OVERVIEW
- Throat pain is a symptom most commonly seen in general practice or by hospital emergency departments usually in children and young adults although it can occur at any age
- When the symptom is chronic or recurrent, then the differential diagnosis may range from being a minor non-serious condition or be a sign of significant disease, such as a specific infective process or a throat cancer
- Worrying symptoms associated with throat pain, such as difficulty breathing, swallowing problems, the need to “clear the throat”, bringing up blood and the presence of a swelling or a neck lump, should be investigated with urgency
- Infective processes if left untreated may develop into a local collection of pus or an abscess, most commonly the peritonsillar abscess or quinsy, but other more serious diagnoses include the parapharyngeal abscess and retropharyngeal abscess, which may be life-threatening if not recognised and treated effectively
Throat pain is a symptom most commonly seen in general practice or by hospital emergency departments, usually in children and young adults, although it can occur at any age. The symptom usually presents acutely, and is most often associated with an infective process—either viral or bacterial. When what seems to be a minor throat symptom with or without pain becomes chronic or recurrent, the range of diagnosis may be a “trivial” non-serious cause to becoming a “life and death” disease such as cancer or a specific infective process. A possible problem in diagnosis is the anatomical area to which the patient or parent is referring when they present with a painful throat. For the trained clinician with either a medical or a nursing background, the throat refers to the area called the pharynx, usually the oropharynx and the hypopharynx, and the term “pharyngitis” or “tonsillitis” is the assumed diagnosis. For patients, this term may be too restrictive. They may include areas such as the “mouth” and the “larynx” or “voice-box”, or even any location within the neck and above the “collar-bone”.
Persisting symptoms associated with throat pain, should alert the clinician to consider a “more serious” diagnosis, more so if associated with breathing difficulties, swallowing problems, the need to “clear the throat”, also “bringing up” blood and/or the presence of a neck swelling or a lump.
The most common tissue involved in the inflammatory or infective process is the lymphoid tissue in the region, with the lateral oropharyngeal tissue (the tonsils) being the obvious and the easiest area to inspect with a tongue depressor and a good light source (Figure 16.1). Other areas where lymphoid tissue can become involved are the posterior tongue and the tissue located in the nasopharynx (the adenoids) collectively known as Waldeyer’s ring. It should also be remembered that lymphoid tissue may be located in other areas of the pharynx superior to the vocal cords. Infective processes if left untreated may develop into a local collection of pus or an abscess. The most common is the peritonsillar abscess or quinsy, but other anatomical areas may also develop abscess particularly parapharyngeal and retropharyngeal areas, which if not recognised and treated early, may be life threatening.
Other tissues (nerves, muscles and cartilages) may be involved in inflammatory processes in the region, particularly with specific infections such as tuberculosis, syphilis, leprosy, AIDS and HIV, as well as with malignant disease including carcinoma and lymphoma.
Acute pharyngitis
Acute pharyngitis is defined by its most prominent symptom, i.e. acute onset sore throat, and has a primarily infectious aetiology. While the term is used interchangeably with acute tonsillitis it is composed of a spectrum of conditions, most commonly viral in origin (40–60%), although bacteria may often be involved (5–30%), ranging from acute inflammation localised primarily to the tonsils to acute pharyngitis with generalised inflammation of the whole of the pharynx. Viral pathogens isolated include rhinoviruses, adenovirus, parainfluenza virus, coxsackie virus, Epstein–Barr virus (EBV; mononucleosis), cytomegalovirus (CMV) as well as human immunodeficiency virus (HIV). Group A beta-haemolytic streptococcus is the commonest cause of bacterial pharyngitis, but co-pathogens in children include Staphylococcus aureus, Haemophilus influenzae, Branhamella catarrhalis and Bacteroides fragilis. There is a short incubation period of 1–5 days and the great majority of individuals do not consult a doctor about their symptoms. Clinically differentiation of the pathogens of pharyngitis is rarely possible and there are no reliable clinical clues to identifying streptococcal infection. Frequently no pathogens are isolated on culture, making the value of this questionable.
Specific pharyngitis
Viral—infectious mononucleosis
Commonly known as glandular fever this is an acute, systemic viral infection presenting typically with sore throat and lymphadenopathy and usually due to the EBV, a human herpes virus. It is primarily a disease of young adults but can present in childhood and in older adults. Transmission is via saliva with an incubation period of between 5 and 7 days.
Initial presentation is with malaise, fatigue and headache for 4–5 days. The most common finding is tender cervical adenopathy, usually accompanied with a sore throat. The pharyngeal signs range from acute follicular tonsillitis indistinguishable from other causes of follicular tonsillitis, to a grey membrane lining the oropharynx, petechiae on the soft palate and sometimes a peritonsillar abscess, which can be bilateral. Systemic manifestations of EBV include hepatosplenomegaly, ascites and, more rarely, cranial nerve palsies, or a Guillain–Barré syndrome.
Diagnosis is made from the clinical picture, together with the finding of mononucleosis on the peripheral blood film. The monospot has a sensitivity of 86% and a specificity of 99%. False positive monospots can occur in healthy controls as well as in mumps, systemic lupus erythematosis and sarcoidosis. Treatment is symptomatic for mild to moderate cases. Ampicillin-based antibiotics should be avoided because of the certainty of producing a rubelliform rash. Acute airway obstruction secondary to EBV is an indication for steroid treatment.
Other viral diseases that may present in a similar manner include: cytomegalovirus, herpes simplex 1, herpes zoster, hand, foot and mouth disease and herpangina.
Other causes of specific pharyngitis
In the developing world and in vulnerable population groups, there are a number of conditions for which the clinician must be alert. These include HIV, TB, syphilis and other granulomatous disorders, inflammatory disorders of the oral cavity related to vasculitis, aphthous ulceration, lichen planus and Bechet’s disease. Any non-healing lesion of the pharynx or oral cavity leads to the suspicion of neoplasia, both carcinoma and lymphoma, and early biopsy may be necessary for diagnosis.
HIV and AIDS
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