What is the appropriate workup and management for a patient with chronic sore throat?

Workup and Management of Chronic Sore Throat

The appropriate workup for chronic sore throat should focus on identifying potential infectious, inflammatory, and structural causes, with treatment targeted at the underlying etiology rather than empiric antibiotic therapy.

Initial Evaluation

History

• Duration of symptoms (chronic defined as >2 weeks)
• Associated symptoms:
  • Fever
  • Exudates
  • Cervical lymphadenopathy
  • Cough or rhinorrhea
  • Difficulty swallowing
  • Voice changes
  • Weight loss
  • Smoking and alcohol history

Physical Examination

• Complete examination of oropharynx and neck
• Inspection for:
  • Tonsillar exudates
  • Pharyngeal erythema
  • Cervical lymphadenopathy
  • Signs of upper airway obstruction

Diagnostic Approach

Clinical Scoring

• Apply Centor criteria to assess likelihood of Group A Streptococcal infection 1:
  • Fever >38.5°C
  • Absence of cough
  • Tender anterior cervical adenopathy
  • Tonsillar exudates

Laboratory Testing

• For patients with 3-4 Centor criteria:
  • Rapid antigen detection test (RADT) for Group A Streptococcus
  • Throat culture if RADT is negative 1
• For chronic symptoms:
  • Complete blood count
  • Consider testing for other pathogens (Mycoplasma, Chlamydia)
  • Consider EBV testing

Additional Testing

• Routine biomarkers like CRP or procalcitonin are not recommended for sore throat assessment 1
• For persistent symptoms:
  • Consider referral for laryngoscopy to evaluate for:
    • Laryngopharyngeal reflux
    • Chronic sinusitis with post-nasal drip
    • Structural abnormalities
    • Malignancy (especially in smokers/drinkers with unilateral symptoms)

Management

Symptomatic Treatment

• First-line treatment for most cases of sore throat should be symptomatic management with analgesics rather than antibiotics 1, 2
• Recommended analgesics:
  • Ibuprofen (shows best benefit-risk profile) 2
  • Acetaminophen/paracetamol 1
  • Flurbiprofen lozenges (effective for swollen and inflamed throat) 3

Topical Treatments

• Local anesthetics with documented efficacy 2:
  • Lidocaine (8mg)
  • Benzocaine (8mg)
  • Ambroxol (20mg)
• Salt water gargles (limited evidence but commonly used) 1

Antibiotic Therapy

• Only indicated for confirmed bacterial infections
• For Group A Streptococcal pharyngitis:
  • Penicillin V for 10 days is first-line therapy 1
  • Only prescribe for patients with positive streptococcal test results 1
• Antibiotics should not be used for patients with 0-2 Centor criteria 1
• Benefits of antibiotics are modest even in confirmed streptococcal cases:
  • Shorten duration by only 1-2 days
  • Number needed to treat: 6 after 3 days, 21 after 1 week 1

Special Considerations

• For severe presentations in adolescents and young adults, consider Fusobacterium necrophorum (associated with Lemierre syndrome) 1
• Rule out potentially life-threatening causes such as epiglottitis or retropharyngeal abscess, especially with severe symptoms 4

Follow-up

• If symptoms persist despite appropriate therapy:
  • Consider ENT referral
  • Evaluate for non-infectious causes:
    • Allergies
    • Gastroesophageal reflux disease
    • Chronic sinusitis
    • Occupational exposures
    • Malignancy

Common Pitfalls to Avoid

1. Overuse of antibiotics for viral pharyngitis (>60% of adults with sore throat receive antibiotics despite most cases being viral) 1
2. Failure to consider serious causes of persistent sore throat (malignancy, abscess)
3. Inadequate duration of antibiotic therapy when indicated (full 10-day course needed for streptococcal pharyngitis) 1
4. Using local antibiotics or antiseptics (not recommended due to lack of efficacy data) 2
5. Missing non-infectious causes of chronic throat pain

Remember that most cases of sore throat are viral in origin and will resolve with symptomatic management alone. Antibiotics should be reserved for confirmed bacterial infections to prevent antibiotic resistance and unnecessary side effects.