Episode Transcript
Hi and welcome to Clerkship Ready – Pediatrics – A podcast aimed at helping you excel during your clinical clerkship in Pediatrics.
I am Dr. Chris Stadnick, and I am a pediatric resident at the University of Virginia.
Today we are going to talk about a very common problem seen in the pediatric ambulatory setting: the sore throat. Reasons for a sore throat can range from benign all the way to serious medical emergencies. So, listen along as we explore the pharynx!
Let’s start with the anatomy to get our bearings. The oropharynx (or mouth) opens up to show the teeth, the tongue, the buccal mucosa (or inside of the cheeks), and then the posterior pharynx (or throat) in the back. The roof of the mouth starts as the hard palate and then becomes the soft palate before transitioning to the posterior pharynx. Oh, and don’t forget about the uvula in the middle of the pharynx! On either side of the pharynx can be the palatine tonsils if they have not been removed, these tonsils help the body’s immune system fight off infections. Looking at these landmarks can help you figure out what’s going on when a patient comes in with a sore throat.
Now that the anatomy is out of the way, let’s start talking about some of the causes of throat pain, how they present, and of course what to do to make them better. We will talk about the more common ones first and then move to some of the more rare causes!
A 4-year-old presents to the office with a sore throat that has been going on for 3 days. He is still able to eat and drink although his intake has decreased a little bit due to the pain in his throat when he swallows. He had a fever yesterday and has been coughing and had a nasty runny nose. Other children at his preschool have been sick with similar symptoms as well. On physical exam, when you look in his mouth, you do not see any oral lesions or gum irritation. His tonsils look a little red but there are no yellow speckles coating his tonsils. The back of his throat also looks red but there’s no evidence of bleeding or trauma. So, what is going on with this patient?
One of the biggest decisions to make (or mystery to solve) with a patient presenting with a sore throat is if the cause is bacterial or viral. This patient shows signs of a viral illness when we examine his story. Fever, cough, and rhinorrhea all point to a virus rather than bacteria. Also, some other children in his class (PRESCHOOL CLASS) have similar symptoms. This makes a viral picture more likely although bacterial infections can be contagious as well. In some cases of viral pharyngitis, you might see oral lesions towards the back of the mouth, scattered across the soft palate. If you see that, you should also look at the child’s hands and feet. If there are vesicles – which mean blisters - or small red spots, then this child has what is called hand foot mouth disease, caused by the coxsackie virus. If the blisters are only in the back of the mouth, then it’s called “herpangina.” Coxsackie infections can cause some severe throat pain and make it very uncomfortable for children to swallow food and liquids. Also, the lesions on the hands and feet can be itchy. The treatment for Coxsackie virus is supportive with pain control with acetaminophen or ibuprofen being of the utmost importance. This can help keep the throat pain in check and allow the child to drink and eat, preventing dehydration! Also make sure you recommend good handwashing. The child should not return to daycare or school until they are fever free.
HSV: Another virus that can cause oral lesions in the mouth and throat pain is the herpes simplex virus – usually type 1. Think about this virus in your adolescents or teenagers that present with pharyngitis. They can have erythema in the back of the throat, some lymphadenopathy, as well as vesicles on the throat or gums and cold sores on the lips although not in all cases (McMillan et al). Their gums can be inflamed as well (McMillan et al). Primary herpes gingivostomatitis – meaning the first time they have HSV infection – usually presents in toddlers but can also be in older children as well. They can have vesicles in their mouth and throat and on their lips. They can also have fever for 5-7 days. The major risk here is dehydration, because it’s too painful to swallow. Treatment for this condition is pain control with acetaminophen or ibuprofen. Some clinicians will also start acyclovir, particularly if the child has had symptoms for <96 hours.
Mono: A teenager presents to your clinic and they look sick. Pharyngitis, fever, body aches, fatigue. She is down in the dumps. You look in her mouth and her throat is red and her tonsils are huge. No oral lesions though. She’s got some cervical lymphadenopathy too. Does she have the flu? You swab her and it returns negative. You think she might also have strep throat so you swab her and even though the rapid test returns negative, you give her some amoxicillin anyway to treat the infection. A few days later you receive a call that the patient has broken out in a diffuse, maculopapular rash all over her body (StatPearls). Is she allergic to amoxicillin? She’s had it before for acute otitis media without any issues. So what is going on with this patient? This patient has Ebstein-Barr virus causing mononucleosis. Yep, mono. The rash she experienced is one that can be caused by the combination of EBV infection and a penicillin such as ampicillin or amoxicillin. This rash differs from the rash caused by mono alone in that it is more widespread whereas the mono rash typically is just on the trunk (Chovel-Sella et al). Some patients with EBV infection can also develop a mild hepatitis – with hepatomegaly – and splenomegaly. Unfortunately there is not a treatment for mono. Just like other viruses it is supportive care and making sure the patient stays hydrated. Some patients with mono can have such severe tonsillar swelling that hospitalization may be needed for IV hydration or because of concerns about airway obstruction. In these patients, steroids may be used to decrease the swelling.There is one additional crucial piece of guidance for this disease, especially if the patient is an athlete. Because mononucleosis can cause splenomegaly, this places the spleen at risk for injury, with the highest occurrence of splenic injury being in the first 3 weeks of the illness and rarely after 4 weeks of illness (Becker & Smith). So if the patient plays a sport, they should not participate in that sport for at least 3 weeks to avoid potential splenic injury and slowly ramp up their activity afterwards (Becker & Smith).
We have talked about a viral appearance of a child, so what would cause you to think about a bacterial cause of their strep throat? There’s one bacterium in particular we are concerned about…that’s right group A strep – or Strep pyogenes. Group A strep is a gram + cocci that can cause pharyngitis and some other nasty problems, which we will get to in a second. A patient who is infected with GAS will look sick and not feel well. They will likely have sore throat and appear tired. You might be able to palpate some tender lymph nodes along the anterior cervical chain on the neck. Looking into their mouth, the tonsils will usually be erythematous, inflamed with exudate – or have yellow dots/spots of pus seeping out of them. Sometimes you can see petechiae on the palate as well. To test for strep throat, you can do a rapid strep test that tests for the antigen, but the gold standard is a throat culture (Martin 2015). Both can be obtained by swabbing the tonsils. If you have a high suspicion that someone has strep throat, you should do the rapid test and a throat culture because the rapid strep has high specificity, but low sensitivity – meaning that if it’s positive, you are pretty sure that it’s truly positive, but there are sometimes false negatives. In most institutions, if the rapid strep is negative, they automatically send the sample for throat culture
CENTOR
One concept I would like to briefly discuss is the CENTOR criteria. This is something that invariably comes up in discussion when you have a patient with a sore throat. The CENTOR criteria was developed by Dr. Centor to help assess the likelihood of GAS in adults and has since been modified for pediatric patients. You get one point each for the symptoms of no cough, tonsillar exudates, lymph nodes, fever, and age of 3-14 years. If you have a score of 3 or more, you should consider a rapid strep test or throat culture; if you have a score of 4, you should consider testing and empiric antibiotics. But are the CENTOR criteria appropriate to use for pediatric patients? A study published in 2013 by Roggen et. al in Brussels examined how applicable the CENTOR criteria are for pediatric patients by retrospectively looking at pediatric charts of children aged 2-16 who had a throat swab during an ED visit. They divided the patients into two groups: preschoolers (2-5) and school-aged children (5-15) (Roggen 2013). They found in the preschool group that preschoolers with a lower CENTOR score of <3 had a higher percentage with GAS compared to those preschoolers with scores of 3 or 4, (Roggen 2013). In the school age group, the percentage of positive tests for GAS were similar regardless of CENTOR scores. What this shows is that, among children, the CENTOR scoring criteria is not an effective measure of determining who has GAS and who does not.
A strep pharyngitis infection can go away on its own, but some of the sequelae that can follow are very harmful to the patient, and we treat GAS infections mainly to prevent these sequelae. The main consequence we want to avoid with GAS is rheumatic fever. Rheumatic fever occurs due to molecular mimicry. The human body, when mounting a response to GAS creates an antibody to a specific molecule on the bacterium…that just so happens to look like another molecule found naturally in the human body. As a result, the immune system starts to attack the body. The symptoms of rheumatic fever are also known as the JONES criteria. A patient will have joint pain (J), mitral valve regurgitation or myocarditis (O for the heart), subcutaneous nodes, which are typically painless bumps on the elbows or knees (N), a rash called erythema marginatum (E), and Sydenham chorea (S) or dancing-like movements of the extremities (Choudhury 2013). The other sequelae include Scarlet fever where a sandpaper-like rash will appear on the patient’s body, and post-streptococcal glomerulonephritis, where deposits on the glomerular-basement membrane will cause damage to the kidneys and result in hematuria, or blood in the urine. One thing to note is that poststreptococcal glomerulonephritis cannot be prevented by treating with antibiotics. @@@
Interestingly, children under the age of 3 rarely need to be tested for GAS pharyngitis because they are unlikely to develop the complications of the disease.
GAS is very susceptible to penicillin. In pediatrics, we usually use amoxicillin as the first line treatement, because it tastes better. What should you do if a patient has a penicillin allergy? If the allergy is not anaphylaxis, then you should try cephalexin, but if it is truly an anaphylactic reaction then the patient should receive a macrolide (Martin 2015).
Alright, now that we’ve got strep throat out of the way and what symptoms to consider if a patient has a viral or bacterial infection, let’s talk about some other causes of pharyngitis.
A 7-year-old child presents to clinic with pharyngitis, profuse rhinorrhea, and some watery eyes…wait this sounds like a viral illness…hold, on…she presents in the spring, just as pollen becomes abundant, oh and she has a history of eczema. What should you be thinking? That’s right, those pesky allergies. The body reacts to the pollen, causing a release of histamine and profuse snot. This snot when not sneezed out has one other way it can leave the nasal cavity, through the back of the throat. This constant drainage can irritate the throat and result in sore throat. What are some physical exam findings you might see? Watery eyes, bilateral conjunctival injection (or red eyes), clear mucus draining from the nostrils with pale, boggy turbinates. You can sometimes see allergic shiners or bags underneath the eyes due to nonstop rubbing. Looking in the back of the throat, you might see cobble stoning where the posterior pharynx looks bumpy, like a cobblestone street. This is caused by the mucus draining down the back of the throat. To treat this kind of pharyngitis in a perfect world the child would be able to avoid the allergen that causes her symptoms, but we do not live in a perfect world. Second generation histamine receptor antagonists like loratadine or cetirizine will help with these symptoms. It is important to take these medications every day to avoid symptoms during allergy season. Additionally, if the child can tolerate it, nasal fluticasone can help prevent mucus production and improve the irritation by decreasing inflammation of the nasopharynx. @@@
Now that we have covered some of the common causes of pharyngitis, let’s move on to the emergent or urgent causes.
A 7 year-old patient presents to the clinic with chief complaint of sore throat. He’s having a lot of difficulty eating and drinking today and has had intermittent fevers here and there over the past 5 days with some runny nose and cough. He nods his head “yes” and “no” when you ask him questions and does not say much, but when he does, his voice sounds muffled. When you look into his mouth after some coaxing you find the cause of his sore throat. His right tonsil is bright red and swollen, so much so that it is causing the uvula to deviate to the left. He has a peritonsillar abscess or PTA. Group A Strep and Staph aureus are two of the most common causes of deep neck infections like PTAs, but some anaerobes like Fusobacterium can be involved too (Esposito et al). A peritonsillar abscess is an uncommon cause of sore throat, but one that must be considered. Treatment for PTAs can vary depending on who is managing it. The plan will involve antibiotics plus or minus surgery (Esposito et al), where surgery can be an incision and drainage, aspiration, or even tonsillectomy. For antibiotic choices, aerobic and anaerobic coverage is necessary so ampicillin-sulbactam or amoxicillin-clavulanate are good choices while a culture might be cooking, if you obtained one (Esposito et al). If the patient is improving on antibiotics, then surgery might not be needed. Other factors that make a procedure less needed are if the child is at least 4 years old and if the abscess is <25 mm in diameter. A CT with contrast is the appropriate study to evaluate the size of a PTA (Esposito et al).
Another infection that is similar to a peritonsillar abscess in that it is an emergency is the retropharyngeal abscess. A patient typically will have some viral symptoms preceding the infection and should have some pain when moving the neck. However, this time instead of the infection/abscess being next to the tonsils, it will be in the deep tissue of the neck, behind the pharynx. This is an emergency because the infection can spread quickly into crucial spaces such as the lungs or brain (Esposito et al). You should get imaging if you suspect a retropharyngeal abscess to evaluate the size and location of the abscess (Esposito et al) and also reach out to your friendly ENT for further management.
The last emergency condition we will talk about is epiglottitis. What’s the most common cause of epiglottitis? If you thought Haemophilus influenzae type b then you would be correct. The classic patient presentation of epiglottitis is a patient (who may or may not be unvaccinated), presents in respiratory distress where she is tri-podding – in other words, is leaning over with her hands on her knees trying to keep the airway open. They will have a lot of drooling, since it is difficult for them to swallow their secretions and their voice will have that muffled “hot-potato” quality. Management first involves making sure the patient has a secure airway. Do not do anything to upset the child, as crying or distress may precipitate airway compromise. You want to have your anesthesia and/or ENT colleagues nearby, because if they cannot maintain their airway, then they will need intubation. Once the airway is secured, then you can put in an IV and start antibiotics to treat the infection.
So now we’ve gone over some scary presentations of a sore throat and associated infections as well as some more common ones. Let’s do quick recap to wrap up this episode.
Pharyngitis can be caused by some easily treatable conditions such as allergies, group A strep infection, and viral infections. Remember that CENTOR criteria is not very helpful in children and if you have a suspicion that they have GAS and are at least 3 years old, you should consider swabbing them and sending a culture. We want to prevent some of those scary sequelae. Always keep your differential open to some of the frightening causes of throat pain such as peritonsillar abscess, retropharyngeal abscess, or epiglottitis. These patients will need antibiotics and probably a trip to the emergency department.
OUTRO:
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