Sore throat

Abstract

Asore throat is a very common presenting complaint. In Scotland it has been estimated that as many as 51 per 1000 patients per year attend their GP or practice nurse with the symptom. However, the incidence of sore throat is much higher; it is estimated that only one in every 18 episodes of sore throat leads to a GP consultation. A sore throat can be the presenting symptom in a variety of acute and chronic conditions. This article describes the features and management of those conditions which are common and/or serious.

The GP curriculum and sore throat

Clinical example 3.15: Care of people with ENT, oral and facial problems lists that GPs should be able to:

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Manage primary contact with patients who have a common/important ENT, oral or facial problem

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Understand when watchful waiting and the use of delayed prescriptions are indicated

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Understand when urgent (or semi-urgent) referral to secondary care may be indicated e.g. quinsy

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Empower patients to adopt self-treatment strategies where possible

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Demonstrate effective strategies for dealing with parental concerns regarding ENT conditions such as recurrent tonsillitis e.g. explain why antibiotics are not always indicated

Anatomy

Figure 1 shows the normal anatomy of the oral cavity and oropharynx. The size and colour of the tonsils does not necessarily correlate well with the presence of acute infection. Therefore, patients may have large tonsils in the absence of inflammatory or infective pathology. The normal pharyngeal mucosa is also variable in colour and the degree of redness does not correlate well with the presence of inflammation. A clinically red throat’ may not show any inflammatory infiltrate on histological examination whereas a normal-looking’ pharyngeal mucosa may have signs of inflammation on histology (Bhalla, Taylor, Jones, and Roland, 2008).

Acute pharyngitis

Acute pharyngitis is a frequently occurring condition causing inflammation of both the tonsils and the rest of the pharyngeal mucosa. It is most commonly due to viral infection and usually associated with either a coryzal-type illness or a respiratory tract infection. Group A beta-hae-molytic Streptococcus (GABHS) is the main bacterial cause. The illness usually lasts between 3 and 4 days and supportive management such as analgesia is all that is required.

Tonsillitis

Symptoms

Acute tonsillitis is common, particularly in childhood. The cause can be bacterial or viral and distinguishing between the two clinically can be difficult. A prodromal illness with headache, malaise and fever may be described before the onset of features such as sore throat, odynophagia (pain on swallowing), neck pain (due to cervical lymphadenopathy) and otalgia. Otalgia in the case of tonsillitis is caused by referred pain along the glossopharyngeal nerve which supplies the middle ear mucosa as well as the oropharynx. Those with a viral precipitant may also complain of rhinorrhoea and a productive cough. The mean duration of illness is approximately a week.

Examination

On examination the tonsils are usually enlarged and erythematous and there may be exudates present. Cervical lymphadenopathy is common particularly at level II (jugu-lodigastric lymph nodes). The patient may be systemically unwell particularly if the causative agent is bacterial. Figure 2 shows the throat of a patient with tonsillitis (the asterisks show the site where a peritonsillar abscess would collect).

Cause

Table 1 summarises the causes of infective tonsillitis. Approximately 50–80% of patients have a viral cause for their sore throat and a further 1–10% is due to the Epstein Barr virus (Scottish Intercollegiate Guidelines Network (SIGN), 2010). Bacterial tonsillitis is most commonly due to Streptococcus pyogenes also known as GABHS infection. This organism accounts for up to 10% of sore throats in adults and between 15 and 30% of sore throats in children. (NHS Clinical Knowledge Summary, 2008).

Table 1.

Causes of tonsillitis.

Viral precipitants	Bacterial precipitants
Rhinovirus	GABHS
Adenovirus	Chlamydia pneumoniae
Coronovirus	Haemophilus influenzae
Influenza	Neisseria meningitides
Herpes simplex	Mycoplasma pneumoniae
Epstein Barr virus	Neisseria gonorrhoea

Diagnosis

Tonsillitis is a clinical diagnosis. Neither throat swabs for microscopy, culture and sensitivity nor swabs for rapid antigen testing are recommended for diagnosis of the causative organism in acute tonsillitis in primary care (SIGN, 2010). This is because there is a poor correlation between organisms grown on swabs from the surface of the tonsil and organisms from the infected tonsillar crypts or tonsillar core, and a large proportion of people are asymptomatic carriers of GABHS.

Treatment of tonsillitis

Given that a larger proportion of infective sore throats are due to viral rather than bacterial causes, current national guidance does not recommend antibiotics for all patients (National Institute for Health and Clinical Excellence (NICE), 2008; SIGN, 2010). The Centor criteria are used to help assess whether or not antibiotics are appropriate (Box 1). The presence of all four clinical features has a low positive predictive value of 40% for a throat swab to test positive for Group A Streptococcus, but the absence of all four variables has a negative predictive value of greater than 80%. Therefore, this scoring system is better for ruling out a streptococcal sore throat than proving it.

Box 1.

The Centor criteria.

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Tonsilar exudate

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Tender anterior cervical lymph nodes

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History of fever

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Absence of cough

NICE (2008) recommends that an immediate prescription for antibiotics should be issued if the patient:

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Is systemically very unwell

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Has signs and/or symptoms suggestive of serious illness and/or complications e.g. peritonsillar abscess, peritonsillar cellulitis

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Is at high risk of serious complications because of comorbidity (e.g. heart, renal or lung disease, immunosuppression, prematurity)

In addition, an immediate antibiotic prescription should be considered for patients with three or more Centor criteria.

For patients with fewer than three Centor criteria, either no antibiotic or a delayed prescription to use if symptoms do not settle within a week or get significantly worse in the interim is suggested. Delayed prescriptions reduce antibiotic usage by 63–80% compared with immediate prescription (NICE, 2008). For patients who are expecting to receive immediate antibiotics during a consultation, 70–90% who receive a delayed prescription instead are satisfied and would choose to receive a delayed prescription again in the future (NICE, 2008).

If antibiotics are indicated, treat according to local prescribing policy (usually penicillin V, or erythromycin or clarithromycin for those who are penicillin-allergic). Amoxicillin should not be used as it may cause a rash if the infection is caused by the Epstein Barr virus.

Adequate pain relief is important in the management of tonsillitis. Paracetamol is the first line treatment in children and ibuprofen is currently recommended as the first line treatment in adults (SIGN, 2010). The two treatments can be combined if needed. Caution should be taken when prescribing ibuprofen for a dehydrated patient as there is potential for renal failure to occur. If this is the case or if ibuprofen is not tolerated or contraindicated, then paracetamol alone should be prescribed.

Patient education

Prescribing antibiotics increases the number of attendances to the GP with a sore throat (Little et al., 1997). This may be due to an incorrect perception that antibiotics will either lessen the severity of the symptoms or will shorten the duration of illness. However, there are only marginal benefits of antibiotics over analgesics in reducing symptom severity and duration of illness is reduced by just 16 hours for patients with tonsillitis (Little et al., 1997).

Antibiotic prescribing is not without risks. For the individual there is a risk of side effects (such as diarrhoea, vomiting, skin rashes or anaphylaxis) which can be serious or even fatal. For society as a whole, as well as the cost of prescribing unnecessary drugs, indiscriminate prescribing increases community antibiotic resistance making serious infections requiring antibiotics harder to treat. When seeing patients with an infective sore throat, it is important to identify the patient's ideas, concerns and expectations regarding antibiotic prescribing. If the patient expects treatment with antibiotics but this is not clinically indicated a thorough explanation of the proper use of antimicrobial therapy is required. This helps to increase patient satisfaction with the consultation and maintain a good doctor/patient relationship.

If issuing a delayed prescription, it is important to explain carefully to the patient or patient's carer how to obtain and use the prescription. GPs do this differently: some GPs give the prescription to the patient together with advice about the expected duration of symptoms and when it is appropriate to take the prescription to the chemist; others leave a prescription at the practice reception desk for the patient to collect if symptoms worsen or do not clear up as expected. Whether issuing an immediate or delayed prescription safety-netting information advising the patient to seek further medical attention if becoming more unwell despite antibiotics or if there are any other concerns is essential.

Antibiotics should not be prescribed solely to prevent secondary complications of tonsillitis. This is because the rate of serious complications is low (SIGN, 2010). Furthermore, in many cases, complications such as a peritonsillar abscess develop quickly and patients do not present to their GP beforehand with tonsillitis (Dunn, Lane, Everitt, & Little, 2007).

Complications of tonsillitis

There are many possible complications of tonsillitis; however, the most serious complications only occur rarely in the UK. Complications are listed in Box 2.

Box 2.

Complications of tonsillitis.

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Quinsy

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Airway obstruction

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Otitis media

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Sinusitis

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Spread of infection: to the mastoid/brain (brain abscess/meningitis/skull osteomyelitis)/ endocarditis etc.

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Parapharyngeal abscess

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Retropharyngeal abscess

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Rheumatic fever (uncommon in the UK)

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Post streptococcal glomerulnephritis

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Septic arthritis

Indications for tonsillectomy

SIGN has issued guidance on the indications for tonsillectomy in patients with recurrent sore throat and these are set out in Box 3. For patients experiencing recurrent tonsillitis, the beneficial effects of tonsillectomy are greater in adults than in children (SIGN, 2010).

Box 3.

Indications for tonsillectomy.

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Seven episodes of tonsillitis in the past year

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Five episodes of tonsillitis each year in two consecutive years

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Three episodes of tonsillitis each year in three consecutive years

Each of the above episodes must be a documented tonsillitis which was disruptive to normal daily activities and treated with antibiotics.

Complications after tonsillectomy

Post-operatively, after tonsillectomy patients will have a sore throat and otalgia secondary to the operation. A small number of these patients may develop a prolonged sore throat and odynophagia/absolute dysphagia necessitating readmission to hospital. The major serious complication after tonsillectomy is haemorrhage. A reactionary haemorrhage is bleeding which begins within the first 24 hours of surgery; this occurs in 0.6% of patients. (Lowe et al., 2007). A secondary haemorrhage occurs more frequently and takes place approximately 5–10 days post-operatively. Up to 3% of patients will have a secondary haemorrhage which might be related to infection (Lowe et al., 2007). These patients should be referred back to hospital as an emergency.

Peritonsillar abscess

A peritonsillar abscess is also known as a quinsy’. The abscess forms in the peritonsillar space between the capsule of the tonsil (often superiorly) and the superior constrictor muscle. The condition may develop either spontaneously or shortly after a tonsillitis. Signs and symptoms are summarised in Table 2. There is often more than one causative organism; however, GABHS and anaerobes such as Peptostreptococcus are commonly implicated. Figure 2 demonstrates the site where a quinsy would develop and Fig. 3 shows a right-sided quinsy with the typical fullness of the soft palate and deviation of the uvula to the contralateral side.

Table 2.

Symptoms and signs of a peritonsillar abscess.

Symptoms	Signs
Unilateral sore throat	‘Hot potato’ voice Drooling
Odynophagia	Trismus
Headache	Peritonsillar swelling
Ipsilateral otalgia	Downwards displacement of the tonsil Bulging soft palate on one side Deviated uvula away from the side of the quinsy May be systemically unwell. Unilateral cervical lymphadenopathy

A patient with a quinsy usually requires same-day hospital admission for aspiration or incision and drainage of the abscess along with intravenous antibiotics such as benzylpenicillin. If the patient has had two episodes of peritonsillar abscess then this is often considered an indication for tonsillectomy once the acute infection has subsided. A quinsy has the potential to lead to life-threatening complications such as airway obstruction and parapharyngeal abscess formation.

Glandular fever

The term glandular fever is used to describe the triad of pharyngitis (causing a sore throat), fever and cervical lymphadenopathy. Infectious mononucleosis also describes this symptom triad but includes lymphocytosis with atypical lymphocytes (Hanna, 2012). The Epstein Barr virus (EBV) causes approximately 90% of cases of infectious mononucleosis. Other causes include cytomegalovirus, human herpes virus 6, toxoplasmosis and human immunodeficiency virus (HIV).

Symptoms and signs

EBV is spread via the saliva and accounts for approximately 1–10% of sore throat presentations (SIGN, 2010). Adolescents are the group most commonly affected. They may complain of a sore throat accompanied by high fevers. On examination the tonsils are enlarged bilaterally and are often completely covered in exudate (Fig. 4). Other signs which may be found on examination include:

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Symmetrical cervical lymphadenopathy

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Axillary and inguinal lymphadenopathy

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Rash

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Haemorrhagic petechiae on the palate

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Splenomegaly (50%) and

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Hepatomegaly.

Complications of glandular fever include thrombocytopenia, autoimmune haemolytic anaemia, splenic rupture, hepatitis (approximately 10%, often with signs of jaundice) and encephalitis.

Diagnosis and treatment

Full blood count shows a lymphocytosis with atypical lymphocytes. The majority of patients (90%) also have abnormal liver function tests. A definitive diagnosis of glandular fever caused by Epstein Barr virus (EBV) can be made through testing for EBV serology and/or a heterophil antibody test. Heterophil IgM produced by patients who have EBV infection characteristically agglutinates sheep red blood cells (Paul Bunnell test) or horse red blood cells (Monospot test).

After an explanation of the condition patients are usually given analgesia, antipyretics and advice on management in case of deterioration. Hospital admission is not usually required except in those who develop a major complication such as absolute dysphagia and dehydration, splenic rupture, airway compromise, significant thrombocytopenia or severe anaemia.

Patient advice

The acute illness of glandular fever tends to last for 1–2 weeks; however, fatigue and malaise can last for significantly longer than this (sometimes months or even years). It is important to advise patients to avoid contact sports for 6 weeks due to the risk of splenic rupture. Advice should also be given against drinking alcohol due to its potential to worsen already deranged liver function.

Parapharyngeal abscess

Spread of infection from the tonsil or quinsy through the superior constrictor muscle of the pharynx into the parapharyngeal space can result in a parapharyngeal abscess. This may present with a sore throat, trismus (inability to open the mouth fully), fever and malaise. On examination the patient has a swelling in the lateral pharyngeal wall which can cause displacement of the tonsil medially. Externally, there is often an erythematous upper lateral neck overlying a tender swelling.

This is a potentially fatal condition as airway obstruction may occur. Other serious complications include rapid spread of infection into the mediastinum and major haemorrhage due to carotid artery involvement. Therefore, if a parapharyngeal abscess is suspected a same-day referral to secondary care should be made.

Retropharyngeal abscess

A retropharyngeal abscess is an abscess in the retropharyngeal space. In children this tends to occur following suppuration of the retropharyngeal lymph node after a viral or bacterial sore throat. Foreign bodies such as fish bones also have the potential to perforate the posterior pharyngeal wall causing infection and subsequent retropharyngeal abscess formation. Another potential reason for the development of an abscess is the spread of tuberculosis from the cervical spine into the retropharyngeal space.

Symptoms and signs

Initially, there may be few symptoms and signs of a retropharyngeal abscess. Patients may present with a sore throat, odynophagia, dysphagia, neck stiffness, voice change, malaise and/or the feeling of a lump in the throat. Rarely, patients may present with spinal cord compression. On examination the pharynx may look completely normal or a swelling may be seen on the posterior pharyngeal wall. The patient may have fever, rigors, unilateral lymphadenopathy and/or airway compromise.

Management and complications

If a retropharyngeal abscess is suspected then emergency admission under the care of an ear, nose and throat (ENT) specialist is required as many life-threatening complications can occur. The most serious of these is the potential of the abscess to compress the airway and cause obstruction. Other complications include osteomyelitis of the cervical spine, abscess rupture leading to an aspiration pneumonia, mediastinitis and carotid artery rupture. Diagnosis is usually made on plain X-rays and computerised tomography. Management is with airway care, incision and drainage of the abscess and a course of intravenous antibiotics.

Oral candida

Candida causing thrush of the mouth and pharynx can cause sore throat. On examination the patient has creamy white plaques on the oropharynx (Fig. 5). In addition to making the diagnosis it is also important to consider the underlying cause. Dehydration, steroid inhalers, undiagnosed diabetes, chemotherapy, radiotherapy or HIV should all be part of the differential diagnosis.

Treatment in mild cases can be with a topical antifungal agent such as miconazole gel or nystatin suspension. In those with a more severe infection, or who are immunocompromised, systemic treatment with an oral drug such as fluconazole should be prescribed. If the patient is systemically unwell, admission for consideration of intravenous therapy is appropriate.

Epiglottitis

Epiglottitis is the condition that killed George Washington in 1799. His physicians considered performing a tracheostomy but opted to treat with venesection, draining a total of 2.5 L of blood. This procedure along with the underlying condition inevitably killed him.

Epiglottitis (supraglottitis) is the term used to describe inflammation and oedema of the epiglottis and surrounding structures usually caused by Haemophilus influenzae type B (HiB). Other causative organisms include Staphylococcus aureus, Streptococci, Candida albicans and Haemophilus parainfluenzae. Epiglottitis is an important condition to recognise as it can rapidly progress to fatal airway obstruction.

Epidemiology and presentation

The incidence of epiglottitis peaks between the ages of 3 and 7 years and then again during adulthood. Recently, there has been a shift in the prevalence of the condition towards the adult population due to the introduction of routine HiB immunisation as an integral part of the UK childhood vaccination programme. Signs and symptoms of the condition are listed in Table 3. Children are more likely to have a high fever, become irritable, drool and develop signs of airway obstruction. In adults the presentation may be less dramatic with the main complaint being that of a severe sore throat.

Table 3.

Symptoms and signs of epiglottitis.

Symptoms	Signs
RAPID onset: usually in hours	Drooling
Sore throat	Pyrexia
Fever	Stridor
Odynophagia	Hoarse voice
Cough	Cervical lymphadenopathy
Change in voice	Sitting in the tripod position’: sitting up and leaning forwards
Otalgia	Often systemically unwell

Management

In a paediatric patient it is important not to examine the throat, cannulate or take bloods as these procedures may cause anxiety and result in complete airway obstruction. Immediate hospital admission should be arranged via emergency (‘blue-light’) ambulance for airway care and intravenous antibiotics.

Scarlet fever

Scarlet fever is now an uncommon condition in the UK. It results from Group A Streptococcal infection and is most commonly seen in children, particularly those aged between 5 and 15 years. It initially causes a sore throat. Following this, the bacteria produce a toxin which causes a red rash to develop on the chest 1–2 days after the sore throat starts. This then spreads to involve the rest of the body sparing the palms of the hands, the soles of the feet and the face. On examination of the oropharynx tonsillitis and pharyngitis may be seen along with a red swollen strawberry tongue’. Treatment is with antibiotics.

Diptheria

Diptheria is rare in the UK due to childhood immunisation. It is, however, still endemic in Russia and the developing world. It is caused by Corynebacterium diphtheriae and can affect multiple body systems. Those presenting primarily with an ENT infection may have a purulent nasal discharge, fever and a sore throat. On examination the tonsils and oropharynx are initially discoloured white before forming a grey-green membrane that can cause airway obstruction.

All patients with suspected diphtheria should be referred as same-day emergencies to hospital. Patients are barrier nursed and treated with an antibiotic such as intravenous benzylpenicillin. In some cases depending on the site and severity of the condition an antitoxin may be given.

Diptheria is a notifiable disease. Consideration should also be given to close contacts of patients with a diagnosis of diptheria as they may require prophylactic antibiotics and immunisation.

Medication

Some drugs (for example, carbimazole and sulfasalazine) have the potential to cause haematological abnormalities such as neutropenia. Neutropenia can predispose individuals to pharyngeal ulceration and oropharyngeal infections. If a patient presents with a sore throat and is on a drug known to cause neutropenia then an urgent full blood count should be taken and the drug should be withheld until the result is obtained. If the white cell count is low or the patient is systemically unwell then urgent specialist advice should be sought.

Causes of a chronic sore throat

Chronic pharyngitis

A chronic sore throat in an adult may be due to physical irritation. Common irritants include smoking, alcohol, steroid inhalers, laryngopharyngeal reflux and sinusitis causing post nasal drip. After ruling out sinister pathology, management involves patient education surrounding precipitating factors and providing support with activities such as smoking cessation.

Cancers of the oral cavity or pharynx

Beware of the sore throat in adults lacking the typical features of an infective aetiology (such as fever) as this could indicate an underlying malignancy. The patient may present with a sore throat (which may be chronic), a neck lump and/or otalgia. The history should be used to identify any of the following red flags:

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Weight loss (lasting more than a few weeks)

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Hoarseness

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Dysphagia

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Otalgia in the absence of otitis media or otitis externa

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Smoking

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Alcohol excess

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Sore throat with otalgia.

Red flag examination findings may include a mass in the oropharynx and palpable cervical lymph nodes that persist longer than 6 weeks or are associated with other red flag features. Suspected malignancies and/or the presence of red flags warrant an urgent referral to ENT

When to refer to secondary care

An urgent referral to ENT should be made in the following situations:

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Peritonsillar abscess

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Signs of airway obstruction (stridor or stertor)

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Absolute dysphagia

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Systemically unwell

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Suspected epiglottitis

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Suspected parapharyngeal or retropharyngeal abscess

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The patient has an unexplained persistent sore or painful throat.

Key points

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Infective tonsillitis is a common cause of a sore throat; most cases are viral in origin

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The Centor criteria can be used to help identify patients requiring antibiotics when a patient is diagnosed with tonsillitis

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Patient education regarding antibiotic prescriptions for tonsillitis is an important part of the consultation

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If a serious complication such as a peritonsillar abscess, parapharngeal abscess or retropharyngeal abscesses is suspected an urgent, same-day ENT referral should be made

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Suspected epiglottitis should be referred to hospital as an emergency, the throat of these patients should not be examined

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Sore throat and unilateral otalgia lacking the acute features of infection should raise the suspicion of a malignancy

Footnotes

Acknowledgement

We would like to thank Dr Amy Dissanayake for her help with the writing of this article under the InnovAiT buddy’ scheme.

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