Sore throat is pain in the back of the throat. The pain can be severe and is usually worsened by swallowing. Many people refuse to eat or drink. Sometimes pain is also felt in the ear (nerves to the back of the throat run very close to nerves from the ear).

Causes

A sore throat results from infection (see Symptoms of Nose and Throat Disorders: Some Causes and Features of Sore Throat). The most common infection is

• Tonsillopharyngitis

Much less common, but more serious, causes of sore throat are

• Abscess
• Infection of the epiglottis (epiglottitis)

Abscess and epiglottitis are of particular concern because they may block the airway.

Tonsillopharyngitis: Tonsillopharyngitis is infection of the tonsils (patches of lymphoid tissue at the back of the throat) and the throat (pharynx). Doctors may use the term tonsillitis when the tonsils are particularly inflamed or the term pharyngitis when the tonsils are not particularly inflamed or when people who have no tonsils have a sore throat.

Tonsillopharyngitis is usually caused by a virus, typically one of the same viruses that causes the common cold. Most common colds begin with a mild sore throat. A less common viral cause is acute mononucleosis (caused by the Epstein-Barr virus), which occurs mainly in children and young adults. Rarer still, sore throat can be part of the initial infection with human immunodeficiency virus (HIV).

About 10% of sore throats in adults (and slightly more in children) are caused by Streptococcus bacteria (streptococci). Such streptococcal infections are often termed strep throat. Strep throat is unusual in children younger than 2 years.

Rare bacterial causes include gonorrhea and diphtheria (in countries with low vaccination rates).

Abscess: A collection of pus (abscess) may form beneath or near one of the tonsils (peritonsillar abscess). The usual cause is a streptococcal infection that has spread from the tonsils into deeper tissue. In young children, an abscess can form in the tissue at the back of the throat (retropharyngeal abscess).

Epiglottitis: The epiglottis is a small flap of tissue that closes the entrance to the voice box and windpipe during swallowing. The epiglottis can become infected by certain bacteria. This infection causes severe pain and swelling. The swelling can close off the windpipe, particularly in infants and children. Epiglottitis used to occur mainly in children and usually was caused by Haemophilus influenzae type B (HiB) bacteria. Now that most children are vaccinated against HiB, epiglottitis is quite rare in children, and most cases occur in adults.

Evaluation

Not every sore throat requires immediate evaluation by a doctor. The following information can help people decide whether a doctor's evaluation is needed and help them know what to expect during the evaluation.

Warning signs: In people with a sore throat, certain symptoms and characteristics are cause for concern. They include

• Squeaking sound when breathing in (stridor)
• Any sign of difficulty breathing (particularly the tripod position, in which children sit upright, leaning forward, with their neck tilted back and jaw thrust forward)
• Drooling
• Muffled, “hot potato” voice (speaking as if a hot object is being held in the mouth)
• Visible bulge in the back of the throat

When to see a doctor: People who have warning signs should go to the hospital right away.

People with a sore throat but no warning signs should call their doctor. People who have typical cold symptoms and mild to moderate discomfort may be advised to stay at home and treat their symptoms with over-the-counter (OTC) remedies (see Symptoms of Nose and Throat Disorders: Treatment). People with severe pain and/or other symptoms (such as fever, extreme fatigue, or a productive cough) typically should be seen within a day or 2.

What the doctor does: Doctors first ask questions about the person's symptoms and medical history and then do a physical examination. What doctors find during the history and physical examination helps decide what, if any, tests need to be done (see Symptoms of Nose and Throat Disorders: Some Causes and Features of Sore Throat).

During the medical history, doctors ask about the following:

• Symptoms of a runny nose, cough, and difficulty swallowing, speaking, or breathing
• Whether the person has had any general feeling of severe weakness before the sore throat (suggests mononucleosis)
• Whether the person has had a previous episode of mononucleosis (people rarely get mononucleosis twice)
• Whether people have any risk factors for gonorrhea (such as recent oral-genital sexual contact) or HIV infection (such as unprotected sex, multiple sex partners, or intravenous drug abuse)

During the physical examination, doctors focus on the nose and throat. However, if doctors suspect epiglottitis in children (because there are warning signs and no evidence of a cold), they do not examine the throat in their office because inserting a tongue depressor may cause a spasm that triggers complete airway blockage.

If epiglottitis is not suspected, doctors do the following:

• Look in the mouth to see whether the throat and/or tonsils are red, whether there are white patches (exudate) on the tonsils, and whether there are any bulges suggesting an abscess
• Examine the neck for enlarged, tender lymph nodes
• Feel the abdomen for an enlarged spleen

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Some Causes and Features of Sore Throat Cause Common Features* Tests Viral tonsillopharyngitis (infection of the tonsils and throat caused by a virus) Mild to moderate throat pain and little or no fever Usually a runny nose and/or cough Throat and tonsils that are slightly to very red and that may be coated with a white discharge or pus Sometimes one or two enlarged lymph nodes in the neck A doctor's examination Strep throat Often severe throat pain and fever Rarely a runny nose or cough Often a very red throat and tonsils that are coated with a white discharge or pus Usually one or two tender, enlarged lymph nodes in the neck Testing of a sample taken from the throat with a swab Mononucleosis (caused by the Epstein-Barr virus) Moderate to severe throat pain, high fever, and constant fatigue but no cold symptoms Usually in adolescents or young adults who have never had mononucleosis Often a very red throat and tonsils, coated with a white discharge or pus Typically many enlarged lymph nodes on both sides of the neck and sometimes an enlarged spleen detected during a doctor's examination A blood test for antibodies to Epstein-Barr virus Abscess† Severe throat pain, often fever, and no cold symptoms Sometimes a muffled voice that sounds as if a hot object is being held in the mouth ("hot potato" voice) Throat and tonsils that may be slightly to very red Typically substantial swelling on one side of the throat detected during the examination Usually removal of pus with a needle (for diagnosis and treatment) Sometimes CT of the neck Epiglottitis† (infection of the epiglottis—the small flap of tissue that covers the opening to the voice box, or larynx) Severe throat pain and difficulty swallowing that begin abruptly In children, often drooling and signs of severe illness (such as little or no eye contact, failure to recognize parents, and irritability) Sometimes (more often in children) respiratory symptoms, including Breathing rapidly (tachypnea) Squeaking when breathing in (stridor) Sitting upright and leaning forward, with the neck tilted back and jaw thrust forward (to try to increase the amount of air reaching the lungs) A throat that typically appears normal seen during the examination (however, examination may not be advisable) For most children and for adults who appear seriously ill, flexible fiberoptic laryngoscopy (insertion of a thin flexible tube into the throat to directly view the epiglottis), done in operating room Sometimes for people who do not have all the symptoms of epiglottitis and who do not appear seriously ill, x-rays of the neck *Features include symptoms and the results of the doctor's examination. Features mentioned are typical but not always present. †These causes are rare. CT = computed tomography.

Testing: The need for tests depends on what doctors find during the history and physical examination, particularly whether warning signs are present.

Possible tests include

• Flexible fiberoptic laryngoscopy
• X-rays of the neck
• Rapid strep screening (for children)
• Throat culture (for adults)

A doctor's first concern is to recognize which people might have epiglottitis. Stridor and drooling are warning signs, particularly in people who appear ill or with difficulty breathing. In such cases, people should not have x-rays. Instead, the doctor looks down the throat with a thin, flexible viewing tube inserted through the nose (flexible fiberoptic laryngoscopy). Because children are more likely to have sudden, complete blockage of their airway when their throat is examined, doctors minimize this danger by doing this examination only in the operating room, where advanced airway equipment and personnel are available. Adults who do not appear seriously ill and have no respiratory symptoms may have neck x-rays to look for a swollen epiglottis or have flexible fiberoptic laryngoscopy done in the emergency department or a specialist's office.

An abscess is often noticeable during the doctor's examination. The doctor can both diagnose and treat the abscess by inserting a small needle into the swollen area after spraying the throat with an anesthetic. If pus comes out, an abscess is confirmed, and the doctor removes as much pus as possible. If the location and extent of an abscess are unclear, doctors do a computed tomography (CT) scan of the neck.

Despite what many people think, it is difficult for doctors to distinguish a strep throat from a sore throat caused by a virus based only on appearance. Both may cause a very red throat with white patches. Thus, unless people clearly have just a cold, doctors usually do tests to diagnose strep throat. There are two types of test, a rapid strep antigen test and a throat culture. Both tests are done on a sample taken from the back of the throat with a swab. The rapid strep antigen test can be done in the doctor's office in about 20 minutes. The rapid test is usually done only in children. If results are positive, children are treated for strep throat with antibiotics. If results are negative, another sample is sent to the laboratory for culture (growing microorganisms on a special gel so that there are enough to identify). If adults need testing for strep throat, doctors usually do only a throat culture because adults may have another bacterial infection that would not be identified by the rapid antigen test.

Doctors do blood tests for mononucleosis or HIV only when they suspect people have one of these infections.

Treatment

Doctors treat any specific or underlying conditions. For example, people with strep throat or other bacterial infections are given antibiotics.

It is important to relieve the pain of sore throat so that people can eat and drink. IbuprofenSome Trade Names
ADVIL MOTRIN
or acetaminophenSome Trade Names
TYLENOL
help relieve pain and fever. People in severe pain may require the short-term use of opioids (such as oxycodoneSome Trade Names
OXYCONTIN
or hydrocodone). Warm saltwater gargles and throat lozenges or throat sprays (such as those containing benzocaineSome Trade Names
ANBESOL CEPACOL LANACANE
, lidocaineSome Trade Names
XYLOCAINE
, or dyclonineSome Trade Names
SUCRETS
) may temporarily help relieve pain. Providing soup is a good way to keep children well hydrated and nourished when swallowing is painful and before their appetite has returned.

Key Points

• Most sore throats are caused by viral tonsillopharyngitis and resolve without treatment.
• Occasionally, sore throats are caused by certain bacteria (particularly streptococci) and result in strep throat.
• It is difficult for doctors to distinguish viral from bacterial causes of tonsillopharyngitis without testing.
• Abscess and epiglottitis are rare but serious causes.

Last full review/revision July 2012 by Marvin P. Fried, MD