Sore Throat

30 Sore Throat


This chapter defines sore throat as pain in the throat at rest that often worsens with swallowing. The most common causes (70% to 80%) of sore throat without pharyngeal ulcers include viral pharyngitis (rhinovirus, adenovirus, influenza, respiratory syncytial virus, coxsackie virus, herpes virus, and Epstein-Barr virus), bacterial pharyngitis and tonsillitis, allergic pharyngitis, pharyngitis secondary to sinusitis, and infectious mononucleosis. Common causes of sore throat with pharyngeal ulceration include herpangina, aphthous stomatitis, herpes simplex, fusospirochetal infection, candidiasis, herpes zoster, and chickenpox (varicella). The less common primary and secondary syphilitic ulcerations are usually not painful.


Pharyngitis is a vexing problem because it is extremely prevalent (1.1% of visits in primary care settings) and because a precise diagnosis is difficult to establish. The annual cost of laboratory tests and medications ordered for patients with sore throats is about $300 million. Even though viral and streptococcal pharyngitis (including infectious mononucleosis) are the most common causes of sore throat, studies have shown that even with careful diagnostic techniques, a precise cause can be determined in only about 50% of patients. Mycoplasma pneumoniae is being recognized more frequently as a cause of pharyngitis in children.


Prompt diagnosis and treatment of streptococcal pharyngitis (group A beta-hemolytic streptococcus [GABHS]) are essential to reducing its spread to close contacts; treatment also prevents acute rheumatic fever. In addition, prompt antibiotic therapy shortens the clinical course and decreases morbidity. Rapid screening tests (rapid antigen detection testing [RADT]) for streptococcal antigens are useful in patients with signs and symptoms of acute pharyngitis. Because of improvement in RADT, a throat culture is not necessary unless the RADT result is negative, symptoms do not improve, or the patient shows no response to appropriate antibiotics. This statement does not mean that throat cultures are of no value, but it does reinforce the need for sound clinical judgment in the diagnosis and treatment of patients with sore throats (Table 30-1).



TABLE 30-1 Probabilities of Streptococcal Isolation in Four Series with Different Clinical Predictors∗

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Nature of Patient


Streptococcal pharyngitis is most prevalent in patients younger than 25 years, particularly those between ages 5 and 15 years. Likewise, herpangina, herpes simplex, fusospirochetal infections, and candidiasis are more common in children. As a cause of pharyngitis, infectious mononucleosis is most prevalent in adolescents and young adults. It does occur, though less frequently, in patients older than 60 years. It is particularly notable that 70% of elderly patients with infectious mononucleosis do not experience pharyngitis, adenopathy, or splenomegaly.


Chlamydia trachomatis and Neisseria gonorrhoeae manifesting as oropharyngeal symptoms are becoming more common as causes of pharyngitis but are often unrecognized. Neisseria has been cultured from the throat in 10% of patients with anogenital gonorrhea. Of those with positive culture results, most do not have pharyngeal symptoms. It is more common in people who engage in orogenital sex. Male homosexuals have a higher incidence of oropharyngeal gonorrheal infections than other groups.


Common ulcerative and vesicular pharyngeal lesions include recurrent aphthous stomatitis, herpes zoster, herpes simplex, fusospirochetal infections, and candidiasis (particularly if the patient is immunosuppressed or taking antibiotics [Table 30-2]). Oral ulcers may occur with periodic fever and PFAPA (periodic fever, aphthae, pharyngitis, cervical adenopathy), a rare childhood disease. Although they are rare, primary and secondary syphilitic lesions are seen in adults. They should be suspected if a lesion is not painful and the usual accompanying symptoms of upper respiratory infection (URI) are absent.



Table 30-2 Common Infections Causing Oropharyngeal Ulceration

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Nature of Symptoms


Marked pain in the throat (frequently associated with dysphagia), tonsillopharyngeal exudate, an oral temperature exceeding 100° F to 101° F (37.7° C to 38.3° C), chills, age 5 to 15 years, and a rapid onset of symptoms suggest the probability of streptococcal pharyngitis.


Sore throat and the presence of a low-grade fever, myalgia, conjunctivitis, coryza, malaise, diarrhea, or fatigue suggest viral pharyngitis. When children (2-6 years) have three or more episodes of nonstreptococcal pharyngitis in a 6-month period, M. pneumoniae pharyngitis should be suspected. A low-grade temperature, gradual onset of pharyngeal symptoms, and systemic symptoms (particularly fatigue) that are more persistent suggest infectious mononucleosis. In reality, it is difficult for the physician to determine the cause of pharyngitis on the basis of the nature of the chief complaint; predisposing factors and physical findings are frequently more useful indicators.



Associated Symptoms


Headache, nausea, vomiting, and abdominal pain may occur with sore throat, especially in children with streptococcal pharyngitis.



Predisposing Factors


Herpangina, herpes simplex, and candidiasis are most common in immunosuppressed patients. Candidiasis is also most prevalent in diabetic patients and in patients taking broad-spectrum antibiotics. Inhaled and nasal steroids predispose an individual to Candida pharyngitis. Herpangina is most common in children and shows a strong seasonal propensity for summer and autumn, whereas streptococcal pharyngitis is most prevalent in the winter and early spring. Aphthous stomatitis is associated with Behçet’s disease, Crohn’s disease, ulcerative colitis, malabsorption syndrome, gluten-sensitive enteropathy, PFAPA syndrome, and human immunodeficiency virus (HIV) infection.

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Mar 21, 2018 | Posted by in BIOCHEMISTRY | Comments Off on Sore Throat

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