Sore Throat

Sore throat occurs when an acute upper respiratory tract infection affects the mucosa of the throat. Clinical descriptions of acute sore throat include: Acute pharyngitis: inflammation of the part of the throat behind the soft palate (oropharynx) and Tonsillitis: inflammation of the tonsils.

Causes

Infectious

Adenovirus, leading to pharyngoconjunctival fever.

Streptococcal infection. Group A beta-haemolytic streptococcus. is the most common bacterial cause of sore throat and may cause pharyngitis, tonsillitis, or scarlet fever.

Herpes simplex virus type 1 (and more rarely type 2), leading to acute herpetic pharyngitis.

Influenza types A and B

Epstein-Barr virus, leading to infectious mononucleosis (glandular fever).

Rhinovirus, coronavirus, parainfluenza virus

Fusobacterium necrophorum, which may cause pharyngitis or tonsillitis, and can (very rarely) lead to Lemierre syndrome (septic phlebitis of the internal jugular vein).

Non-infectious (uncommon)

Hayfever.

Physical irritation (e.g. from a nasogastric tube or from smoke).

Gastro-oesophageal reflux disease.

Kawasaki disease

Oral mucositis secondary to radiotherapy or chemotherapy, which may become secondarily infected.

Haematological disorders: leukaemia and aplastic anaemia

Drugs which can cause blood disorders (e.g. neutropenia, agranulocytosis, thrombocytopenia) leading to infection and acute sore throat.

Diagnosis: Examination

Pharyngitis is often is associated with pharyngeal exudate and cervical lymphadenopathy

Tonsillitis is associated with tonsillar exudate and enlargement and erythema of the tonsils. There may be anterior cervical lymphadenopathy.

Examine the person's throat and neck

Diagnosis: History

Fever

Fluid intake (pain on swallowing)

Headache

Information about wet nappies for babies/young children

Signs of dehydration

Abdominal pain

Consider FeverPAIN or Centor score to determine likelihood of streptococcal infection (requirement for antibiotic therapy)

Nausea and vomitting

FeverPAIN criteria are: score 1 point for each (maximum score of 5) - Fever over 38°C, Purulence (pharyngeal/tonsillar exudate), Attend rapidly (3 days or less), Severely Inflamed tonsils, No cough or coryza

Be alert for serious underlying causes: Epiglottitis, Peritonsillar abscess, Retropharyngeal abscess or lemierre syndrome.

Management: Primary care

Refer or seek urgent specialist advice for anyone who has severe oral mucositis.

Arrange appropriate specialist referral for anyone with a suspected serious (but not immediately life-threatening) cause for sore throat (such as cancer or HIV), with urgency determined by clinical judgement.

If the person is on chemotherapy, has known or suspected leukaemia, asplenia, aplastic anaemia or HIV/AIDS, or is taking an immunosuppressive drug following a transplant: seek specialist advise immediately, meanwhile check FBC urgently.

If the person is taking carbimazole (which can cause idiosyncratic neutropenia): Take an urgent FBC and withhold the drug until the result is available, seek specialist advice and consider prescribing an antibiotic.

If group A streptococcus (GAS) has been confirmed as the cause of sore throat by rapid antigen testing, or is strongly suspected after applying a FeverPAIN score (score 4 or 5) or Centor score of 3 or 4, and the results of throat cultures are pending, consider prescribing antibiotics.

DMARD and admission not appropriate: obtain FBC, withhold DMARD while awaiting the result/until discussed with rheumatology service, seek advise if low white cell count or deteriorates, consider prescribing antibiotic.

Prescribe phenoxymethylpenicillin as the first-choice antibiotic. In penicillin allergy, clarithromycin is an alternative. Prescribe erythromycin for a pregnant woman with penicillin allergy.

Arrange hospital admission with anyone with breathing difficulties, clinical dehydration, peri-tonsillar abscess ore cellulitis, parapharyngeal abscess retropharyngeal abscess or lemierre syndrome, signs of marked systemic illness or sepsis, or rare cause such as Kawasaki disease, diptheria or yersinial pharyngitis.

Antibiotics should not be withheld if the person has very severe symptoms and there is concern about their clinical condition.

For people not in a vulnerable group, and without severe symptoms, or who have a FeverPAIN score of 2 or3 consider a delayed antibiotic prescribing strategy.

Arrange 999 ambulance transfer for anyone with suspected epiglottitis

If the diagnosis of GAS needs to be confirmed with certainty (such as in people at high risk of rheumatic fever, vulnerable people such as the very old or young, or people who are at risk of immunosuppression, or people with very severe symptoms), arrange a rapid antigen test for group A streptococcus. A negative antigen test in a person (particularly a child) with suspected GAS should be followed up with a throat culture.

Common (non-strep) infectious causes: Common cold, influenza etc

If gonococcal or chlamydial infection is confirmed, treat appropriately.

If infectious mononucleosis is confirmed, see the CKS topic on Glandular fever (infectious mononucleosis) for advice on management.

If candidal pharyngitis is suspected, prescribe nystatin for mild to moderate cases, and fluconazole if the fungal infection is more widespread or the person has experienced a long duration of symptoms.

Advise adequate fluids. Use of ibuprofen/Paracetamol as antipyretic/analgesic. Salt water gargling, medicated lozenges may provide temporary relief. Hot drinks should be avoided as may exacerbate pain.

Recurrent tonsillitis - referral to ENT.

Routine follow up not required however safety netting important. Seek advise if symptoms not improved after 3/4 days of antibiotic therapy, or in pain does not improve after 3 days and/or fever is over 38.3, or if it becomes difficult to swallow salvia or liquids, any breathing difficuls, or one sided neck pain or throat swelling.