influenza A and B, Coxsackie, rhinovirus, coronavirus, and

Epstein-Barr virus (EBV).

Group A �-hemolytic streptococcus (GABHS) is the

most common bacterial cause of pharyngitis. It accounts

for 1 5-30% of cases of pharyngitis in children and 5-15%

in adults. The peak age group is 5-15 years old. Most cases

are seen in the winter and spring. GABHS pharyngitis is

rare in patients younger than 2 years. Antibiotics are used to

treat GABHS and to prevent suppurative andnonsuppurative

complications. Suppurative complications include abscess

formation. Nonsuppurative complications include scarlet

fever, acute rheumatic fever (ARF), poststreptococcal glomerulonephritis, and streptococcal toxic shock syndrome.

Scarlet fever, presenting with pharyngitis and a diffuse

erythematous rash, is the result of the skin's reactivity to

• Suspected group A �-hemolytic streptococcus (GABHS)

infections can be confirmed by performing a ra pid

antigen screening test or a throat culture.

• Antibiotic treatment is used to prevent suppurative and

nonsuppurative (immune-mediated) complications GABHS.

the release of pyrogenic exotoxin by GABHS. ARF is a

delayed sequela and can present with arthritis, carditis,

chorea, erythema marginatum, and subcutaneous nodules.

Poststreptococcal glomerulonephritis is caused by nephritogenic strains of GABHS. Children <7 years of age are at

the highest risk. Streptococcal toxic shock syndrome is a

severe GABHS infections presenting with shock and multisystem organ failure. The pharynx, skin, mucosa, and

vagina can be portals of entry for GABHS resulting in streptococcal toxic shock syndrome.

...... Life-Threatening Causes of Sore Throat

Epiglottitis is an infection of the epiglottis and adjacent

supraglottic structures that can result in respiratory arrest and

death if swelling is severe enough to airway occlusion. The

widespread use of Haemophilus influenzae type B (HIB) conjugate vaccine in young children has dramatically changed the

epidemiology of epiglottitis, and the incidence has decreased.

Epiglottitis is currently more often seen in adolescents and

adults. Common organisms include Streptococcus pneumoniae, Staphylococcus aureus, nontypeable H. influenza, and

�-hemolytic streptococcus.

Retropharyngeal abscess is a deep space neck infection

involving the lymph nodes that drain the nasopharynx,

adenoids, posterior paranasal sinuses, and middle ear. The

disease can start as an infection in these nodes (adenitis)

225

CHAPTER 53

leading to a suppurative adenitis, phlegmon formation, and

finally, a retropharyngeal abscess. Incidence peaks between

2 and 4 years of age, as the retropharyngeal lymph nodes are

prominent in young children but atrophy before puberty.

Peritonsillar abscess (PTA) is a collection of pus between

the tonsillar capsule and the palatopharyngeal muscle. It is

usually preceded by pharyngitis or tonsillitis with progression

from cellulitis to phlegmon, and then abscess. It is the most

common deep neck infection in children and adolescents.

Infections are polymicrobial and include anaerobic and a erobic organisms (GABHS, S. aureus, fusiform, and bacteroides).

CLINICAL PRESENTATION

Most patients with pharyngitis will complain of sore throat

and fever. Symptoms are acute in onset with GABHS

pharyngitis. There is also pain on swallowing (odynophagia)

or difficulty swallowing (dysphagia). Young children may

not localize the pain to the throat and will complain of headache and/or abdominal pain instead of sore throat. Nausea

and vomiting may also be present. Toddlers can present with

fever, fussiness, or refusal to take liquids and solids.

Coryza, conjunctivitis, and hoarseness are symptoms

suggestive of viral illness. Pharyngitis with fever, red

eyes, and rash prompts concern for Kawasaki disease

(mucocutaneous lymph node syndrome). Fatigue and

anorexia are associated with infectious mononucleosis.

Drooling and the inability to handle oral secretions are

seen is patients with epiglottitis, peritonsillar, or retropharyngeal abscess. Increased work of breathing (tachypnea, r etractions, and stridor) is seen in patients with e piglottitis. Severe

unilateral throat pain and inability to open the mouth ( trismus) is seen in patients with a peritonsillar abscess. A muffled

or "hot potato" voice can be heard in patients with a peri ton ­

sillar abscess, but is also present with epiglottitis and retropharyngeal abscess. Children with a retropharyngeal abscess may

also have neck stiffness and pain with extension of the neck.

� Physical Examination

Airway patency must be assured, and impending airway

compromise needs to be rapidly identified. Evaluate the

hydration status, focusing on findings that have been correlated with dehydration in children. Signs and symptoms

include a general "ill" appearance, the absence of tears with

crying, dry mucous membranes, decreased skin turgor,

tachycardia, and delayed capillary refill (>2 seconds).

Auscultate the heart and document murmurs that might

suggest the presence of acute rheumatic fever.

Patients with epiglottitis will be "toxic" appearing,

showing signs of respiratory distress with stridor. The

patient may prefer to sit in the "sniffing position" with the

neck extended. Drooling, respiratory distress, and

hyperextension of the neck are seen in patients with

retropharyngeal abscess. Anterior bulging of the posterior

pharyngeal wall may be visualized on examination. Those

with a peritonsillar abscess may have trismus, "hot potato"

muffled voice, and drooling with a fluctuant bulge in the

posterior aspect of soft palate with contralateral deviation

of the uvula (Figure 53-lA). Classic findings in GABHS

pharyngitis are fever, tender cervical adenopathy, tonsillar

erythema, exudates, and hypertrophy (Figure 53- lB).

Those with scarlet fever may have a fine, erythematous,

"sandpaper-like" rash. Palatal petechiae (Figure 53- lC), a

A

B

(

Figure 53-1. A. Peritonsillar abscess. B. Tonsill itis.

C. Pa latal petechiae. (a rrows)

PHARYNG ITIS

B

Figure 53-2. A. Epiglottitis. The epiglottis is located by tracing the base of the tongue inferiorly until it reaches

the va llecula. The structure immediately posterior is the epiglottis. If the epiglottis is enlarged (th umb print) and

the va llecula is sha llow, epiglottitis is present. B. Retropharyngeal abscess. The normal retropharyngeal soft tissue

space is <7 mm at C2, <14 mm at C6 in children, and <22 mm at C6 in adu lts.

white or red "strawberry tongue" (inflamed tongue

papillae), desquamating rash, and Pastia lines (accentuation

of rash in flexor creases) are also suggestive of GABHS

infection and scarlet fever.

Patients with infectious mononucleosis will have

pharyngeal injection with exudates, posterior cervical

adenopathy, and hepatosplenomegaly. A maculopapular

rash is often seen in patients who are treated with amoxicillin or ampicillin.

DIAGNOSTIC STUDIES

..... Laboratory

Rapid antigen detection of GABHS is 70-90% sensitive

and 95-100% specific when performed correctly. GABHS

diagnosis based solely on clinical grounds is accurate 50%

of the time. A negative rapid strep test should be confirmed

with a throat culture. Throat culture is the gold standard

for diagnosis of GABHS pharyngitis, but results can take

up to 48 hours.