Briefs: Exam based approach to the patient with a sore throat

The Differential Diagnosis for sore throat is quite long, though it is usually infectious. I will approach the approach that you should consider using when you approach the patient with a sore throat. I hope I don’t face reproach for the gratuitous approach laden approach.

Does the patient have respiratory distress?

If the answer is yes to this one stop everything and assess the airway. Stridor that accompanies sore throat and dysphagia could signal epiglottitis, retropharyngeal abscess or peritonsillar abscess or foreign body. Though it is true that many of the patients with these conditions can protect their airway is up to us to determine whether they can continue to maintain it or if their disease process will immanently worsen. Patients are drooling and cannot handle their secretions are worrisome as are those with an unintelligible voice.

: A unilaterally enlarged tonsil and uvular deviation in a patient with a peritonsillar abscess

: The thumb sign in a patient with epiglottitis

: Lateral neck X-Ray indicating an enlarged prevertebral soft tissue plan consistent with retropharyngeal abscess

And remember, when facing an agitated patient with a potentially compromised airway keep them calm! Airway resistance on inspiration can increase fourfold when the child is crying or upset. So keep a parent close by. You should be able to carefully inspect the pharynx and clinically diagnose a PTA. If you’re concerned that the patient has epiglottitis and they’re stable and lateral neck X-Ray can be diagnostic. Finally, if you have to intubate this patient be careful, very careful… Awake fiber-optic intubation or securing the airway in the operating room are too safe approaches.

Does the patient have inflammation of the gums or buccal mucosae?

Herpetic gingivostomatitis leads to inflammation of the gums and anterior oral mucosae. You will often note that they are beefy red before you see the characteristic ulcerative lesions. Very ill appearing patients with sloughing of the buccal mucosae and lips might have Stevens-Johnson syndrome, an illness that presents like sepsis and is the only true Derm condition that will get them to come in at 2 AM.

: Inflamed gums in a patient with herpetic gingivostomatitis

: Sloughing of the tongue seen in Stevens-Johnson syndrome

Is the pharynx erythematous and inflamed?

The answer to this one is probably yes – since this is the most common finding you’ll see in the ED. Infectious pharyngitis can cause minimal erythema all the way up to beefy swelling with copious exudates. These findings could signal Group A Strep, mono or respiratory viruses (like adenovirus). Strep pharyngitis could be up to 30-50% of cases of sore throat when there are winter outbreaks, but may be less common at other times. A rapid strep antigen test, or careful use of the Centor score can help. And of course, strep is known to look a myriad of different ways.

Strep pharyngitis

This is also a case of strep pharyngitis

Strep throat as well

This is strep pharyngitis

Strep pharyngitis right here

Viruses are the other common etiology of course. Mono has been known to look exactly like strep. When you see ulcers on the posterior pharynx – especially during summer outbreaks think about coxsackie hand, foot and mouth (and butt) disease.

Mucosal lesions in hand, foot and mouth disease

And don’t forget that children with Kawasaki will have oral changes as well. These should go hand in hand with the other diagnostic criteria – but in isolation the pharynx could look similar to other infectious causes.

Are there any exposures I should be concerned about?

Well, some cases of irritative pharyngitis are due to exposure to forced, heated air in the winter. You may see this in a kid who just attended a sleepover and whose mother is worried that he caught strep throat from his sleepover mates. The exam however will be normal, and the kid should be well appearing. Chemical burns can present with mild erythema initially, with liquefactive necrosis setting in later for high pH alkali burns (lye). You should also be highly suspicious of esophageal injuries in such patients. Patients with a normal exam may have globus hystericus AKA psychogenic pharyngitis. This is usually associated with anxiety (exposed to stressful stuff) and will present with subjective sore throat and frequent and difficult swallowing (and probably a few negative strep tests along the way).