Vanderbilt University School of Medicine
VC3 – Vanderbilt Core Clinical Curriculum

Sore Throat  

 

Sore throat is a frequent complication of upper respiratory tract infections. It is a very common presenting complaint in office-based practice. Patients have acute pharyngitis when the principal site of infection is the throat. Viruses cause the vast majority of pharyngeal infections. The principal bacterial organism that causes pharyngitis is Group A streptococcus. Distinguishing between viral causes from Group A streptococcus is important, because untreated Group A streptococcal tonsillopharyngeal infection may lead to important nonsuppurative complications such as acute rheumatic fever. 

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Prerequisites

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Describe and discuss:

  • anatomy of the oropharynx and upper airways, including the nasal passages and sinuses
  • pathogenesis and pathophysiology of conditions that contribute to sore throat

Demonstrate:

  • ability to take medical history
  • ability to perform a physical exam
  • ability to communicate appropriately

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Apply Medical Knowledge

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1.     Describe and discuss common organisms which infect and colonize the pharynx.

2.     Describe and discuss the signs and symptoms that suggest different etiologies for sore throat.

3.     Describe and discuss the natural history of sore throat.

4.     Describe and discuss the differential diagnosis of sore throat in children and adolescents and identify the most common etiologies.

5.     Describe and discuss the appropriate diagnostic tests to evaluate sore throat, recognizing that laboratory tests are not indicated in most common viral infections.

6.     Describe and discuss pharmacology of drugs used to treat sore throat.

7.     Describe and discuss epidemiology of sore throat.

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Diagnose

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1.     Obtain, document, and present an age appropriate history that differentiates among the different causes of pharyngitis, including information about symptoms more commonly associated with streptococcal pharyngitis:

  • sudden onset of symptoms and high fever
  • headache
  • sore throat
  • abdominal pain
  • absence of symptoms cold symptoms, such as cough, rhinorrhea

2.     Perform a through, age appropriate examination of the oropharynx, recognizing findings suggestive of streptococcal pharyngitis, which may include:

  • pharyngeal erythema, “strawberry tongue”
  • palatal petechiae
  • tonsillar exudates
  • tender anterior cervical lymph nodes
  • scarlitinform rash (“scarlet fever”)

3.     Generate a differential diagnosis recognizing specific history and physical exam findings that distinguish causes of sore throat, ruling out:

  • peritonsillar abscess
  • retropharyngeal abscess
  • epiglottitis 

4.     Recommend when to order imaging and laboratory tests, both prior to and after initiating treatment, based on the differential diagnosis and the age of the patient. Justify ordering tests and interpret the results (with consultation). Consider test cost and performance characteristics as well as patient preferences. Note that:

  • rapid antigen test or throat culture can be performed to make the diagnosis of Group A streptococcus
  • diagnosis of Epstein-Barr virus (EBV) infection (“mononucleosis”) is made by a positive IgM heterophile antibody test (Monospot) in patients older than 5 years
  • specific EBV serology can confirm the diagnosis in all ages
  • other laboratory findings suggestive of EBV infection include atypical lymphocytosis and mild elevated hepatic transaminase
  • imaging may be indicated in patients with suspected peritonsillar abscess, retropharyngeal abscess and epiglottitis

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Develop a Management Plan

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1.     Describe and discuss indications, mechanism of action, side effects, adverse reactions, and significant interactions of medications that could be prescribed for patients with sore throat.

2.     Based on the patient’s age, history, physical examination, differential diagnosis and laboratory/imaging results, evidence about treatment options, patient characteristics, and patient preferences, develop an appropriate plan for management.

  • treatment of viral pharyngitis is supportive, with antipyretics (if the patient is febrile or uncomfortable), fluids and rest
  • treatment of streptococcal pharyngitis involves antibiotics to decrease the duration of symptoms, reduce the spread of infection, and prevent acute rheumatic fever
  • penicillin remains the drug of choice; macrolide antibiotics or first generation cephalosporins may be used in those patients who are penicillin allergic

3.     Describe and compare the cost-effectiveness of various agents within each class of medications.

4.     Select an approach to treatment for the patient with sore throat based on the diagnosis.

5.     Formulate a prognosis for the patient with sore throat based on the diagnosis, the treatment plan, and the patient’s characteristics.

6.     Communicate the diagnosis, treatment plan, and prognosis of the disease to patients and their families in a caring and compassionate manner, reflecting an understanding of the emotional impact of the diagnosis and its potential effect on the patient.

7.     Provide education for the patient about his or her treatment plan.

8.     Provide counseling to patients when indicated about issues related to prevention.

9.     Access and utilize appropriate information systems to ascertain information about health system and community resources.

10.  Plan for follow-up.

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Differential Diagnosis

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In Pediatrics

 Common Conditions

  • viral pharyngitis
  • post nasal drip
  • group A streptococcal pharyngitis
  • mononucleosis/EBV  

Other conditions to consider/Don’t Miss Diagnoses

  • peritonsillar abscess
  • retropharyngeal abscess
  • epiglottitis
  • cervical adenitis 

In Adults

Acute common

  • viral pharyngitis
  • post nasal drip
  • group A streptococcal pharyngitis

Acute uncommon

  • non-streptococcal bacterial pharyngitis (Gonococcal, Diptheria)
  • herpes simplex virus (HSV)

Subacute/chronic

  • allergic rhinitis
  • mononucleosis
  • candidiasis 

Don’t Miss Diagnosis

  • peritonsillar abscess
  • retropharyngeal abscess
  • epiglotitis  

Miscellaneous

  • dysphagia or odynophagia is sometimes confused with sore throat