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Associate Editor(s)-in-Chief: Mydah Sajid, MD[1]

Sore throat in adults resident survival guide

Overview

Sore throat is one of the most common complaints among patients visiting their primary care physicians. In the United States, approximately 12 million ambulatory care visits are due to sore throat annually[1]. It mostly occurs in children and adolescents. The etiology is mostly acute self- limiting viral infection. Group A streptococcal infection is the most common causative bacteria for acute pharyngitis in adults[2]. As a physician, it is important to identify clinical signs for life-threatening airway obstruction and deep tissue infection and treat them promptly. This section provides a short and straight to the point overview of the sore throat in adults.

Causes

Life-threatening Causes

Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated.

  • Does not include any known cause

Common Causes

  • Viral upper respiratory tract infection (Adenovirus, rhinovirus, coronavirus, enterovirus, influenza A and B, parainfluenza virus, respiratory syncytial virus, and severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). [3][4][5]
  • Group A streptococcal (GAS) infection
  • Group C and G Streptococcus infection[6]
  • Arcanobacterium haemolyticum[6]
  • Fusobacterium necrophorum[7]
  • Mycoplasma and Chlamydia species[3]
  • Corynebacterium diphtheriae
  • Acute HIV infection[8]
  • Neisseria gonorrhoeae
  • Epstein-Barr virus and other herpes viruses cytomegalovirus (CMV) and herpes simplex virus (HSV)[9]
  • allergic rhinitis, sinusitis
  • gastroesophageal reflux disease
  • smoking
  • inhalation of dry air (particularly in winters)
  • Vocal strain[10]
  • Medications: Angiotensin-converting enzyme inhibitors, chemotherapeutic drugs[10]

Evaluation

Shown below is an algorithm summarizing the diagnosis of sore throat in adults[11][12][13]:

Treatment

Shown below is an algorithm summarizing the treatment of sore throat in adults according to the Infectious Diseases Society of America guidelines.[6][14]

 
 
 
 
 
 
 
Are Alarming clinical signs for upper airway obstruction or deep neck infection present?
  • “Hot potato” voice
  • Drooling
  • Stridor
  • Respiratory distress
  • “Tripod position”
  • Fever and chills
  • Severe unilateral sore throat
  • Bulging of the pharyngeal wall or soft palate
  • History of penetrating trauma to the neck
  • Lockjaw
  • Crepitus
  • Neck stiffness
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Stabilize ABC and refer patient urgently to emergency or inpatient care unit
 
 
 
 
 
 
 
 
Are clinical signs for Viral URTI (including conjunctivitis, coryza, cough, viral exanthem and voice hoarseness) present?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Manage patient with supportive care.
 
Does patient have clinical features of GAS throat infection?
  • Fever (temperature ≥100.4 degrees F)
  • Acute onset of sore throat
  • Inflammation and edema of tonsillopharyngeal and uvular mucosa
  • Tonsillar and peritonsillar yellow or white exudates
  • Painful cervical lymphadenopathy
  • Scarlatiniform rash
  • History of GAS exposure
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
Uncertain
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Apply Centor criteria for patient's clinical signs and symptoms. Is score ≥3?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Perform Rapid antigen detection test
 
 
 
 
 
 
 
 
 
 
 
Consider other viral, bacterial or noninfectious causes of sore throat. The illness is mostly self-limiting and specific tests for diagnosis are not carried out.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Positive
 
 
 
 
Negative
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Perform throat culture in patients with any of the following risk factors:
  • Patient with weak immune system or history of complications of GAS infection i.e. acute rheumatic fever.
  • Patients in close contact with individuals who have a high risk of complications (i.e. infants and immunocompromised elderly population)
  • Young adults living in close proximity (i.e. college dormitories)
  • Patients residing in endemic areas of acute rheumatic fever
  • Patient with negative RADT but with Centor criteria scores ≥3
 
 

Do's

  • Physicians should administer antibiotics with judicious care in patients with a sore throat due to the risk of developing adverse reactions and bacterial resistance in the community. A physician should only prescribe antibiotics in patients with high clinical suspicion for GAS or those with positive rapid antigen detection test and throat culture[15].
  • Antibiotics reduce the severity of symptoms and fasten the rate of recovery in the patients. The primary goal of treatment with antibiotics is to reduce the incidence of complications with GAS infection[16].
  • The Infectious Disease Society of America (IDSA) has recommended the use of aspirin, nonsteroidal anti-inflammatory drugs (NS-AIDs), or acetaminophen as supportive therapy for alleviation of pain[6]. The randomized clinical trials have shown NSAIDs as a more effective option for the relief of symptoms compared to acetaminophen[17].

Dont's

  • The oral glucocorticoids should not be prescribed to patients as their adverse effects outweigh their benefits as an oral analgesics. Glucocorticoids should only be considered in patients with significant odynophagia and dysphagia.

References

  1. ↑ Schappert SM, Rechtsteiner EA (2008). "Ambulatory medical care utilization estimates for 2006". Natl Health Stat Report (8): 1–29. PMID 18958997.
  2. ↑ Komaroff AL, Pass TM, Aronson MD, Ervin CT, Cretin S, Winickoff RN; et al. (1986). "The prediction of streptococcal pharyngitis in adults". J Gen Intern Med. 1 (1): 1–7. doi:10.1007/BF02596317. PMID 3534166.
  3. ↑ 3.0 3.1 Huovinen P, Lahtonen R, Ziegler T, Meurman O, Hakkarainen K, Miettinen A; et al. (1989). "Pharyngitis in adults: the presence and coexistence of viruses and bacterial organisms". Ann Intern Med. 110 (8): 612–6. doi:10.7326/0003-4819-110-8-612. PMID 2494921.
  4. ↑ Bisno AL (2001). "Acute pharyngitis". N Engl J Med. 344 (3): 205–11. doi:10.1056/NEJM200101183440308. PMID 11172144.
  5. ↑ Arons MM, Hatfield KM, Reddy SC, Kimball A, James A, Jacobs JR; et al. (2020). "Presymptomatic SARS-CoV-2 Infections and Transmission in a Skilled Nursing Facility". N Engl J Med. 382 (22): 2081–2090. doi:10.1056/NEJMoa2008457. PMC 7200056 Check |pmc= value (help). PMID 32329971 Check |pmid= value (help).
  6. ↑ 6.0 6.1 6.2 6.3 Shulman ST, Bisno AL, Clegg HW, Gerber MA, Kaplan EL, Lee G; et al. (2012). "Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America". Clin Infect Dis. 55 (10): 1279–82. doi:10.1093/cid/cis847. PMID 23091044.
  7. ↑ Centor RM, Atkinson TP, Ratliff AE, Xiao L, Crabb DM, Estrada CA; et al. (2015). "The clinical presentation of Fusobacterium-positive and streptococcal-positive pharyngitis in a university health clinic: a cross-sectional study". Ann Intern Med. 162 (4): 241–7. doi:10.7326/M14-1305. PMID 25686164.
  8. ↑ Tindall B, Barker S, Donovan B, Barnes T, Roberts J, Kronenberg C; et al. (1988). "Characterization of the acute clinical illness associated with human immunodeficiency virus infection". Arch Intern Med. 148 (4): 945–9. PMID 3258508.
  9. ↑ McMillan JA, Weiner LB, Higgins AM, Lamparella VJ (1993). "Pharyngitis associated with herpes simplex virus in college students". Pediatr Infect Dis J. 12 (4): 280–4. doi:10.1097/00006454-199304000-00004. PMID 8387178.
  10. ↑ 10.0 10.1 Renner B, Mueller CA, Shephard A (2012). "Environmental and non-infectious factors in the aetiology of pharyngitis (sore throat)". Inflamm Res. 61 (10): 1041–52. doi:10.1007/s00011-012-0540-9. PMC 3439613. PMID 22890476.
  11. ↑ Snow V, Mottur-Pilson C, Cooper RJ, Hoffman JR, American Academy of Family Physicians. American College of Physicians-American Society of Internal Medicine; et al. (2001). "Principles of appropriate antibiotic use for acute pharyngitis in adults". Ann Intern Med. 134 (6): 506–8. doi:10.7326/0003-4819-134-6-200103200-00018. PMID 11255529.
  12. ↑ Fine AM, Nizet V, Mandl KD (2012). "Large-scale validation of the Centor and McIsaac scores to predict group A streptococcal pharyngitis". Arch Intern Med. 172 (11): 847–52. doi:10.1001/archinternmed.2012.950. PMC 3627733. PMID 22566485.
  13. ↑ Webb KH, Needham CA, Kurtz SR (2000). "Use of a high-sensitivity rapid strep test without culture confirmation of negative results: 2 years' experience". J Fam Pract. 49 (1): 34–8. PMID 10678338. Review in: J Fam Pract. 2000 Jul;49(7):660
  14. ↑ Harris AM, Hicks LA, Qaseem A, High Value Care Task Force of the American College of Physicians and for the Centers for Disease Control and Prevention (2016). "Appropriate Antibiotic Use for Acute Respiratory Tract Infection in Adults: Advice for High-Value Care From the American College of Physicians and the Centers for Disease Control and Prevention". Ann Intern Med. 164 (6): 425–34. doi:10.7326/M15-1840. PMID 26785402.
  15. ↑ Little P, Gould C, Williamson I, Warner G, Gantley M, Kinmonth AL (1997). "Reattendance and complications in a randomised trial of prescribing strategies for sore throat: the medicalising effect of prescribing antibiotics". BMJ. 315 (7104): 350–2. doi:10.1136/bmj.315.7104.350. PMC 2127265. PMID 9270458.
  16. ↑ BRINK WR, RAMMELKAMP CH, DENNY FW, WANNAMAKER LW (1951). "Effect in penicillin and aureomycin on the natural course of streptococcal tonsillitis and pharyngitis". Am J Med. 10 (3): 300–8. doi:10.1016/0002-9343(51)90274-4. PMID 14819035.
  17. ↑ Lala I, Leech P, Montgomery L, Bhagat K (2000). "Use of a simple pain model to evaluate analgesic activity of ibuprofen versus paracetamol". East Afr Med J. 77 (9): 504–7. doi:10.4314/eamj.v77i9.46696. PMID 12862143.
 
 
 
 
 
 
 
Does patient have strong clinical suspicion for viral URTI?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Is patient having clinical picture suggestive of GAS pharyngitis along with positive RADT?
 
 
 
 
 
 
 
 
Manage patient with supportive care including analgesics, hot fluids, lozenges, and soft diet.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Treat patients with empirical antibiotic course for 10 days
  • The drug of choice is 500mg oral penicillin V two or three times a day.
  • Benzathin G penicillin intramuscular injection can be administered as a single dose.
  • Cephalosporins or Macrolides should be given to patients experiencing allergic reactions with penicillin.
 
Provide supportive care to the patients.
  • If the patients have risk factors suggestive of other causes (i.e. acute HIV infection, gonorrhea, or non-infectious causes), perform relevant investigations.
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