creation date: 2026-09-28 18:00
tags: Workups
Sore Throat (Pediatrics)
Background
Sore throat refers to any painful sensation localized in or around the pharynx. It is important to differentiate dysphagia and difficulty swallowing from a sore throat as young patients may verbalize that as a sore throat.
Differential Diagnosis
Life-threatening conditions
- Epiglottitis (toxic, high fever, stridor, drooling)
- Retropharyngeal abscess (neck pain, fever, difficulty swallowing)
- Lateral pharyngeal abscess (high fever, trismus, swelling below mandible)
- Peritonsillar abscess (evident on inspection: bulge in posterior aspect of soft palate, deviates uvula to contralateral side of pharynx)
- Infectious mononucleosis (severe tonsillar hypertrophy)
- Diphtheria (thick pharyngeal membrane, marked cervical adenopathy)
- Lemierre syndrome (ill-appearing, neck pain, severe pharyngitis, respiratory distress; dissemination of infection by septic emboli)
Common conditions
- Viral pharyngitis
- Adenoviruses (pharyngoconjunctival fever, cervical adenitis)
- Coxsakie A viruses (Herpangina or HFM disease)
- Seasonal influenza (high fever, cough, rhinitis, diffuse myalgias, malaise)
- Herpes simplex virus - usually stomatitis but may cause pharyngitis with immunocompromised
- COVID-19 virus (fever, cough, pharyngeal erythema)
- Candidal infection (pain; marker of immunosuppression)
- Streptococcal pharyngitis - group A strep/Streptococcus pyogenes (absence of cough, tender anterior cervical lymph nodes, school aged, exudative tonsillopharyngitis, high fever, palatal petechiae)
Others
- Unusual infections - Neisseria gonorrhoeae, Corynebacterium diphtheriae, Francisella tularensis, anaerobic bacteria
- Irritative pharyngitis (winter months, after night’s sleep in house with forced hot-air heating)
- Foreign body
- Herpetic stomatitis (usually confined to anterior buccal mucosa but may extend to tonsillar pillars)
- Systemic inflammatory conditions
- Kawasaki disease
- Stevens-Johnson syndrome
- Behcet syndrome
- Periodic fever with aphthous stomatitis, pharyngitis, and adenitis (PFAPA syndrome)
- Chemical exposure - paraquat and various alkalis
- Referred pain - dental abscesses, cervical adenitis, otitis media
- Psychogenic pharyngitis - anxiety at times of frequency/difficult swallowing
- Immunosuppressed host
Initial Evaluation
History
Key components to the history include:
- Concomitant respiratory distress (suggests obstruction)
- Fever (suggests infectious)
- Fatigue (prolonged suggests infectious mononucleosis)
- Abrupt onset (suggests epiglottitis if hours)
Other factors include:
- Sick contacts
- Immunocompromise status
- Immunization
- Recent travel
Physical Exam
Careful physical examination of the oropharynx/ENT is warranted:
- Stridor, drooling, respiratory distress (suggests airway obstruction)
- Inflamed TM suggests referred from non-oropharyngeal site, swelling around tooth suggests dental abscess
- Vesicles on buccal mucosa anterior to tonsillar pillars (suggests herpetic stomatitis or noninfectious syndromes)
- Generalized inflammation of oral mucosa with persistent fever (suggests Kawasaki)
- Foreign body
- Significant assymmetry of tonsils (suggests abscess or peritonsillar cellulitis)
- Diffuse erythema rash (suggests scarlet fever from GAS)
Investigations
While history and physical is generally sufficiency, ancillary studies may be useful for specific suspected conditions:
- Swab for strep
- COVID swab
- Neck imaging (lateral plain radiograph) - epiglotitis, retropharyngeal abscess