Pharyngitis: Clinical Presentation
Pharyngitis typically presents as a sore throat that worsens with swallowing, often accompanied by fever, tonsillopharyngeal erythema, and tender anterior cervical lymphadenopathy. 1
Core Symptoms
The primary symptom complex includes:
- Sore throat with pain on swallowing - the hallmark presenting complaint, often with sudden onset 1
- Fever - commonly present, particularly in bacterial cases 1
- Constitutional symptoms - headache, nausea, vomiting, and abdominal pain (especially in children) 1
Physical Examination Findings
Signs Suggesting Bacterial (Group A Streptococcal) Pharyngitis
The modified Centor criteria identify key bacterial indicators: fever by history, tonsillar exudates, tender anterior cervical adenopathy, and absence of cough. 1
Specific physical findings include:
- Tonsillopharyngeal erythema with or without exudates 1, 2
- Tender, enlarged anterior cervical lymph nodes (lymphadenitis) 1, 2
- Palatal petechiae 1, 2
- Beefy red, swollen uvula 1, 2
- Scarlatiniform rash 1
- Swollen tonsils with possible exudates 1
- Excoriated nares (particularly in infants) 1
Signs Suggesting Viral Pharyngitis
Patients with cough, nasal congestion, conjunctivitis, hoarseness, diarrhea, or oropharyngeal lesions are more likely to have viral illness and should not undergo further testing. 1
Viral indicators include:
- Cough - strongly suggests viral etiology 1
- Coryza (nasal discharge) 1
- Conjunctivitis 1
- Hoarseness 1
- Discrete ulcerative lesions or vesicles in the oropharynx 1
- Viral exanthem 1
- Diarrhea 1
Red Flag Signs Requiring Urgent Evaluation
Patients presenting with difficulty swallowing, drooling, neck tenderness, or neck swelling should be evaluated immediately for serious complications such as peritonsillar abscess, parapharyngeal abscess, epiglottitis, or Lemierre syndrome. 1, 2
These warning signs include:
- Difficulty swallowing 1, 2
- Drooling 1, 3
- Neck tenderness or swelling 1, 2
- Unusually severe symptoms in adolescents or young adults (consider Fusobacterium necrophorum and Lemierre syndrome) 1
Epidemiological Context
- Age predilection: Primarily affects children 5-15 years of age 1
- Seasonal pattern: More common in winter and early spring in temperate climates 1
- Prevalence: Accounts for approximately 12 million outpatient visits annually in the United States 1
Clinical Pitfall
No single clinical sign or symptom is specific enough to diagnose Group A streptococcal pharyngitis without microbiological confirmation. 2 The Centor criteria have low positive predictive value, so they should be used primarily to identify patients with low probability of bacterial infection who do not need testing (those with fewer than 3 criteria). 1