TABLE 24-1. Acute throat pain differential | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Throat Pain and Reflux
Throat Pain and Reflux
Phyllis Peng
Jessica W. Lim
Gady Har-El
Although the causes of throat pain are often straightforward, throat pain may present a diagnostic challenge. Throat pain can be derived from a pathologic process anywhere in the upper aerodigestive tract since the sensory fibers innervating the upper aerodigestive tract arise from the ninth and tenth cranial nerves.
MEDICAL HISTORY AND PHYSICAL EXAMINATION
In general, the medical history and physical examination lead the otolaryngologist to the appropriate diagnosis. Important details to elicit in the history include the quality, onset, duration, frequency, alleviating or aggravating factors, and radiation of the pain. The quality of the throat pain can often be distinguished as sharp, dull, scratchy, or burning, presumably because of the specialized distal sensory fibers. Chronic throat pain may pose a greater diagnostic challenge than acute pain, but both may necessitate use of ancillary diagnostic tests. In addition, referred otalgia may be a concomitant symptom as the trigeminal, glossopharyngeal and the vagus nerves have somatic sensory branches that supply the middle and external ear.
DIFFERENTIAL DIAGNOSIS
Acute Pain
Acute throat pain may be caused by an infectious condition, neuralgia (glossopharyngeal or superior laryngeal nerve), trauma, or a neoplasm (Table 24-1).
Viral Pharyngitis
Acute pharyngitis is most often caused by viruses. These include respiratory viruses (adenovirus, influenza virus, respiratory syncitial virus, parainfluenza virus, and rhinovirus) as well as coxsackievirus, herpes simplex virus, and Epstein-Barr virus. Viral pharyngitis often involves both nasopharynx and oropharynx. The patient usually has a diffuse sore throat, often accompanied by malaise. High fever can occur among younger children. Other symptoms of a viral upper respiratory infection often are present—conjunctivitis, coryza, or diarrhea. Examination of the throat usually reveals mild erythema and edema of the posterior oropharyngeal wall. Nodules or oval islands of lymphoid tissue can be seen studding the mucosa in classic lymphonodular or granular pharyngitis. The tonsils usually are not inflamed. Cervical lymph nodes may be slightly enlarged but rarely are tender.
A rapid antigen detection test (RADT) for group A β-hemolytic streptococci and a throat culture specimen should be obtained in the pediatric population to rule out bacterial causes. Treatment for viral pharyngitis is symptomatic, including humidification, hydration, saline gargles, and acetaminophen for pain with expected improvement in 3 to 4 days.
Bacterial Pharyngitis
Bacterial pharyngitis is most often caused by group A β-hemolytic streptococci. Other causative agents include groups C and G streptococci, Neisseria gonorrhoeae, Corynebacterium diphtheriae, Arcanbacterium haemolyticum, and Yersinia enterocolitica, and Yersinia pestis. Certain characteristic features include an age predisposition toward children between 5 to 14 years and a tendency to occur in winter and early spring. The onset of sore throat is usually sudden. The temperature may rise to more than 102°F (38.9°C). The pharyngeal mucosa often is erythematous and swollen. Edema of the uvula and erythema and petechiae of the soft palate may develop. Tender, high cervical lymph nodes often are present. Bacterial pharyngitis is often accompanied by bacterial tonsillitis. In pharyngotonsillitis, the tonsils are swollen with exudate in the crypts.
Patients with such a history and physical findings should be tested with RADT, which has a specificity of greater than 95%. Because 15% to 30% of acute pharyngitis in the pediatric population is caused by group A streptococci, and given the risk of rheumatic fever or rheumatic carditis, a throat swab culture should also be performed in children (higher sensitivity of 90% to 95%). Antistreptococcal antibody titers that reflect past infections are not used to diagnose acute pharyngitis but are valuable to confirm rheumatic fever or postreptococcal glomerulonephritis.
Group A β-hemolytic streptococcal pharyngitis is the only commonly occurring form of pharyngitis in which antimicrobial therapy is of proven benefit. Pencillin V, amoxicillin, first-generation cephalosporins, macrolides, and clindamycin have all been shown to be appropriate antimicrobial therapy. Generally a 10-day oral therapy course is indicated; for clarithromycin, azithromcyin, and some cephalosporins, a 5-day course is effective. The indications for tonsillectomy and adenoidectomy are discussed in Chapter 30.
Infectious Mononucleosis
Infectious mononucleosis is a viral illness that often mimics acute bacterial tonsillitis. Bilateral exudative tonsillitis with nonspecific malaise, low-grade fevers, cervical lymphadenopathy, and splenomegaly should make the otolaryngologist suspect this diagnosis. A complete blood cell count usually shows atypical lymphocytosis, and serologic tests for heterophile antibodies are usually positive.