Sore throat

Background

  • Sore throat is one of the most common chief complaints in the ED and primary care
  • Most cases are viral and self-limited
  • The primary ED goals are to identify dangerous causes (peritonsillar abscess, retropharyngeal abscess, epiglottitis, Ludwig's angina) and appropriately test/treat for Group A Strep
Anatomy of the posterior pharynx.
Infrahyoid deep neck spaces

Clinical Features

  • Key history: onset, severity, dysphagia, drooling, voice change ("hot potato voice"), trismus, neck stiffness/swelling, fever, rash
  • Red flags suggesting dangerous cause:
    • Inability to swallow secretions/drooling
    • Trismus (inability to open mouth)
    • Stridor or respiratory distress
    • Unilateral swelling or uvular deviation
    • Toxic appearance
    • Neck swelling (especially floor of mouth)
  • Physical exam:
    • Pharyngeal erythema, exudates, tonsillar enlargement
    • Uvular deviation → peritonsillar abscess
    • Floor of mouth swelling → Ludwig's angina
    • Cervical lymphadenopathy
    • Assess for trismus, drooling, and airway compromise

Differential Diagnosis

Acute Sore Throat

Bacterial infections


Viral infections


Noninfectious


Other

Chronic Sore Throat

Evaluation

  • Centor criteria (modified/McIsaac) to guide Group A Strep testing:[2]
    • Tonsillar exudates (+1)
    • Tender anterior cervical lymphadenopathy (+1)
    • Fever >38°C / 100.4°F (+1)
    • Absence of cough (+1)
    • Age 3-14 (+1), Age 15-44 (0), Age ≥45 (-1)
  • Score ≤1: No testing needed; unlikely GAS
  • Score 2-3: Rapid strep test; treat if positive
  • Score ≥4: Rapid strep test (or empiric treatment); treat if positive
  • CT neck with IV contrast if deep space infection suspected (peritonsillar abscess, retropharyngeal abscess, Ludwig's angina)
  • Consider monospot or EBV testing if infectious mononucleosis suspected (especially adolescents/young adults with prolonged symptoms, significant lymphadenopathy, hepatosplenomegaly)
  • Lateral soft tissue neck X-ray — if epiglottitis or retropharyngeal abscess suspected (prevertebral soft tissue widening)
  • Flexible nasopharyngoscopy if airway concern or supraglottic pathology suspected

Management

  • Most sore throats are viral → supportive care:
    • NSAIDs and/or acetaminophen for pain
    • Encourage PO fluids
    • Warm salt water gargles, throat lozenges
  • Group A Strep pharyngitis:
  • Peritonsillar abscess:
    • Needle aspiration or incision and drainage
    • Antibiotics (see PTA)
  • Epiglottitis:
    • Emergent airway management, avoid agitating patient
    • IV antibiotics (see Epiglottitis)
  • Ludwig's angina:
    • Emergent airway management
    • IV antibiotics, surgical consultation
  • Dexamethasone single dose (10 mg IV or 0.6 mg/kg PO) may reduce pain in moderate-severe pharyngitis[3]

Disposition

  • Admit:
    • Peritonsillar abscess (if unable to tolerate PO after drainage, or bilateral/complicated)
    • Retropharyngeal abscess
    • Epiglottitis
    • Ludwig's angina
    • Airway compromise
    • Severe dehydration
  • Discharge with follow-up:
    • Viral pharyngitis
    • Strep pharyngitis with appropriate antibiotics
    • Successfully drained PTA with ability to tolerate PO
    • Return precautions: difficulty breathing, inability to swallow, worsening symptoms

See Also

External Links

References

  1. ↑ Melio, Frantz, and Laurel Berge. “Upper Respiratory Tract Infection.” In Rosen’s Emergency Medicine., 8th ed. Vol. 1, n.d.
  2. ↑ McIsaac WJ, et al. A clinical score to reduce unnecessary antibiotic use in patients with sore throat. CMAJ. 1998;158(1):75-83.
  3. ↑ Hayward G, et al. Corticosteroids for the common cold. Cochrane Database Syst Rev. 2015;(10):CD008116.
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