🩺 Sore Throat

Sore throat is an extremely common presentation, usually representing a self-limiting viral pharyngitis or tonsillitis. However, it can occasionally signal more serious pathology such as Quinsy or Epiglottitis. In the UK, management focuses on reducing unnecessary antibiotic prescribing using validated scoring systems while identifying patients at risk of airway compromise or systemic sepsis. Most cases resolve within a week with simple analgesia, but recognition of the 'B-side' of tonsillar infections—like glandular fever—is vital for appropriate advice regarding contact sports and alcohol.

Inquire about the onset, severity of pain, and presence of cough (absence of cough makes bacterial infection more likely). Ask about systemic symptoms like fever, malaise, and headache. Evaluate for 'red flag' symptoms such as difficulty breathing, inability to swallow liquids, or a muffled voice. Review social history for smoking and sexual history for risk of gonococcal pharyngitis or HIV seroconversion.

Assess the oropharynx for tonsillar enlargement, erythema, and the presence of exudates. Check for palatal petechiae (common in EBV). Palpate the cervical lymph nodes. Observe the patient's ability to swallow saliva (drooling is a red flag for epiglottitis). Check for trismus (difficulty opening the mouth), which suggests a peritonsillar abscess. Systemic examination should include abdominal palpation for splenomegaly if EBV is suspected.

Viral pharyngitis (Rhinovirus, Adenovirus), Group A Strep (GABHS), Infectious Mononucleosis (EBV), Peritonsillar abscess (Quinsy), Epiglottitis, Candidasis (thrush), and Aphthous ulcers.

Stridor, drooling, muffled 'hot potato' voice, trismus (inability to open mouth), unilateral swelling/uvular deviation, and 'tripod' positioning to breathe.

Diagnosis is primarily clinical. Rapid Antigen Detection Tests (RADTs) or throat swabs are not routinely recommended by NICE for standard cases but may be used in specific clusters. A Monospot test (or EBV serology) is indicated for suspected glandular fever. FBC may show lymphocytosis with atypical lymphocytes in EBV. If epiglottitis is suspected, do NOT examine the throat; instead, involve senior ENT/Anaesthetics and consider lateral neck X-ray or nasendoscopy in a controlled environment.

The Centor Criteria or FeverPAIN score should be used to estimate the probability of a bacterial (Streptococcal) infection. If the patient has a 'hot potato' voice and deviated uvula, suspect a peritonsillar abscess (Quinsy), which is a surgical emergency. Glandular fever (Infectious Mononucleosis) can cause a severe sore throat with significant exudate and should be suspected in teenagers with prolonged symptoms and hepato-splenomegaly. Avoid amoxicillin if glandular fever is suspected due to the risk of a maculopapular rash.

Mapped to 'Sore Throat' and 'Upper Respiratory Tract Infection'. Knowledge of the FeverPAIN and Centor criteria for antibiotic stewardship is essential. Understand the complications of Strep throat, such as rheumatic fever and post-streptococcal glomerulonephritis.