Pharyngitis, peritonsillar abscess, and retropharyngeal abscess (pediatrics): Clinical sciences

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Introduction0:00–0:32

Pharyngitis, or simply inflammation of the pharynx, can be caused by non-infectious conditions, like allergic rhinitis, as well as viral and bacterial infections.
Pharyngitis is a common pediatric condition that’s easy to treat, but, in rare cases, it can progress to complications, such as peritonsillar or retropharyngeal abscess.Now, if your patient presents with chief concerns suggesting pharyngitis, peritonsillar abscess, or retropharyngeal abscess, first perform an ABCDE assessment.

Unstable0:32–1:23

If the patient is unstable, stabilize their airway, breathing, and circulation; obtain IV access; and consider starting IV fluids.
Next, put your patient on continuous vital sign monitoring, including blood pressure, heart rate, and pulse oximetry. Finally, if needed, don’t forget to provide supplemental oxygen.Now here’s a clinical pearl to keep in mind!
Audible stridor and stertor are highly suggestive of airway obstruction, so, in this case, be sure to examine your patient in the operating room in case you need to establish an artificial airway emergently!Okay, now let’s go back and take a look at stable patients.

Stable1:23–1:54

In this case, you should first obtain a focused history and physical examination. These individuals usually report a sore throat that may or may not be associated with odynophagia and fever.
On the exam, you will find pharyngeal erythema, and you may also detect tonsillar exudates as well as cervical lymphadenopathy.
With this combination of findings, you can diagnose pharyngitis.Your next step is to assess the underlying cause. Patients with noninfectious causes of pharyngitis may report rhinorrhea, nasal congestion, sneezing, and coughing, but they don’t have fever, and they don’t feel acutely ill.

Noninfectious Pharyngitis1:54–2:49

On exam, the posterior pharynx may have a cobblestone appearance, and the nasal mucosa may appear boggy and pale. These findings are highly suggestive of noninfectious pharyngitis, which is most commonly due to allergic rhinitis or gastroesophageal reflux in children.To treat noninfectious pharyngitis, first, address the underlying cause.
If you suspect allergic rhinitis, start an antihistamine, and if you suspect gastroesophageal reflux, consider a proton pump inhibitor.
Additionally, provide supportive care, such as warm salt water gargles or topical anesthetics.Now, let’s switch gears and discuss infectious causes, starting with viral pharyngitis.

Viral Pharyngitis 2:49–4:22

Affected patients usually report a gradual onset of symptoms, with rhinorrhea, nasal congestion, and cough. They typically feel ill and report fatigue and malaise.
Additionally, history findings might include symptoms like hoarseness, diarrhea, or conjunctivitis. The exam typically reveals a swollen nasal mucosa with variable amounts of mucous drainage.
These findings are highly suggestive of viral pharyngitis. In this case, the treatment includes supportive care with antipyretics and analgesics, as well as adequate oral hydration and rest.
Now, here’s a clinical pearl to keep in mind! Specific exam findings may give clues about the particular virus causing the pharyngitis.
For example, oral or pharyngeal vesicles with associated gingival erythema, friability, and pain are commonly seen in HSV gingivostomatitis.
On the other hand, an erythematous maculopapular rash involving the palms of the hands, soles of the feet, and oropharynx is associated with coxsackie infection, also known as hand, foot, and mouth disease.
Finally, pharyngitis in combination with conjunctivitis suggests adenovirus infection; while prolonged pharyngitis associated with intense fatigue suggests infectious mononucleosis.Next up is Group A Streptococcal pharyngitis, or Strep throat for short!

Group A Streptococcal Pharyngitis4:22–6:35

Affected patients typically report an abrupt onset of throat pain with fatigue and malaise. They may also experience headache, abdominal pain and vomiting.
Notably, these patients usually don’t have rhinorrhea, nasal congestion, or cough. On exam, you’ll typically see a beefy red pharynx, with or without palatal petechiae and tonsillar exudates.
Additionally, you may detect tender anterior cervical lymphadenopathy or a sandpaper-like rash. With these findings you should suspect Group A Strep pharyngitis.
Your next step is to obtain a pharyngeal swab to check for Group A Strep using a rapid Strep antigen test. If the rapid Strep test is negative, send a throat culture.
If the throat culture is negative for Group A Strep, or it grows only normal throat flora, your patient most likely has viral pharyngitis.
Again, provide supportive care with antipyretics and analgesics, and don’t forget adequate oral hydration and rest. However, if the throat culture is positive for Group A Strep, diagnose Group A Strep pharyngitis.
Alternatively, if the initial rapid Strep test is positive, you can also diagnose Strep throat without sending a confirmatory throat culture.
Once you’ve made your diagnosis, begin treatment with a beta-lactam antibiotic, such as penicillin or amoxicillin, as well as antipyretics and analgesics, as needed.
Always treat Strep throat promptly to reduce the risk of transmission and the development of sequelae, such as acute rheumatic fever!
Now, here’s a high yield fact to keep in mind! If you diagnose Strep throat and your patient develops a sandpaper-like rash that blanches with pressure, with linear erythema along their neck, axillae, or inguinal areas; and a strawberry tongue, then diagnose Scarlet fever!
Okay, now let’s take a look at patients with gonococcal pharyngitis. These individuals may report a history of oral-genital contact, and physical exam often reveals prominent tonsillar exudates.

Gonococcal Pharyngitis6:35–7:04

When you see this, suspect gonococcal pharyngitis, and send a pharyngeal swab for a gonorrhea NAAT. If it’s positive, diagnose gonococcal pharyngitis, and treat your patient with an injection of high-dose ceftriaxone.
Now let’s consider patients with peritonsillar abscess, which can occur in any age group, but is most commonly seen in adolescents.

Peritonsillar Abscess7:04–8:17

These individuals often describe a progressively worsening sore throat, as well as decreased oral intake and a classic “hot potato” voice.
They might also report dysphagia and unilateral otalgia. The physical exam typically reveals unilateral tonsillar bulging, and you may also notice uvular deviation, drooling, or trismus.
These findings are highly suggestive of a peritonsillar abscess, so obtain a surgical consultation for possible needle aspiration or incision and drainage.
In addition, begin a broad-spectrum antibiotic, since these infections typically are polymicrobial, and tailor antibiotics to culture results if you send aspirated fluid for culture.Now, here’s a clinical pearl!
Peritonsillar abscess can be diagnosed clinically without imaging studies. If left untreated, a peritonsillar abscess can extend into the internal jugular vein and cause a septic thrombophlebitis, known as Lemierre syndrome.
Finally, let’s discuss retropharyngeal abscess, which can occur in any age group but is most commonly seen in preschool-age children.

Retropharyngeal Abscess8:17–10:16

Affected patients typically have a preceding viral upper respiratory infection and subsequently develop neck pain and dysphagia.
They may have poor oral intake due to dysphagia, and some patients might even report chest pain and dyspnea. On exam, they are often anxious and ill-appearing, with a stiff neck and limited neck mobility.
You may also detect a palpable neck mass, drooling, and respiratory distress. Here’s a clinical pearl!
A big differential to consider here is epiglottitis. Usually, children with epiglottitis drool and lean forward in the “tripod position,” while children with retropharyngeal abscesses drool and hyperextend their necks.
These findings are highly suggestive of a retropharyngeal abscess, so as a next step, send labs, including a throat culture, blood culture, and CBC.
While you are waiting for lab results, promptly begin broad-spectrum intravenous antibiotics, such as clindamycin, a beta-lactamase-resistant penicillin, or a third-generation cephalosporin.
Now, let’s look at lab results. The throat culture and blood culture might be positive for the culprit organism, while the CBC typically reveals leukocytosis and thrombocytosis.
Here’s a clinical pearl! Sometimes, you may order an x-ray of the neck, which would demonstrate widening of the retropharyngeal space or prevertebral soft tissue swelling, resulting in widening of the space between the vertebrae and pharynx.After initiating antibiotics, be sure to assess your patient’s response to treatment.
If your patient’s symptoms are improving, there’s an adequate response to treatment, so continue antibiotics.However, if your patient’s symptoms are not improving after 48 to 72 hours, are worsening despite antibiotics, or if there’s airway compromise, you should suspect a persistent retropharyngeal abscess.

Persistent Retropharyngeal Abscess10:16–11:45

Next, you should order imaging, primarily a lateral neck X-ray. However, if your patient has respiratory symptoms, such as chest pain or dyspnea, the infection may have traveled down the retropharyngeal space.
In this case, order a chest X-ray to look for signs of mediastinitis. Finally, you might need to order a neck CT to evaluate the extent of the abscess and determine whether it has spread to adjacent structures.A lateral neck X-ray might reveal thickening of the prevertebral soft tissues; while the chest X-ray might reveal signs of mediastinitis, such as abnormal mediastinal soft tissue, mediastinal widening or subcutaneous emphysema.
The neck CT often shows a hypodense fluid collection in the retropharyngeal space with peripheral ring enhancement, and it may demonstrate a mass effect.
If these findings are present, you can confirm the diagnosis of persistent retropharyngeal abscess, so obtain a surgical consultation for possible incision and drainage.
Alright, as a quick recap… Pharyngitis can be caused by non-infectious and infectious conditions. In noninfectious pharyngitis, you should treat the underlying cause, such as allergies or gastroesophageal reflux.

Review11:45–12:48

Regarding infectious conditions, in viral pharyngitis, you should focus on supportive care. Next, if you suspect group A streptococcal pharyngitis, order a rapid antigen test and throat culture to confirm the diagnosis.
Treatment primarily relies on beta-lactam antibiotics. Untreated bacterial pharyngitis can lead to a peritonsillar abscess, which is commonly seen in adolescents and requires broad-spectrum intravenous antibiotics and sometimes even surgical drainage.
On the flip side, retropharyngeal abscess typically occurs in preschool age and requires treatment with broad-spectrum intravenous antibiotics.
If symptoms are not improving, are getting worse, or if there’s airway compromise, order imaging and consult your surgery team for possible incision and drainage.