What causes a sore throat that worsens with yawning?

Sore Throat with Yawning: Causes and Clinical Approach

A sore throat that worsens with yawning is most commonly caused by viral pharyngitis, which accounts for the vast majority of acute pharyngitis cases, with mechanical stretching of inflamed pharyngeal tissues during yawning exacerbating the pain. 1

Primary Etiologies

Viral Causes (Most Common)

• Respiratory viruses are the predominant cause, including rhinovirus, coronavirus, adenovirus, influenza, parainfluenza, respiratory syncytial virus, herpes simplex virus, Epstein-Barr virus, and cytomegalovirus 1, 2
• Viral pharyngitis accounts for 65-85% of acute sore throat cases in adults 3
• The stretching motion of yawning mechanically stresses inflamed pharyngeal mucosa, intensifying pain regardless of the underlying viral etiology 4

Bacterial Causes (Less Common)

• Group A Streptococcus (GAS) is the most common bacterial pathogen, accounting for 5-15% of adult pharyngitis cases 3
• Other bacterial causes include Groups C and G streptococci, Arcanobacterium haemolyticum, Neisseria gonorrhoeae (in sexually active individuals), and Fusobacterium necrophorum (particularly in adolescents and young adults) 1

Chronic Causes

• Gastroesophageal reflux disease (GERD) is the second most common cause of chronic sore throat, presenting without typical heartburn or regurgitation in up to 75% of cases 3
• Laryngopharyngeal reflux causes upper respiratory tract irritation without aspiration 3
• Thyroid disease, particularly thyroiditis, can cause chronic sore throat through local inflammatory effects 3

Clinical Differentiation

Features Suggesting Viral Etiology

• Associated symptoms including cough, nasal congestion, conjunctivitis, hoarseness, diarrhea, or oropharyngeal lesions (ulcers or vesicles) strongly suggest viral illness 1, 2
• These patients do not warrant further testing for bacterial causes 1

Features Suggesting Bacterial Etiology

• Persistent fever, rigors, night sweats, tender lymph nodes, tonsillopharyngeal exudates, scarlatiniform rash, palatal petechiae, and swollen tonsils suggest bacterial infection 1
• Use modified Centor criteria: fever by history, tonsillar exudates, tender anterior cervical adenopathy, and absence of cough 1
• Patients meeting fewer than 3 Centor criteria do not need bacterial testing 1

Red Flags Requiring Urgent Evaluation

• Unusually severe signs including difficulty swallowing, drooling, neck tenderness or swelling, or stridor warrant immediate evaluation for peritonsillar abscess, retropharyngeal abscess, epiglottitis, or Lemierre syndrome 1, 5
• These life-threatening conditions require urgent diagnosis and treatment to prevent complications and death 1, 5

Management Algorithm

For Suspected Viral Pharyngitis

• No antibiotic therapy is indicated 1
• Offer analgesic therapy with aspirin, acetaminophen, nonsteroidal anti-inflammatory drugs, or throat lozenges 1
• Symptoms typically resolve within one week in 82% of cases without antibiotics 6

For Suspected Bacterial Pharyngitis

• Test for Group A Streptococcus with rapid antigen detection test, throat culture, or both 1
• Antibiotic therapy is recommended only for patients with positive streptococcal test results 1
• Treatment duration should be 10 days with appropriate narrow-spectrum antibiotics to eradicate GAS and prevent complications including acute rheumatic fever 1

For Chronic Sore Throat (>3 weeks)

• Consider GERD as the primary etiology, even without typical reflux symptoms 3
• Evaluate for laryngopharyngeal reflux with laryngoscopy if indicated 3
• Assess for thyroid disease and other systemic causes 3

Common Pitfalls

• Do not prescribe antibiotics based on clinical grounds alone—the signs and symptoms of bacterial and viral pharyngitis overlap too broadly, and even experienced physicians cannot distinguish them with certainty 1
• Do not assume GERD requires heartburn or regurgitation symptoms—up to 75% of GERD-related chronic sore throat presents without these typical features 3
• Do not overlook severe complications in patients with unusually severe symptoms—peritonsillar abscess, Lemierre syndrome, and epiglottitis are rare but life-threatening 1, 5
• Do not continue empiric antibiotics without identifying the underlying cause in patients with severe refractory symptoms 5