Pediatric emergency medicine trisk 370

appearance, high fever, stridor, and drooling In every reported series of cases, sore throat appears on the list of symptoms Although this rarely may be the primary complaint in a child, other more striking findings almost always predominate Epiglottitis should be easily excluded as a diagnosis in the patient with a sore throat who is without stridor and appears relatively well Kawasaki Disease Classic Kawasaki disease is characterized by a minimum of days of high fever along with at least four of the five following findings: (i) Bilateral bulbar conjunctivitis, (ii) oral mucous membrane changes, (iii) peripheral extremity changes (erythema and/or edema), (iv) polymorphous rash, and (v) cervical adenopathy (see Chapter 101 Rheumatologic Emergencies ) The oral mucous membrane changes most commonly involve the lips, but occasionally pharyngitis may be a prominent feature Other systemic inflammatory conditions (e.g., Behỗet syndrome) may involve the pharynx as well Stevens–Johnson Syndrome Stevens–Johnson syndrome, a disease of unknown etiology but presumed to be immune mediated, is characterized by vesicular and ulcerative lesions of the mucosa, including the pharynx, the genitalia, and the conjunctivae ( e-Fig 74.3A,B ) In addition, children with this condition may have a diffuse rash, often characterized by target lesions or vesicles and bullae Chemical Exposure Certain ingestions, such as paraquat and various alkalis, may produce a chemical injury to the mucosa of the pharynx (see Chapter 102 Toxicologic Emergencies ) Usually, these findings occur in the setting of a known ingestion and are accompanied by lesions of the oral mucosa Referred Pain Occasionally, pain from the inflammation of extrapharyngeal structures is described as arising in the pharynx Examples include dental abscesses, cervical adenitis, and, occasionally, otitis media Psychogenic Pharyngitis Some children who complain of a sore throat have no organic explanation for their complaint after a thorough history and physical examination and a throat culture In these cases, the emergency clinician should consider the possibility of anxiety, at times associated with frequent or difficult (globus hystericus ) swallowing Pharyngitis in the 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 EVALUATION AND DECISION The history and physical examination should focus on systemic illnesses causing pharyngitis and the appearance of the oral cavity A careful medical history of an immunosuppressive disorder or incomplete immunizations should raise the specter of unusual infections A sudden onset is most characteristic of epiglottitis Fever, either historical or measured, points to an infection or, less commonly, Kawasaki disease Toxicity and/or respiratory distress occur with infections leading to respiratory obstruction, such as peritonsillar, retropharyngeal, and lateral pharyngeal abscesses; epiglottitis; diphtheria; and infectious mononucleosis with severe tonsillar hypertrophy Conjunctivitis suggests pharyngoconjunctival fever (adenovirus), Kawasaki disease, or Stevens–Johnson syndrome; generalized adenopathy occurs with infectious mononucleosis and HIV A rash is seen with scarlet fever (group A streptococci), Kawasaki disease, infectious mononucleosis, particularly after the administration of amoxicillin, and rarely with Arcanobacterium hemolyticum in adolescents FIGURE 74.2 Diagnostic approach to the child with sore throat 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 emergency clinician should first at least briefly consider several more serious disorders ( Fig 74.2 ) 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), and diphtheria Generally, ill appearance, stridor, and signs of respiratory distress accompany the complaint of sore throat in epiglottitis and in some cases of retropharyngeal abscess Drooling and voice changes are common in children with these two conditions, as well as in patients with peritonsillar abscess and severe infectious tonsillar hypertrophy In cases of epiglottitis or retropharyngeal abscess that are not clinically obvious, a lateral neck radiograph, obtained under appropriate supervision can be confirmatory Peritonsillar abscess and tonsillar hypertrophy are diagnosed by visual examination of the pharynx Diphtheria is rarely a consideration except in unimmunized children, particularly those from underdeveloped nations 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 ( Fig 74.3 ) The appearance of vesicles on the buccal mucosa anterior to the tonsillar pillars points to a herpetic stomatitis or noninfectious syndromes such as Behỗet or StevensJohnson syndrome (erythema multiforme) Uncommonly, a small, pointed foreign body, most commonly a fishbone, 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 in a patient with trismus Kawasaki disease produces a systemic syndrome with a prolonged fever and other characteristic findings that are usually more prominent than the pharyngeal involvement The remaining organic diagnoses, once those already discussed have been eliminated by history, physical examination, and occasionally imaging, include referred pain, irritative pharyngitis, and infectious pharyngitis Sources of referred pain (e.g., otitis media, dental abscess, and cervical adenitis) are usually 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 upon awakening and resolving by midday Infectious pharyngitis ( Fig 74.3 ) evokes a spectrum of inflammatory responses that range from minimal injection of the mucosa to beefy erythema ... pharyngitis in the child with a sore throat Before settling on infectious pharyngitis, however, the emergency clinician should first at least briefly consider several more serious disorders ( Fig