Sore Throat: Navigating

the Differential Diagnosis

Two case histories demonstrate the vital importance of staying on your toes
when dealing with this routine complaint.

By Brian L. Porche, MD, and Jennifer Avegno, MD

A localized infection primarily affects the lymphatic

system of the pharyngeal structure, with tonsillar
suppuration, edema, fever, and cervical lymphade-
nopathy as prominent findings.
Most cases of acute pharyngitis run a benign
course, and sequelae have decreased significantly with
the widespread use of appropriate antibiotics. How-
ever, a few life-threatening infections may have a sore
throat as their main presenting symptom, so health
care providers need to stay vigilant to diagnose them.
The following two cases illustrate significant, emer-
gent, alternative diagnoses to consider when evaluat-
ing the patient who complains of a sore throat.

CASE 1: EPIGLOTTITIS
Mr. P, age 33, presents to an urgent care center com-
plaining of a scratchy throat, a fever of up to 100.5°F,
and mild rhinorrhea for two days. He reports that
he was seen yesterday at another facility, where he
was diagnosed with an upper respiratory infection
(URI) and sent home with instructions to stay well
hydrated and take ibuprofen and an over-the-coun-
ter decongestant. Unfortunately, his sore throat has

P
atients complaining of sore throats ac- gotten worse and he now has odynophagia, dyspha-
count for 1% to 2% of all visits to U.S. gia, a higher fever, a change in his voice, and pain
physicians’ offices, urgent care centers, and in the anterior neck.
emergency departments, adding up to at Mr. P has an unremarkable medical history with
least 14 million patient encounters a year. Acute in- completed immunizations and no allergies, chronic
© 2009 Coney Jay/Science Photo Library

fectious pharyngitis may be caused by viral, bacterial, medications, or surgeries. He has smoked five ciga-
and fungal sources. Infection is generally transmitted rettes a day for 10 years. His vital signs are: tempera-
through respiratory secretions and outbreaks often ture, 102°F; heart rate, 122; blood pressure, 134/82;
occur where overcrowding or close quarters exist. respiratory rate, 17, with 99% oxygen saturation on
room air. He looks ill and seems anxious, is lean-
Dr. Porche is a staff physician at Ochsner Health Systems ing forward in the sniffing position, speaks with a
and Dr. Avegno is a clinical instructor at Louisiana State
University Health Sciences Center, section of emergency muffled (“hot potato”) voice, and has tenderness on
medicine, in New Orleans. lateral movement of the larynx. Although no drool-

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ing or stridor is noted, the patient has become more
anxious and says he is beginning to have trouble
breathing.
Based on these findings, Mr. P’s physicians deter-
mine that he has epiglottitis.

AGGRESSIVE INFECTION
Epiglottitis, also called supraglottitis, is an aggressive
infection of the epiglottis and the surrounding tissues
that is usually caused by bacteria. The incidence of
epiglottitis is thought to be relatively low—about one
patient in 100,000. In the past, the disease was most
often seen in early childhood and was associated with
significant morbidity and mortality. The most com-
mon organism identified was Haemophilus influenzae
type b (HiB). However, routine infant vaccination
with the HiB vaccine since 1991 has decreased the
incidence of pediatric epiglottitis dramatically, mak-
ing the disease rare in immunized children.
In contrast, the incidence of adult epiglottitis is
increasing both in the United States and interna-
tionally. Whether because of initial misdiagnosis or >Radiographic red flags. Epiglottitis on lat-
undertreatment in the adult population, the mortal- eral neck x-ray showing the thumbprint sign (red
arrow) and vallecula sign (yellow arrow).
ity is higher in adults than in children. The overall
Published with permission from LearningRadiology.com
mortality in all age groups is less than 7%. Because
the disease is now far more common in adults than
in children, this article will focus on adult epiglottitis.
Male smokers are more commonly affected, and there Staphylococcus species, Moraxella catarrhalis, Klebsiella
does not seem to be an age or seasonal prevalence. pneumoniae); viruses (varicella virus, adenovirus, her-
Adult epiglottitis usually starts as a localized cel- pesvirus, and respiratory syncytial virus); and fungi
lulitis of the epiglottis and then spreads to the supra- (most commonly, Candida).
glottic structures, including the base of the tongue,
vallecula, aryepiglottic folds, arytenoid soft tissues, CLINICAL PRESENTATION
and lingual tonsils. However, some patients have Adults with acute epiglottitis typically have prodro-
a normal epiglottis in the setting of severe supra- mal symptoms of a benign URI that last one to
glottic involvement, so many authors feel the term two days. However, the onset may also be insidious,
supraglottitis is a more accurate description of the lasting up to one week, or abrupt and severe. Pa-
disease process. tients usually report dysphagia, odynophagia, severe
The histology and anatomy of the epiglottis are sore throat, otalgia, and a
important in the pathogenesis of the disease. There muffled voice, although >>FAST TRACK<<
is a large potential space that can expand as in- hoarseness is uncommon. Adults with acute
flammatory cells and fluid from edema accumulate Fever is variable and may epiglottitis typically have
during infection. Inflammation and edema do not not be present early in the prodromal symptoms of a
extend inferiorly to the infraglottic regions because disease; in fact, it is en- benign URI that last one to
the submucosa is densely adherent to the mucosa tirely absent in up to 50% two days.
inferior to the vocal cords. The most commonly of patients.
isolated organism causing adult epiglottis is H. in- Physical examination may reveal a patient who
fluenzae type b, but many other organisms have been appears ill and anxious. In patients with fever, tachy-
implicated. These include bacteria (Streptococcus and cardia out of proportion to the fever may correlate

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 SORE THROAT

>Laryngoscopic view. Epiglottitis on direct visualization (arrows indicate airway opening).

with severe disease. A reliable finding in epiglottitis for further evaluation, the tests described below may
is tenderness on palpation of the anterior neck near help confirm the diagnosis of acute epiglottitis.
the hyoid and on horizontal movement of the larynx.
Other signs and symptoms pointing to a more severe RADIOGRAPHIC EVIDENCE OF EPIGLOTTITIS
disease process and imminent airway obstruction in- Lateral soft tissue neck radiographs have a sensitivity
clude respiratory distress, stridor, drooling, aphonia, of up to 90%, but a normal or nondiagnostic film
and the patient assuming the sniffing position for does not exclude adult epiglottitis. Patients sent to
comfort and ease of breathing. radiology should be observed closely because of the
Diagnosis of epiglottitis requires a high index risk of acute airway obstruction. Radiographic evi-
of suspicion and a thorough history and physical dence of an epiglottic width of more than 8 mm or an
examination, as there are many diseases with simi- aryepiglottic fold width of more than 7 mm suggests
lar presenting signs and symptoms. The differential epiglottitis. Other radiographic findings consistent
diagnosis includes the following infectious causes: with epiglottitis include an enlarged, thumb-shaped
deep space abscess, infectious mononucleosis, lin- epiglottis, obliteration of the vallecula, swelling of
gual tonsillitis, diphtheria, pertussis, and pharyngi- the arytenoids and aryepiglottic folds, edema of the
tis. Noninfectious causes include laryngeal trauma, prevertebral and retropharyngeal soft tissue, and bal-
angioedema, allergic reactions, foreign body aspi- looning of the hypopharynx and mesopharynx.
ration, laryngospasm, tumor, and toxic inhalation The vallecula sign confirms a diagnosis of epi-
or aspiration. glottitis. To observe this sign, identify the base of
When the diagnosis is evident on clinical grounds the tongue on the radiograph and trace it inferiorly
alone (usually in severe cases), immediate plans to the hyoid bone. The diagnosis is confirmed if
should be made to admit there is no pocket of air extending almost to the
>>FAST TRACK<< the patient to the hos- hyoid bone and roughly parallel to the pharyngo-
When the diagnosis pital for airway control, tracheal air column. The thumbprint sign also helps
is evident on clinical administration of paren- confirm the diagnosis. The swollen epiglottis looks
grounds alone, immediate teral antibiotics, and close like a thumbprint on a radiograph (see image on
plans should be made to observation, possibly with page 7).
admit the patient. ICU admission. Act with Direct or indirect laryngoscopy (see image) con-
extreme care and urgency, firms the diagnosis in stable patients. Modalities such
because these patients are at significant risk for life- as flexible fiberoptic laryngoscopy are ideal for this
threatening airway obstruction and death. When the procedure, since they provide direct visualization
diagnosis is unclear and the patient is stable enough of the epiglottis and the airway and also provides a

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 SORE THROAT

means to guide the intubation when indicated with last 24 hours with new symptoms of dysphagia, ody-
direct visualization. Direct visualization may reveal nophagia, fever, and drooling. He also will not move
a classic cherry-red epiglottis (or the epiglottis may his neck in any direction.
appear pale and edematous), as well as edema sur- Ryan’s history includes up-to-date immuniza-
rounding the supraglottic structures. In patients with tions, no known allergies or medical problems, and
severe symptoms, including respiratory distress, stri- enrollment in day care. His vital signs are: rectal
dor, drooling, and aphonia, plans for direct laryn- temperature, 101.7°F; heart rate, 108; blood pres-
goscopy with backup measures to obtain definitive sure, 96/58; respiratory rate, 18, with 99% oxygen
airway control should be implemented. Ideally, this saturation on room air. The physical examination
procedure should occur with an otorhinolaryngol- finds a well-developed toddler who is irritable,
ogy (ENT) or anesthesia consultation and should drooling, and appears ill. He refuses to move his
be performed in an operating room. neck to help with the examination. His tympanic
membranes are clear on the right, with mild ery-
AIRWAY CONTROL AND ANTIBIOTICS thema and loss of landmarks on the left. His nares
The keys to therapy for epiglottitis are airway con- and oropharynx are normal, without exudate or ton-
trol and empiric antibiotics. After a definitive air- sillar enlargement. Range of motion of the neck is
way is obtained, antibiotics covering H. influenzae painful, with more pain elicited on extension than
and other previously mentioned pathogens should on flexion. There is mild swelling of the left an-
be initiated. Pending cultures and sensitivities, ce- terolateral aspect of the neck, with tenderness on
fotaxime or ceftriaxone are first-line agents. Alter- palpation of that area.
native antibiotics include ampicillin-sulbactam and These findings point to a diagnosis of retropha-
trimethoprim-sulfamethoxazole. Adjunctive therapy ryngeal abscess.
options include steroids to decrease the inflamma-
tion of the supraglottic structures and racemic epi- DEEP SPACE INFECTION
nephrine nebulizer treatments. The efficacy of these Retropharyngeal abscess, a deep space neck infec-
last two practices has not been proven, although tion, is an uncommon but significant complication
they are frequently used in the treatment of adult of URI in children. On rare occasions, it is seen in
acute epiglottitis. adults who have ingested foreign bodies, had recent
The most significant complications of epiglottitis ENT procedures, or experienced regional trauma,
are airway obstruction, respiratory failure, the need or are immunocompromised. In the past, retropha-
for surgical procedures, and death. As the incidence ryngeal abscesses caused significant morbidity and
of adult epiglottitis increases, so does a more com- mortality secondary to complications, but advances
mon complication—epiglottic abscess. Patients with in imaging, prompt detection, and early administra-
epiglottic abscesses may need incision and drainage tion of antibiotics have reduced these complications,
before clinical improvement occurs. Concomitant and long-term sequelae are rare.
infections are more common in the pediatric popu- The disease occurs most
lation, but extraepiglottic infections or complications often in pediatric patients >>FAST TRACK<<
may also occur in adults and include meningitis, between six months and Retropharyngeal abscess
retropharyngeal abscess, pneumothorax, empyema, four years old—the peak occurs most often
pneumonia, sepsis, adult respiratory distress syn- age for numerous URIs in pediatric patients
drome, and pulmonary edema. and their complications, between six months and
such as otitis media and si- four years old.
CASE 2: RETROPHARYNGEAL ABSCESS nusitis. The retropharyn-
Ryan, age 3, is brought to an urgent care center by geal lymph nodes are implicated in the development
his parents because of a sore throat, left ear pain, and of a retropharyngeal abscess. These nodes atrophy
clear rhinorrhea for five days. Ryan was examined by between ages four and six, and repeated lymph node
his pediatrician, who diagnosed left otitis media and drainage after many URIs also tends to obliterate
prescribed high-dose amoxicillin. However, Ryan’s the nodes. Consequently, the incidence of retropha-
parents report that he has become worse over the ryngeal abscesses beyond this age group is markedly

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 SORE THROAT

aureus, H. influenzae, and anaerobes, such as Fuso-

bacteria, Prevotella, and Veillonella species.

CLINICAL PRESENTATION
Patients with retropharyngeal abscesses commonly
complain of a preceding illness with URI symptoms
or otitis media, and they are often already being
treated with antibiotics. Symptoms of retropharyn-
geal abscess are a result of inflammation and pressure
on the surrounding tissues of the airway, pharynx,
or upper digestive tract. Patients appear generally
ill, are febrile, and (if verbal) complain of dysphagia,
odynophagia, neck swelling, or neck pain on move-
ment. Parents often report that the child has a stiff
neck, is drooling, and has some element of respira-
tory distress.
On physical examination, the child may appear
toxic, irritable, and have a muffled voice, stridor, or
tachypnea (or all three of these findings). The child
may also present with torticollis or may refuse to
move his neck because of the pain. Usually, neck
extension is more painful than neck flexion. A mid-
line or unilateral swelling of the posterior pharyngeal
wall may be noted and may be fluctuant, but care
must be taken to avoid aggressive palpation, which
can result in abscess rupture. Trismus is an unusual
> Painful pressure. Retropharyngeal abscess
finding when the site of infection is in the retropha-
on lateral neck x-ray.
ryngeal space.
Image courtesy Loren Yamamoto, MD, MPH
Occasionally, patients with retropharyngeal ab-
scess will display classic signs and symptoms, so the
diagnosis can be made on clinical grounds alone.
decreased, so our discussion here will focus on the However, it is important to consider alternative diag-
pediatric population. noses, because many life-threatening airway condi-
Keep in mind that the retropharyngeal space is tions mimic retropharyngeal abscess in a toxic child
a potential space in the neck between the posterior with fever, sore throat, and neck pain. The differen-
pharyngeal wall and the prevertebral fascia. The space tial diagnosis includes epiglottitis, lateral pharyngeal
is composed of two chains of lymph nodes that drain abscess, peritonsillar abscess, infectious mononucle-
the nasopharnyx, adenoids, osis, diphtheria, internal jugular vein thrombophle-
>>FAST TRACK<< posterior paranasal sinuses, bitis, meningitis, viral pharyngitis, and streptococcal
Many life-threatening middle ear, and Eustachian pharyngitis, among other diseases.
airway conditions mimic tube. Therefore, infections
retropharyngeal abscess in this area may be compli- TAKING CARE WITH THE CHILD
in a toxic child with cations of viral or bacterial Once clinical suspicion for a retropharyngeal abscess
fever, sore throat, and URIs that seed infection is high, an initial workup and confirmatory testing
neck pain. and ultimately cause ab- may be performed. Close airway monitoring and
scess formation. The bac- definitive management should take precedence over
terial pathogens implicated are similar to other deep imaging or other testing. Practitioners should take
space neck abscesses and are usually polymicrobial. care not to upset the child and possibly worsen air-
They include group A Streptococcus, Staphylococcus way obstruction. The airway should be managed by

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 SORE THROAT

the most qualified physician available in a setting

with multiple resources.
A lateral soft tissue neck radiograph (see image
opposite) is usually performed to help delineate a
retropharyngeal abscess. To avoid false positives,
care must be taken to obtain an adequate film and
perform the study correctly. To obtain a true lateral
neck film, the neck must be kept in extension dur-
ing the study, and the film should be taken during
inspiration to avoid a false thickening in the ret-
ropharyngeal space. Positive findings are contro-
versial, but 7 mm of prevertebral soft tissue width
at C2 and 14 mm of prevertebral soft tissue width
at C6 are considered indicative of retropharyngeal
abscess. Other findings include reversal of the nor-
mal lordosis of the cervical spine, an air fluid level,
foreign bodies, or vertebral body destruction in
extensive cases.
When the diagnosis is unclear or the patient is
uncooperative during lateral films, definitive diag-
nosis should be based on a computed tomography
(CT) scan of the neck with intravenous contrast >Diagnostic confirmation. Retropharyngeal
(see image). Although this modality is not a perfect abscess seen on computed tomography scan with
tool, CT has been shown to have superior sensitiv- intravenous contrast.
ity and specificity in diagnosing retropharyngeal Image courtesy Loren Yamamoto, MD, MPH
abscess. It also helps to differentiate retropharyn-
geal abscess from retropharyngeal cellulitis and to
detect extension of the abscess to contiguous struc- picillin-sulbactam or clindamycin. Once the patient
tures in the neck and surrounding tissues. Whereas is clinically improved and afebrile, conversion to
complete rim enhancement is most indicative of oral antibiotics, such as amoxicillin-clavulanate or
abscess, CT findings of a low-density core, soft clindamycin, is recommended to complete a 14-day
tissue swelling, obliterated fat planes, and mass ef- course of therapy.
fect may be seen in both retropharyngeal abscess Although most patients do very well with appro-
and cellulitis. priate airway management, antibiotics, and surgery
When a retropharyngeal abscess is suspected or for complicated cases, the following life-threaten-
confirmed in the urgent care setting, arrangements ing complications can oc-
for transfer and admission to the hospital should be cur: airway compromise; >>FAST TRACK<<
made with the consultation of an ENT physician. pulmonary complications Once the patient is
Treatment of retropharyngeal abscess consists of from abscess rupture clinically improved and
airway control if indicated, empiric parenteral anti- and aspiration, including afebrile, conversion
biotics, and ENT surgical consultation for possible pneumonia, empyema, and to oral antibiotics is
transoral or transcervical drainage. Historically, sur- asphyxiation; direct exten- recommended to complete
gical drainage and parenteral antibiotics were the sion along tissue planes a 14-day course of therapy.
mainstays of therapy. But according to many recent leading to mediastinitis or
studies, close observation and parenteral antibiotics mediastinal abscess, pericarditis, or pleuritis; neu-
lead to effective resolution of symptoms and less rologic/orthopedic complications, including atlan-
unnecessary invasive surgeries. Empiric antibiotics toaxial separation, transverse myelitis, and epidural
should cover previously mentioned bacterial patho- abscess; erosion into the esophagus or auditory canal;
gens. Appropriate regimens include parenteral am- necrotizing fasciitis; sepsis; and death. continued

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 SORE THROAT

POTENTIAL CHALLENGES Harris JH Jr and Harris WH: Spine, including soft tissues
of the pharynx and neck. The Radiology of Emergency
Any patient with the chief complaint of sore throat
Medicine, 4th ed, Lippincott Williams and Wilkins, pp. 137-
presents a potential airway and infectious disease 298.
challenge. A thorough history, including immuniza- Marx JA, et al.: Upper respiratory infections. Rosen’s
tion status and previous antibiotic use, is essential and Emergency Medicine: Concepts and Clinical Practice, 5th
should be combined with a detailed head and neck ed, Mosby, 2002, pp. 973-977.

examination. Patients suspected of having epiglotti- Page NC, et al.: Clinical features and treatment of
retropharyngeal abscess in children. Otolaryngol Head
tis or retropharyngeal abscess should be immediately Neck Surg 138(3):300, 2008.
transferred to the hospital for definitive care. Q Tintinalli J, et al.: Disorders of the neck and upper airways.
Emergency Medicine: A Comprehensive Study Guide, 5th
SUGGESTED READING ed, McGraw-Hill, 1999, pp. 1556-1560.
Alcaide ML and Bisno AL: Pharyngitis and epiglottitis. Wald ER: Peritonsillar cellulitis and abscess in children
Infect Dis Clin North Am 21(2):449, 2007. and adolescents. UpToDate (2008). Available at: www.
uptodate.com. Accessed February 11, 2009.
Berger G, et al.: The rising incidence of adult acute
epiglottitis and epiglottic abscess. Am J Otolaryngol Wood N, et al.: Epiglottitis in Sydney before and after the
24(6):374, 2003. introduction of vaccination against Haemophilus influenzae
type b disease. Intern Med J 35(9):530, 2005.
Craig FW and Schunk JE: Retropharyngeal abscess in
children: clinical presentation, utility of imaging, and current Woods CR: Epiglottitis. UpToDate (2007). Available at:
management. Pediatrics 111(6 Pt 1):1394, 2003. www.uptodate.com. Accessed February 11, 2009.
Ducic Y, et al.: Description and evaluation of the vallecula Young LS and Price CS: Complicated adult epiglottis due
sign: a new radiologic sign in the diagnosis of adult to methicillin-resistant Staphylococcus aureus. Am J
epiglottitis. Ann Emerg Med 30(1):1, 1997. Otolaryngol 28(6):441, 2007.