What is the best course of treatment for a chronic sore throat with swelling near the root of the tongue and difficulty swallowing?

Chronic Recurrent Pharyngitis with Lingual Root Swelling

For a singer with chronic recurrent sore throat, swelling at the tongue root, and dysphagia requiring urgent resolution, immediate evaluation for serious deep space infection (tongue abscess, lingual tonsillitis, or peritonsillar abscess) is essential, followed by symptomatic management with ibuprofen 400mg and consideration of whether this represents chronic GAS carriage versus recurrent acute infection. 1, 2

Immediate Evaluation Required

This presentation demands urgent assessment to exclude life-threatening conditions:

• Tongue abscess presents with swelling in deep tongue tissues, throbbing pain radiating to ears, dysphagia, and potential airway compromise—this is a rare but serious condition requiring immediate drainage 1
• Deep space infections (retropharyngeal abscess, epiglottitis) can present similarly and require aggressive early airway management 3
• Examine for fluctuance, asymmetric swelling, trismus, drooling, or respiratory distress—any of these findings necessitates emergency ENT consultation 1, 3

Distinguishing Chronic Carriage from Recurrent Infection

The pattern of "regular recurrence for years" suggests chronic GAS carriage with intercurrent viral infections rather than true recurrent bacterial pharyngitis:

• Chronic pharyngeal carriers harbor GAS without active immunologic response, may be colonized for ≥6 months, and experience viral pharyngitis episodes that mimic streptococcal infection 4
• Up to 20% of school-age children (and adults in similar environments like performers) may be asymptomatic GAS carriers during winter/spring 4
• Key distinction: Carriers don't require antimicrobial therapy, are unlikely to spread infection, and have very low risk of complications 4

Clinical clues favoring chronic carriage over acute infection:

• Recurrent episodes despite previous antibiotic courses 4
• Symptoms occurring "regularly for years" rather than isolated episodes 4
• If testing shows GAS but patient lacks rising anti-streptococcal antibody titers 4

Symptomatic Management (First Priority)

Regardless of etiology, immediate symptom relief is critical for the upcoming audition:

• Ibuprofen 400mg is superior to acetaminophen 1000mg for throat pain relief, showing significantly better efficacy at all time points after 2 hours 5, 2, 6
• Paracetamol is an acceptable alternative if ibuprofen is contraindicated 2, 6
• Topical measures: Benzydamine hydrochloride spray every 3 hours, particularly before speaking/singing; if inadequate, viscous lidocaine 2% can be used 4
• White soft paraffin ointment for any mucosal irritation 4

Antibiotic Decision Algorithm

Do NOT prescribe antibiotics reflexively despite previous antibiotic use:

If Centor Score 0-2:

• No antibiotics indicated for symptom relief 4, 2
• Antibiotics provide minimal benefit (NNTB = 18 at one week) and 82% resolve without treatment 7

If Centor Score 3-4:

• Consider rapid antigen detection test (RADT) or throat culture 4
• If positive for GAS: Penicillin V twice or three times daily for 10 days remains first-line 4, 2
• Modest benefit (1-2 days symptom reduction) must be weighed against resistance concerns, side effects, and costs 4
• Delayed prescribing (>48 hours) is a valid option with no difference in complication rates 4

If This Represents Chronic Carriage:

Antimicrobial therapy is NOT routinely indicated 4

Special situations where carrier eradication may be justified:

• Family history of acute rheumatic fever 4
• Excessive anxiety about GAS infections 4
• Community outbreak of invasive GAS 4

If carrier treatment is deemed necessary:

• Clindamycin 20-30 mg/kg/day in 3 doses for 10 days (max 300mg/dose) 4
• Penicillin V + rifampin combination for 10 days 4
• Amoxicillin-clavulanate 40mg amoxicillin/kg/day in 3 doses for 10 days 4

Critical Pitfalls to Avoid

• Never dismiss swelling at tongue root as simple pharyngitis—this location raises concern for tongue abscess or deep space infection requiring drainage 1
• Don't assume recurrent symptoms = recurrent infection—chronic carriage with viral superinfection is more likely given the years-long pattern 4
• Avoid routine post-therapy retesting unless symptoms recur, as this is no longer recommended 4
• Don't prescribe antibiotics solely to prevent rheumatic fever in low-risk patients without previous rheumatic fever history 4
• Tonsillectomy is NOT recommended solely to reduce GAS pharyngitis frequency 4

Urgent Referral Indications

Refer immediately to ENT if:

• Fluctuant mass palpable in tongue or pharynx 1
• Progressive dysphagia or odynophagia 1
• Respiratory distress or stridor 3, 1
• Inability to handle secretions 3
• Asymmetric tonsillar swelling suggesting quinsy 3