Jason Leibowitz and Jason G. Newman

Throat pain is a ubiquitous symptom. It may be acute or chronic, constant or intermittent, and mild to severe. The time course of the pain is a critical factor in establishing the diagnosis because acute pain tends to be associated with infectious etiologies or trauma, whereas chronic pain may be associated with chronic inflammation or neoplasm. Key points of the history include the following:

Time course of symptoms

Otalgia (unilateral otalgia in the absence of ear disease may indicate an underlying malignancy)

Dysphagia or odynophagia

Stridor or other respiratory symptoms (may indicate an underlying airway obstruction)

Reflux or heartburn-related symptoms

Neck mass

Hemoptysis

Inflammatory symptoms such as fever and malaise

Constitutional symptoms such as weight loss or night sweats

Patient risk factors (tobacco, alcohol, sick contacts, trauma, or foreign body ingestion)

A full head and neck exam is essential. Careful attention should be paid to the ears, mucosal membranes of the upper aerodigestive tract, and neck.

Infectious Causes of Throat Pain

Infectious causes of throat pain include the following:

Pharynx

Viral pharyngitis: Most common infectious etiology. Sore throat associated with malaise, low-grade fever, and upper respiratory infection (URI) symptoms. Commonly caused by adenovirus and rhinovirus. Other causes of acute viral pharyngitis include the following:

— Herpes simplex virus: Sore throat may be seen in both primary infection and reactivation with associated vesicular or ulcerative lesions.

— Measles: Sore throat, coryza, and conjunctivitis. Intraoral Koplik spots (erythematous spots on buccal mucosa) are pathognomonic.

— Infectious mononucleosis: Epstein-Barr virus (EBV). Symptoms include severe sore throat with odynophagia, dysphagia, high fevers, posterior cervical lymphadenopathy, rashes, exudative tonsillitis, and hepatosplenomegaly.

Bacterial pharyngitis: Acute onset, significant throat pain with otalgia, dysphagia, odynophagia, cervical adenitis, and high fevers. May see tonsillar and posterior pharyngeal erythema with exudates on physical exam. Most common bacterial cause is group A β-hemolytic streptococcus. Other bacterial causes include the following:

— Staphylococcus: Mucopurulent drainage and localized pustules on the tonsils

— Diphtheroid: Usually seen in children > 6 years old who are not immunized. Exam reveals gray-black membrane firmly adherent to the underlying pharyngeal mucosa, with extension to the larynx or nasopharynx. Symptoms include sore throat and airway obstruction.

— Pertussis: Acute onset of sore throat in children associated with a whooping cough.

— Gonorrhea: Sexually active patient with sore throat, tonsillar hypertrophy, and cervical adenitis

— Syphilis: May appear as a painless papule that ulcerates in the primary stage in the tonsils, or as a pharyngitis/tonsillitis in later stages (painless superficial erosions with raised erythematous margins in the pharynx).