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Sore Throat or Pharyngitis

Sore throat, or pharyngitis, is a common reason for visits to family physicians' offices. There are many potential causes for pharyngitis, including viral and bacterial infections, allergies, gastroesophagal reflux, thyroiditis, smoking, and other irritants. A careful history and physical examination can help determine which patients need further evaluation. Appropriate laboratory investigations can help identify the cause of these symptoms. Bacteria and viruses are responsible for causing most cases of infectious pharyngitis and are spread from person to person either by inhalation of airborne particles or by exposure to respiratory or oral secretions. Winter and early spring are peak seasons for sore throat. The incubation period for symptoms to develop may he as short as 24 to 72 hours.

The most common etiologic viral agents are respiratory viruses, such as adenovirus, parainfluenr, a virus, and rhinovirus. Pliarvngitis associated with infections with these agents is usually part of a broader upper respiratory trait infection causing rhinorrhea, cough, and often conjunctivitis. Herpangina, characterized by tonsillar and palatal ulcerations, is caused by Coxsackievirus. Infectious mononucleosis caused by EBV may present with pharyngitis alone or with fever, posterior cervical lymphadenopathy, and malaise. The herpesvirus can also cause a pharyngitis or stomatitis.

Streptococcus pyogenec (group A strep) pharyngitis accounts for infectious cases in adults and as many as 35%in children. It typically presents with fever and sore throat that is self-limited, Immunologically mediated complications of strcptococcal infection include acute rheumatic fever and glomerulonephritis. Rheumatic fever can lead to long-term valvular heart disease, such as mitral steno-us, unless treated within IO days of onset Acute glomerulonephritis is sell-limited and prompt antibiotic therapy does not prevent this complication. Serious local complications include peritonsillar and retropharyngeal abscesses that result from tissue invasion by group A ~'trop. These infections may lead to deeper infections and airway compromise.

Other bacteria that may lead to self-limited pharyngitis, either alone or as part of a respiratory infection, include Mvcoplasma, Chlamydia, Ff urnopdhilus, and Coryiubacterium. Pharyngitis may occur in association with sinusitis. Fungal pharyngitis may occur in immunocomproinised patients, and gonococcal pharyngitis may occur as a sexually transmitted disease with oral sex.

Noninfectious causes of pharyngitis include sleep apnea, GERD, and cigarette smoke through primary irritant effects. Allergies may cause lymphoid hyperplasia, nasal obstruction, and postnasal drip, which can lead to pharyngeal irritation.

Sore Throat Symptom

Streptococcal infection most commonly occurs in children from 5 to 15 years of age and is rare in children below age 3. Mononucleosis is classically a disease of teenagers. The history should include associated symptoms and known exposures to illness. For example, only 259f of patients with positive strop cultures will have rhinorrhea and cough. The presence of these symptoms and aloes-guide fever suggests a viral etiology. 'The classic symptoms for streptococcal infection are fever over To I °F (38.3°C) in association with a sore throat but few other respiratory symptoms. 'I,he ehrouic_ity of the disease is also helpful in determining its cruse Viral and uncomplicated bacterial infections resolve in about I week, whereas noninfectious causes are more persistent. Iiarly-morning sore throat without lever or other associated symptoms suggests a noninfectious cause such as GERD.

Past medical history may suggest potential causes or lead to consideration of less common ones. For esample, patients with a history of allergies may he experiencing a sore throat related to the allergies. Immunocompromised patients may develop fungal infection or complications with bacterial infection (e.g., peritonsillar abscess). Greenish exudates and clysuria with pharyngitis are present in gonococcal pharyngitis. Patients with sandpaper-like exanthems With a strawberry tongue" may have scarlet fever, which is associated with group A beta-hemolytic streptococci A past history of rheumatic fever with or without carditis warrants evaluation for recurrence of streptococcal disease.

Group A streptococcus may lead to rheumatic fever. A rare complication is poststreptococcal glomertdonephritis. Other complications are peritonsillar abscess, retropharyngeal abscess, meningitis, pneumonia, bacteremia, otitis media, sinusitis, cervical lymphadenitis, and scarlet fever.

PHYSICAL EXAMINATION for sever sore throat, sore throat swollen gland

Vital signs and an examination of the cars, nose, and throat are essential parts of the evaluation. The throat in classic group A strep infection is erytbematous with tonsillar exudates. There are often palatal petechiae and there may be a strawberry tongue," with prominent red papillae on a white-coated tongue. Tender cervical lymphadenopathy is often present. The physical examination should also include a lung examination, since many patients also have respiratory symptoms. Patients with a history of a previous streptococcal infection may present with symptoms and signs of rheumatic fever. They may present with joint swelling, pain, subcutaneous nodules, erythema marginatum, or a heart murmur. Mononucleosis, gonococcal infection, and on occasion other bacterial or viral infections may, on pharyngeal examination, he indistinguishable from streptococcal pharyngitis. About half of the patients with mononucleosis have splenic enlargement on abdominal examination. Vesicular lesions suggest either herpesvirus or Coxsackievirus infection, while adenovirus often causes an accompanying conjunctivitis. Diphtheria is characterized by an adherent gray membrane, low-grade fever, tonsillitis, and tender cervical lyrnphadenopathy. Kawasaki disease affects children who are below S years of age. Signs and symptoms include conjunctivitis, a strawberry tongue., fever, and a rash involving the hands and feet. The rash leads to desctuamation of the palms.

Noninfectious causes of pharyngitis should he suspected in patients without fever and with persistent or recurring symptoms. Common infectious causes of pharyngitis include sleep apnea, gastroesophageal reflux, allergies, and referred pain from primary otologic or dental disease. Uncommon but important noninfectious Causes include malignancy, aplastic anemia, lymphoma, and leukemia.

Physical examination alone cannot accurately determine whether a bacterial infection is present. Options in testing for group A strep include rapid antigen detection assays, used in many offices, and throat culture. Throat culture is the "gold standard" test and is considered definitive.

Sore Throat TREATMENT and Remedies

Streptococcal pharyngitis should be treated in order to prevent rheumatic fever, prevent suppurative complications and decrease person-to-person spread of the infection. The treatment of choice for strep throat is penicillin, either as a 10-day oral course or a single intramuscular injection. For patients allergic to penicillin, clindamycin, erythromycin, or a newer macrolide such as azithromycin may be used. For treatment failures, amoxicillin-clavulanic acid or clindamycin is commonly used.

Treatment for viral pharyngitis is largely supportive and symptomatic. Lozenges and warm saltwater gargles may provide topical relief Analgesic drugssuch as acetaminophen or ibuprofen can help reduce pain.

KEY POINTS for Sore Throat or Pharyngitis

There are many potential causes of pharyngitis, including viral and bacterial infections, allergies, and irritants. Evaluation and testing for infectious etiologies is largely targeted toward identification of group A strep infection because of its association with complications such as rheumatic fever.

The treatment of choice for strep throat is penicillin, whereas treatment for the other causes of pharyngitis is largely symptomatic.

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