Pediatric emergency medicine trisk 369

Stomatitis caused by herpes simplex virus is usually confined to the anterior
buccal mucosa but occasionally may extend to the anterior tonsillar pillars and
involve the upper esophagus in immunocompetent patients on rare occasions (
e-Fig. 74.1 ). Particularly in more extensive cases, the child may complain of a
sore throat.

Peritonsillar Abscess
A peritonsillar abscess may complicate a previously diagnosed infectious
pharyngitis or may be the initial source of a child’s discomfort. This occurs most
commonly in older children and adolescents. Trismus is common in these
patients. The diagnosis is evident from visual inspection, augmented occasionally
by careful palpation. These abscesses produce a bulge in the posterior aspect of
the soft palate, deviate the uvula to the contralateral side of the pharynx, and have
a fluctuant quality on palpation ( e-Fig. 74.2 ).


TABLE 74.1
DIFFERENTIAL DIAGNOSIS OF SORE THROAT IN THE
IMMUNOCOMPETENT HOST
Infectious pharyngitis
Respiratory viruses
Group A streptococci
Epstein–Barr virus (infectious mononucleosis)
Human immunodeficiency virus
Neisseria gonorrhoeae
Anaerobic bacteria
Group C and G streptococci
Arcanobacterium haemolyticum
Mycoplasma pneumoniae (unconfirmed)
Chlamydia pneumoniae (unconfirmed)
Francisella tularensis

Corynebacterium diphtheriae (diphtheria)
Other causes
Herpetic stomatitis
Irritative pharyngitis
Foreign body
Peritonsillar abscess
Retropharyngeal and lateral pharyngeal abscesses
Epiglottitis
Kawasaki disease
Stevens–Johnson syndrome
Chemical exposure
Psychogenic pain
Referred pain

Retropharyngeal and Lateral Pharyngeal Abscesses
Retropharyngeal abscess is an uncommon cause of sore throat, usually occurring
in children younger than 4 to 6 years. Although most children with this disorder
often appear toxic and have neck pain and occasionally respiratory distress, a few
complain of sore throat and dysphagia without other manifestations early in the
course. Some infants and young children may also manifest torticollis. A young


child with a retropharyngeal abscess who presents with a high fever, toxic
appearance, and torticollis is sometimes incorrectly suspected to have meningitis.
A soft tissue lateral neck radiographic examination may demonstrate the lesion,
whereas direct visualization is often impossible. Unfortunately, flexion (even
limited) of the neck during the radiograph may cause a buckling of the
retropharyngeal tissues that resembles a purulent collection. The clinician must
insist on a radiograph with the neck fully extended before hazarding an
interpretation. If the diagnosis remains uncertain despite adequate radiographs, a

computed tomography (CT) scan with intravenous contrast should be obtained.
TABLE 74.2
COMMON CAUSES OF SORE THROAT
Infectious pharyngitis
Respiratory viruses
Group A streptococci
Epstein–Barr virus
Irritative pharyngitis
Forced hot air heating
TABLE 74.3
LIFE-THREATENING CAUSES OF SORE THROAT
Retropharyngeal and lateral pharyngeal abscesses
Epiglottitis
Tonsillar hypertrophy (severe) with infectious mononucleosis
Diphtheria
Peritonsillar abscess
Lemierre syndrome
Lateral pharyngeal abscesses manifest in a fashion similar to retropharyngeal
infections but occur less often. High fever is a common symptom, and both
trismus and swelling below the mandible may be seen. Lateral neck radiographs
are often unrevealing, with no appreciable thickening in the prevertebral space. A
CT scan helps to confirm the diagnosis.
The Children’s Hospital of Philadelphia Clinical Pathway


ED Clinical Pathway for the Evaluation/Treatment of the Child With
a Suspected Deep Neck Space Infection
URL: />Authors: R. Abaya, MD; M. Joffe, MD; L. Vella, MD; M. Dunn, MD; S.
MacFarland, MD; M. Rizzi, MD; K. Shekdar, MD; R. Bellah, MD; J.
Lavelle, MD

Posted: February 2017, reviewed October 2019

FIGURE 74.1 Incidence by age of infectious mononucleosis in three large studies.

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 toxic