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

There is no data available regarding historical perspective for sore throat in children.

Classification

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

Infectious

• Bacterial:Group A Streptococci,Staphylococcus aureus, Hemophilus influenza, gonococci, chlamydia, Mycoplasma, Treponema pallidum, Fusobacterium.
• Viral: Adenovirus, Coxsackievirus, Enterovirus, Influenza, Parainfluenza, Epstein Barr Virus, Corona Viruses, Polio Virus, Rhino Virus.
• Protozoal: Babesia microti, Toxoplasma gondii,- less common causes.
• Fungal: Candida.

Non Infectious

• Autoimmune: Steven Johnson's syndrome, Bechet's disease, Psychotic, Kawasaki's disease, PFAPA syndrome.
• Traumatic: Insertion of a pen, stick, or other sharp object in the throat.
• Chemical exposure : smoking, air pollutants
• Physical factors : snoring, shouting, tracheal intubation

Pathophysiology

Prostaglandins and bradykinin act on the sensory nerves in the pharynx, which leads to sore throat. 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 form of sneezing. The inflammation when reaches the larynx, and stimulates the sensory nerves then coughing is initiated.

A sore throat is most likely caused by the action of prostaglandins and bradykinin on sensory nerve endings in the upper respiratory tract. The sensation of pain is mediated by the cranial nerves supplying the nasopharynx. The mechanism of nasal congestion relies on the dilation of the venous sinuses in the nasal epithelium in response to the vasodilator mediators such as bradykinin. Nasal discharge in respiratory infections is a complex mixture of plasma and glandular exudates with cellular elements (e.g., goblet cells, plasma cells, and neutrophils) of variable composition that changes over the course of the infection and severity of the inflammatory response.

Sneezing is related to inflammatory responses in the nose and nasopharynx that stimulate the trigeminal nerves.

Coughing is initiated in the airway through stimulation of the sensory nerves in the larynx or below (Widdicombe 1995). The airway inflammation associated with rhinitis must reach the larynx to cause coughing. Coughing in respiratory tract infections is believed to be mediated by hyper-reactivity of the cough reflex due to the effects of inflammatory mediators on the airway’s sensory nerve endings. The mechanism of a headache associated with a respiratory tract infection is unknown but headaches may be triggered by cytokines released in response to a viral infection. Fever is a classic response to infection. It is a manifestation of cytokine release in response to a variety of stimuli. It is believed to be beneficial for the host’s response to infection (Cabanac 1990; Eccles 2005) and is usually associated with novel or severe viral infections such as influenza (Monto et al. 2000).

Sore throat is the most common initial symptom of an upper respiratory tract infection. It is commonly described as a painful sensation in the throat. Inflammation by viral and bacterial pathogens releases prostaglandins and bradykinin which irritate the sensory nerve endings in the throat. The cranial nerves that supply the nasopharynx are responsible for pain perception.

Causes

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

Bacteria

• Goup A beta-haemolytic Streptococcus (most commonly isolated)
• Haemophilus influenzae
• Moraxella catarrhalis

Viruses

• Rhinovirus
• Coronavirus
• Respiratory syncytial virus
• Metapneumovirus
• Epstein–Barr virus

• Life threatening causes include: Epiglottitis,retropharygeal abscess, Parapharyngeal abscess, Peritonsillar abscess, Diptheria, Infectious mononucleosis
• other causes include: trauma,psychogenic and autoimmune

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. For an algorithmic approach to sore throat, click here.

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 retrophayngeal 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, non suppurative complications does not need immediate treatment.

Risk Factors

• Common risk factors in the development of Sore throat are lack of Vaccinations,immunosuppression,seasonal variations, and contact exposure.

Natural History, Complications and Prognosis

• The majority of patients with Sore throat acquire it as a course of the respiratory tract or oropharyngeal infections remain asymptomatic for [duration/years].
• 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, cough depending on the type of infection.
• Common complications if left untreated in infectious conditions include Retropharyngeal abscess, Parapharyngeal abscess, Quinsy, Sepsis.
• 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.

Diagnosis

Diagnostic Criteria

The four important diagnostic criteria for sore throat are

Absent cough and runny nose

Fever >38 C (100.4 F)

Tonsillar exudate

Anterior cervical lymphadenopathy

All 4 criteria present GABHS most likely

2 or 3 criteria further testing required

0 or 1- GABHS testing 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.

In life-threatening conditions, the patients appear severely ill.

• 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:

• Exudative Pharyngitis, petechiae on the posterior palate, anterior Cervical lymphadenopathy are seen in streptococcal pharyngitis.
• Thick white exudate with a membranous covering of tonsils, which cannot be removed without bleeding is seen in Diptheria.
• Erythematous Pharynx with posterior cervical lymphadenopathy and hepatosplenomegaly is seen in infectious mononucleosis.
• Vesicular rash on the posterior pharynx is seen in herpangia, and vesicular rash on hand foot, and mouth is seen in hand, foot, and mouth disease. Both are caused by Coxsackie Virus.
• Erythematous pharynx with a diffuse erythematous rash is seen in Scarlet fever.
• Stridor, respiratory distress, dysphagia, odynophagia with high grade fevers can be seen in Quinsy, retropharyngeal abscess, Parapharyngeal abscess, epiglottitis, Laryngotracheobronchitis. Most of these are life threatening. Significant asymmetry of the tonsils should raise suspicion for peritonsillar abscess.
• Vesicles on the buccal mucosa should raise suspicion for Herpetic Gingivostomatitis. Patients should also be screened for non-infectious causes such as bechet syndrome,Steven Johnson syndrome.
• Inflammed tympanic membrane might suggest a dental abscess. Other possible oropharyngeal pathologies should be ruled out.
• Pernio like lesions in the pharynx is seen in COVID 19 infection.
• If a persistently febrile child demonstrates strawberry tongue, generalized erythema of oropharynx, cracked red lips, cervical lymphadenopathy, non purulent conjunctivitis, along with desquamation of periungual region and swelling of hands and foot and then suspect kawasaki disease.

Laboratory Findings

• There are no specific laboratory findings associated with [disease name].

• A [positive/negative] [test name] is diagnostic of [disease name].
• An [elevated/reduced] concentration of [serum/blood/urinary/CSF/other] [lab test] is diagnostic of [disease name].
• Other laboratory findings consistent with the diagnosis of [disease name] include [abnormal test 1], [abnormal test 2], and [abnormal test 3].

Electrocardiogram

There are no ECG findings associated with [disease name].

OR

An ECG may be helpful in the diagnosis of [disease name]. Findings on an ECG suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

X-ray

There are no x-ray findings associated with [disease name].

OR

An x-ray may be helpful in the diagnosis of [disease name]. Findings on an x-ray suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

There are no x-ray findings associated with [disease name]. However, an x-ray may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

Echocardiography or Ultrasound

There are no echocardiography/ultrasound findings associated with [disease name].

OR

Echocardiography/ultrasound may be helpful in the diagnosis of [disease name]. Findings on an echocardiography/ultrasound suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

There are no echocardiography/ultrasound findings associated with [disease name]. However, an echocardiography/ultrasound may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

CT scan

There are no CT scan findings associated with [disease name].

OR

[Location] CT scan may be helpful in the diagnosis of [disease name]. Findings on CT scan suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

There are no CT scan findings associated with [disease name]. However, a CT scan may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

MRI

There are no MRI findings associated with [disease name].

OR

[Location] MRI may be helpful in the diagnosis of [disease name]. Findings on MRI suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

There are no MRI findings associated with [disease name]. However, an MRI may be helpful in the diagnosis of complications of [disease name], which include [complications 1], [complication 2], and [complication 3].

Other Imaging Findings

There are no other imaging findings associated with [disease name].

OR

[Imaging modality] may be helpful in the diagnosis of [disease name]. Findings on an [imaging modality] suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

Other Diagnostic Studies

• [Disease name] may also be diagnosed using [diagnostic study name].
• Findings on [diagnostic study name] include [finding 1], [finding 2], and [finding 3].

Treatment

Medical Therapy

• Sore throat caused by Group A beta Hemolytic Streptococcus is most commonly treated by Penicillin.
• Amoxicillin, erythromycin and first generation cephalosporins are used as alternatives in penicillin allergic patients.

• Treatment for sore throat caused by viral infections is primarily supportive.
• Acetaminophen, Non Steroidal anti inflammatory drugs and steam inhalation help alleviate the pain.

• There is no treatment for Sore throat in children; the mainstay of therapy is supportive care and systemic analgesia.

• The mainstay of therapy for is [medical therapy 1] and [medical therapy 2].
• [Medical therapy 1] acts by [mechanism of action 1].
• Response to [medical therapy 1] can be monitored with [test/physical finding/imaging] every [frequency/duration].

Surgery

• Surgery is the mainstay of therapy for [disease name].
• [Surgical procedure] in conjunction with [chemotherapy/radiation] is the most common approach to the treatment of [disease name].
• [Surgical procedure] can only be performed for patients with [disease stage] [disease name].

Prevention

Certain measures for the primary prevention of sore throat are

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.

• Once diagnosed and successfully treated, patients with [disease name] are followed-up every [duration]. Follow-up testing includes [test 1], [test 2], and [test 3].