• Summary
  Click here to print a Quick Reference Guide
• Background
• Clinical Diagnosis
• Investigation
• Treatment
• Non-Antimicrobial Treatment
• Empirical Antimicrobial Treatment
• Directed Antimicrobial Treatment (when microbiology results are known)
• Duration of Treatment
• Switch to oral agent(s)
• Treatment Failure
• Referral Criteria

History - assess:

• Rapidity of onset of sore throat.
• Difficulty breathing/speaking.
• Ability to eat/drink/swallow.
• Associated neck pain/swellings.
• Symptoms of systemic infection e.g. fever, chills, rigors, general malaise.
• Travel history.

Examination -- assess

• Airway - patients with stridor need urgent senior review.
• Ability to swallow - patients unable to swallow secretions (drooling) need urgent ENT assessment.
• Examine oropharynx for trismus, erythema and tonsillar size
• Examine head and neck lymph nodes.
• Check MEWS score.

Diagnose acute tonsillar pharyngitis in patients with symmetrically inflamed tonsils and pharynx.
Severe infection: patient has marked systemic symptoms of infection and/or unable to swallow.
Non-severe infection (none of the above).

Consider infectious mononucleosis in patients with symmetrically inflamed tonsils / soft palate inflammation and posterior cervical lymphadenopathy

Suspect epiglottitis in patients with sudden onset of severe sore throat, no inflammation of the tonsils and/or oropharynx and systemic symptoms/signs of infection.

Suspect quinsy (peritonsillar abscess) in patients with systemic symptoms and asymmetrical tonsillar swelling.

Investigations required:

Outpatient/ambulatory treatment (non-severe infection): No routine investigations, unless infectious mononucleosis is suspected (see below).

Inpatients (severe infection):

• Suspected infectious mononucleosis: blood sample for Monospot or EBV VCA (viral capsular antigen) IgM and IgG antibody and EBNA IgG.
• Blood cultures, full blood count, urea and electrolytes and liver function tests

Non-Antimicrobial Management

Patients with stridor or suspected epiglottitis:

• Supplemental humidified high flow oxygen should be provided.
• Nebulised adrenaline (1mg adrenaline in 5mls sodium chloride 0.9%) in patients with rapidly deteriorating symptoms prior to securing an airway.
• Give helium/oxygen mixture (Heliox) if hypoxic in spite of supplemental oxygen.
• Establish an appropriate airway.
• A senior anaesthetist and senior ENT surgeon (Registrar or above) should be present.
• Patients should be intubated preferably in theatre with the ability to perform an emergency tracheostomy if intubation fails.

All patients:

• Analgesia e.g. paracetamol 1g 6-hourly or ibuprofen 200-400mg 6-hourly.
• Aspiration of peritonsillar / parapharyngeal abscess (Quinsy).

Antimicrobial treatment

Most acute sore throats do not require antibiotics.
Treat patients with severe acute tonsillar pharyngitis, quinsy or epiglottitis.
Consider antimicrobials in non-severe acute tonsillar pharyngitis if symptoms present for 1 week and getting worse.

*doses may need amending in renal impairment/failure.

Treatment course 10 days. Convert to oral medication after 24 hours if able to swallow and other oral switch criteria satisfied.

Referral criteria

In addition to above, patients with a suspected retropharyngeal abscess should be referred urgently to ENT

Back to top

The term acute sore throat describes the rapid onset of pain in the throat due to inflammation. This is usually caused by infection of the oropharyngx and/or tonsils. Epiglottitis is a rare but serious cause of acute sore throat.

Acute tonsillar pharyngitis

Acute tonsillar pharyngitis is commonly caused by viruses, however in a third of people, no cause can be found(1).
Common infectious causes include(1):

• Rhinovirus, coronovirus, parainfluenza virus (25% of sore throats).
• Influenza types A and B (4% of sore throats).
• Adenovirus (4% of sore throats).
• Herpes simplex virus type 1 (and more rarely type 2):(2% of sore throats).
• Epstein-Barr virus (glandular fever, < 1% of sore throats).
• Streptococcal infection. Group A beta-haemolytic Streptococcus (GABHS) is the most common bacterial cause of sore throat. (15–30% of sore throats in children, and 10% in adults). Group C and G beta-haemolytic streptococci can also cause acute tonsillar pharyngitis.
• Chlamydophylla pneumoniae and Mycoplasma pneumoniae are probably an under diagnosed cause of acute sore throat.

Rare cause of tonsillar pharyngitis:

• Neisseria gonorrhoeae (Gonococcal pharyngitis)
• HIV-1
• Corynebacterium diphtheriae (Diptheria)

How common is it?
A GP with 2000 patients will see around 120 people with an acute throat infection every year(2). In 1996 acute tonsillitis was the 8th commonest acute presentation to a GP practice. However, most people with sore throat do not visit their GP: one UK study found that only 1 in 18 episodes of sore throat led to a GP consultation(3).

Natural History?
Sore throat due to a viral or bacterial cause is usually a self-limiting condition. Symptoms resolve within three days in 40% of people, and within one week in 85% of people, irrespective of whether or not the sore throat is due to a streptococcal infection(4;5). The symptoms of infectious mononucleosis (Glandular fever) usually resolve within 1–2 weeks although mild cases may resolve within days. However lethargy often continues for some time afterwards and in rare cases may continue for months or years(6).

Epiglottitis

Epiglottitis, also termed supraglottitis, is an inflammation of structures above the glottis. The condition is almost always caused by bacterial infection. Affected structures include the epiglottis, aryepiglottic folds, arytenoid soft tissue, and, occasionally, the uvula(7). The epiglottis is the most common site of swelling. Acute epiglottitis and associated upper airway obstruction has significant morbidity and mortality and may cause respiratory arrest and death within 24 hours.

Causes of epiglottitis(7):

Haemophilus influenzae type b (Hib) was the commonest cause and the aetiological agent in more than 90% of paediatric epiglottitis cases but the Hb vaccine has significantly reduced the rate of epiglottis (1)(8)

• Other known bacterial causes include the following:
• Streptococcus pneumoniae
• Group A and group C (ie, beta-hemolytic) streptococci
• Staphylococcus aureus
• Moraxella catarrhalis
• Haemophilus parainfluenzae
• Neisseria meningitidis
• Pseudomonas species
• Candida albicans
• Klebsiella pneumoniae
• Pasteurella multocida
• Although viruses normally do not cause epiglottitis, a prior viral infection may allow bacterial superinfection to occur. Viral agents may include herpes simplex, parainfluenzae, varicella-zoster, and Epstein-Barr.
• Noninfectious aetiologies include thermal injuries, trauma, angioneurotic oedema, and acute leukaemia.

Persisting sore throat

Patients presenting with a persistently sore throat for more than three weeks should have their diagnosis reviewed. Consider non-infectious causes of sore throat (for example, gastro-oesophageal reflux disease, chronic irritation from cigarette smoke, alcohol, or hay fever).

Back to top

History:

Symptoms of tonsillitis and or pharyngitis are usually mild but severe pharyngeal pain, painful swallowing, headache, and a high temperature may be present(1). Patients may complain of a tender neck due to enlarging lymphadenopathy.
In practice it is not usually possible to distinguish between the different microbial causes of acute sore throat on clinical grounds. In particular it is not possible to diagnose acute streptococcal sore throat on clinical features alone.

Unilateral symptoms typically with referred otalgia, trismus and a ‘hot potato’ characteristic when speaking may indicate a developing a peritonsillar abscess (Quinsy).

Infectious mononucleosis presents in most people as a clinical triad of sore throat, fever, and lymphadenopathy. Sore throat is the most frequent complaint and jaundice may develop. It is usually severe for 3–5 days and then gradually resolves over 7–10 days. The degree of malaise is often out of proportion to the clinical picture(1;6;9).

Epiglottitis is characterized by abrupt onset of severe sore throat with painful swallowing that may rapidly progress to respiratory obstruction and death in a matter of hours. Fever is usually the first symptom and temperatures often reach 40°C. This is rapidly followed by stridor and laboured breathing. Dysphagia, refusal to eat, muffled (ie, guttural) or hoarse voice, and sore throat are common (10). A study of 35 people (34 adults and 1 infant) presenting with epiglottitis in Denmark found that 94% had painful swallowing, 60% had drooling, 57% had a history of fever, and 29% had a muffled voice. Only 4% had stridor (12).

Examination

The tonsils are inflamed and may be enlarged. A patchy grey-yellow exudate is often present on the tonsils and the uvula may be oedematous. The cervical lymph nodes, especially jugular digastric are enlarged and tender (1). If the tonsils are significantly enlarged stertor (a harsh inspiratory noise generated due to oropharyngeal congestion -not stridor) may be present. In severe cases patients may be dehydrated due to the difficulty in swallowing.

Figure 1 Acute Tonsillitis (viral or bacterial)

Figure 2 Acute tonsillar-pharyngitis

Patients presenting with a peritonsillar abscess (Quinsy) have an apparent unilateral tonsillar enlargement due to a collection of pus pushing the tonsil towards the midline. The uvula may be deviated and the abscess may point through the soft palate. The collection of pus around the pterygoid muscle results in trismus with poor mouth opening.

Rarely other suppurative complications may occur. Spreading sepsis may result in a retropharyngeal or parapharyngeal abscess or thrombosis of the internal jugular vein (Lemiere’s Syndrome).

Figure 3 Right peritonsillar abscess

Patients with infectious mononucleosis typically have a fever of 38–39°C. Cervical lymphadenopathy is symmetrical and includes the posterior triangle lymph nodes. The tonsils are usually symmetrically enlarged, occasionally meeting in the midline and the pharynx may be erythematous with exudate. Palatal petechiae may be present but are not diagnostic of infectious mononucleosis. Splenomegaly occurs in over 50% of people and is maximal at the beginning of the second week(9;11). A few people with infectious mononucleosis may develop jaundice, hepatomegaly, or a rash which may be macular, petechial, scarletiniform, urticarial, or like erythema multiforme.

Figure 4 Infectious mononucleosis

In patients with epiglottitis there is usually a normal looking oral cavity(1)

Figure 5 Epiglottitis

Scarlet fever
Scarlet fever is rare in the UK and consists of tonsillitis, a rash fig 6 and raspberry tongue fig 7. The child can only have the rash once in a lifetime. Scarlet fever begins with sudden high fever, throat pain and a rash. The rash is red and starts in the face later spreading onto the rest of the body. Penicillin should be started to reduce complications.


Figure 6 Scarlet fever rash

Figure 7 Scarlet fever strawberry tongue

Admission criteria for acute sore throat [Evidence level D]:

1. Severe infection.
   • Signs of being markedly systemically unwell.
   • Stridor, stertor, respiratory distress.
   • Unable/reluctant to swallow (drooling) or dehydrated.
   • Suspected suppurative complications (e.g. peri-tonsillar abscess, para-pharyngeal abscess, retropharyngeal abscess, or Lemiere syndrome -thrombosis of the jugular vein) as there is a risk of airway compromise or rupture of the abscess.
2. Immunosuppression. (severe, primarily neutropenic patients or those on chemotherapy.) Consider admission: always discuss with the paediatric haem/onc team. If febrile, refer to the neutropenic sepsis guideline

Back to top

Suspected tonsillar-pharyngitis:

• Recommendation: In patients presenting with non severe acute tonsillar pharyngitis no investigations are required. [Evidence level B]

• Recommendation: Throat swabs should not be carried out routinely in the investigation of acute sore throat. Throat swabs cannot differentiate between infection and carriage/colonisation, they have poor sensitivity, results take up to 48 hours to be reported and the analysis is relatively expensive (3;13). [Evidence level B]

• Recommendation: Rapid antigen tests for detection of group A streptococcal antigen on a throat swab are not recommended. Although these tests produce results within a few minutes they have poor sensitivity and make little impact on prescribing decisions (3;14). [Evidence level B]

• Recommendation: Patients with severe tonsillar-pharyngitis who are being admitted for intravenous antimicrobials should have the following tests: full blood count, white cell count, urea and electrolytes and blood cultures. [Evidence level D]

N.B Group A beta-haemolytic streptococci (GABHS) can be isolated from up to 30% of people presenting with sore throat (1). However, figures for asymptomatic carriage range from 6% to 40%(13). Carriers have low infectivity and are not at risk of developing complications.

Suspected peritonsillar abscess, retropharyngeal abscess

Recommendation: Patients with suspected peritonsillar abscess, retropharyngeal abscess should be referred to ENT and considered for aspiration or drainage. Aspirates should be sent for microscopy and culture. [Evidence level C]

Recommendation: As above, patients’ with severe tonsillar-pharyngitis who are being admitted for intravenous antimicrobials should have the following tests: full blood count, white cell count, urea and electrolytes and blood cultures. [Evidence level D]

Suspected infectious mononucleosis (glandular fever):

Recommendation: The following tests should be done:

• Full blood count, differential white cell count and blood film, Urea and electrolytes, Liver function tests.
• Heterophile antibodies (Monospot): N.B false negative results are less likely after the second week of the illness. False-negative rates may be 25% in week one of infection, falling to approximately 5% in week three.
• EBV VCA (viral capsular antigen) IgM and IgG antibody and EBNA IgG. EBV IgM -In children under 12 years of age and in people who are immunocompromised at any age, viral serology for the Epstein-Barr virus is preferred as the monospot test has a high false negative rate. A positive EBV VCA IgM result with negative EB VCA IgG and negative EBNA IgG supports the diagnosis of acute EBV infection.

Suspected epiglottis:
Recommendation: The following tests should be done:

• Blood culture x2 (Hib in 12-90% of cases)
• Swab of epiglottis obtained under direct vision (usually at endoscopy) (positive in 50% of cases)

• Full blood count, white cell count, urea and electrolytes and blood cultures.

[Evidence level D]

Back to top

Suspected epiglottitis and patients with stridor.

Recommendation: Supplemental oxygen should be provided. [Evidence level C]

• Nebulised adrenaline (1mg adrenaline in 5mls sodium chloride 0.9%) can be used in patients with rapidly deteriorating symptoms prior to securing an airway.
• Helium/oxygen mixture (Heliox) can be used in stridulous patients.

Recommendation: Establish an appropriate airway. [Evidence level B]

• A senior anaesthetist and senior ENT surgeon should be present.
• Patients should be intubated preferably in theatre with the ability to perform an emergency tracheostomy if intubation fails.

Evidence is extrapolated from children with epiglottitis; mortality rates for those who receive endotracheal intubation are less than 1%. Children who do not receive intubation have mortality rates as high as 10% (7;10).

All patients with sore throat
Analgesia.
Recommendation: Oral analgesics (e.g. paracetamol or ibuprofen) are recommended for the symptomatic relief of sore throat (3). A systematic review found systemic analgesics (paracetamol, nonsteroidal anti-inflammatory drugs) to be helpful in relieving symptoms of sore throat(15). [Evidence level A]

Local analgesia.
Recommendation: Routine use of local analgesics is not recommended. Although licensed for symptomatic relief of sore throat, the evidence for flurbiprofen lozenges and benzydamine gargle is poor. [Evidence level C]

Surgery
Recommendation: Patients with a suspected peritonsillar abscess or retropharyngeal abscess should be referred to ENT and considered for aspiration or drainage. [Evidence level C]

Back to top

Most treatment of acute sore throat is empirical because routine throat swabs are not recommended.

1. Tonsillar-pharyngitis

Prescribe antimicrobials for:

• Those with severe infection
• Persistent / worsening symptoms for at least one week
• Immunosuppression. (severe, primarily neutropenic patients or those on chemotherapy.)

Consider prescribing antimicrobials for:

• Those at increased risk of complications with systemic symptoms. Have a low threshold / delayed strategy for prescribing an antibiotic in the patient groups in Box 1.

Box 1. Patient groups at increased risk of complications from acute sore throat.

Empirical oral therapy

Recommendation: If the patient has non severe infection and is able to swallow prescribe Phenoxymethylpenicillin 500mg six hourly (or Clarithromycin if the person is allergic to penicillin). [Evidence level A].

Phenoxymethylpenicillin remains the treatment of choice compared with other antibiotic options, based on the combination of its proven efficacy, narrow spectrum, safety, and low cost (2;3;17).

Delayed prescribing strategy

Recommendations for the delayed antibiotic prescribing strategy are based on National Institute for Health and Clinical Evidence (NICE) guidelines (19). Patients are advised to take antibiotics within 48 hours if their symptoms show any sign of worsening. However no guidelines are offered on who should be offered a delayed prescribing strategy. A Cochrane review concluded that a delayed prescribing strategy reduced antibiotic use but was no different to a 'no antibiotics' prescribing strategy regarding symptom control, patient satisfaction, or complication rates (20).
This approach could be considered for patient groups in box 1.

Empirical intravenous therapy (patients admitted to hospital): 
Benzyl penicillin 1.2g 6-hourly iv (or Clarithromycin 500mg 12-hourly iv if true penicillin allergy) until they are able to manage oral medication.

Evidence to support the choice of antibiotic is limited and culture results from aspiration of any abscess are crucial to optimising antimicrobial treatment (see investigations/non antimicrobial management). However most studies suggest that penicillin to be an effective choice (21-23).[Evidence level D]

1. Peritonsillar Abscess
   Arrange admission and intravenous antibiotics.
   Recommended regimen Benzyl penicillin 1.2g 6-hourly iv
   Recommended regimen for patients with immediate-type (IgE mediated) allergy to penicillin: Clarithromycin 500mg 12-hourly IV
   [Evidence level C]
   
   
2. Antimicrobial Management of Epiglottitis
   A third-generation cephalosporin antibiotic with broad-spectrum activity against a range of bacteria, including H influenzae, Enterobacteriaceae, and Streptococci is recommended (7;10).
   Recommended regimen: Cefotaxime 1 g IV 8-hourly
   [Evidence level C]
   Recommended regimen for patients with immediate-type (IgE mediated) allergy to penicillin: Teicoplanin IV (see dosing guideline) plus Ciprofloxacin 400mg 12-hourly iv
   [Evidence level D]

Back to top

Most treatment of acute sore throat is empirical because routine throat swabs are not recommended.

1. Tonsillar-pharyngitis

Prescribe antimicrobials for:

• Those with severe infection
• Persistent / worsening symptoms for at least one week
• Immunosuppression. (severe, primarily neutropenic patients or those on chemotherapy.)

Consider prescribing antimicrobials for:

• Those at increased risk of complications with systemic symptoms. Have a low threshold / delayed strategy for prescribing an antibiotic in the patient groups in Box 1.

Box 1. Patient groups at increased risk of complications from acute sore throat.

Empirical oral therapy

Recommendation: If the patient has non severe infection and is able to swallow prescribe Phenoxymethylpenicillin 500mg six hourly (or Clarithromycin if the person is allergic to penicillin). [Evidence level A].

Phenoxymethylpenicillin remains the treatment of choice compared with other antibiotic options, based on the combination of its proven efficacy, narrow spectrum, safety, and low cost (2;3;17).

Delayed prescribing strategy

Recommendations for the delayed antibiotic prescribing strategy are based on National Institute for Health and Clinical Evidence (NICE) guidelines (19). Patients are advised to take antibiotics within 48 hours if their symptoms show any sign of worsening. However no guidelines are offered on who should be offered a delayed prescribing strategy. A Cochrane review concluded that a delayed prescribing strategy reduced antibiotic use but was no different to a 'no antibiotics' prescribing strategy regarding symptom control, patient satisfaction, or complication rates (20).
This approach could be considered for patient groups in box 1.

Empirical intravenous therapy (patients admitted to hospital): 
Benzyl penicillin 1.2g 6-hourly iv (or Clarithromycin 500mg 12-hourly iv if true penicillin allergy) until they are able to manage oral medication.

Evidence to support the choice of antibiotic is limited and culture results from aspiration of any abscess are crucial to optimising antimicrobial treatment (see investigations/non antimicrobial management). However most studies suggest that penicillin to be an effective choice (21-23).[Evidence level D]

1. Peritonsillar Abscess
   Arrange admission and intravenous antibiotics.
   Recommended regimen Benzyl penicillin 1.2g 6-hourly iv
   Recommended regimen for patients with immediate-type (IgE mediated) allergy to penicillin: Clarithromycin 500mg 12-hourly IV
   [Evidence level C]
   
   
2. Antimicrobial Management of Epiglottitis
   A third-generation cephalosporin antibiotic with broad-spectrum activity against a range of bacteria, including H influenzae, Enterobacteriaceae, and Streptococci is recommended (7;10).
   Recommended regimen: Cefotaxime 1 g IV 8-hourly
   [Evidence level C]
   Recommended regimen for patients with immediate-type (IgE mediated) allergy to penicillin: Teicoplanin IV (see dosing guideline) plus Ciprofloxacin 400mg 12-hourly iv
   [Evidence level D]

Back to top

For both severe tonsillar-pharyngitis / quinsy and epiglottitis a 10–day treatment course is recommended (2;3).
[Evidence level A for tonsillar-pharyngitis and C for epiglottitis]

This is to ensure the maximal rate of eradication of the infection(17). In people with group A streptococcal pharyngitis, one randomized trial found that those treated with Phenoxymethylpenicillin for 7 days had a significantly greater treatment failure rate (30/96, 31%) compared with those receiving 10 days of Phenoxymethylpenicillin (17/95, 18%). Compliance rates were 66–81% of patients(18).

Back to top

Recommendation: For epiglottitis give intravenous antibiotics for a minimum of 48 hours. [Evidence level D] Change to oral antimicrobials when the patient can tolerate oral fluids and antibiotics. Oral 

Co-amoxiclav 625mg 8-hourly is an appropriate choice in the absence of positive cultures. [Evidence level D]

Recommendation: Patients with severe tonsillar-pharyngitis give intravenous antibiotics for a minimum of 24 hours and change to oral when patient can manage fluids. [Evidence level C]

Recommendation: Patients with peritonsillar abscess consider oral switch after 24 hours provided the abscess has been drained. [Evidence level D]

Back to top

Back to top

Refer patients with suspected quinsy, retropharyngeal or parapharyngeal abscess, epiglottitis or severe sepsis to ENT as a matter of urgency.
[Evidence level C]

Refer anyone with suspected cancer to ENT as a matter of urgency - especially if there is a persistent neck mass, red/white patches, or ulceration or swelling of the oral/pharyngeal mucosa for more than 3 weeks.
[Evidence level C]

Back to top