What are the next steps for a persistent sore throat lasting 2 months?

Persistent Sore Throat for 2 Months: Urgent Evaluation Required

A sore throat lasting 2 months is highly atypical and requires immediate evaluation for serious non-infectious causes, particularly malignancy, as well as life-threatening complications—this is not simple pharyngitis and should never be treated empirically with antibiotics. 1

Why This Duration is Concerning

• Most viral and bacterial pharyngitis resolves within less than one week, with over 80% achieving complete symptom resolution by 7 days 1, 2
• Even untreated streptococcal pharyngitis shows fever disappearing within 3-4 days, with throat soreness lasting at most 1-2 days longer than antibiotic-treated cases 1, 2
• Persistence beyond 2 weeks without other symptoms is atypical and warrants consideration of non-infectious causes 1
• The ESCMID guideline specifically excludes persistent cases (>14 days) from their acute pharyngitis algorithms, recognizing these require different diagnostic approaches 1

Immediate Evaluation Steps

Rule Out Life-Threatening Complications First

Evaluate urgently for serious complications requiring immediate intervention 1, 3:

• Peritonsillar abscess (quinsy): unilateral throat swelling, trismus, uvular deviation, muffled "hot potato" voice 4
• Lemierre syndrome: internal jugular vein thrombophlebitis with septic emboli, presents with pleuritic chest pain and pulmonary nodules 4
• Retropharyngeal abscess: neck stiffness, drooling, respiratory distress 3
• Descending mediastinitis: severe pleuritic chest pain, can originate from tonsillar abscess 4
• Epiglottitis: cherry-red epiglottis, respiratory compromise, requires aggressive early airway management 5, 3

Consider Non-Infectious Etiologies

At 2 months duration, non-infectious causes become the primary concern 1:

• Malignancy: particularly important in adults; oropharyngeal cancer, laryngeal cancer, or lymphoma must be excluded 1
• Gastroesophageal reflux disease (GERD): can present as chronic throat irritation without typical heartburn symptoms 6, 1
• Thyroiditis: uncommon but recognized cause of persistent throat pain 5

Specific Diagnostic Workup

Direct laryngoscopy/nasopharyngoscopy is essential to visualize the pharynx, larynx, and surrounding structures for masses or structural abnormalities 1

For GERD evaluation if suspected 6:

• Clinical profile assessment: chronic throat clearing, hoarseness, globus sensation
• 24-hour esophageal pH monitoring if empiric therapy fails
• Do NOT rely on Bernstein test (negative result cannot exclude GERD as cause)

What NOT to Do

Critical Pitfalls to Avoid

• Do not assume this is streptococcal pharyngitis and prescribe antibiotics empirically—the 2-month duration makes this diagnosis essentially impossible 1
• Do not apply Centor or modified Centor scores—these tools are validated only for acute presentations (<14 days) and have no role in persistent cases 6, 1
• Do not dismiss the patient with reassurance alone—absence of other symptoms does not rule out serious pathology in a 2-month presentation 1
• Do not order throat culture or rapid strep test—these are irrelevant at this duration and will delay appropriate workup 1

Symptomatic Management While Evaluating

• Ibuprofen or acetaminophen for pain relief remain appropriate first-line analgesics regardless of underlying etiology 1, 7
• Salt water gargles and throat lozenges may provide temporary relief 7

If Streptococcal Infection Were Somehow Confirmed

Even if testing were positive (which would be incidental colonization, not causative):

• Penicillin V 250-500mg twice or three times daily for 10 days remains first-line 1, 7
• However, at 2 months duration, antibiotic benefit for symptom reduction is negligible as the natural course has already exceeded the 1-2 day benefit window 1, 2

The Bottom Line

This patient needs urgent ENT referral and direct visualization of the pharynx/larynx, not antibiotics. The 2-month duration places this outside the realm of typical infectious pharyngitis and into the differential of malignancy, chronic inflammatory conditions, or serious complications requiring surgical intervention 1, 4, 3.