Sore throat: Difference between revisions
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==Background== | ==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 | |||
[[File:Gray1014.png|thumb|Anatomy of the posterior pharynx.]] | [[File:Gray1014.png|thumb|Anatomy of the posterior pharynx.]] | ||
[[File:Infrahyoid deep neck spaces.png|thumb|Infrahyoid deep neck spaces]] | [[File:Infrahyoid deep neck spaces.png|thumb|Infrahyoid deep neck spaces]] | ||
==Clinical Features== | ==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== | ==Differential Diagnosis== | ||
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*[[GERD]] | *[[GERD]] | ||
*Obstructive sleep apnea | *Obstructive sleep apnea | ||
*[[Fungal infections]] ( | *[[Fungal infections]] (e.g., [[Candidiasis|candida]]) | ||
*Chronic [[sinusitis]] with post nasal drip | *Chronic [[sinusitis]] with post-nasal drip | ||
*Inhalation of irritants (smoke, [[chlorine gas]]) | *Inhalation of irritants (smoke, [[chlorine gas]]) | ||
*Glossopharyngeal neuralgia | *Glossopharyngeal neuralgia | ||
*Tumor | *Tumor (tongue, larynx, thyroid) | ||
*[[Thyroiditis]] | *[[Thyroiditis]] | ||
*[[Esophageal | *[[Esophageal foreign body|Retained foreign body]] | ||
==Evaluation== | ==Evaluation== | ||
*'''Centor criteria''' (modified/McIsaac) to guide Group A Strep testing:<ref>McIsaac WJ, et al. A clinical score to reduce unnecessary antibiotic use in patients with sore throat. CMAJ. 1998;158(1):75-83.</ref> | |||
**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== | ==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:''' | |||
**[[Penicillin V]] or [[amoxicillin]] x 10 days (first line) | |||
**[[Azithromycin]] if penicillin allergic | |||
**See [[Streptococcal 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<ref>Hayward G, et al. Corticosteroids for the common cold. Cochrane Database Syst Rev. 2015;(10):CD008116.</ref> | |||
==Disposition== | ==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== | ==See Also== | ||
*[[Pharyngitis]] | *[[Pharyngitis]] | ||
*[[ | *[[Streptococcal pharyngitis]] | ||
*[[Peritonsillar abscess]] | |||
*[[Retropharyngeal abscess]] | |||
*[[Epiglottitis]] | |||
*[[Ludwig's angina]] | |||
*[[Infectious mononucleosis]] | |||
*[[Uvulitis]] | |||
*[[Neck mass]] | *[[Neck mass]] | ||
==External Links== | ==External Links== | ||
Revision as of 22:57, 20 March 2026
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
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
- Streptococcal pharyngitis (Strep Throat)
- Neisseria gonorrhoeae
- Diphtheria (C. diptheriae)
- Bacterial Tracheitis
Viral infections
- Infectious mononucleosis (EBV)
- Patients with peritonsillar abscess have a 20% incidence of mononucleosis [1]
- Laryngitis
- Acute Bronchitis
- Rhinovirus
- Coronavirus
- Adenovirus
- Herpesvirus
- Influenza virus
- Coxsackie virus
- HIV (Acute Retroviral Syndrome)
Noninfectious
Other
- Deep neck space infection
- Peritonsillar Abscess (PTA)
- Epiglottitis
- Kawasaki disease
- Penetrating injury
- Caustic ingestion
- Lemierre's syndrome
- Peritonsillar cellulitis
- Lymphoma
- Internal carotid artery aneurysm
- Oral Thrush
- Parotitis
- Post-tonsillectomy hemorrhage
- Vincent's angina
- Acute necrotizing ulcerative gingivitis
Chronic Sore Throat
- GERD
- Obstructive sleep apnea
- Fungal infections (e.g., candida)
- Chronic sinusitis with post-nasal drip
- Inhalation of irritants (smoke, chlorine gas)
- Glossopharyngeal neuralgia
- Tumor (tongue, larynx, thyroid)
- Thyroiditis
- Retained foreign body
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:
- Penicillin V or amoxicillin x 10 days (first line)
- Azithromycin if penicillin allergic
- See Streptococcal 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
- Pharyngitis
- Streptococcal pharyngitis
- Peritonsillar abscess
- Retropharyngeal abscess
- Epiglottitis
- Ludwig's angina
- Infectious mononucleosis
- Uvulitis
- Neck mass
External Links
References
- ↑ Melio, Frantz, and Laurel Berge. “Upper Respiratory Tract Infection.” In Rosen’s Emergency Medicine., 8th ed. Vol. 1, n.d.
- ↑ McIsaac WJ, et al. A clinical score to reduce unnecessary antibiotic use in patients with sore throat. CMAJ. 1998;158(1):75-83.
- ↑ Hayward G, et al. Corticosteroids for the common cold. Cochrane Database Syst Rev. 2015;(10):CD008116.