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CHAPTER 74 ■ SORE THROAT
CHRISTINA LINDGREN, ANDREW M. FINE

INTRODUCTION
Sore throat refers to any painful sensation localized to the pharynx or the
surrounding areas. Because young children, particularly those of preschool age,
cannot describe their symptoms as precisely as adults, the clinician who evaluates
a child with a sore throat must first define the exact nature of the complaint.
Occasionally, young patients with dysphagia (see Chapter 56 Pain: Dysphagia ),
which results from disease in the area of the esophagus or with difficulty
swallowing because of a neuromuscular disorder, will verbalize these feelings as
a sore throat. Careful questioning and examination usually suffices to distinguish
between these complaints.
Although a sore throat is less likely to portend a life-threatening disorder than
dysphagia or the inability to swallow, this complaint should not be dismissed
without a thorough evaluation. Most children with sore throats have self-limiting
or easily treated pharyngeal infections, but a few have serious disorders such as
retropharyngeal or lateral pharyngeal abscesses. Even if the reason for the
complaint of sore throat is believed to be an infectious pharyngitis, several
different organisms may be responsible. Symptomatic therapy, antibiotics, antiinflammatory drugs, or surgical intervention may be appropriate at times. Most
children experience no adverse consequences from misdiagnosis and
inappropriate therapy, but a few may develop local extension of infection or
sepsis, chronically debilitating illnesses such as rheumatic fever, or lifethreatening airway obstruction.

DIFFERENTIAL DIAGNOSIS
Infectious Pharyngitis
Infection is the most common cause of sore throat and is usually caused by
respiratory viruses including adenoviruses, coxsackievirus A (various serotypes),
influenza, or parainfluenza virus (see Chapter 94 Infectious Disease Emergencies
and Tables 74.1 to 74.3 ). Viruses are the causative agents of infectious

pharyngitis in 70% to 85% of patients, especially in adolescents and in children
younger than 2 years of age. Several of the respiratory viruses produce easily
identifiable syndromes, including hand–foot–mouth disease (coxsackievirus) and


pharyngoconjunctival fever (adenovirus). These viral infections are closely
followed in frequency by bacterial infections caused by group A streptococci
(Streptococcus pyogenes ). During streptococcal outbreaks, as many as 30% to
50% of episodes of pharyngitis may be caused by S. pyogenes in school-aged
children. Another common infectious agent in pharyngitis is the Epstein–Barr
virus, which causes infectious mononucleosis. Although infectious
mononucleosis is not often seen in children younger than 5 years ( Fig. 74.1 ), it
commonly affects the adolescent. One additional important consideration in
adolescents with an infectious mononucleosis-like syndrome is acute human
immunodeficiency virus (HIV) infection, which does not commonly cause
significant pharyngeal inflammation.
Other organisms produce pharyngitis only rarely; these include Neisseria
gonorrhoeae,
Corynebacterium
diphtheriae,
Francisella
tularensis,
Fusobacterium necrophorum, and other bacteria. N. gonorrhoeae may cause
inflammation and exudate but more often remains quiescent, being diagnosed
only by culture. Diphtheria is a life-threatening but seldom encountered cause of
infectious pharyngitis, characterized by a thick membrane and marked cervical
adenopathy. Oropharyngeal tularemia is rare and should be entertained only in
endemic areas among children who have an exudative pharyngitis that cannot be
categorized by standard diagnostic testing and/or persists despite antibiotic
therapy. Although unusual, mixed anaerobic infections should be considered in

the ill-appearing adolescent with a severe pharyngitis because these organisms
occasionally lead to complications such as infected thrombophlebitis and sepsis
(Lemierre syndrome). Arcanobacterium haemolyticum has been isolated from
0.5% to 2.0% of adolescents with pharyngitis, often in association with a
maculopapular rash. Other pathogens—group C and G streptococci, Mycoplasma
pneumoniae, and Chlamydia pneumoniae —have been implicated as agents of
pharyngitis in adults, but in childhood, their roles remain unproven and their
frequency is unknown.

Irritative Pharyngitis/Foreign Body
Drying of the pharynx may irritate the mucosa, leading to a complaint of sore
throat. This condition occurs most commonly during the winter months,
particularly after sleeping in a house with forced hot-air heating. Occasionally, a
foreign object such as a fishbone or popcorn shell may become embedded in the
pharynx resulting in pain.

Herpetic Stomatitis