Allergic reaction | Often history of recent food intake; may progress over 5–30 minutes, when severe; quality of voice may help identify location of the swelling (hoarse: supraglottic airway; muffled or nasal: oropharynx); edematous mucosa (uvula, soft palate) may be visible by direct oropharynx inspection | Epinephrine, 0.3 mg SQ; diphenhydramine, 50 mg IM; methylprednisolone, 125 mg IV/IM; histamine blockers (famotidine, ranitidine) are controversial; intubate if severe obstruction is present | Multiple possible routes of antigen entry, though most are ingestion or inhalation; may be accompanied by hives or anaphylaxis; throat pain may be the minor complaint |
Anaerobic pharyngitis (Vincent angina) | May involve mouth and pharynx, associated with poor oral hygiene; mucosal ulceration, pseudomembranes, foul breath | Hydrogen peroxide rinses and oral penicillin or doxycycline | Clinical diagnosis |
Bacterial Common; pharyngitis | Fever; sore throat without cough; bilateral tonsillar swelling; and white, tender cervical lymphadenopathy; often difficult to differentiate from viral pharyngitis on clinical grounds; culture | Although streptococci predominate in children, other organisms (Mycoplasma, Chlamydia) may cause some adult illness; benzathine penicillin, 1.2 million units IM (300,000–600,000 units if <27 kg) affords good compliance | Consider epiglottitis; uncommonly causes airway obstruction, but admit patient if oral secretions are difficult to control; penicillin has a 10–20% failure rate; use erythromycin or equivalent if treatment failure; untreated group A streptococcal infection is associated with acute rheumatic fever |
Diphtheria | Ill appearing; fever, dysphagia common; prominent gray pseudomembrane over tonsillar pillars; diphtheria culture of throat swabs | Give antitoxin, observe for allergic reaction; erythromycin or penicillin; admit with respiratory isolation | Uncommon in United States; occasional toxic systemic sequelae |
Epiglottitis | Fever, voice hoarseness, severe pain, worse with swallowing; drooling and sniffing position when swelling is severe; condition is now as or more prevalent in adults, who may have less acute presentations; useful studies: soft tissue neck X-ray (enlarged epiglottis—“thumbprint” sign), fiberoptic laryngoscopy (red, swollen only at bedside in stable adults) | Immediate airway intervention in unstable patients or ENT consultation and operating room intubation in less acute children; consider blood cultures and early IV antibiotics (ceftriaxone, 50 mg/kg IV q 12 h); all patients need admission coverage | Routine use of the H. influenzae vaccine has sharply decreased the incidence among children; epiglottitis in a vaccinated individual should prompt consideration of an antibiotic with S. aureus and streptococci |
Gonococcal, chlamydial pharyngitis | Variable exudate, symptoms sometimes mild; culture of DNA testing of oropharyngeal swabs; requires genital examination and testing; test sex contacts | Similar to genital infections, though more failures occur with oral form; ceftriaxone, 125 mg IM × 1 dose, and doxycycline, 100 mg q 12 h × 10 d | Results from orogenital contact; symptoms may be mild and chronic |
Herpes pharyngitis | Vesicles in oropharynx and mouth, exudate, fever; laboratory examination of lesion scrapings permits confirmation | Acyclovir, famciclovir, or valacyclovir are indicated in immunocompromised patients and may shorten the course for others | Typically history of orogenital contact |
Infectious mononucleosis | Fever, pale exudates on tonsillar pillars; generalized lymphadenopathy, splenomegaly; monospot and liver function tests; blood count differential: atypical mononuclear cells | Supportive care; consider steroids, IV fluids, and admission for patients with severe swelling and dehydration | Typically aged 15–30 years |
Ludwig angina | Fever, dysphagia, mouth floor and neck swelling, pain; often associated with voice change; typically follows poor dental care or recent lower molar extraction; elevation and firm, tender floor of mouth–often unilateral; trismus and firm, tender upper neck often present; CT scan most useful to confirm diagnosis in stable patients | Position patient upright and protect airway as dictated by clinical appearance; when indicated, fiberoptic intubation is preferred; IV antibiotics for polymicrobial and anaerobic flora: ticarcillin–clavulanate or piperacillin–tazobactam with clindamycin or metronidazole; all patients need admission | Surgery is required for patients who do not respond to antibiotics; dental examination and removal of affected teeth; high aspiration complication rate |
Peritonsillar cellulitis and abscess | Most common deep-space infection in throat; a progression of bacterial tonsillitis; most common in young adults; fever, difficulty and pain with swallowing, “hot potato” voice, and foul-smelling breath; trismus is typical, and the examination reveals unilateral soft palate swelling and uvular deviation; consider CT scan | Typically responds to incision and drainage, though multiple (3–4) punctures with an 18-gauge needle and aspiration have been advocated; penicillin and clindamycin; patients with mild cases and no airway compromise can be discharged with ENT follow-up | To prevent uncontrolled rupture, use only gentle intraoral pressure on the peritonsillar mass; the carotid artery is 2.5 cm posterior and lateral to the peritonsillar tissue; avoid deep penetration of the abscess with sharp instruments |
Retropharyngeal, prevertebral abscess | Mainly affects children aged <6 years; fever, pain, and difficult swallowing; voice change (described as a “duck quack” sound); stridor if severe; pain with forced side-to-side movement of the thyroid cartilage; lateral neck X-rays demonstrate anterior displacement of trachea by diffuse soft tissue mass; CT scan with IV contrast if plain X-rays not definitive | Stabilize airway, ENT consultation, IV antibiotics to cover mixed oral and anaerobic infection (see Ludwig angina), admission. Large abscesses will require incision and drainage | Abscess may rupture into mediastinal or pleural spaces; presence of trismus and a tender, firm swelling in the anterior neck triangle should increase suspicion for parapharyngeal abscess |