What is the treatment for excessive throat swelling in mononucleosis (mono)?

Treatment of Excessive Throat Swelling in Mononucleosis

For patients with infectious mononucleosis who develop excessive throat swelling causing airway compromise, immediate administration of intravenous corticosteroids (1-2 mg/kg/day methylprednisolone or equivalent) is the treatment of choice, with concurrent emergency department evaluation for potential airway management. 1

Immediate Assessment and Risk Stratification

When a patient with mononucleosis presents with excessive throat swelling, rapidly assess for signs of airway compromise:

• Difficulty swallowing (dysphagia) - a critical warning sign 1
• Shortness of breath or stridor - indicates significant airway narrowing 1
• "Kissing tonsils" - tonsils meeting at midline represent severe tonsillar hypertrophy 1
• Inability to handle secretions - suggests imminent airway obstruction 2

This represents a potentially life-threatening complication occurring in a small subset of patients, particularly adolescents and young adults. 2, 3, 1

Corticosteroid Therapy Protocol

For grade 2-3 airway compromise (moderate to severe swelling with respiratory symptoms):

• Initiate methylprednisolone 1-2 mg/kg/day intravenously 4
• Symptoms typically improve rapidly within hours of steroid administration 1
• Continue treatment until airway swelling resolves to grade <1 4
• Taper over 4-6 weeks for moderate cases, 6-8 weeks for severe cases 4

For mild throat swelling without respiratory compromise:

• Consider oral prednisone 10-20 mg/day 4
• Monitor closely for progression requiring escalation to IV therapy 4

Critical Management Considerations

Rule out bacterial superinfection: While the throat may appear erythematous and exudative, verify no concurrent streptococcal pharyngitis requiring antibiotics. 4, 5, 1 The American Academy of Pediatrics notes that EBV-related oral lesions typically do not present with exudates unlike bacterial pharyngitis. 5

Avoid aminopenicillins: Do not prescribe amoxicillin or ampicillin, as these cause a characteristic maculopapular rash in 80-100% of patients with active EBV infection. 3

Emergency airway management: Patients with severe airway compromise require immediate emergency department evaluation for potential intubation or emergency airway intervention. 2, 1 This is a medical emergency comparable to other causes of upper airway obstruction.

Supportive Care Measures

While corticosteroids address the airway swelling, provide concurrent symptomatic management:

• Topical analgesics: Benzydamine hydrochloride rinses for painful oral lesions 5
• Warm saline mouthwashes to cleanse the oral cavity 5
• Systemic analgesics: Ibuprofen or paracetamol for pain relief 4
• Avoid NSAIDs if splenic enlargement present due to bleeding risk 3

Monitoring and Follow-up

• Counsel patients about airway obstruction risk at initial diagnosis, as this is a recognized complication alongside splenic rupture and meningitis 1
• Serial examinations to assess response to corticosteroids 1
• Activity restriction: Avoid contact sports and strenuous exercise for 8 weeks or while splenomegaly persists 3

When Corticosteroids Fail

If no improvement occurs within 72 hours of corticosteroid therapy, escalate treatment and consult specialists:

• Consider tocilizumab (8 mg/kg) or infliximab (5 mg/kg) 4
• Alternative immunosuppressive agents may be necessary 4
• ENT consultation for potential surgical airway management 1

The key clinical pitfall is underestimating the severity of airway compromise in mononucleosis patients with throat swelling. This complication, while rare (occurring in <1% of cases), can be life-threatening and requires aggressive intervention. 2, 1 Physicians must maintain a high index of suspicion and act decisively when respiratory symptoms accompany pharyngeal swelling.