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Chapter 31 • Sleep Problems
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379
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
is mumbling; after a great deal of effort, he or she
can be awakened but will have little to no memory
of the episode. Providing a safe environment is
important because there is a genuine risk of injury
during the sleepwalking episode. Sleepwalking in an
elderly person may be a sign of dementia.
with a blank look on the face. Sometimes the person
DIFFERENTIAL DIAGNOSIS OF
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
SPECIFIC DISORDERS
Restless legs syndrome Irresistible urge to move legs while in bed Normal Sleep studies;
Periodic limb movement Older than 65 yr; reports of rhythmic jerking
Obstructive sleep apnea Apneic episodes, loud snoring, restless sleep
Narcolepsy Excessive sleepiness, cataplexy Normal Referral to sleep
Delayed sleep phase
syndrome
Secondary to medical
condition or medica-
tions
Poor sleep hygiene Routine, habits, environment not conducive to
Lifestyle Shift work, travel, jet lag Normal Sleep diary
Adolescent with extreme shift in sleep/wake
GERD, COPD, PND, CHF, enlarged prostate/
Medications: antidepressants, decongestants,
Common Causes of Sleep Disorders
of legs or arms while asleep
patterns
cycle; unable to fall asleep for many hours
nocturia, depression, or anxiety
bronchodilators, b-blockers, thyroid preparations,
phenytoin, methyldopa, corticosteroids
sleep; use of alcohol, caffeine, diet pills, nicotine
Normal Sleep studies
Decreased oxygen;
enlarged adenoids,
tonsils
Normal Referral to sleep
Consistent with med-
ical condition
Normal Sleep diary
serum ferritin
Sleep studies:
polysomnography,
home testing
specialist
specialist
Consistent with un-
derlying medical
condition; trial
off or change of
medication(s)
AGE-RELATED SLEEP DISORDERS
Night awakening Single to repeated awakenings at night Initial physical exami-
Sleep refusal Refusal of child to go to sleep Normal None
Night terrors Inconsolable awakening occurring early
Nightmares Occur later in sleep cycle; dream is remembered Normal None
Adolescent patterns Decrease in amount of sleep obtained Normal Sleep diary
Menopausal women Hot flashes Consistent with
Older adult patterns Nighttime arousals and awakenings; night owl
Conditioned insomnia Identify initial trigger with persistent problem Physical examination
Trained night crier Child unable to soothe self Normal None
Trained night feeder History of frequent feedings on awakening at night Normal None
Somnambulism
CHF, Congestive heart failure; COPD, chronic obstructive pulmonary disease; GERD, gastroesophageal reflux disease; PND, paroxysmal nocturnal dyspnea.
As directed by
nation to eliminate
associated medical
illness
Normal None
in sleep, lasting 15 min, no memory of event
menopause
Physical examination
pattern; early wakening; daytime napping
Sleepwalking in early sleep cycle Normal None
to rule out underlying medical condition
to rule out underlying medical
condition
examination
Sleep diary
Sleep diary
Sleep diary
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Chapter 31 • Sleep Problems
References and Readings
American Academy of Pediatrics: Policy statement: SIDS and other
sleep-related infant deaths: Expansion of recommendations for a
safe infant sleeping environment. Task Force on Sudden Infant
Death Syndrome, Pediatrics 128:1030, 2011.
Babcock D: Evaluating sleep disorders in pediatric primary care set-
ting, Pediatr Clin North Am 58:543, 2011.
Bayard M, Avonda T, Wadzinski J: Restless legs syndrome, Am Fam
Physician 78:235, 2008.
Bhargava S: Diagnosis and management of common sleep problems
in children, Pediatr Rev 32:91, 2011.
Budur K, Rodriguez C, Foldvary-Schaefer N: Advances in treating
insomnia, Cleve Clin J Med 74:251, 2007.
Buysse DJ: Insomnia, JAMA 309:706, 2013.
Davis KF, Parker KP, Montgomery GL: Sleep in infants and young
children: Part two. Common sleep problems, J Pediatr Health
Care 18:130, 2004.
Epstein LJ, Kristo D, Strollo PJ Jr, 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.
Falloon K, Arroll B, Elley CR, et al: The assessment and manage-
ment of insomnia in primary care, BMJ 342:d2899, 2011.
Guidozzi F: Sleep and sleep disorders in menopausal women,
Climacteric 16:214, 2013.
Hoban TF: Sleep and its disorders in childhood, Semin Neurol
24:327, 2004.
Kirsch DB: PRO: Sliding into home: Portable sleep testing is effective
for diagnosis of obstructive sleep apnea, J Clin Sleep Med 9:5,
2013.
Lewandowski A, Ward T, Palermo T: Sleep problems in children and
adolescents with common medical conditions, Pediatr Clin North
Am 58:699, 2011.
Marcus C, Schechter M: Updated guidelines for childhood sleep
apnea, Contemp Pediatr 11:36, 2013.
Roepke SK, Ancoli-Israel S: Sleep disorders in the elderly, Indian J
Med Res 131:302, 2010.
Schutte-Rodin S, Broch L, Buysse D, et al: Clinical guideline for the
evaluation and management of chronic insomnia in adults, J Clin
Sleep Med 4:487, 2008.
Usmani ZA, Chai-Coetzer CL, Antic NA, et al: Obstructive sleep
apnoea in adults, Postgrad Med J 89:148, 2013.
Wolkove N, Elkholy O, Baltzan M, et al: Sleep and aging: 1. Sleep
disorders commonly found in older people, CMAJ 176:1299, 2007.
Zunkel GM: Insomnia: Overview of assessment and treatment strat-
egies, Clin Rev 15:38, 2005.
CHAPTER
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32
Sore Throat
ore throat, or pharyngitis, is one of the most common
S
concerns of patients in primary care. It is most often a
transient condition of viral origin (adenoviruses, coxsackie
A viruses, inuenza, or parainuenza virus). 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 environmental irritants 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 according to whether
or not pharyngeal ulcers are present. This will 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 b-hemolytic streptococcus
(GABHS) infection and those with epiglottitis. Patients
with GABHS infection are at risk for rheumatic fever
and glomerulonephritis, and timely treatment can reduce
the possibility of sequelae of peritonsillar and retropharyngeal abscess. GABHS is the most common bacterial
cause of acute pharyngitis, responsible for 10% of sore
throat visits in adults and 30% in children, especially
during winter months.
DIAGNOSTIC REASONING: FOCUSED
HISTORY
l
Have you been restless, unable to stay still?
l
Have you been unable to talk?
History
The previous symptoms signal acute epiglottitis. The
history is usually elicited from another individual because the patient is either a child or too ill to talk.
Acute epiglottitis is rare: its incidence is 10:100,000 in
children younger than 15 years and 1 to 8:100,000 in
adults. The morbidity and mortality that result from
airway obstruction, however, are signicant.
Associated Symptoms
Symptoms and signs of epiglottitis are sore throat, difculty swallowing, dyspnea, drooling, and inspiratory
stridor. Haemophilus inuenzae type b is the most com-
mon pathogen, although it is decreasing in vaccinated
children. The incidence of H. inuenzae type b epiglot-
titis 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.
Severe throat pain with trismus and refusal to speak
indicates severe peritonsillitis, which may lead to
peritonsillar abscess formation (quinsy). 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
l
Have you been drooling?
l
Have you been unable to swallow?
l
Have you been unable to lie down?
What does the presence of fever tell me?
Key Questions
l
Have you had a fever?
l
When did it start?
l
How high has it been?
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Chapter 32 • Sore Throat
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 typically ranging from 37.8° to 40° C (100°
to 104° F). Children with adenoviral infection can be
afebrile or have a fever greater than 40° C (104° F).
Patients with Epstein-Barr virus (EBV) have a lowgrade 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 may also suggest a noninfectious cause, such as candidiasis and aphthous
stomatitis.
Is the sore throat related to an infectious cause?
Key Questions
l
Is anyone else at home sick?
l
Are any of your friends or co-workers sick?
l
When did the pain start?
l
How severe is the pain?
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. 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 (also referred to as the reticuloendothelial system or the mononuclear phagocytic 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. 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.
What does the presence of upper respiratory tract
symptoms tell me?
Key Questions
l
Do you have a cough?
l
Have you had a runny nose? If so, what color is the
drainage?
l
Do you have postnasal drip?
l
Do you have eye redness or discomfort?
l
Have your eyes been itchy or watery?
l
Have you been hoarse?
l
Have you been sneezing?
l
Have you been wheezing?
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 most often
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 also associated with
exposure to allergens.
Chapter 32 • Sore Throat
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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
l
Do you have muscle aches?
l
Have you had nausea, vomiting, or diarrhea?
Systemic Symptoms
Systemic symptoms, such as myalgia, are common in
inuenza and GABHS infection. Streptococcal pharyngitis or inuenza in children older than 2 years is
associated with headache, abdominal pain, and vomiting. Fatigue, especially if prolonged, may indicate
mononucleosis.
Inuenza is often associated with several days of
fever and systemic symptoms, such as myalgias,
cough, and rhinorrhea. Common cold viruses associated with pharyngitis can also produce systemic symptoms such as myalgia.
Does the presence of risk factors help me narrow the
cause?
Key Questions
l
How old are you?
l
What is your smoking history?
l
What kind of work do you do?
l
Do you engage in oral sex?
l
Are you taking medications?
l
Do you have any chronic health problems?
l
Are your immunizations up to date?
Adenoviruses, the major viral agents isolated in
exudative pharyngitis in younger children, are 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 than
children and older adults to have a sore throat associated with mononucleosis caused by EBV. In older
adults, mononucleosis often occurs 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 people with a history
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). People with diabetes and those
taking broad-spectrum antibiotics are more susceptible
to candidiasis. People with a history of gastroesophageal reux disease 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 H. inuenzae type b
responsible for epiglottitis in children. Adults should
get 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. Inuenza affects all
ages; whereas parainuenza and respiratory syncytial
viruses (RSV) primarily affect children. Almost all
children below 2 years of age will have RSV, and 25%
to 40% will develop bronchiolitis or pneumonia.
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,
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Chapter 32 • Sore Throat
stridor, difculty breathing, drooling, inability to swallow, and high fever signals epiglottitis and requires
immediate referral. Further physical examination with
a tongue blade 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. They 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, or canker sores, are lesions
that 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 32-1),
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
mouth, and the orices of Wharton and Stensen ducts
(Figure 32-1). 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 tests, which may include 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.
Frenulum of
upper lip
Soft
palate
Posterior
wall of
oropharynx
Buccinator
muscle
Hard
palate
Uvula
Palatine
tonsil
Table 32-1
GRADE TONSIL LOCATION
1 Behind pillars
2 Between pillars and uvula
3 Touching uvula
4 Extending beyond midline of oropharynx
Grading Tonsillar Size
Gingiva
Frenulum of
lower lip
FIGURE 32-1 Anatomical structures of the mouth. (From Ball JW,
Dains JE, Flynn J, et al: Seidel’s guide to physical examination,
ed. 8, St. Louis, 2015, Elsevier.)
Dorsum
of tongue
Vestibule
of mouth
Chapter 32 • Sore Throat
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385
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.
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; in contrast, pale, boggy turbinates indicate
an allergic process. 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
atypical 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 and 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.
Auscultate the Lungs
Mycoplasma pneumoniae is frequently associated with
sore throat in adolescents and young adults. If pneumonia is present, palpation, percussion, and auscultation
of the lungs reveal an area of consolidation and adventitious breath sounds (see Chapter 14 for further discussion of the lung examination).
What is the Current Evidence on Management
EVIDENCE-BASED PRACTICE
of Peritonsillar Abscess?
This literature review was limited to articles published from
1991 to 2011 and examined areas of controversy about peritonsillar abscess. Findings showed that (1) intraoral ultrasound has a sensitivity and specificity of between 89% and
95% and 79% and 100%, respectively, for correctly diagnosing peritonsillar abscess and is currently underused; (2) steroids can effectively aid recovery, reducing hospitalization
time and improving symptom relief; however, further study is
needed, especially related to risk/benefit ratio. Penicillin and
metronidazole are an effective combination in at least 98%
of cases of peritonsillar abscess; (3) there is no convincing
evidence in favor of either aspiration or incision and drainage;
Data from Powell J, Wilson JA: An evidence-based review of peritonsillar abscess, Clin Otolaryngol 37:136, 2012.
tonsillectomy with an abscess present is safe and reduces
overall recovery time when compared with tonsillectomy when
symptoms are not present; (4) peritonsillar abscess can be
effectively managed on an outpatient basis in many cases;
and (5) the recurrence rate of peritonsillar abscess is poorly
defined but estimated as 9% to 22%. Interval tonsillectomy
may be indicated in patients at high risk of recurrence. The
authors concluded that peritonsillar abscess is a common
condition with increasing incidence. However, lack of consensus suggests that better evidence is needed for peritonsillar
abscess management, especially for recurrence rates and different management strategies.
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Chapter 32 • Sore Throat
Palpate the Abdomen
Splenomegaly is found in about half the cases of
mononucleosis, although hepatomegaly is rare. Gastroesophageal reux disease (GERD) may be associated
with palpable upper epigastric tenderness.
LABORATORY AND DIAGNOSTIC STUDIES
The laboratory evaluation of sore throat is generally
limited to the identication of GABHS. Other infectious causes, such as gonorrhea or diphtheria, are rare,
and testing is conducted only if the history indicates
exposure. It is important to diagnose streptococcal
pharyngitis so it can be treated promptly with antibiotics, avoiding serious sequelae, such as peritonsillar
abscesses, rheumatic fever, or glomerulonephritis.
Rapid Screening Tests
A throat swab is a rapid screen for streptococcal antigens and should be done if GABHS is suspected. If it
is positive, the patient is treated without follow-up
cultures. If the swab is negative, a throat culture is
obtained. The test has a sensitivity of 75% to 85% and
a specicity of 95% to 98%.
The Monospot is a rapid slide test that detects
heterophil antibody agglutination; it is not specic
for EBV. It is most sensitive 1 to 2 weeks after symptoms appear and remains positive for up to 1 year. If
chronic fatigue syndrome is being considered as a
differential diagnosis, specic EBV antibody tests
should be considered.
Culture
A throat culture to detect GABHS is the gold standard
of diagnosis, with a 10% or lower false-negative
rate. When obtaining a culture, rst remove crusts
from lesions, taking care to touch only the throat or
tonsils with the sterile swab. Avoid touching the
tongue. Roll the throat swab over one tonsil, proceed
across the posterior pharynx, and then swab the other
tonsil. A culture can conrm a diagnosis of gonococcal pharyngitis.
Antistreptolysin O Titer
GABHS produces enzymes that include streptolysin.
An ASO titer is a serology test that detects the presence
of a previous streptococcal infection. This titer does not
increase until 1 to 6 months postinfection, so it is of no
diagnostic value. It is used to aid in the diagnosis of
streptococci-associated infections, such as rheumatic
fever, glomerulonephritis, and pericarditis. A caution,
however, is that in as many as 50% of positive streptococcal cultures, an elevated ASO titer will not be found
postinfection.
Potassium Hydroxide Smear for Wet Mount
Obtain a sample of pharyngeal discharge using a
cotton-tipped applicator. Using a microscope, examine
the potassium hydroxide slide for branching and budding hyphae that are characteristic of yeast infection
(see Chapter 37).
Complete Blood Count With Differential
Test results of 50% lymphocytes and at least
10% atypical lymphocytes support a diagnosis of
mononucleosis; a positive Monospot test result is
diagnostic.
Computed Tomography Scan
Suspicion of an obstruction or swelling of the throat
should be referred for further evaluation with computed tomography.
Nasal Smear
Nasal cytology can be performed on secretions obtained by having the patient blow his or her nose into a
paper or by using a cotton-tipped swab to obtain secretions from the nose. The presence of eosinophils on a
nasal smear stained with Wright stain viewed under a
high-power microscope suggests an allergic, inammatory process.
DIFFERENTIAL DIAGNOSIS
Pharyngitis Without Ulcers
Epiglottitis
Epiglottitis is caused by infection with H. inuenzae
type b that produces inammation and edema of the
epiglottis and the surrounding areas, obstructing the
ow of air. The edematous epiglottis may be pulled
into the larynx during inspiration and can completely
occlude the airway. Symptoms are respiratory distress,
sore throat, difculty with secretions, drooling, pain on
swallowing, and a toxic appearance. The infection occurs in both children and adults.
Peritonsillar/Retropharyngeal Abscess
A peritonsillar abscess, also called quinsy, is a collection of pus between the tonsil and the capsule of the
tonsillar pillar. This condition occurs in children but is
more common in adults, especially in people with a
history of recurrent tonsillitis. The patient’s presenting
Chapter 32 • Sore Throat
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concerns usually include a history of respiratory symptoms, difculty swallowing, otalgia, malaise, fever,
and cervical lymphadenopathy. On examination, there
may be trismus; asymmetrical swelling of the uvula,
tonsils, or posterior pharynx; or a visible abscess.
Children’s presenting symptoms typically include
fever, toxic appearance, refusal to swallow, drooling,
and stridor. Children with retropharyngeal abscess are
usually under the age of 4 and need immediate referral.
Viral Pharyngitis
Most sore throats are caused by viral infections.
Patients usually have symptoms of malaise, fever,
headache, cough, and fatigue. The pharynx is usually
erythematous, or it may be pale, boggy, and swollen.
There usually is no tonsillar enlargement or pharyngeal
exudate although infection with an adenovirus may
produce exudate. The presence of concomitant upper
respiratory tract symptoms such as cough and congestion makes the diagnosis of viral pharyngitis more
likely than that of streptococcal pharyngitis. Common
cold viruses cause sore throats most frequently during
the colder months of the year.
Streptococcal Pharyngitis
The major differential diagnoses for sore throat will be
viral or bacterial infection. About 10% of adults and
30% of children who seek care for sore throat symptoms, especially during winter months, have streptococcal tonsillopharyngitis. However, reliance on clinical impression to arrive at a specic diagnosis is
problematic. The symptoms most likely to occur with
streptococcal pharyngitis include a fever with a temperature of 38.5° C (101.5° F) or higher, tonsillar
exudate, anterior cervical adenopathy, and a history of
recent exposure. The incidence of streptococcal pharyngitis increases from 10% in the summer and fall to
40% during the winter and early spring. GABHS cannot be reliably diagnosed on the basis of signs and
symptoms, and even when cultures are obtained, a
causative agent may not be identied in 50% of patients. Table 32-2 shows the groups at risk for GABHS.
Mononucleosis
Mononucleosis causes about 5% of sore throats. It occurs most often in young adults, and the causative agent
is EBV in more than 90% of cases. History typically
reveals a gradual onset, low-grade fever, mild sore
throat, posterior cervical lymphadenopathy, weight
loss, and pronounced malaise and fatigue. Diagnosis
can be conrmed with a positive Monospot test and a
Table 32-2
Groups at Risk for Group A
b-Hemolytic Streptococcus
(GABHS) Pharyngitis
RISK FACTORS DIAGNOSTIC TESTS
HIGH RISK
Tonsillar exudate
Temperature .38.5° C
(101.5° F)
Cervical lymphadenopathy
Existing valvular rheumatic
heart disease
PRESUMED STREP
Scarlet fever
Strep epidemic
Antibiotics already started
MEDIUM RISK
Exudate, nodes, or fever
present
Prior rheumatic fever
“Low risk” by PE but
,25 yr old and no URI
Person with diabetes
Recent “strep” exposure
LOW RISK
No exudate, nodes, or fever Rapid strep screen; if
PE, Physical examination; URI, upper respiratory tract infection.
complete blood count that shows greater than 50% lymphocytosis. Splenomegaly occurs in about 50% of
cases, and palatine petechiae are a less common symptom. GABHS occurs concomitantly in 10% to 20% of
cases.
Gonococcal Pharyngitis
This form of pharyngitis can occur in patients with a
history of orogenital sexual activity. The patient may
have no symptoms. Examination shows an exudative
pharyngitis with bilateral cervical lymphadenopathy.
Gram staining or culture will conrm the diagnosis.
Inflammation
Inammatory sore throat occurs in the presence of sinusitis or exposure to local irritants. The patient often
reports postnasal drip and allergic symptoms (itchy,
watery eyes, runny nose) that may follow seasonal patterns. On examination, the patient may have sinus
None; treat on basis of risk
factors
None; treat
Rapid strep screen; if
positive, treat; if
negative, culture; treat
if culture positive; do not
treat if culture negative
positive, treat; if negative,
do not culture; do not
treat if culture negative
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Chapter 32 • Sore Throat
tenderness. The pharynx may be swollen or pale with
posterior drainage present. The patient does not have
fever or lymphadenopathy.
Pharyngitis With Ulcers
Herpangina
Herpangina is an infection caused by the coxsackievirus. The patient reports a painful sore throat, fever,
and malaise. Headache, anorexia, and neck, abdomen,
and extremity pain may occur. Within 2 days of onset,
small, grayish, papulovesicular lesions appear on the
soft palate and pharynx. These progress to shallow
ulcers, usually less than 5 mm in diameter. Outbreaks
occur during the summer months. Coxsackie virus
peaks in August, September, and October, although
some cases occur during the winter months. It is more
common in children and in immunosuppressed
patients. Diagnosis is based on symptoms and characteristic oral lesions. An antibody titer can conrm
diagnosis.
Vincent Angina
Vincent angina is caused by a fusospirochetal infection that results in necrotizing ulcerative gingivostomatitis. The patient’s symptoms include painful
ulcers, foul breath, and bleeding gums. Without secondary infection, there usually is no fever. On examination, gray, necrotic ulcers without vesicles are
apparent on the gingivae and interdental papillae.
Gram staining shows spirochetes and conrms the
diagnosis.
Aphthous Stomatitis
Aphthous stomatitis, or “canker sores,” appears as discrete
ulcers without preceding vesicles. The ulcers are located
on the inner lip, tongue, and buccal mucosa. Lesions last
about 1 to 2 weeks. The cause of the lesions is unknown,
but immunological mechanisms play a major role.
Herpes Simplex Virus Type 1
An infection from herpes simplex virus type 1 (HSV-1)
is associated with fever, headache, sore throat, and
lymphadenitis. Characteristic clusters of yellow vesicles appear on the palate, pharynx, and gingiva. Lesions
last 2 to 3 weeks. Recurrent lesions are characterized by
prodromal symptoms of burning, tingling, or itching.
Active lesions are usually painful. Recent studies indicate that HSV-1 infections afict about 30% to 90% of
the U.S. population.
Candidiasis
Candidiasis is a yeast infection that produces white
plaques over the tongue and oral mucosa with erythema; the plaques bleed when scraped. Candida infection occurs commonly in otherwise normal infants
in the rst weeks of life; in immunocompromised
people, including those with diabetes; and in people
taking antibiotics or using inhaled steroids.
DIFFERENTIAL DIAGNOSIS OF
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
PHARYNGITIS WITHOUT ULCERS
Epiglottitis
Peritonsillar/
retropharyngeal
abscess
Viral pharyngitis Scratchy, sore throat, malaise,
Common Causes of Sore Throat
Sore throat, difficulty with
secretions, odynophagia (seen
in pediatric patients ,2 years),
unable to lie flat, unable to talk
History of recurrent tonsillitis;
sore throat, difficulty swallowing,
respiratory tract symptoms, fever,
malaise
myalgias, headache, chills, cough,
rhinitis
Respiratory distress, drooling, toxic
appearance; do not examine the
pharynx
Orthopnea, dyspnea, symmetrical
swelling, abscess, trismus
Erythema, edema of throat, tender
posterior cervical nodes
Refer immediately
Refer immediately:
CT scan; head and
neck radiographs;
laryngoscopy
None
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