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Pharyngitis www.haiwatch.com DISCLAIMER: The content of this Website is not influenced by sponsors. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.

Introduction Sore throat related to inflamed tonsils, also called pharyngitis (swelling and redness to the back of the throat) and/or tonsillitis (swelling and redness of the tonsils), is a common complaint among children and adolescents. In the pediatric clinic setting, acute pharyngitis is the second-most common diagnosis. Throat pain may be caused by an infectious process, traumatic injury, allergic reaction, irritant inhalant, or dryness. Traumatic causes of throat pain include foreign body injury, hot liquids, harsh chemical agents, and inhaled toxic gases, any of which may cause an inflammatory reaction.

Common Causes of Sore Throat Bacteria Bacterial pharyngitis usually requires specific antibiotic therapy. Among bacterial organisms causing acute pharyngitis/tonsillitis, Streptococcus pyogenes (Group A beta-hemolytic streptococcus, also called Group A Strep) is the most common. The most common age range for Group A Strep pharyngitis is 5 to 15 years of age.

Group A Strep is the most frequent bacterial cause of infectious pharyngitis. In the winter months during strep outbreaks, as many as 30 percent of episodes of pharyngitis may be caused by Group A Strep.

Unfortunately, there is no single sign or symptom that reliably identifies Group A Strep pharyngitis. In children older than three years, Group A Strep pharyngitis typically has a rapid onset. Fever, headache, abdominal pain, nausea, and vomiting may accompany the sore throat, which can lead to poor oral intake. Additional features may include enlarged, red, swollen tonsils covered with white pus, enlarged and tender neck lymph nodes, red spots on the roof of the mouth, and a red and swollen uvula (the tissue that hangs down in the back of your throat). Symptoms usually go away on their own in three to five days.

Strep infections usually present with not-so-typical symptoms in child

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A number of other bacteria can cause acute pharyngitis but do so much less frequently than Group A Strep. M.

pneumoniae can cause pharyngitis in children older than six years. M. pneumoniae accounts for 5 to 16 percent of cases of pharyngitis. N. gonorrhoeae is a relatively rare cause of pharyngitis that may occur in sexually active adolescents, particularly those who engage in oral-genital sex. N. gonorrhoeae pharyngitis has no typical characteristics. On examination, the throat may have redness, swelling, pus, or it may appear completely normal.

Treatment is necessary to prevent the spread to other people and the spread to other areas of the body.

Nongroup A streptococci, especially groups C and G, can cause pharyngitis. Although there has been some controversy over the harm these organisms may cause, there are convincing data that they cause both epidemic and sporadic pharyngitis in school-age children and adults.

A. haemolyticum pharyngitis occurs predominantly in adolescents. Exam findings overlap with those of Group A Strep. These include fever, pus-covered, enlarged, red tonsils, and a rash on the back of the arms. The rash occurs in approximately one-half of patients, but in contrast to the rash of scarlet fever, it does not peel.


Viral agents are the most common infectious cause of pharyngitis in children. Adenoviruses, enteroviruses, rhinoviruses, coronaviruses, influenza viruses A and B, and parainfluenza viruses 1, 2, and 3 are the most frequently encountered in the patient with a normal immune system. Some viruses directly infect the back of the throat and produce dramatic inflammation. Examples include the Epstein-Barr virus (EBV), cytomegalovirus (CMV), adenoviruses, herpes simplex virus (HSV), influenza viruses, and enterovirus.

Features on exam suggestive of viral cause include the typical sore throat findings seen with bacteria along with red eyes, runny nose, cough, hoarseness, inflammation of the tongue, discrete ulcerative lesions, rashes, and/or diarrhea.

Mononucleosis, EBV and CMV, account for the majority of cases of the mononucleosis syndrome. Infectious mononucleosis classically occurs in adolescents and is characterized by fever, severe pharyngitis, and diffuse lymph node enlargement in the front and back of the neck. Other significant symptoms include fatigue, loss of appetite, and weight loss. The illness lasts longer than usual as compared with pharyngitis caused by other organisms. Patients who are treated with ampicillin or amoxicillin may develop a characteristic rash.

Exam findings include pus-covered, enlarged, swollen and red tonsils along with enlarged neck lymph nodes;

swelling around the eyes and eyelid, mild enlargement of the liver, and enlargement of the spleen can be seen.

Laboratory evidence of hepatitis is common. Pharyngitis generally is less prominent and hepatitis more evident when CMV is the cause. In contrast to adolescents, who typically present with classic symptoms, younger patients with EBV infection may have a more subtle presentation that can make diagnosis difficult.

Adenovirus is a common cause of sore throat in children; it may manifest as pharyngitis, tonsillitis, with or without inflammation of the eyes. There are no distinguishing characteristics of infections caused by adenovirus except in patients with pharyngitis will have conjunctivitis along with a fever. The presence of pus-covered tonsils are variable.

Influenza infection is characterized by high fever, cough, headache, and muscle aches that occur in seasonal epidemics. Pharyngitis caused by influenza may have pus-covered tonsils.

Enteroviruses, specifically coxsackie A viruses, cause herpangina, which is characterized by the presence of small blisters in the back of the throat. In one series of 50 children (aged 1 to 10 years) with acute pharyngitis, testing for enterovirus was positive in 8 percent.

Herpes simplex virus (HSV) is an important cause of pharyngitis in adolescents. Nearly one-half of patients have pus-filled tonsils, and about 10 percent have a telltale ulcerative lesion over the lip. If HSV is suspected, appropriate cultures can be obtained and treatment initiated with acyclovir. In younger children, HSV can cause ulcerating blister-like lesions in the front of the mouth. Fever, severe discomfort, and neck lymph nodes are common. Most cases are caused by HSV-1. Approximately 15 percent of cases of pharyngitis are caused by HSV-2.

New-onset HIV infection may cause an “acute retroviral syndrome” (similar to infectious mononucleosis) in sexually active adolescents or rarely in children who have been sexually abused. The onset of symptoms usually occurs within days to weeks after the initial exposure. Clinical features of new-onset HIV infection include fever, weight loss (average 10 lbs), enlarged lymph nodes, rash, and an enlarged spleen.

Life-Threatening Causes of Pharyngitis

Epiglottitis- The incidence of epiglottitis, a well-appreciated cause of life-threatening upper airway infection, has declined significantly since the introduction of vaccination against Haemophilus influenzae type b. This disease manifests with a severely ill appearing child, high fever, stridor (a harsh, raspy, vibrating sound heard while breathing in), and drooling. Sore throat occurs in many cases, but is only rarely the primary complaint.

There are different types of abscesses that can occur in the back of the throat- retropharyngeal, lateral pharyngeal abscess, and peritonsillar abscess. Retropharyngeal abscesses can cause sore throat and usually occur in children less than four years of age. Other complaints include neck pain and fever. There may be difficulty swallowing and respiratory distress. The location of the abscess makes it difficult to visualize on physical examination. X-rays or cat scans are often required to confirm the diagnosis. Lateral pharyngeal abscesses produce symptoms similar to retropharyngeal infections but occur less often. High fever is common. Other signs include trismus (difficulty swallowing along with drooling) and swelling below the chin. A peritonsillar abscess may complicate a previously diagnosed infectious pharyngitis or may be the initial source of a child's discomfort. This disease is most common in older children and adolescents. The diagnosis is evident from visual inspection, and may be detected by careful palpation of the area. The abscess produces a bulge in the rear aspect of the soft palate, deviates the uvula to the opposite side of the throat, and has a fullness quality on palpitation.

Infectious mononucleosis can rarely cause airway blockage from severe tonsillar enlargement.

Diphtheria is a life-threatening but seldom encountered cause of infectious pharyngitis, characterized by a thick membrane that occurs in the back of the throat and very large neck lymph nodes.

Other Causes of Pharyngitis Irritative pharyngitis- drying of the back of the throat may irritate the lining of the mouth, leading to a complaint of sore throat. This condition occurs most commonly during the winter months, particularly after a night's sleep in a house with central hot-air heating.

Foreign body- occasionally, a foreign object such as a fish bone may become embedded in the back of the throat.

Herpetic stomatitis- inflammation of the lining of the mouth caused by herpes simplex usually is confined to the inner lip but may extend to the back of the mouth. In these more extensive cases, the child may complain of a sore throat.

Typical History of Pharyngitis Some information that may assist in determining the cause of the sore throat include, difficulty breathing, fever, fatigue, and the speed in which the symptoms come on. The combination of sore throat and difficulty breathing suggests conditions in or near the back of the throat that may be producing a blockage, including epiglottitis, retropharyngeal or lateral pharyngeal abscess, peritonsillar abscess, massive tonsillar enlargement caused by infectious mononucleosis, and rarely diphtheria.

Fatigue, particularly when it lasts a long time, is typical of infectious mononucleosis.

Among the diseases causing pharyngitis, epiglottitis has a particularly rapid onset, in a matter of hours, while infectious mononucleosis manifests over a period of days or weeks. Other factors in the history that may be important in selected cases include, chronic illness that cause the immune system to be impaired, whether or not the patients have been immunized, any recent travel, and sexual activity. The patient with a compromised immune system is susceptible to a number of infections, including a fungal infection causing thrush (Candida albicans). Diphtheria is a rare disease, except in unimmunized children and those from underdeveloped nations. With a history of oral sexual activity, pharyngeal gonorrhea may be a concern.

There is no single sign or symptom that reliably identifies the bacterial infection Group A Strep. The distinction is important because Group A Strep requires antibiotics and the remainder of the infectious causes do not. The

following factors are suggestive of a Group A Strep infection:

- Age (5 to 15 years)

- Season (late fall, winter, early spring)

- Evidence of inflammation (redness, swelling, and/or pus-filled tonsils)

- Tender, enlarged (1 cm) lymph nodes in the front of the neck

- Middle-grade fever (between 101 and 103ºF)

- Absence of usual signs and symptoms associated with viral upper respiratory tract infections (nasal discharge and congestion) If a patient has all 6 symptoms, the likelihood of a positive throat culture for Group A Strep is approximately 85 percent. However, if a patient has a score of five, the likelihood falls to 50 percent.

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Physical Exam To a large degree, accurate diagnosis of a sore throat hinges on a careful physical examination, particularly of the back of the throat. If a patient has a harsh, raspy, vibrating sound that occurs with breathing in (stridor), drooling, or respiratory distress, this may indicate an airway blockage and may be present in the occasional patients with conditions such as epiglottitis or retropharyngeal abscess. An inflamed eardrum suggests pain from a site not related to the throat and swelling around a tooth indicates a likely dental abscess. The appearance of blisters on the inner lip points to a herpetic infection. Generalized inflammation of the mouth lining, and a persistent fever, suggests a disease called Kawasaki disease.

A foreign body, such as a fish bone, may uncommonly become lodged in the folds of the tonsils or the back of the throat; usually, the history suggests this diagnosis, but an unanticipated sighting may occur in the younger child.

Significant difference in size of the tonsils indicates a skin infection around the tonsils or, if extensive, an abscess.

The diagnosis of an abscess is reserved for the tonsil that protrudes beyond the midline, causing the uvula to deviate to the uninvolved side.

Infectious pharyngitis causes a number of inflammatory responses that range from minimal redness of the surface of the mouth and throat to significantly red tonsils with white pus and swelling. Patients who do not have one of the life threatening conditions discussed above and do not have another easily identifiable cause of sore throat (eg, foreign body) are likely to have infectious pharyngitis.

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