Approach to the Problem
Throat redness is a familiar complaint to the general pediatrician or family practitioner. Erythema of the posterior oropharynx suggests an inflammatory or infectious process, but can also be caused by exposure to environmental allergens, airborne irritants, or acid from chronic laryngopharyngeal reflux. The majority of pediatric infections involving the posterior oropharynx are of viral origin. Careful attention to details provided in the patient’s history, and to findings observed on the physical examination, will help to identify patients for whom additional testing, such as group A streptococcus rapid antigen detection, should be performed. It is imperative to recognize the acutely ill patient with pharyngeal erythema, and direct the medical evaluation and treatment plan accordingly. For patients with a persistent or recurrent complaint of throat redness, one must broaden the differential diagnosis to include less common etiologies or pathogens.
Key Points in the History
• Pharyngitis may cause neck pain and stiffness.
• Throat redness associated with upper respiratory tract symptoms (rhinorrhea, cough, and conjunctivitis) and/or lower gastrointestinal tract manifestations (vomiting with diarrhea) are characteristic of viral infection and rarely represent a bacterial throat infection.
• Throat pain due to postnasal drip is often worse at night or in the early morning, but improves during the day.
• Infection with adenovirus is associated with conjunctivitis and/or otitis media.
• In group A streptococcal pharyngitis, symptom onset is typically acute. Sore throat, dysphagia, fever, headache, abdominal pain, and vomiting commonly occur.
• Younger children with streptococcal pharyngitis may present with fever, headache, vomiting, abdominal pain, and decreased oral intake. They may not identify sore throat as a primary complaint.
• Incidence of group A beta-hemolytic streptococcal pharyngitis peaks in the late winter and early spring.
• Epidemics of group A beta-hemolytic streptococcal pharyngitis occur in patients who live in close quarters such as military units, dormitories, mental health facilities, schools, homeless shelters, and group homes.
• Otalgia, with referred pain due to sensory innervation of the glossopharyngeal and vagus nerves supplying both the throat and the ear, can be a presenting symptom of streptococcal pharyngitis.
• Retropharyngeal abscesses are most common in children between 2 and 4 years of age.
• Consider infectious mononucleosis, due to Epstein–Barr virus (EBV) infection, in adolescents with fever, throat pain, enlarged posterior lymph nodes, and significant fatigue.
• Adolescents may not disclose sexual risk behaviors; therefore, test teens with persistent pharyngitis for sexually transmitted diseases, such as gonorrhea.
• Candida may be associated with inhaled steroid use for persistent asthma, or seen in patients who are immunosuppressed or immunocompromised.
• Mycoplasma infection is usually associated with cough.
• Increased throat pain after meals or when supine suggests pain related to gastroesophageal reflux.
• Chronic mouth breathing associated with obstructive sleep apnea leads to dry, irritated mucosae and a sore throat, which is worse in the morning and improves throughout the day as the patient drinks fluids. Asking about ambient room temperatures, especially in the winter months, can provide useful history to support this diagnosis.
Key Points in the Physical Examination
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