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Sore Throat and Tonsillopharyngitis

Acute infections of the upper respiratory tract. Among uncomplicated cases it is usually important only to identify those children who have a group A streptococcal infection.

Classification of Acute Upper Respiratory Infections, tonsillitis, pharyngitis, sore throat, colds, flu

Among patients who have an uncomplicated acute URI, the most important step is to identify those who do not need an antibiotic from those who have a streptococcal infection.

Some patients who do not require an antibiotic can be recognized clinically. Such symptoms as rhinitis, conjunctivitis, and cough or the finding of an enanthem or exanthem indicative of an enteroviral infection are indication of respiratory virus infection, and withholding specific antibiotic treatment.


The adenoviruses are the most common cause of tonsillopharyngitis, especially types 1, 2, 3, and 5, which are the types that infect small children most frequently. Other respiratory viruses are less common causes of tonsillitis; the parainfluenza viruses probably are the most frequently isolated in this group.

Herpes simplex virus also is recognized as an occasional cause of tonsillopharyngitis, as is Epstein-Barr virus.

The most frequent causes of the common cold, the rhinoviruses and coronaviruses, involve the tonsils.

Viral Causes of Tonsillopharyngitis in Children

Adenoviruses, types 1, 2, 3, and 5

Less Common


Epstein-Barr virus

Herpes simplex virus

Influenza viruses

Parainfluenza viruses

Respiratory syncytial virus





Bacteria. Group A Streptococcus is the most important and frequent cause of tonsillopharyngitis. It is frequently associated with acute rheumatic fever and acute glomerulonephritis. Appropriate treatment of streptococcal pharyngotonsillitis prevents the occurrence of rheumatic fever.


Prevalence. The average incidence of all acute URIs is five to seven per child per year. It is estimated that children have one streptococcal infection every 4 to 5 years. Group A streptococci is isolated in 30-36.8% of children with pharyngitis.

Age Occurrence. Pharyngitis is infrequent in the first 2 years of life, when all URIs are most frequent. Most cases of pharyngitis occur in school-age children, when the incidence of all infections is still high but less than in the first 2 years.


Viruses are isolated in about 50% of children less than 2 years old but infrequently after that.

Group A streptococcus is isolated most frequently in school-age children, while M pneumoniae is most often in teenagers.

Season. The group A Streptococcus causes infections most frequently in late winter and early spring and is pharyngitis, sore throat, colds, flu rare in late spring and summer, although it causes some infections throughout the year.


All respiratory agents are spread by close contact or large droplets, with the exception of influenza, which also is spread by small droplets and the airborne route.

A history of a household, school, or outside contact with another patient who has tonsillopharyngitis due to a known agent, especially the group A Streptococcus, increases the likelihood that the index infection has the same etiology.

Clinical Features

Bacterial Infections. Only one third to one half of patients infected with group A streptococci have classic findings of streptococcal tonsillopharyngitis; the remainder have mild, atypical, or asymptomaticdisease.

Classic Features of Streptococcal Tonsillopharyngitis
Sudden onset

Sore throat (pain on swallowing)



Nausea, vomiting, abdominal pain (especially in children)

Marked inflammation of throat and tonsils

Patchy discrete exudate

Tender, enlarged anterior cervical nodes

Scarlet fever

Features rarely associated with streptococcal--suggestive of other etiologies


Laryngitis (stridor, croup)


Nasal discharge (except in young children)

Muscle aches/malaise

Viral Infections

The adenoviruses are the cause of pharyngoconjunctival fever. Hand, foot, and mouth disease and lymphonodular pharyngitis are caused by the enteroviruses. There are no distinctive clinical features caused by the other respiratory virus

The classic feature of herpes simplex infections in young children is gingivostomatitis, but in older children this agent causes , which is indistinguishable.