Sore Throat
INTRODUCTION
An acutely sore throat is a common symptom in emergency medicine. The most common diagnoses are: is viral pharyngitis, strep throat or infectious mononucleosis. However, the emergency physician must remain vigilant for more serious infections such as peritonsillar abscess, retropharyngeal abscess, and acute epiglottitis. An inflamed painful throat often raises the question of viral versus bacterial infection. Most pharyngitis, regardless of the cause, resolve spontaneously. However, the standard is to treat acute group A β-hemolytic strep infections with antibiotics to minimize the risk of acute rheumatic fever. Various clinical rules in association with rapid streptococcal antigen testing successfully identify pharyngitis due to bacterial infection and can decrease the use of unnecessary antibiotics. Although the treatment for infectious mononucleosis is only symptomatic treatment, early diagnosis can be beneficial to the patient in anticipating a protracted course of the illness and the need to minimize physical activities. Peritonsillar abscess requires drainage in the emergency department. Acute epiglottitis can cause life-threatening airway obstruction and must be diagnosed. A patient with retropharyngeal abscess often requires hospitalization and drainage and should be considered in a systemically ill patient with a sore throat.
COMMON CAUSES OF SORE THROAT
Streptococcal pharyngitis (group A, β-hemolytic)*
Infectious mononucleosis*
Herpangina*
Viral pharyngitis
Aphthous stomatitis
LESS COMMON CAUSES OF SORE THROAT NOT TO BE MISSED
Peritonsillar abscess*
Acute epiglottitis*
Retropharyngeal abscess*
Gonococcal pharyngitis
Diphtheritic pharyngitis
Thyroiditis
Vincent angina
Ludwig angina*
OTHER CAUSES OF SORE THROAT
Candidiasis
Legionella pharyngitis
Mycoplasmal pharyngitis
HISTORY
Streptococcal pharyngitis (“strep” throat) is characterized by the relatively sudden onset of pain on swallowing and fever. It is important to note that acute pharyngitis associated with infectious mononucleosis or caused by gonococcus, meningococcus, Mycoplasma, or Legionella organism, although less common than streptococcal pharyngitis, is clinically indistinguishable from it. Children with streptococcal pharyngitis may present primarily with abdominal pain, and sore throat is often mild or occasionally absent. Acute epiglottitis may present dramatically with the sudden onset of high fever, severe sore throat, drooling, and dyspnea. Change or muffling of the voice, often characterized as the “hot-potato voice, ” in association with severe sore throat, fever, drooling, and local neck pain or pain referred to the ear should suggest peritonsillar abscess. Fatigue, malaise, anorexia, and fever in a young adult with a sore throat should suggest infectious mononucleosis. Patients with herpangina report severe mouth, tongue, or throat pain often impairing deglutition. Patients with thyroiditis report pain and tightness of the lower throat radiating to the ears, which is often accompanied by fatigue and malaise.
PHYSICAL EXAMINATION
Fever of 38 °C or greater associated with anterior cervical adenopathy and a pharyngotonsillar exudate are suggestive of streptococcal pharyngitis. A pharyngeal exudate, although noted in many patients with streptococcal pharyngitis, is a nonspecific finding and can be seen with gonococcal, Haemophilus, and diphtheritic pharyngitis, and a variety of viral syndromes including those resulting from adenovirus infection and associated with infectious mononucleosis. In many patients with streptococcal pharyngitis, simple erythema without gross exudate is noted. If the particular streptococcal strain produces erythrogenic toxin, a number of cutaneous phenomena are noted; these define the entity of scarlet fever and include a generalized, often subtle erythematous rash, circumoral pallor, a strawberry-colored tongue, and Pastia lines (accentuated flexor creases).
“Muffling” or change in voice, often characterized as the “hot-potato voice” is noted in and should suggest peritonsillar abscess; other findings include drooling, moderate to high fever, local lymphadenopathy, and asymmetry of the pharynx manifest as swelling, fullness, or bulging of the involved soft palate and anterior pillar. In these patients, erythema and exudate are often noted to involve the pharynx generally, and the uvula may be displaced medially away from the involved side as the abscess expands. Examination of the posterior pharyngeal wall in patients with retropharyngeal abscess, most of whom will be young children, should disclose a unilateral area of erythema, swelling, and fluctuance; such patients typically (if able) report a “lump in the throat” that persists despite food intake and swallowing. Importantly, such patients may have symptoms related to or showing evidence of airway obstruction, which are typically improved by lying down.
The oropharynx appears normal in acute epiglottitis and, especially in patients with the relatively dramatic onset of severe sore throat, high fever, and hoarseness, the absence of oropharyngeal pathology should raise one’s index of suspicion that epiglottitis may be present. When the diagnosis of epiglottitis is considered, aggressive examination of the posterior pharynx is deferred (including obtaining a culture), and evaluation of the epiglottic area with a lateral neck radiograph, direct or indirect larnygoscopy should be promptly obtained. Acute upper airway obstruction induced by examination of the oropharynx in patients with acute epiglottitis is a known complication of which the physician should be aware.Related posts:
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