Sore throat in children

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Sunita Kumawat, M.B.B.S[2]

Synonyms and Keywords: Sore throat in kids

Overview

Sore throat is an infection of the respiratory mucosa of the throat.It is most commonly felt as a sensation of pain in the pharynx. In children it can be classified as acute, subacute or recurrent. Common etiologies include bacterial, Viral and Protozoal organisms. It is usually self resolving, but can be associated with more severe disease forms. Treatment in general is conservative, however Antibiotics and Antivirals can be used depending on the Etiology, and severity of clinical presentation.


Historical Perspective

  • In the year 1879, R. L. Bowles, M.D., described sore throat as 'some variants of sore throat' in the British Medical Journal. [1]
  • Later, in the year 1885, pathology, clinical findings and management were described by David Newman, M.D., at the Glasgow Royal Infirmary.[2]
  • In 1910, the importance of laboratory tests was illustrated by Dr. Donelan.[3]
  • In 1931, WM. W. PRIDDLE, B.A., M.D., described that certain infections like whooping cough, measles were associated with chronic nasopharyngitis.[4]

Classification

  • Sore throat can be classified into Infectious and Non infectious causes based on the etiology.[5]

Infectious

Non Infectious

Pathophysiology

  • Prostaglandins and bradykinin act on the sensory nerves in the pharynx, which leads to sore throat.
  • Fever is the result of cytokine release and thought to benefit host's response to infection. Cytokines can also cause headache.
  • The cranial nerves that supply the nasopharynx are responsible for pain perception.
  • Vasodilator mediators like bradykinin causes dilation of the venous sinuses in the nasal epithelium which is responsible for nasal congestion.
  • Glandular secretions with different cells (e.g. neutrophils, plasma cells, goblet cells) and plasma together in different compositions at different times, form nasal discharge.
  • Inflammation in the nasopharynx, stimulates the trigeminal nerves, which presents in the form of sneezing.
  • The inflammation when reaches the larynx, and stimulates the sensory nerves then coughing is initiated. The inflammatory mediators when act on the sensory nerve endings of the airway cause hyper-reactivity of the cough reflex. [6]

Causes

Sore throat in children can be acutely life-threatening or from common causes.[7]

Bacteria

Viruses

Differentiating Sore throat in children from other Diseases

Sore throat is a symptom and can be seen in many varieties of diseases as an initial complaint of presentation. Clinical history and physical examination can help to distinguish between them.[8]

Differential diagnosis of sore throat
Disease Clinical presentation Physical examination
Aphthous stomatitis systemic symptoms absent anterior oral mucosa ulcers
Herpangina high fever, sore throat multiple, small ulcers in the posterior oropharynx
Herpetic gingivostomatitis fever, pharyngeal erythema, sore throat multiple, small ulcers around the lips and anterior oral cavity
Hand-Foot-Mouth disease fever, malaise, oral pain, sore throat ulcers around and inside the mouth, rash on hands, feet and buttocks
Measles high grade fevre, cough, conjunctivitis and coryza, pharyngeal erythema Koplik spots, erythematous rash beginning from face and disseminates to whole body
Infectious Mononucleosis fever, fatigue, headache, sore throat tonsilar exudate, cervical lymphadenopathy, hepatosplenomegaly
Primary HIV infection fever, sore throat lymphadenopathy, rash, enlarged spleen
Group A Streptococcus fever, headache, malaise, sore throat erythematous pharynx, anterior cervical lymphadenopathy
Cornybacterium diphtheriae fever, malaise, sore throat grayish-white pseudomembrane in the pharynx which cannot be scraped off, cervical lymphadenopathy
Oral thrush sore throat, cotton like feeling in mouth, cracked lips, loss of taste erythematous pharynx, cotton-cheese like lesions which can be easily scraped off with slight bleeding

Epidemiology and Demographics

One of the most common medical conditions is sore throat, primarily caused by viruses and bacteria. Group A streptococcus(GAS) is the most common causative agent, resposible for 15-25% of cases of pharyngitis in children and 10% in adults. Diagnosis of GAS is important for the treatment and reduction of infectivity. It also prevents post infectious complications. The acute suppurative complications are retropharyngeal and peritonsillar abscess, acute bacterial sinusitis, cervical adenitis and acute otitis media. The late nonsuppurative complications are acute rheumatic fever (ARF) and post-streptococcal glomerulonephritis. In adults, nonsuppurative complications does not need immediate treatment.[9]

Risk Factors

Natural History, Complications and Prognosis

  • The majority of patients with Sore throat acquire it as a course of the respiratory tract or oropharyngeal infections and remain asymptomatic for 1-4 days.[11]
  • Early clinical features include pain in the throat, itching, discomfort while more severe forms include difficulty swallowing, difficulty breathing.
  • These symptoms are usually accompanied by fever, myalgias, arthralgias, rhinorrhea, cough depending on the type of infection.
  • Common complications if left untreated in infectious conditions include sinusitis, mastoiditis, otitis media, cervical lymphadenitis, Retropharyngeal abscess, Parapharyngeal abscess, Quinsy, Sepsis.[8]
  • The nonsuppurative complications include include acute glomerulonephritis, acute rheumatic fever, reactive arthritis.
  • Prognosis is generally excellent and when identified early in acute conditions, minimal to no complications occur. However sore throat is one of the most common complaints and can be relieved by symptomatic treatment if viral. Most of the patients improve spontaneously within 7-10 days.[12]

Diagnosis

Diagnostic Criteria

The four important diagnostic criteria, also known as Centor criteria for sore throat are [13]

  • Absent cough and runny nose
  • Fever >38 C (100.4 F)
  • Tonsillar exudate
  • Anterior cervical lymphadenopathy

All 4 criteria present GABHS most likely, no testing required, start empiric antibiotics.

2 or 3- further testing required

0 or 1- further testing or antibiotics not required

Symptoms

  • Sudden onset of sore throat and fever.
  • Other symptoms may include:
  • Nausea and vomiting, headache, malaise, discomfort in swallowing and abdominal pain.
  • Cough, conjunctivitis, nasal congestion and rhinorrhoea are present in viral etiology
  • Redness and swelling of tonsils and pharynx are present.
  • Tender and enlarged anterior cervical lymph nodes.
  • Pharyngeal exudate that can be easily scraped off is present.

Physical Examination

  • Patients with Sore throat usually appear normal in common infections.
  • Physical examination may be different depending on the underlying etiology as well as pathology. Examination of the pharynx is the key. However comprehensive examination gives hints for possible etiologies. Notable findings include:[14]

Laboratory Findings

There is an overlap of clinical findings between various types of sore throat and to narrow down the diagnosis, we use some laboratory tests and imaging studies.[15]

  • Rapid Antigen Detection Test(RADT)- It is first line diagnostic test for Group A Streptococcal (GAS) pharyngitis. A positive test is diagnostic of GAS infection and antibiotics should be started. If the test comes out to be negative, then a follow-up throat culture should be done.
  • Throat culture-(90-99 % sensitive) - Though its best test, but takes time for the result. Used in non-emergency situations and when the RADT is negative. If positive, antibiotics are started, if negative, symptomatic management is given.
  • Antistreptococcal antibodies are useful for the confirmation of previous GAS infection in case of acute rheumatic fever or other nonsuppurative complications.[16]
  • Monospot test- Used for the diagnosis of Infectious Mononucleosis due to Epstein-Barr virus.
  • Peripheral blood smear shows atypical lymphocytes in Infectious Mononucleosis.
  • Complete blood count (CBC), ESR and CRP are usually not used due to low predictive value

Imaging Studies

Imaging studies are usually not used for uncomplicated sore throat and reserved for complicated cases only.[17]

  • X-Ray of neck, lateral view for suspected epiglottitis and airway compromise. Epiglottitis appears as thumb print sign in the x-ray.
  • CT scan neck, there are no CT scan findings associated with sore throat. However, a CT scan may be helpful in the diagnosis of complications of sore throat, which include retropharyngeal abscess, peritonsillar abscess and suppurative cervical lymphadenitis.

Treatment

Medical Therapy


Surgery

Surgical procedures are used in some specific conditions in children [19]

  • Complete tonsillectomy is the mainstay of therapy for recurrent tonsillitis, if the episodes are
    • equal to or greater than 7 in a year.
    • equal to or greater than 5/year in 2 consecutive years.
    • equal to or greater than 3/year in 3 consecutive years.
  • Partial tonsillectomy is the preferred procedure for tonsillar hyperplasia with ronchopathia.
  • Aspiration or tonsillectomy punction is used for draining tonsillar abscess.

Prevention

Certain measures for the primary prevention of sore throat are [20]

  • Regular hand-washing.
  • Keep the eating utensils of the infected person separately and wash them thoroughly.
  • Toys of an infected toddler should be cleaned properly.
  • Try to dispose of any dirty tissues and wipes , and wash your hands.
  • A child with strep throat infection should not return to school until she or he finishes a 24 hour course of antibiotics with symptom improvement.

Follow up

A follow-up is required if [21]

  • fever and throat pain lasts for more than 48hours after starting treatment
  • dysphagia
  • new symptoms

References

  1. Bowles RL (1879) Some Varieties of Sore-Throat. Br Med J 1 (953):503-4. PMID: 20749164
  2. Newman D (1885) Two Lectures on Chronic Laryngitis and Chronic Pharyngitis: Their Pathology, Symptoms, and Treatment. Br Med J 2 (1279):5-7. PMID: 20751315
  3. Grant JD (1910) Secondary Specific Pharyngitis in a Young Woman. Proc R Soc Med 3 (Laryngol Sect):28. PMID: 19974411
  4. Priddle WW (1931) CHRONIC NASO-PHARYNGITIS AND CHRONIC BRONCHIAL INFECTION. Can Med Assoc J 25 (4):441-3. PMID: 20318472
  5. Kenealy T (March 2014). "Sore throat". BMJ Clin Evid. 2014. PMC 3948435. PMID 24589314.
  6. 8.0 8.1 "Sore Throat".
  7. "Sore Throat (Pharyngitis) - Infectious Disease and Antimicrobial Agents".
  8. "Sore throat - Symptoms and causes - Mayo Clinic".
  9. Butler CC, Kinnersley P, Hood K, Robling M, Prout H, Rollnick S, Houston H (November 2003). "Clinical course of acute infection of the upper respiratory tract in children: cohort study". BMJ. 327 (7423): 1088–9. doi:10.1136/bmj.327.7423.1088. PMC 261746. PMID 14604932.
  10. "Pharyngitis - StatPearls - NCBI Bookshelf".
  11. Worrall GJ (November 2007). "Acute sore throat". Can Fam Physician. 53 (11): 1961–2. PMC 2231494. PMID 18000276.
  12. "Sore Throat in Children – Clinical Considerations and Evaluation | Learn Pediatrics".
  13. "Streptococcal Pharyngitis - StatPearls - NCBI Bookshelf".
  14. "Pharyngitis".
  15. "Pharyngitis Workup: Laboratory Studies, Imaging Studies, Procedures".
  16. "Clinical Practice Guidelines : Sore throat".
  17. Stelter K (2014). "Tonsillitis and sore throat in children". GMS Curr Top Otorhinolaryngol Head Neck Surg. 13: Doc07. doi:10.3205/cto000110. PMC 4273168. PMID 25587367.
  18. "Sore Throat (Pharyngitis) - Harvard Health".
  19. "www.med.umich.edu" (PDF).