Sore Throat

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. The coronavirus that causes COVID-19 and other coronaviruses can also cause a sore throat. Rarer still, sore throat can be part of the initial infection with human immunodeficiency virus (HIV) or due to chronic fungal infections in people with HIV infections, such as thrush.

About 10% of sore throats in adults (and slightly more in children) are caused by a type of Streptococcus bacteria (streptococci). Such streptococcal infections are often called strep throat. Strep throat is unusual in children younger than 2 years. If untreated, streptococcal infections can lead to serious complications such as rheumatic fever (now rare in developed countries), a kidney disorder called glomerulonephritis, or an abscess)

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

Strep Throat

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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).

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 (epiglottitis). 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, in areas where most children are vaccinated against HiB, epiglottitis is quite rare in children, but HiB is still a cause in adults and unvaccinated children.

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 when children sit upright and lean forward, with their neck tilted back and jaw thrust forward to try to help them breathe better)

• 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

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. People with severe pain and/or other symptoms (such as fever, extreme fatigue, or a productive cough) typically should be seen right away.

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 them decide what, if any, tests need to be done (see table Some Infectious 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 fatigue before the sore throat (suggesting 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, which may occur in people with mononucleosis

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

Possible tests include

• Rapid strep screening (for children)

• Throat culture (for adults)

• Flexible fiberoptic laryngoscopy

• X-rays of the neck

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.

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.

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, computed tomography (CT) of the neck is performed.

Throat Swab

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