Sore throat: Difference between revisions

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==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:Infrahyoid deep neck spaces.png|thumb|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==
==Differential Diagnosis==
===Acute===
{{Sore throat DDX}}
====Bacterial Infections====
#[[Streptococcal Pharyngitis]] (Strep Throat)
#[[N. gonorrhea]]
#C. diptheriae


====Viral Infections====
===Chronic Sore Throat===
#Rhinovirus
*[[GERD]]
#Coronavirus
*Obstructive sleep apnea
#Adenovirus
*[[Fungal infections]] (e.g., [[Candidiasis|candida]])
#[[Herpesvirus]]
*Chronic [[sinusitis]] with post-nasal drip
#Influenza virus
*Inhalation of irritants (smoke, [[chlorine gas]])
#Coxsackievirus
*Glossopharyngeal neuralgia
#[[EBV]]
*Tumor (tongue, larynx, thyroid)
#HIV (Acute Retroviral Syndrome)
*[[Thyroiditis]]
*[[Esophageal foreign body|Retained foreign body]]


====Noninfectious====
==Evaluation==
#[[Stevens-Johnson Syndrome]]
*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>
#Pemphigus
**Tonsillar exudates (+1)
#[[Angioedema]]
**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


====Other====
==Management==
*[[Retropharyngeal Abscess]]
*Most sore throats are viral → supportive care:
*[[Peritonsillar Abscess]]
**NSAIDs and/or acetaminophen for pain
*[[Epiglottitis]]
**Encourage PO fluids
*[[Kawasaki Disease]]
**Warm salt water gargles, throat lozenges
*[[Neck Trauma|Penetrating injury]]
*Group A Strep pharyngitis:
*Caustic exposure
**[[Penicillin V]] or [[amoxicillin]] x 10 days (first line)
*[[Lemierre's Syndrome]]
**[[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>


===Chronic===
==Disposition==
*[[GERD]]
*Admit:
*obstructive sleep apnea
**Peritonsillar abscess (if unable to tolerate PO after drainage, or bilateral/complicated)
*fungal infections (ex. candida)
**Retropharyngeal abscess
*chronic [[sinusitis]] with post nasal drip
**Epiglottitis
*inhalation of irritants (smoke, chlorine gas)
**Ludwig's angina
*breathing dry air
**Airway compromise
*glossopharyngeal neuralgia
**Severe dehydration
*Tumor:
*Discharge with follow-up:
**Tongue
**Viral pharyngitis
**Larynx
**Strep pharyngitis with appropriate antibiotics
**Thyroid
**Successfully drained PTA with ability to tolerate PO
*monomyelocytic leukemia
**Return precautions: difficulty breathing, inability to swallow, worsening symptoms
*[[Thyroiditis]]
*[[Esophageal Foreign Body|Retained Foreign Body]]


==See Also==
==See Also==
[[Strep Pharyngitis]]
*[[Pharyngitis]]
*[[Streptococcal pharyngitis]]
*[[Peritonsillar abscess]]
*[[Retropharyngeal abscess]]
*[[Epiglottitis]]
*[[Ludwig's angina]]
*[[Infectious mononucleosis]]
*[[Uvulitis]]
*[[Neck mass]]
 
==External Links==


==Source==
==References==
Harwood-Nuss, Rosens, Tintinalli
<references/>


[[Category:ENT]]
[[Category:ENT]]
[[Category:Symptoms]]

Latest revision as of 09:35, 22 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
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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