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Sore Throat

by Marvin P. Fried, MD

Pharyngitis (sore throat) is pain in the posterior pharynx that occurs with or without swallowing. Pain can be severe; many patients refuse oral intake.


Sore throat results from infection; the most common cause is

  • Tonsillopharyngitis

Rarely, an abscess or epiglottitis is involved; although uncommon, these are of particular concern because they may compromise the airway.


Tonsillopharyngitis is predominantly a viral infection; a lesser number of cases are caused by bacteria.

The respiratory viruses (rhinovirus, adenovirus, influenza, coronavirus, respiratory syncytial virus) are the most common viral causes, but occasionally Epstein-Barr virus (the cause of mononucleosis), herpes simplex, cytomegalovirus, or primary HIV infection is involved.

The main bacterial cause is group A β-hemolytic streptococci (GABHS), which, although estimates vary, causes perhaps 10% of cases in adults and slightly more in children. GABHS is a concern because of the possibility of the poststreptococcal sequelae of rheumatic fever, glomerulonephritis, and abscess. Uncommon bacterial causes include gonorrhea, diphtheria, mycoplasma, and chlamydia.


An abscess in the pharyngeal area (peritonsillar, parapharyngeal, and, in children, retropharyngeal) is uncommon but causes significant throat pain. The usual causative organism is GABHS.


Epiglottitis, perhaps better termed supraglottitis, used to occur primarily in children and usually was caused by Haemophilus influenzae type B (HiB). Now, because of widespread childhood vaccination against HiB, supraglottitis/epiglottitis has been almost eradicated in children (more cases occur in adults). Causal organisms in children and adults include Streptococcus pneumoniae, Staphylococcus aureus, nontypeable H. influenzae, Haemophilus parainfluenzae, β-hemolytic streptococci, Branhamella catarrhalis, and Klebsiella pneumoniae. HiB is still a cause in adults and unvaccinated children.



History of present illness should note the duration and severity of sore throat.

Review of systems should seek important associated symptoms, such as runny nose, cough, and difficulty swallowing, speaking, or breathing. The presence and duration of any preceding weakness and malaise (suggesting mononucleosis) are noted.

Past medical history should seek history of previous documented mononucleosis (recurrence is highly unlikely). Social history should inquire about close contact with people with documented GABHS infection, risk factors for gonorrhea transmission (eg, recent oral-genital sexual contact), and risk factors for HIV acquisition (eg, unprotected intercourse, multiple sex partners, IV drug abuse).

Physical examination

General examination should note fever and signs of respiratory distress, such as tachypnea, dyspnea, stridor, and, in children, the tripod position (sitting upright, leaning forward with neck hyperextended and jaw thrust forward).

Pharyngeal examination should not be done in children if supraglottitis/epiglottitis is suspected, because it may trigger complete airway obstruction. Adults with no respiratory distress may be examined but with care. Erythema, exudates, and any signs of swelling around the tonsils or retropharyngeal area should be noted. Whether the uvula is in the midline or appears pushed to one side should also be noted.

The neck is examined for presence of enlarged, tender lymph nodes. The abdomen is palpated for presence of splenomegaly.

Red flags

The following findings are of particular concern:

  • Stridor or other sign of respiratory distress

  • Drooling

  • Muffled, “hot potato” voice

  • Visible bulge in pharynx

Interpretation of findings

Supraglottitis/epiglottitis and pharyngeal abscess pose a threat to the airway and must be differentiated from simple tonsillopharyngitis, which is uncomfortable but not acutely dangerous. Clinical findings help make this distinction.

With supraglottitis/epiglottitis, there is abrupt onset of severe throat pain and dysphagia, usually with no preceding URI symptoms. Children often have drooling and signs of toxicity. Sometimes (more often in children), there are respiratory manifestations, with tachypnea, dyspnea, stridor, and sitting in the tripod position. If examined, the pharynx almost always appears unremarkable.

Pharyngeal abscess and tonsillopharyngitis both may cause pharyngeal erythema, exudate, or both. However, some findings are more likely in one condition or another:

  • Pharyngeal abscess: Muffled, “hot potato” voice (speaking as if a hot object is being held in the mouth); visible focal swelling in the posterior pharyngeal area (often with deviation of the uvula)

  • Tonsillopharyngitis: Accompanied by URI symptoms (eg, runny nose, cough)

Although tonsillopharyngitis is easily recognized clinically, its cause is not. Manifestations of viral and GABHS infection overlap significantly, although URI symptoms are more common with a viral cause. In adults, clinical criteria that increase suspicion of GABHS as a cause include

  • Tonsillar exudate

  • Tender lymphadenopathy

  • Fever (including history)

  • Absence of cough

Adults with 1 criterion reasonably may be presumed to have viral illness. If 2 criteria are present, the likelihood of GABHS is high enough to warrant testing but probably not high enough to warrant antibiotics, but this decision needs to be patient-specific (ie, threshold for testing and treatment may be lower in those at risk because of diabetes or immunocompromise). In children, testing usually is done.

Regarding rarer causes of tonsillopharyngitis, infectious mononucleosis should be considered when there is posterior cervical or generalized adenopathy, hepatosplenomegaly, and fatigue and malaise for > 1 wk. Patients with no URI symptoms but recent oral-genital contact may have pharyngeal gonorrhea. A dirty-gray, thick, tough membrane on the posterior pharynx that bleeds if peeled away indicates diphtheria (rare in the US). HIV infection should be considered in patients with risk factors.


If supraglottitis/epiglottitis is considered possible after evaluation, testing is required. Patients who do not appear seriously ill and have no respiratory symptoms may have plain lateral neck x-rays to look for an edematous epiglottis. However, a child who appears seriously ill or has stridor or any other respiratory symptoms should not be transported to the x-ray suite. Such patients (and those with positive or equivocal x-ray findings) usually should have flexible fiberoptic laryngoscopy. (C aution : Examination of the pharynx and larynx may precipitate complete respiratory obstruction in children, and the pharynx and larynx should not be directly examined except in the operating room, where the most advanced airway intervention is available .)

Pearls & Pitfalls

  • If epiglottitis is considered, directly examine a child's pharynx only in the operating room to minimize the risk of complete airway obstruction.

Many abscesses are managed clinically, but if location and extent are unclear, immediate CT of the neck should be done.

In tonsillopharyngitis, throat culture is the only reliable way to differentiate viral infection from GABHS. To balance timeliness of diagnosis, cost, and accuracy, one strategy in children is to do a rapid strep screen in the office, treat if positive, and send a formal culture if negative. In adults, because other bacterial pathogens may be involved, throat culture for all bacterial pathogens is appropriate for those meeting clinical criteria described previously.

Testing for mononucleosis, gonorrhea, or HIV is done only when clinically suspected.


Specific conditions are treated. Patients with severe symptoms of tonsillopharyngitis may be started on a broad-spectrum antibiotic (eg, amoxicillin/clavulanate) pending culture results.

Symptomatic treatments such as warm saltwater gargles and topical anesthetics (eg, benzocaine, lidocaine, dyclonine) may help temporarily relieve pain in tonsillopharyngitis. Patients in severe pain (even from tonsillopharyngitis) may require short-term use of opioids.

Key Points

  • Most sore throats are caused by viral tonsillopharyngitis.

  • It is difficult to clinically distinguish viral from bacterial causes of tonsillopharyngitis.

  • Abscess and epiglottitis are rare but serious causes.

  • Severe sore throat in a patient with a normal-appearing pharynx should raise suspicion of epiglottitis.

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