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Chapter 28 • Sleep Problems 351
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Ferritin Level
Serum iron stores (measured by serum ferritin) have
been shown to correlate inversely with restless legs
syndrome. Iron is a cofactor in tyrosine hydroxylase,
the rate-limiting enzymatic step in the conversion of
tyrosine to dopamine.
DIFFERENTIAL DIAGNOSIS
Restless Legs Syndrome
Restless legs syndrome includes the sensation of crawl-
ing, pulling, and tingling with an irresistible urge
to move the legs. Symptoms increase in the evening,
especially when the person is lying down and remaining
still. The symptoms occur before sleep, causing a delay
in sleep onset. Patients often have coexisting periodic
limb movements in sleep. Renal failure with uremia or
iron or folate deciency sometimes underlies restless
legs syndrome.
Periodic Leg Movement
Periodic leg movements during sleep are common in
people older than 65 years. Bilateral repeated, rhythmic
jerking or twitching movements, primarily in the legs,
characterize periodic limb movement disorder. Less fre-
quent movement can occur in the arms. The movements
occur every 20 to 90 seconds and can cause brief arousal
that disrupts sleep and decreases the amount of time in the
deep stages of sleep. The patient may not report waking
up but reports that sleep was not refreshing. The condition
commonly coexists with restless legs syndrome.
Obstructive Sleep Apnea
Clinically, OSA is dened by the occurrence of daytime
sleepiness, loud snoring, witnessed breathing interrup-
tions, or awakenings due to gasping or choking, in the
presence of at least ve obstructive respiratory events
(apneas, hypopneas, or respiratory effort–related arousals) per hour of sleep. Obstructive sleep apnea hypopnea syndrome (OSAHS) is characterized by daytime
somnolence, snoring, difcult-to-control hypertension,
refractory arrhythmias, angina, or heart failure.
During sleep, the normal tone of the airway
muscles is relaxation, especially during REM sleep
cycles. However, the diaphragm during this time is
active. The activity of the diaphragm unchecked by
the airway muscles leads to the collapse of the upper
airway. Associated with this is any anatomical
barrier, such as enlarged adenoids, with resulting
obstruction. The signs, symptoms, and consequences
of OSA occur as a result of repetitive collapse of
the upper airway, sleep fragmentation, hypoxemia,
hypercapnia, marked swings in intrathoracic pressure, and increased sympathetic activity.
Risk factors for sleep apnea include male sex and
obesity (especially a heavy or thick neck). The condition may be associated with hypothyroidism, neurodegenerative disorders, and cardiovascular disorders.
Generally in children, OSA is the result of enlarged
tonsils and adenoids after age 6 weeks. Children ages
4 to 6 years are most prone to this condition. Most
children presenting with OSA have failure to thrive
and may also exhibit nocturnal enuresis, hyperactivity,
learning problems, and morning headaches.
The patient may report insomnia but more commonly notes excessive daytime sleepiness. Hundreds
of apneic episodes occur during the night. The frequent
interruptions coupled with repeated drops in blood
oxygen saturation may cause a marked decline in daytime alertness and performance. The patient should be
evaluated in a sleep laboratory (see the EvidenceBased Practice box).
EVIDENCE-BASED PRACTICE
A recent review of the evidence indicates that questionnaires,
physical examination, and clinical prediction rules estimate
the pretest probability of obstructive sleep apnea hypopnea
syndrome (OSAHS), but are not specific enough to make the
diagnosis. The Epworth Sleepiness Scale is a reliable measure
of daytime sleepiness. Physical examination offers clues—
decreased visibility of the posterior pharynx when the patient
opens his mouth and sticks out his tongue, truncal obesity, and
a waist-to-hip ratio was .1 in men and .0.85 in women make
Data from Jacobs CK, Coffey J: Clinical inquiries. Sleep apnea in adults: how accurate is clinical prediction? J Fam Pract 58:327, 2009.
Diagnosing Obstructive Sleep Apnea
the occurrence of OSA more likely but are not sufficient to
make a diagnosis. The Institute for Clinical Systems Improvement recommends polysomnography for patients with symptoms of OSAHS and 1 or more of the following: cardiovascular
disease, hypertension, coronary artery disease, obesity, sleep
concern, type 2 diabetes mellitus, recurrent atrial fibrillation,
and large neck circumference. Polysomnography is routinely
recommended by the American Academy of Sleep Medicine
for the diagnosis of sleep-related breathing disorders.
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Narcolepsy
Narcolepsy is a disorder of excessive daytime sleepiness. It is characterized by sudden, irresistible attacks
of daytime sleepiness that last 10 to 30 minutes. Most
adults with narcolepsy also experience cataplexy, a
sudden loss of muscle tone in response to sudden emotional stimuli. Although the episodes are typically brief,
the person is at risk for falls or other accidents because
he or she cannot move or speak. Cataplexy is not commonly seen in children. Persons with narcolepsy usually
experience sleep paralysis once or twice a week at the
time of sleep onset. There is a period of mental alertness,
but the person is paralyzed except for respiratory and
eye musculature. Hypnagogic (brief, vivid, dreamlike)
hallucinations typically occur at sleep onset. Involuntary
daytime sleep attacks may begin in adolescence or
young adulthood. People with this problem may have
symptoms for years before the disorder is diagnosed.
Not all persons with the disorder experience all symptoms. Narcolepsy is fairly uncommon in children.
Delayed Sleep Phase Syndrome
This is an extreme shift in sleep-wake schedule seen in
adolescents. The adolescent goes to bed but does not
fall asleep for many hours, is then awakened to attend
school, having had only a few hours of sleep. On the
weekend, the adolescent, when allowed to sleep, will
sleep at least eight hours.
Secondary to Medical Condition
or Medications (Comorbid Insomnia)
GERD, COPD, peptic ulcer disease, and congestive
heart failure are associated with paroxysmal nocturnal
dyspnea. The sleep disturbance is often interpreted by
the patient as insomnia. Prostatic hypertrophy may
cause nocturia and thus disturb sleep.
Many medications can have stimulating effects and
cause sleep disruption. Common offenders include antidepressants (activating selective serotonin reuptake inhibitors), decongestants, bronchodilators, b-blockers, thyroid
preparations, phenytoin, methyldopa, and corticosteroids.
Pain may interfere with sleep onset or contribute to
early awakenings. Patients with chronic pain may have
mood and cognitive disturbances that contribute to
insomnia and early morning awakening.
Psychological conditions that cause insomnia include depression, anxiety disorder, panic disorder, mania, and acute psychosis.
Poor Sleep Hygiene
Sleep hygiene is related to health practices and environmental inuences on sleep. Bedtime routines, environmental distracters, and stimulants affect the ability
to fall asleep. Lights and televisions produce awakening cues. Routinely using the bedroom for other activities may also condition the patient to an arousal state
while in the bedroom. Noise may reduce the amount of
REM sleep and lead to daytime sleepiness.
Caffeine, diet pills, and nicotine are stimulants that
can cause sleep disruption. Alcohol consumed before
bedtime tends to shorten total sleep time and exacerbate other conditions, such as GERD and sleep apnea.
A child who is put to bed still awake and learns to
fall asleep using self-comforting measures is often able
to calm himself or herself and return to sleep when he
or she rouses in the middle of the night, as do most
children and adults. Toddlers are fearful of separation,
and bedtime routines need to be established.
Infants who sleep with parents may have sleep
problems. As parents arise or move from the bed, the
infant awakens because of the lighter sleep state.
The American Academy of Pediatrics recommends
that all infants sleep on their backs for the rst 6 months
of life to decrease the risk of sudden infant death syndrome (SIDS). The sleep environment should be quiet and
dark and the room temperature should be comfortable.
Lifestyle
Shift work, particularly periodic shift work, has been a
reported cause of sleep disruption. It may interrupt the
usual circadian rhythm or alter usual sleeping patterns
and habits.
Sleeping in unfamiliar surroundings affects the
quality of sleep and increases sleep latency. It is associated with more wakefulness, an increased amount of
light sleep, and a shorter REM sleep stage.
Jet lag is a common cause of sleep disruption. It
may interrupt the usual circadian rhythm or alter usual
sleeping patterns and habits. Even 1 to 2 hours of time
zone change can disrupt the usual sleep/wake pattern.
Age-Related Sleep Disorders
Night Awakening
Newborns wake every 20 minutes to 4 hours during a
24-hour period, reecting their sleep/wake cycle. This
cycle changes between 3 and 6 months with the establishment of a diurnal sleep/wake rhythm. During this
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time an initial “settling” period that typically takes 10
to 20 minutes begins to occur. The infant drifts from
stage 1 NREM sleep into stage 3 or 4. The infant may
return to stage 1 and cycle again. After one or two
cycles of NREM sleep, REM is entered at about 60 to
90 minutes. The initial one third of the night is mostly
deep sleep (NREM stages 3 and 4). The last half of the
night is predominantly stage 2 NREM and REM. Daytime sleep decreases over the next 3 years and consolidates at night. At age 4, most children no longer nap.
School-age children sleep approximately 8 hours a
night. Stage 4 sleep decreases to 75 to 80 minutes. This
decline is associated with an increase in stage 2 sleep.
The onset of REM sleep decreases from about
140 minutes in the 6- to 7-year-old to 124 minutes in
the 10- to 11-year-old.
Sleep Refusal
Toddlers are emerging from a sensory-motor period to
a preoperational period. They have a strong attachment
to their caregiver, and separation from this person at
bedtime causes distress and sleep problems. Further,
older toddlers who are in the preoperational stage are
developing a sense of autonomy and use going to
bed as an issue of control and/or a general pattern of
oppositional behavior. Examination of the child’s naptime is important. In the school-age child and adolescent, anxiety, negative conditioning, delayed sleep
phase (often caused by caffeine), or a bedtime that is
too early may be the cause. Also, vigorous activity
before bedtime may delay sleep onset.
Night Terrors
Night terrors are nocturnal episodes in which the child
sits straight up in bed, screams, and is inconsolable for
up to 30 minutes before relaxing and falling back to
sleep. These actions occur within the rst few hours of
sleep. Children at around the age of 3 years have
NREM occurring more in the rst part of the night; this
may account for the night terror. The child is not readily awakened, although he or she seems to be awake. It
is not possible to console the child, and the child has
no recollection of the event the next day. Night terrors
occur between the ages of 3 and 10 years.
Nightmares
Nightmares are bad dreams that awaken the dreamer.
They occur later at night than night terrors and occur
during REM sleep, which in children is near the end
of the sleep cycle. Unlike night terrors, the dream is
remembered and the child is awake and may be
consoled by the caregiver. Nightmares occur at
any age.
Adolescent Patterns
Adolescents have an increase in slow-wave sleep with
an increase in the amount of sleep required. However,
most adolescents are in a sleep debt because they tend
to leave less time for sleep. Repeated changes in the
sleep cycle (short sleep periods followed by occa-
sional long sleep periods) may disrupt the circadian
rhythm, causing a delayed sleep phase syndrome.
Menopausal Women
Menopause-related changes may contribute to or cause
sleep disturbance. Evidence that sleep difculties are
related to the hormonal changes of menopause is
mixed. Hot ashes and night sweats promote arousal
from sleep.
Older Adult Patterns
Sleep in older adults is characterized by more night-
time awakenings and reduced or nonexistent deep
states of NREM sleep. However, REM sleep tends to
be preserved. That older adults sleep less than younger
adults may reect their ability to sleep, not their need
to sleep. Although a mild deterioration in sleep quality
may be normal in the aging process, signicantly dis-
rupted nighttime sleep or excessive daytime function-
ing is not considered part of normal aging. Older per-
sons have a circadian rhythm disruption and tend to
awaken earlier in the morning. If the onset of sleep is
not correspondingly earlier, excessive daytime sleepi-
ness may result. Daytime napping may reduce the
drive for sleep at the usual bedtime hour. A night owl
pattern is delayed bedtime until early morning hours,
and the condition may progress to day-night reversal,
where sleep does not begin until dawn and continues
until midday.
Conditioned Insomnia
Trained Night Crier
Children who do not have self-comforting behaviors
will be unable to fall asleep on their own. These criers
awaken, cry, and want to be held or rocked before they
can go back to sleep. An infant older than 6 months
who continues to wake during the night is considered a
trained night crier.
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Trained Night Feeder
A child who needs to be fed when awakened at night is
noted as a trained night feeder. The child does not need
the additional nutrition but becomes conditioned to
requiring a feeding to go to sleep. Caregivers often
bottle-feed or breastfeed the child until the child falls
back to sleep. The intake of nighttime feeding after
7 or 8 months of age may prevent the development of
a more mature circadian rhythm. This rhythm is a
digestive-endocrine-sleep/wake cycle that adjusts to a
day/night cycle, resulting in a consolidation of sleep.
Continued nocturnal feeding keeps the infant in a
recurrent interruption pattern of frequent night awakening and prevents consolidation of sleep.
Somnambulism
Sleepwalking occurs during NREM stages 3 and 4,
which occur in the initial one third of the night. Sleepwalking usually occurs only once a night and lasts
about 15 minutes. The person gets out of bed and
moves about slowly and in an automatic manner with
a blank look on the face. Sometimes the person is
mumbling; after a great deal of effort, the person can
be awakened but will have little to no memory of the
episode. Providing a safe environment is important
because genuine risk of injury exists during the sleepwalking episode. Sleepwalking in an elderly person
may be a sign of dementia.
DIFFERENTIAL DIAGNOSIS OF Common Causes of Sleep Disorders
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
Specific Disorders
Restless legs
syndrome
Periodic limb
movement
Obstructive sleep
apnea
Narcolepsy Excessive sleepiness, cataplexy Normal Referral to sleep
Delayed sleep
phase syndrome
Secondary to
medical condition
or medications
Poor sleep
hygiene
Lifestyle Shift work, travel, jet lag Normal Sleep diary
Age-Related Sleep Disorders
Night awakening Single to repeated awakening at
Sleep refusal Refusal of child to go to sleep Normal None
Night terrors Inconsolable awakening occurring
Irresistible urge to move legs while
in bed
Older than 65 years; reports of
rhythmic jerking of legs or arms
while asleep
Apneic episodes, loud snoring,
restless sleep patterns
Adolescent with extreme shift in
sleep awake cycle; unable to fall
asleep for many hours
GERD, COPD, PND, CHF, enlarged
prostate/nocturia; depression or
anxiety
Medications: antidepressants,
decongestants, bronchodilators,
b-blockers, thyroid preparations,
phenytoin, methyldopa, corticosteroids
Routine, habits, environment not
conducive to sleep; use of alcohol, caffeine, diet pills, nicotine
night
early in sleep, lasting 15 minutes,
no memory of event
Normal Sleep studies; serum
ferritin
Normal Sleep studies
Decreased O2; enlarged
adenoids, tonsils
Normal Referral to sleep
Consistent with medical
condition
Normal Sleep diary
Initial physical examina-
tion to eliminate medical associated illness
Normal None
Sleep studies:
polysomnography
specialist
specialist
Consistent with underly-
ing medical condition;
trial off or change of
medication(s)
As directed by
examination
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DIFFERENTIAL DIAGNOSIS OF Common Causes of Sleep Disorders—cont’d
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
Nightmares Occur later in sleep cycle; dream is
remembered
Adolescent
patterns
Menopausal
women
Older adult patterns Nighttime arousals and awaken-
Conditioned
insomnia
Trained night crier Child unable to soothe self Normal None
Trained night feeder History of frequent feedings on
Somnambulism Sleepwalking in early sleep cycle Normal None
CHF, congestive heart failure; COPD, chronic obstructive pulmonary disease; GERD, gastroesophageal reflux disease; PND, paroxysmal nocturnal
dyspnea.
Decrease in amount of sleep
obtained
Hot flashes Consistent with
ings; night owl pattern; early
wakening; daytime napping
Identify initial trigger with persis-
tent problem
awakening at night
Normal None
Normal Sleep diary
Sleep diary
menopause
Physical examination
to rule out underlying
medical condition
Physical examination
to rule out underlying
medical condition
Normal None
Sleep diary
Sleep diary
REFERENCES AND READINGS
Anders T, Eiben L: Pediatric sleep disorders: a review of the past
10 years, J Am Acad Child Adolesc Psychiatry 36:9, 1997.
Bayard M, Avonda T, Wadzinski J: Restless legs syndrome, Am Fam
Physician 78:235, 2008.
Bower CM: Pediatric obstructive sleep apnea syndrome, Otolaryngol
Clin North Am 33:49, 2000.
Budur K, Rodriguez C, Foldvary-Schaefer N: Advances in treating
insomnia, Cleve Clin J Med 74:251, 2007.
Capp P, Pearl P, Lewin D: Pediatric sleep disorders, Prim Care Clin
Ofce Pract 32:549, 2005.
Culpepper L: Insomnia: a primary care perspective, J Clin Psychiatry
66:14, 2005.
Davis KF, Parker KP, Montgomery GL: Sleep in infants and young
children: part two: common sleep problems, J Pediatr Health
Care 18:130, 2004.
Doghramji K, Neubauer DN: Insomnia: waking up to a signicant
problem, Consultant 45:53, 2005.
Epstein LJ, Kristo D, Strollo PJ Jr, Friedman N, Malhotra A, Patil SP
et al: Clinical guideline for the evaluation, management and
long-term care of obstructive sleep apnea in adults, J Clin Sleep
Med 5:263, 2009.
Hoban TF: Sleep and its disorders in childhood, Semin Neurol
24:327, 2004.
Kass, L: Sleep problems, Pediatr Rev 27:455, 2006.
Jacobs CK, Coffey J: Clinical inquiries. Sleep apnea in adults: how
accurate is clinical prediction? J Fam Pract 58:327, 2009.
Morgenthaler T, Alessi C, Friedman L, Owens J, Kapur V,
Boehlecke B et al: Practice parameters for the use of actigraphy
in the assessment of sleep and sleep disorders: an update for
2007, Sleep 30:519, 2007. Available online at www.guideline.
gov. Accessed May 30, 2010.
Schutte-Rodin S, Broch L, Buysse D, Dorsey C, Sateia M: Clinical
guideline for the evaluation and management of chronic insomnia
in adults, J Clin Sleep Med 4:487, 2008.
Shaver JL, Zenk SN: Sleep disturbance in menopause, J Womens
Health Gend Based Med 9:109, 2000.
Thiedlke C: Sleep disorders and sleep problems in childhood, Am
Fam Physician 63:277, 2001.
Wolkove N, Elkholy O, Baltzan M, Palayew M: Sleep and aging: 1.
Sleep disorders commonly found in older people, CMAJ 176:1299
2007.
Zunkel GM: Insomnia: overview of assessment and treatment strategies,
Clin Rev 15:38, 2005.
C H A P T E R
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29
Sore Throat
ore throat, or pharyngitis, is one of the most
common concerns of patients in primary care. It
S
is most often a transient condition of viral origin. Throat pain is the result of an inammation of the
mucosa of the oropharynx, secondary to an infectious
cause (e.g., viral, bacterial, fungal, or spirochetal).
Less commonly, sore throat may be a symptom of systemic illness, such as mononucleosis. The posterior
pharynx is also vulnerable to irritants from the environment and drainage from the nose and sinuses. Thus
pharyngitis begins as an inammation of the mucous
membranes with secondary involvement of the lymph
node drainage system, rarely progressing to deep neck
and mediastinal involvement. Throat pain can also be
referred from other structures, most commonly the ears
and thyroid gland.
Sore throats can be classied as those with pharyngeal
ulcers and those without. The classication serves as a
device to sort out those relatively few sore throats caused
by specic viral or fungal infections that produce pharyngeal ulcers and those caused by agents and processes
characterized by an absence of pharyngeal ulcers.
The goals of assessment and diagnosis are to identify those patients with group A ß-hemolytic streptococcus (GABHS) infection (because they are at risk for
rheumatic fever and glomerulonephritis), to reduce the
possibility of sequelae of peritonsillar and retropharyngeal abscess, and to identify epiglottitis.
DIAGNOSTIC REASONING:
FOCUSED HISTORY
History
The previous complaints signal acute epiglottitis. The
history is usually elicited from another individual
because the ill person either is a child or is too ill to
talk. Acute epiglottitis is rare, with an incidence of
10:100,000 in pediatric patients younger than 15 years
and 1 to 8:100,000 adult patients. The morbidity and
mortality that result from airway obstruction, however,
are signicant.
Associated Symptoms
Symptoms of epiglottitis are sore throat, difculty
swallowing, and respiratory distress. These are characterized by drooling, dyspnea, and inspiratory stridor.
Haemophilus inuenzae type b is the most common
pathogen. The incidence of H. inuenzae type b epi-
glottitis is highest in children ages 2 to 5 years. Epiglottitis is a rapidly progressive illness with a potentially fatal outcome and must be recognized and
referred immediately.
Peritonsillar abscess is also an acute infection that
needs to be identied immediately for referral and
treatment. The symptoms of peritonsillar abscess and
cellulitis include a severe sore throat, odynophagia,
trismus (spasm of the masticatory muscles and difculty opening the mouth), and medial deviation of
the soft palate and peritonsillar fold. These symptoms are caused by infection penetrating the tonsillar
capsule and surrounding tissues. About 30% of
patients with peritonsillar abscess require an emergency tonsillectomy.
Is this an emergency?
Key Questions
n Have you been drooling?
n Have you been unable to swallow?
n Have you been unable to lie down?
n Have you been restless, unable to stay still?
n Have you been unable to talk?
356
Is the sore throat related to an infectious
cause?
Key Questions
n Is anyone else at home sick?
n Are any of your friends or co-workers sick?
n When did the pain start?
n How severe is the pain?
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Exposure
Exposure to other ill individuals increases the likelihood of viral or bacterial infection. Respiratory illness
caused by GABHS is spread within families, with
approximately 20% of family members becoming
infected. Epstein-Barr virus (EBV) is not highly contagious and requires intimate contact between susceptible individuals and symptomatic shedders of the
virus. Transmission is primarily through saliva.
Onset
The sudden onset of sore throat is often caused by
GABHS. The organisms invade the pharyngeal epithelium, where they multiply and cause an intense immune
response. Gradual onset is more common in infectious
mononucleosis. The EBV infects B lymphocytes of the
pharynx with resultant dissemination throughout the
lymphoreticular system, causing an immune response
that is more gradual in onset
In viral pharyngitis, a sore throat begins a day or
two after the onset of other illness symptoms, reaching
its peak by the second or third day.
Noninfectious causes of sore throat typically have
an insidious onset. The patient often is not able to pinpoint when the sore throat started but notes that it has
been persistent.
Severity
Throat pain associated with streptococcal infection is
usually intense. Throat pain associated with inuenza
and adenovirus is severe, with prominent edema of
the throat. Severe throat pain with trismus and refusal
to speak indicates severe peritonsillitis, which may
lead to peritonsillar abscess formation (quinsy). The
throat pain produced by noninfectious causes tends to
be less severe and may be described as “scratchy” or
“annoying.”
Young children may not be able to express the sensation of a sore throat or the severity of it. Instead, they
may refuse to eat or drink. Pain in the younger child, if
present, more commonly indicates the presence of epiglottitis or laryngitis, abscess, diphtheria, or scarlatina.
What does the presence of fever tell me?
Key Questions
n Have you had a fever?
n When did it start?
n How high has it been?
Patterns of Fever
Fever is almost always present with GABHS and is the
most commonly occurring symptom in children. The
fever is of sudden onset and the temperature rises
above 38.5° C (101.5° F), with malaise, headache, and
painful swallowing. Fever is also present in children
and adults with epiglottitis.
Inuenza is characterized by the abrupt onset of fever,
with temperatures ranging from 37.8° C to 40° C
(100° F to 104° F). Adenoviral infection in children
typically presents with a temperature greater than 40° C
(104° F). Patients with EBV have a low-grade fever.
Fever, followed by an interval of several days without fever and then recurrent fever, or a continuing fever
for several days may indicate peritonsillar abscess.
The absence of fever suggests a noninfectious
cause. Patients with candidiasis and aphthous stomatitis may also present without a fever.
What does the presence of upper respiratory
tract symptoms tell me?
Key Questions
n Do you have a cough?
n Have you had a runny nose? If so, what color is the
drainage?
n Do you have postnasal drip?
n Do you have eye redness or discomfort?
n Have your eyes been itchy or watery?
n Have you been hoarse?
n Have you been sneezing?
Cough and Rhinorrhea
Cough, rhinitis, conjunctivitis, and hoarseness rarely
occur with streptococcal pharyngitis, and the presence
of two or more of these signs or symptoms suggests a
viral infection.
Inuenza is often associated with several days of
fever, cough, and rhinorrhea. Viral pharyngitis is characterized by a sore, scratchy throat, nasal congestion,
rhinorrhea, and cough.
Clear nasal discharge is common in allergic pharyngitis
and may produce postnasal drip that causes a sore throat.
Conjunctivitis
Conjunctivitis rarely occurs with streptococcal pharyngitis. Mild conjunctivitis is common with viral infection. Watery or itchy eyes are associated with exposure
to allergens.
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Sneezing
Sneezing is common with both viral infection and allergen exposure. The sneezing associated with allergic
pharyngitis is more persistent and is often seasonal.
Hoarseness
Hoarseness is not uncommon in allergy-associated
sore throat and may be present with viral infection
as well. Inammation produces laryngeal edema that
results in hoarseness. Hoarseness is not typically
associated with GABHS infection.
What do the associated symptoms tell me?
Key Questions
n Do you have muscle aches?
n Have you had nausea, vomiting, or diarrhea?
Systemic Complaints
Systemic complaints, such as myalgia, are common in
inuenza and GABHS infection. Streptococcal pharyngitis or inuenza in children older than 2 years is associated
with reports of headache, abdominal pain, and vomiting.
Inuenza is often associated with several days of fever
and systemic symptoms, such as myalgias, cough, and
rhinorrhea. Common cold viruses associated with pharyngitis produce systemic symptoms, such as myalgia.
Does the presence of risk factors help me
narrow the cause?
Key Questions
n How old are you?
n What is your smoking history?
n What kind of work do you do?
n Do you engage in oral sex?
n Are you taking medications?
n Do you have any chronic health problems?
n Are your immunizations up to date?
endemic. In military populations, adenovirus type 4
and, to a lesser extent, types 3, 7, and 21 are the most
common causes of pharyngitis.
Adolescents and young adults are more likely to have
a sore throat associated with mononucleosis caused by
EBV. Mononucleosis occurs in older adults but often
without pharyngitis, adenopathy, or splenomegaly.
Irritant Exposures
Agents such as tobacco smoke, smog, dust, and allergens
can irritate the throat. These agents cause mucosal irritation and set up the inammatory process. People who
work outdoors may have greater exposure to environmental allergens. Housekeepers have an increased risk of
exposure to dust mites and chemical irritants.
Sexual Behavior
Pharyngitis from Chlamydia trachomatis or Neisseria
gonorrhoeae is more prevalent in persons with a his-
tory of orogenital sexual activity. Gonococcal pharyngitis is present in about 10% of patients with anogenital gonorrhea.
Medications and Chronic Health Problems
Immunosuppression increases susceptibility to viral
agents that produce pharyngeal ulcers (e.g., herpangina, herpes simplex). Persons with diabetes and those
taking broad-spectrum antibiotics are more susceptible
to candidiasis. Persons with a history of gastroesophageal reux disease (GERD) may have a sore throat
secondary to reux of gastric contents.
Immunizations
Infants receive the DTaP and Hib vaccines as part of routine immunization. DTaP prevents diphtheria, tetanus, and
pertussis. Hib prevents Haemophilus inuenzae type b
responsible for epiglottitis in children. Adults are advised
to have a booster dose of Td every 10 years. Unimmunized children and adults are at higher risk for infection.
Age
Group A streptococcal infection is primarily a disease
in children 5 to 15 years of age. GABHS is rare in
children younger than 3 years. Inuenza affects all
ages, whereas parainuenza and respiratory syncytial
viruses primarily affect children.
Adenoviruses, the major viral agents isolated
in exudative pharyngitis in younger children, are
DIAGNOSTIC REASONING:
FOCUSED PHYSICAL EXAMINATION
Assess Severity of Illness
Assessment of the patient begins with general observation about the severity of illness. Severe illness, with
signs of upper airway obstruction, such as restlessness,
stridor, difculty breathing, drooling, inability to swallow, and high fever, signals epiglottitis and requires
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immediate referral. Further examination could trigger
laryngospasms and lead to airway obstruction.
Inspect the Mouth
Examine the buccal mucosa, tongue, and sublingual area
for the presence of ulcers. Note the location, number,
size, and appearance of any lesions.
The lesions produced by the group A coxsackievirus
(herpangina) rst appear as small, grayish, papulovesicular lesions on the soft palate and pharynx. These
progress to shallow ulcers, usually less than 5 mm in
diameter.
Vincent angina (necrotizing ulcerative gingivostomatitis) is a fusospirochetal infection of the gingiva.
The gingiva appears inamed and ulcerated, often
covered with a gray slough. As the infection spreads,
ulcers may appear on the oral mucosa and posterior
pharynx.
Aphthous stomatitis lesions affect about 20%
of the general population and are associated with
immunological mechanisms. They occur most often
on the buccal mucosa, tongue, and soft palate. The
lesions rst appear as indurated papules and then
progress to shallow ulcers. The ulcers have a yellow
membrane and red halo. Herpes simplex lesions involve the anterior oral mucosa and the gums. Herpetic pharyngitis is manifested by vesicles, ulcers, or
exudate of the oral and pharyngeal mucosa. Specically, the lesions involve the tonsils, pharynx, uvula,
and edges of the soft palate. Vesicular lesions may or
may not be intact.
Streptococcal infection in children may cause enlarged papillae on the tongue, which gives the tongue a
strawberry appearance.
Inspect the Posterior Pharynx and Observe
Swallowing
Examine for edema, color, and exudate of the posterior
pharynx, and determine the presence, size (Table 29-1),
and condition of the palatine tonsils. Good visualization
is critical for accurate diagnosis. Use a good light
source, and ask the patient to open wide and say “ah”
but not to protrude the tongue. If you cannot view the
pharynx, depress the tongue rmly with a tongue blade,
far enough back to have a good view but not enough to
cause the patient to gag. Use two tongue depressors to
retract tissues medially and laterally when examining
such areas as the retromolar region, the oor of the
Table 29-1
GRADE TONSIL LOCATION
1 Behind pillars
2 Between pillars and uvula
3 Touching uvula
4 Extending beyond midline of oropharynx
Grading Tonsillar Size
mouth, and the orices of Wharton and Stensen ducts
(Figure 29-1). The best visualization is achieved with a
headlight.
Drooling may indicate peritonsillar abscess or epiglottitis partially occluding the pharynx and esophagus. Only occasionally can the red, swollen epiglottis
be visualized above the base of the tongue. If you suspect epiglottitis, do not examine the pharynx because
manipulation may precipitate laryngospasms and airway obstruction. Refer the patient immediately for
specialist evaluation and further diagnosis, which may
involve soft tissue radiography of the head and neck
and laryngoscopy.
Edema of the affected tonsil, with movement of the
tonsil toward midline, indicates peritonsillar abscess.
Diphtheria may appear as a thick, gray tonsillar exudate
or pseudomembrane, spreading to the tonsillar pillars,
uvula, soft palate, posterior pharyngeal wall, and
larynx. The exudate is not easily removable and bleeds
easily.
Pharyngeal or tonsillar exudate can be present with
either a bacterial or a viral infection. A yellowish exudate of GABHS pharyngitis is often present. Generally
the exudate of viral agents tends to be whiter than that
from GABHS.
A bright red uvula and the presence of petechiae on
the posterior pharynx and palate indicate group A
streptococcal pharyngitis. “Doughnut lesions” or red,
raised hemorrhagic lesions with a yellow center, are
diagnostic of streptococcal pharyngitis.
Postnasal drainage can irritate the posterior pharynx
and should be observed for color. Purulent drainage
that is yellow or greenish is associated with infectious
sinusitis. White curdlike patches that bleed on scraping
are characteristic of oral candidiasis.
When examination reveals normal ndings, suspect
a systemic referred cause for the sore throat, particularly acute otitis media, sinusitis, or thyroiditis.
360 Chapter 29 • Sore Throat
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Parotid
gland
Uvula
Palatine
arch
Submandibular
gland
FIGURE 29-1 Anatomical structures of the mouth. (From Barkauskas VH, Baumann
LC, Darling-Fisher CS: Health and physical assessment, ed 3, St Louis, 2002, Mosby.)
Stensen's duct opening
Palatine
tonsil
Sublingual
gland
Wharton's duct opening
Palpate the Cervicofacial Lymph Nodes
In streptococcal pharyngitis, the anterior cervical
lymph nodes are often enlarged and tender. In viral
infections, the posterior cervical nodes are more often
enlarged. Lymphadenopathy is a cardinal sign of infectious mononucleosis, with more than 90% of patients
having enlarged posterior cervical nodes.
Inspect the Nasal Mucosa
Red, swollen turbinates indicate an infectious process,
whereas pale, boggy turbinates indicate an allergic
process. The presence of mucoid discharge occurs in
allergic rhinitis. Purulent discharge suggests infectious
sinusitis.
Inspect the Conjunctivae
Injected conjunctivae associated with a sore throat may
indicate pharyngoconjunctival fever. It is caused by an
adenovirus and is often associated with nonpurulent
discharge, fever, and pharyngitis. It frequently occurs
in epidemics. Mild conjunctivitis in the presence of
itching eyes and clear watery discharge is associated
with an allergic process.
Inspect the Tympanic Membrane
Evidence of otitis media with effusion may indicate nontypical H. inuenzae acute otitis media (conjunctivitis-
otitis syndrome). Earache can be caused by referred pain,
especially from the tonsils.
Palpate the Thyroid
Acute thyroiditis is associated with a sore throat in the
presence of a normal throat examination but with an
enlarged or tender thyroid gland.
Inspect the Skin
Evidence of a ne maculopapular erythema that has a
generalized distribution with accentuation in the skinfolds, circumoral pallor, and sparing of the palms and
soles indicates scarlet fever. The rash characteristically
is followed by a ne desquamation, starting at the
hands.
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