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Key Points

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  • Distinguish potentially life-threatening (epiglottitis, peritonsillar, and retropharyngeal abscess) and benign (uncomplicated pharyngitis) conditions.

  • Use a scoring system to guide management of pharyngitis.

  • Suspected group A β-hemolytic streptococcus (GABHS) infections can be confirmed by performing a rapid antigen screening test or a throat culture.

  • Antibiotic treatment is used to prevent suppurative and nonsuppurative (immune-mediated) complications GABHS.

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Introduction

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Sore throat is a common complaint seen in the emergency department (ED). Pharyngitis is inflammation of the throat and is usually the cause of sore throat. Inflammation of the tonsils (ie, tonsillitis) may also be present. The goal of the initial evaluation of patients with a complaint of sore throat is to exclude the most serious conditions (eg, abscess, epiglottitis).

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Infectious pharyngitis involves direct invasion of the pharyngeal mucosa by bacteria or viruses leading to a local inflammatory response. Viruses are the most common cause of pharyngitis and include adenovirus, parainfluenza, influenza A and B, Coxsackie, rhinovirus, coronavirus, and Epstein-Barr virus (EBV).

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Group A β-hemolytic streptococcus (GABHS) is the most common bacterial cause of pharyngitis. It accounts for 15–30% 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 and nonsuppurative 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 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.

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Life-Threatening Causes of Sore Throat

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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 β-hemolytic streptococcus.

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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) 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.

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Peritonsillar abscess (PTA) is a collection of pus between the tonsillar capsule and the palatopharyngeal ...

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