Evaluation of sore throat in children

INTRODUCTION — This topic will review conditions that can cause the symptom of sore throat. The discussion will include pertinent features of the history and physical examination and an algorithmic approach to common and life threatening conditions. The approach and treatment of children with infectious pharyngitis are discussed in more detail elsewhere. (See "Group A streptococcal tonsillopharyngitis in children and adolescents: Clinical features and diagnosis" and "Acute pharyngitis in children and adolescents: Symptomatic treatment" and "Treatment and prevention of streptococcal pharyngitis in adults and children".)

DEFINITION — Sore throat refers to any painful sensation localized to the pharynx or surrounding anatomy. The developmental ability of young children to identify and define their symptoms varies and the physician must pay careful attention to the patient and the caretaker in order to clarify the exact nature of the complaint.

Sore throat can be the symptom of a disease process that does not directly affect the pharynx. Occasionally, young patients with dysphagia that results from disease in the area of the esophagus or with difficulty swallowing because of a neuromuscular disorder may verbalize these sensations as a sore throat or their symptoms may be interpreted by a caretaker as a sore throat.

CAUSES — The etiology of sore throat varies by age (table 1) and can further be divided by conditions that are life-threatening, common, or less common.

Life-threatening conditions

Epiglottitis — The incidence of epiglottitis, a well-appreciated cause of life-threatening upper airway infection, has declined significantly since the introduction of vaccination against Haemophilus influenzae type b. This disease manifests with a toxic appearance, high fever, stridor, and drooling. Sore throat occurs in many cases, but is only rarely the primary complaint. (See "Epiglottitis (supraglottitis): Clinical features and diagnosis".)

Retropharyngeal abscess — Retropharyngeal abscesses can cause sore throat and usually occur in children less than four years of age. Other complaints include neck pain and fever. There may be difficulty swallowing and respiratory distress. The posterior location of the abscess makes it difficult to visualize on physical examination. Imaging is often required to confirm the diagnosis. (See "Retropharyngeal infections in children".)

Lateral pharyngeal abscesses — Lateral pharyngeal abscesses produce symptoms similar to retropharyngeal infections but occur less often. High fever is common. Other signs include trismus and swelling below the mandible.

Peritonsillar abscess — A peritonsillar abscess may complicate a previously diagnosed infectious pharyngitis or may be the initial source of a child's discomfort. This disease is most common in older children and adolescents. The diagnosis is evident from visual inspection, augmented occasionally by careful palpation. The abscess produces a bulge in the posterior aspect of the soft palate, deviates the uvula to the contralateral side of the pharynx, and has a fluctuant quality on palpation. (See "Retropharyngeal infections in children".)

Infectious mononucleosis — Infectious mononucleosis can rarely cause airway obstruction from severe tonsillar hypertrophy. (See "Infectious mononucleosis", section on 'Complications including airway obstruction'.)

Diphtheria — Diphtheria is a life-threatening but seldom encountered cause of infectious pharyngitis, characterized by a thick pharyngeal membrane and marked cervical adenopathy. (See "Epidemiology and pathophysiology of diphtheria".)

Lemierre syndrome — This unusual infection is caused by Fusobacterium necrophorum [1] or mixed anaerobic flora and is associated with jugular venous thrombophlebitis and the dissemination of infection by septic emboli. Both children and adults with Lemierre’s syndrome almost always have pharyngitis at presentation [2,3]. It should be considered in the ill-appearing patient with neck pain, severe pharyngitis, and respiratory distress [4,5]. (See "Lemierre syndrome: Septic thrombophlebitis of the internal jugular vein".)

Common conditions

Viral pharyngitis — Infection is the most common cause of sore throat and the etiologic agents are usually respiratory viruses, of which a few cause a readily identifiable syndrome including (table 1):

●Adenoviruses – Pharyngoconjunctival fever, a benign follicular conjunctivitis often accompanied by a febrile pharyngitis and cervical adenitis (see "Pathogenesis, epidemiology, and clinical manifestations of adenovirus infection", section on 'Eyes')

●Coxsackie A viruses – Herpangina or hand, foot, and mouth disease (picture 1 and picture 2 and picture 3) (common in infants and young children; decreases in frequency as age increases) (see "Hand, foot, and mouth disease and herpangina")

Herpes simplex virus usually causes stomatitis (discussed below). However, it may cause pharyngitis in the immunocompromised child, and rarely in the immunocompetent child. (See "Epidemiology, clinical manifestations, and diagnosis of herpes simplex virus type 1 infection", section on 'Primary infection'.)

Coronavirus disease 2019 (COVID-19) — Sore throat and pharyngeal erythema occur in <30 percent of symptomatic children with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Fever and cough are other common symptoms that often accompany a sore throat. Fatigue, nasal congestion, diarrhea, and vomiting have also been described but occur less frequently. Although COVID-19 is rarely life threatening in children, it may occasionally be so. (See "COVID-19: Clinical manifestations and diagnosis in children", section on 'Clinical manifestations'.)

Candidal infection — Oropharyngeal candidal infections (thrush) (picture 4) can cause significant pain and, outside of early infancy, are a marker for immunosuppression (eg, after chemotherapeutic treatment of cancer or immunodeficiency [eg, human immunodeficiency virus]). (See "Esophageal candidiasis in adults".)

Streptococcal pharyngitis — Viral etiologies are closely followed in frequency by group A streptococcus (Streptococcus pyogenes), which is the most frequent bacterial cause of infectious pharyngitis [6,7]. In the winter months during streptococcal outbreaks, as many as 30 percent of episodes of pharyngitis may be caused by S. pyogenes in school age children. Clinical manifestations include high fever, exudative tonsillopharyngitis, palatal petechiae, and swollen, tender anterior cervical lymph nodes. (See "Group A streptococcal tonsillopharyngitis in children and adolescents: Clinical features and diagnosis", section on 'Epidemiology'.)

Infectious mononucleosis — The only other common infectious agent in pharyngitis is the Epstein-Barr virus (EBV), which causes infectious mononucleosis and affects adolescents most frequently. Rarely, infectious mononucleosis can cause life threatening airway obstruction from tonsillar hypertrophy. (See "Clinical manifestations and treatment of Epstein-Barr virus infection".)

An additional consideration in adolescents with an infectious mononucleosis-like syndrome is human immunodeficiency virus (HIV). (See "The natural history and clinical features of HIV infection in adults and adolescents".)

Other conditions

●Unusual infections – Other organisms produce pharyngitis only rarely; these include Neisseria gonorrhoeae, Corynebacterium diphtheriae, Francisella tularensis, and anaerobic bacteria.

•N. gonorrhoeae may cause inflammation and exudate but more often remains quiescent and is diagnosed only by culture [8]. (See "Clinical manifestations and diagnosis of Neisseria gonorrhoeae infection in adults and adolescents".)

•Oropharyngeal tularemia is rare and should be entertained only in endemic areas among children who have an exudative pharyngitis that cannot be categorized by standard diagnostic testing and/or persists despite antibiotic therapy. (See "Tularemia: Microbiology, epidemiology, and pathogenesis" and "Tularemia: Clinical manifestations, diagnosis, treatment, and prevention".)

•Other organisms, including group C and G streptococci, Arcanobacterium hemolyticum, Mycoplasma pneumoniae, and Chlamydia pneumoniae [9], have been implicated as agents of pharyngitis in adolescents and adults, but in childhood their roles remain unproven and their frequency is unknown.

●Irritative pharyngitis – Drying of the pharynx may irritate the mucosa, leading to a complaint of sore throat. This condition occurs most commonly during the winter months, particularly after a night's sleep in a house with forced hot-air heating.

●Foreign body – Occasionally, a foreign object such as a fish bone may become embedded in the pharynx. (See "Airway foreign bodies in children", section on 'Presentation'.)

●Herpetic stomatitis – Stomatitis caused by herpes simplex usually is confined to the anterior buccal mucosa but may extend to the tonsillar pillars. In these more extensive cases, the child may complain of a sore throat. (See "Epidemiology, clinical manifestations, and diagnosis of herpes simplex virus type 1 infection", section on 'Primary infection'.)

●Systemic inflammatory conditions – Examples include:

•Kawasaki disease is classically characterized by high fever along with at least four of the five following findings [10]: conjunctivitis, mucositis, peripheral erythema and/or edema, truncal rash, cervical adenopathy. Kawasaki disease is discussed in detail separately. (See "Kawasaki disease: Clinical features and diagnosis", section on 'Clinical manifestations'.)

•Stevens-Johnson syndrome is a disease of unknown etiology, but presumed to be immune mediated, which is characterized by vesicular and ulcerative lesions of the mucosa, including the pharynx, genitalia, and conjunctivae. Additionally, children with this condition may have a diffuse rash, often consisting of target lesions or vesicles and bullae. Usually self-limited, occasional cases may lead to dehydration or progress to involve the pulmonary system. Rarely, Stevens-Johnson syndrome may be fatal. (See "Stevens-Johnson syndrome and toxic epidermal necrolysis: Pathogenesis, clinical manifestations, and diagnosis".)

•Behçet syndrome is a more chronic systemic inflammatory disease that may involve the oral cavity. It is uncommon in children. (See "Clinical manifestations and diagnosis of Behçet syndrome".)

•Periodic fever with aphthous stomatitis, pharyngitis and adenitis (PFAPA syndrome) is a cyclical inflammatory disease of unknown etiology. Episodes occur primarily in school age children approximately every four weeks. Mean duration of illness ranges from four to eight years. (See "Periodic fever with aphthous stomatitis, pharyngitis, and adenitis (PFAPA syndrome)", section on 'Clinical manifestations' and "Periodic fever with aphthous stomatitis, pharyngitis, and adenitis (PFAPA syndrome)", section on 'Natural history'.)

●Chemical exposure – Certain ingestions, such as paraquat and various alkalis, may cause a chemical injury to the mucosa of the pharynx. Usually these findings occur in the setting of a known ingestion and are accompanied by lesions of the oral mucosa. (See "Caustic esophageal injury in children".)

●Referred pain – Occasionally, pain from inflammation of extrapharyngeal structures is described as arising in the pharynx. Examples include dental abscesses, cervical adenitis, and otitis media. (See "Epidemiology, pathogenesis, and clinical manifestations of odontogenic infections" and "Acute otitis media in children: Clinical manifestations and diagnosis", section on 'Clinical diagnosis' and "Cervical lymphadenitis in children: Etiology and clinical manifestations", section on 'Infectious causes'.)

●Psychogenic pharyngitis – Some children who complain of a sore throat have no organic explanation for their complaint identified after a thorough history and physical examination and a throat culture. In these cases, the physician should consider the possibility of anxiety, at times associated with frequent or difficult (globus hystericus) swallowing. (See "Globus sensation".)

●Immunosuppressed host – Immunosuppressed hosts may develop pharyngitis from any of the previously discussed causes. In addition, these patients exhibit a particular susceptibility to infections with fungal organisms, such as Candida albicans. (See "Candida infections in children", section on 'Oropharyngeal candidiasis'.)

HISTORY — Key historical variables that may assist in the diagnosis of a specific cause of sore throat include respiratory distress, fever, fatigue, and the rapidity of the onset of symptoms.

●Sore throat and respiratory distress – The combination of sore throat and respiratory distress suggests conditions in or near the pharynx that are producing an obstruction, including epiglottitis, retropharyngeal or lateral pharyngeal abscess, peritonsillar abscess, massive tonsillar hypertrophy secondary to infectious mononucleosis, and, rarely, diphtheria. In addition, patients with COVID-19 may display fever and respiratory distress due to a pneumonia. (See "COVID-19: Clinical manifestations and diagnosis in children".)

●Fever – Fever points to one of the many infectious causes (table 1) but may also occur with inflammatory conditions.

●Fatigue – Fatigue, particularly when prolonged, characterizes infectious mononucleosis.

●Abrupt onset – Among the diseases causing pharyngitis, epiglottitis has a particularly abrupt onset, in a matter of hours, while infectious mononucleosis manifests over a period of days or weeks.

Other factors in the history that may be important in selected cases include immunocompromising conditions, immunizations, travel, sexual activity, exposure to an individual with known COVID-19 infection, and frequent recurrences. The patient with a compromised immune system is susceptible to a number of infections, including Candida albicans. Diphtheria rarely merits consideration, except in unimmunized children and those from underdeveloped nations. With a history of oral sexual activity, pharyngeal gonorrhea may be a concern. Frequently recurring episodes of pharyngitis are usually secondary to respiratory viruses and/or GABHS infections but may indicate PFAPA.

PHYSICAL EXAMINATION — To a large degree, the evaluation of the child with a complaint of sore throat hinges on a careful physical examination, particularly of the pharynx.

●Stridor, drooling, or respiratory distress indicate airway obstruction and may be present in the occasional patients with conditions such as epiglottitis or retropharyngeal abscess.

●An inflamed eardrum suggests pain from a non-oropharyngeal site and swelling around a tooth indicates a likely dental abscess.

●The appearance of vesicles on the buccal mucosa anterior to the tonsillar pillars points to a herpetic stomatitis or noninfectious syndromes, such as Behçet or Stevens-Johnson syndrome (erythema multiforme). (See "Stevens-Johnson syndrome and toxic epidermal necrolysis: Pathogenesis, clinical manifestations, and diagnosis" and "Clinical manifestations and diagnosis of Behçet syndrome".)

●Generalized inflammation of the oral mucosa, in a persistently febrile child, suggests Kawasaki disease. (See "Kawasaki disease: Epidemiology and etiology".)

●A foreign body, such as a fish bone, may uncommonly become lodged in the mucosal folds of the tonsils or pharynx; usually, the history suggests the diagnosis, but an unanticipated sighting may occur in the younger child.

●Significant asymmetry of the tonsils indicates a peritonsillar cellulitis or, if extensive, an abscess. Clinically, the diagnosis of an abscess is reserved for the tonsil that protrudes beyond the midline, causing the uvula to deviate to the uninvolved side.

●A diffuse erythematous rash suggests scarlet fever due to group A streptococcus or, in an ill-appearing patient, MIS-C (table 2). (See "COVID-19: Multisystem inflammatory syndrome in children (MIS-C) clinical features, evaluation, and diagnosis".)

●Pernio-like lesions or "COVID toes" (picture 5 and picture 6) have been reported in children and young adults with COVID-19, but their association with COVID-19 has not been clearly established. (See "COVID-19: Clinical manifestations and diagnosis in children", section on 'Clinical manifestations'.)

Infectious pharyngitis evokes a spectrum of inflammatory responses that range from minimal injection of the mucosa to beefy erythema with exudation and edema formation. Erythema and exudate, which may be secondary to either viral or bacterial pathogens, will be present in the majority of patients. (See "Group A streptococcal tonsillopharyngitis in children and adolescents: Clinical features and diagnosis", section on 'Differential diagnosis'.) Several specific findings are useful in pinpointing an etiologic agent.

●Viral pharyngitis that results from Coxsackie virus will be self-evident in a few cases on the basis of vesicular formation in the posterior pharynx alone (herpangina) or in combination with involvement of the extremities (hand, foot, and mouth disease). (See "Enterovirus and parechovirus infections: Clinical features, laboratory diagnosis, treatment, and prevention" and "Epidemiology, clinical manifestations, and diagnosis of herpes simplex virus type 1 infection".)

●The typical appearance of streptococcal pharyngitis includes fever, exudative pharyngitis, palatal petechiae, and swollen anterior cervical lymph nodes. Strategies for improving the clinical diagnosis of streptococcal pharyngitis, including a scoring system, are discussed elsewhere [11]. In general, scoring systems do not replace the need for rapid streptococcal antigen testing.

●Diphtheria causes a particularly thick exudate (diphtheritic membrane), often in association with tremendous enlargement of the cervical lymph nodes ("bull neck"). (See "Epidemiology and pathophysiology of diphtheria".)

●In infectious mononucleosis, the examination may show large, mildly tender posterior cervical lymph nodes, diffuse lymphadenopathy outside the cervical region, and splenomegaly or, less commonly, hepatomegaly. Although some young children with EBV infection do not always develop this typical pattern of signs and symptoms, many will have fever, pharyngitis, and cervical lymphadenopathy [12]. (See "Clinical manifestations and treatment of Epstein-Barr virus infection".)

ANCILLARY STUDIES — The history and physical examination will often suffice for diagnosis. Ancillary studies that may be useful in many cases include:

●Testing for streptococcal disease and infectious mononucleosis – Testing for streptococcal disease by antigen detection or culture and a heterophile test and white blood cell count with differential for infectious mononucleosis [13] (see "Group A streptococcal tonsillopharyngitis in children and adolescents: Clinical features and diagnosis", section on 'Diagnosis').

Children, particularly those under age 10 years or early in the course of their infections, can have symptomatic primary EBV infection without the production of heterophile antibodies and EBV specific serology may be necessary to make the diagnosis [14]. (See "Infectious mononucleosis", section on 'Diagnosis'.)

●Evaluation for COVID-19 – If possible, all symptomatic patients with suspected severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection should undergo testing; the diagnosis cannot be definitively made without microbiologic studies. Local health departments may have specific criteria for testing. Of note, although positive testing for other infections (eg, streptococcal pharyngitis or infectious mononucleosis) does not exclude co-infection with SARS-CoV-2, dual infections have not been described.

Additional findings such as a pneumonia on chest radiograph or computed tomography (CT) of the chest, low white blood cell count with lymphopenia, and/or elevated procalcitonin or C-reactive protein can be supportive of the diagnosis of COVID-19 but are present in the minority of children. (See "COVID-19: Clinical manifestations and diagnosis in children", section on 'Approach to diagnosis' and "COVID-19: Diagnosis", section on 'Choosing an initial diagnostic test'.)

●Neck imaging – A soft-tissue radiographic examination of the lateral neck may be useful in the child who is ill appearing, has significant difficulty swallowing, or who will not move their neck. In children with epiglottitis, an abnormal epiglottis is virtually always seen in this view and an enlarged prevertebral space may be visible in those with retropharyngeal abscess, although the sensitivity is variable, and CT may be necessary (image 1). (See "Epiglottitis (supraglottitis): Clinical features and diagnosis", section on 'Imaging'.)

In order to diagnose a retropharyngeal abscess, the radiograph should be a true lateral, and the child must keep the neck in extension during inspiration to avoid a false thickening of the retropharyngeal space. Findings consistent with a retropharyngeal abscess include a prevertebral space that is increased in depth compared with the anteroposterior measurement of the adjacent vertebral body, or a retropharyngeal space that is greater than 7 mm at C2 or 14 mm at C6 (image 2). Another method for interpreting the width of the prevertebral space is that it should normally measure no more than half the thickness of the vertebral body from C1-C4, or the full thickness from C5-C7. If the diagnosis remains uncertain despite adequate radiographs, a CT scan with contrast should be obtained. A CT scan will confirm the diagnosis of a lateral abscess (image 3). (See "Retropharyngeal infections in children", section on 'Imaging'.)

If radiographs are normal and a lateral pharyngeal abscess is suspected on the basis of torticollis or asymmetrically enlarged anterior cervical lymph nodes, then a CT scan is indicated.

ALGORITHMIC APPROACH — The tendency of most clinicians is to assume that one of the common organisms is the cause of pharyngitis in the child with a sore throat. Before settling on infectious pharyngitis, however, the clinician should first at least briefly consider several more serious disorders (algorithm 1).

Acutely ill patients — Conditions that have immediate life-threatening potential include epiglottitis, retropharyngeal and lateral pharyngeal abscesses, peritonsillar abscess, severe tonsillar hypertrophy (usually as an exaggerated manifestation of infectious mononucleosis), diphtheria, and Lemierre's syndrome. COVID-19 should also be considered in acutely ill children presenting with sore throat, but severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) rarely causes serious illness in the pediatric age group and would be unlikely to present predominantly with a complaint of sore throat. (See "COVID-19: Clinical manifestations and diagnosis in children", section on 'Clinical manifestations'.)

Generally, stridor and signs of respiratory distress accompany the complaint of sore throat in epiglottitis and retropharyngeal abscess. Drooling occurs commonly in children with these two conditions, particularly with epiglottitis. Patients with epiglottitis, peritonsillar abscess, or severe infectious tonsillar hypertrophy often experience a change in their voice. In cases of epiglottitis or retropharyngeal abscess that are not clinically obvious, a lateral neck radiograph, obtained under appropriate supervision, may be confirmatory, but CT is often required to diagnose a retropharyngeal abscess. (See "Epiglottitis (supraglottitis): Clinical features and diagnosis", section on 'Imaging' and "Retropharyngeal infections in children", section on 'Imaging'.)

Peritonsillar abscess and tonsillar hypertrophy are diagnosed by visual examination of the pharynx. Diphtheria, which produces a thick pharyngeal exudate and markedly enlarged cervical lymph nodes, is rarely a consideration except in unimmunized children, particularly those from underdeveloped nations.

Lemierre syndrome is rare but potentially fatal, and is characterized by septic thrombophlebitis, often caused by Fusobacterium necrophorum. Most common in adolescents and young adults, the patient appears toxic, has high fever, neck pain, often has asymmetrically enlarged anterior cervical lymph nodes, and may be hypotensive. (See "Lemierre syndrome: Septic thrombophlebitis of the internal jugular vein".)

The next phase of the evaluation of the child with a complaint of sore throat hinges on a careful physical examination, particularly of the pharynx. The appearance of vesicles on the buccal mucosa anterior to the tonsillar pillars points to a herpetic stomatitis or noninfectious syndromes, such as Behçet or Stevens-Johnson syndrome (erythema multiforme), and generalized inflammation of the oral mucosa in a persistently febrile child suggests Kawasaki disease.

Uncommonly, a small, pointed foreign body, perhaps a fish bone, becomes lodged in the mucosal folds of the tonsils or pharynx; usually, the history suggests the diagnosis, but an unanticipated sighting may occur in the younger child. Significant asymmetry of the tonsils indicates a peritonsillar cellulitis or, if extensive, an abscess. Clinically, the diagnosis of an abscess is reserved for the tonsil that protrudes beyond the midline, causing the uvula to deviate to the uninvolved side.

A pharynx that is not inflamed suggests a source of referred pain or irritative pharyngitis. Sources of referred pain (otitis media, dental abscess, and cervical adenitis) usually are identified during the examination. Irritative pharyngitis, seen most commonly during the winter among older children who live in homes with forced hot-air heating, produces minimal or no pharyngeal inflammation. It often is transient, appearing on arising and resolving by midday.

Suspected infectious pharyngitis — Patients who do not have one of the life threatening conditions discussed above and do not have another easily identifiable cause of sore throat (eg, foreign body) are likely to have infectious pharyngitis.

Infectious pharyngitis evokes a spectrum of inflammatory responses that range from minimal injection of the mucosa to beefy erythema with exudation and edema formation (algorithm 2). The three relatively common causes are streptococci, respiratory viruses, and infectious mononucleosis. In a few cases, a viral pharyngitis that results from Coxsackie virus infection will be evident on the basis of vesicular formation in the posterior pharynx alone (herpangina) or in combination with involvement of the extremities (hand, foot, and mouth disease). Such patients require no further testing and only symptomatic therapy.

For patients without pharyngeal vesicles who have significant symptoms with pharyngeal erythema and/or exudate, it is prudent to obtain a rapid test for group A streptococcus, followed by a throat culture if the rapid test is negative. Back up culture for a rapid antigen diagnostic test is recommended in children. However back up testing (either culture or rapid DNA probe) may not be necessary in older adolescents similar to the approach in adult patients. (See "Evaluation of acute pharyngitis in adults", section on 'Testing for GAS'.) In settings where a rapid test is not routinely performed or available, a throat culture for group A streptococcus should be obtained.

Sore throat is well described in COVID-19 in children, and diagnostic testing is warranted for those with nonexudative pharyngitis and fever. (See "COVID-19: Diagnosis", section on 'Choosing an initial diagnostic test'.)

In the rare child with an unusual history, the physician should consider diagnoses such as gonococcal pharyngitis (sexual abuse, oral sex) or diphtheria (immigration from an underdeveloped country, lack of immunization). In this situation, the clinician should inform the laboratory that pathogens other than group A streptococcus are also under consideration. If no diagnosis has yet been made in a child who has persistent sore throat and fever, infectious mononucleosis merits consideration even in the absence of lymphadenopathy and splenomegaly. (See "Clinical manifestations and treatment of Epstein-Barr virus infection".)

Some authorities find it acceptable not to perform either culture or rapid antigen diagnostic testing if all clinical features point towards a viral etiology (no exudate, no palatal petechiae, no cervical lymphadenopathy, URI symptoms present) in a developed country with a low risk of non-suppurative post-streptococcal complications, such as rheumatic fever [15,16].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Streptococcal tonsillopharyngitis" and "Society guideline links: Peritonsillar cellulitis and abscess".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: Sore throat in children (The Basics)" and "Patient education: Strep throat in children (The Basics)")

●Beyond the Basics topic (see "Patient education: Sore throat in children (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Definition – Sore throat refers to any painful sensation localized to the pharynx or surrounding anatomy. The developmental ability of young children to identify and define their symptoms varies and the physician must pay careful attention to the patient and the caretaker in order to clarify the exact nature of the complaint. (See 'Definition' above.)

●Causes – The etiology of sore throat varies by age (table 1) and can further be divided by conditions that are life-threatening, common, or less common. (See 'Causes' above.)

●History – Key historical variables that may assist in the diagnosis of a specific cause of sore throat include respiratory distress, fever, fatigue, and the rapidity of the onset of symptoms. (See 'History' above.)

●Physical examination – Careful oropharyngeal examination often provides the etiology for the sore throat (eg, viral pharyngitis, streptococcal pharyngitis, or peritonsillar abscess). (See 'Viral pharyngitis' above and 'Streptococcal pharyngitis' above and 'Physical examination' above.)

●Ancillary studies – Ancillary studies that may be useful frequently in selected patients include testing for streptococcal disease by antigen detection or culture and a heterophile test and white blood cell count with differential for infectious mononucleosis. (See 'Ancillary studies' above.)

●Algorithmic approach – The tendency of most clinicians is to assume that one of the common organisms is the cause of pharyngitis in the child with a sore throat. Before settling on infectious pharyngitis, however, the clinician should first consider several more serious disorders such as epiglottitis, retropharyngeal and lateral pharyngeal abscesses, peritonsillar abscess, severe tonsillar hypertrophy (usually as an exaggerated manifestation of infectious mononucleosis), diphtheria, and Lemierre's syndrome (algorithm 1). (See 'Algorithmic approach' above and 'Acutely ill patients' above.)

Patients who do not have one of the life-threatening conditions discussed above and do not have another easily identifiable cause of sore throat (eg, foreign body) are likely to have infectious pharyngitis. Infectious pharyngitis evokes a spectrum of inflammatory responses that range from minimal injection of the mucosa to beefy erythema with exudation and edema formation (algorithm 2). The three relatively common causes are Streptococcus species, respiratory viruses, and infectious mononucleosis. (See 'Suspected infectious pharyngitis' above.)

●COVID-19 – Sore throat occurs with COVID-19 in children, and diagnostic testing is warranted for those with nonexudative pharyngitis and fever, whenever possible and according to local criteria. (See "COVID-19: Diagnosis", section on 'Choosing an initial diagnostic test'.)