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 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
↑ 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.
