Red flag symptoms - Sore throat

It can be difficult to clinically distinguish between laryngitis, pharyngitis and tonsillitis, says Dr Tillman Jacobi.

A sore throat with adenopathy and possible enlargement of the spleen could indicate glandular fever
A sore throat with adenopathy and possible enlargement of the spleen could indicate glandular fever

Sore throats are one of the most common ENT complaints in general practice and affect all age groups. Most cases of sore throat are viral in origin and can be part of a temporary upper respiratory tract infection.

It can be difficult to clinically distinguish laryngitis, pharyngitis and tonsillitis. Routinely swabbing sore throats is mostly unnecessary and unhelpful.

Red flay symptoms
  • Unilateral
  • Prolonged in smokers or heavy drinkers
  • Immunosuppressed patient
  • Severe swallowing problems and dehydration
  • Breathing difficulties or stridor
  • Behavioural changes

The main bacterial cause of tonsillitis is group A beta-haemolytic streptococcus, accounting for up to 10 per cent of cases. It is associated with post-strep complications, including rheumatic fever and glomerulonephritis.

However, there is little evidence that antibiotic treatment is effective in preventing these complications.

Cause for concern
Due to the nerves in the oral region, any irritation or swelling may feel amplified to the patient. It is concerning if a sore throat causes breathlessness, stridor or significant dysphagia with or without recurrent sickness and an accelerating risk of dehydration.

In these cases, admission to hospital is necessary, even if it turns out to be only a short stay with improvement resulting from fluid resuscitation, adequate analgesia and possible IV antibiotic treatment.

If physical examination shows significant unilateral swelling in the area of the tonsillar bed in a patient with a 'hot potato' voice, there may be a peritonsillar abscess (quinsy) that typically needs drainage.

It is worth remembering that quinsy is unlikely to gradually build up on top of ongoing tonsillitis but that it typically develops suddenly.

Children and infants
Close examination of the back of the throat is contraindicated in feverish and drooling infants with a chance of epiglottitis, because of the risk of respiratory arrest. Since the introduction of HiB vaccinations the potential for epiglottitis has decreased.

In young patients and sore throat with general malaise, posterior cervical or generalised adenopathy and possible enlargement of the spleen, you should suspect glandular fever.

Testing for glandular fever can be unreliable, because the Monospot test only shows a positive result two weeks after the infection has started.

There have been reports of children developing baffling mental health problems after a sore throat, including anxiety, tics and obsessive behaviour.

Sore throat in adults
Smokers and heavy drinkers with prolonged (>three weeks) soreness in the back of the throat, with or without visible lesions, should be referred for potential oral cancer.

Equally, any patient with significant and possibly progressive swelling of other lymphatic structures may need to be checked for the chance of non-Hodgkin's lymphoma and related conditions.

Patients known to be immunosuppressed because they are taking medication (namely methotrexate) should report any occurrence of a sore throat immediately to exclude agranulocytosis. In some patients, reflux, either experienced as heartburn or as asymptomatic silent reflux, can cause and maintain a sore throat.

Occasionally, foreign bodies need to be excluded in the case of a continuing sore throat, although this applies more to children and patients with behavioural problems.

  • Dr Jacobi is a salaried GP in York
  • Streptococcal or viral tonsillitis
  • Glandular fever
  • Oesophageal reflux
  • Oral cancer
  • Peritonsillar abscess (quinsy)
  • Epiglottitis
  • Foreign body

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