrophy (Figure 53-1B). Those with scarlet fever may have a fine, erythematous, “sandpaper-like” rash. Palatal petechiae (Figure 53-1C), a white or red “strawberry tongue” (inflamed tongue papillae), desquamating rash, and Pastia lines (accentuation of rash in flexor creases) are also suggestive of GABHS infection and scarlet fever.
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