What is the approach to managing a sore throat in an adult?

Approach to Sore Throat in Adults

Initial Assessment: Rule Out Life-Threatening Conditions First

Before considering routine pharyngitis management, immediately evaluate for severe complications if the patient presents with unusually severe symptoms, lack of response to initial therapy, or any red flag features. 1

Red Flags Requiring Urgent Evaluation

• Peritonsillar abscess: Look for unilateral tonsillar swelling, uvular deviation, trismus, "hot potato voice," and severe difficulty swallowing 1
• Retropharyngeal abscess: Assess for neck stiffness, neck tenderness or swelling, drooling, and difficulty swallowing 1
• Epiglottitis: Evaluate for drooling, stridor, sitting forward position, and respiratory distress—this is an airway emergency 1
• Lemierre syndrome: Consider in adolescents and young adults with severe pharyngitis and high fever, as this can progress to life-threatening septic thrombophlebitis 1, 2

If any of these conditions are suspected, do not continue empiric antibiotic therapy without identifying the underlying cause—proceed directly to urgent evaluation. 1

Management of Uncomplicated Acute Sore Throat (<14 Days)

Step 1: Symptomatic Treatment (First-Line for All Patients)

Either ibuprofen or paracetamol (acetaminophen) are recommended as first-line treatment for relief of acute sore throat symptoms. 3

• Ibuprofen and diclofenac provide slightly more effective pain relief than paracetamol, but both are safe for short-term use 3
• These analgesics reduce sore throat pain, difficulty swallowing, and the sensation of a swollen throat 3, 4
• Continue symptomatic treatment regardless of whether antibiotics are prescribed 2

Step 2: Assess Need for Antibiotics Using Clinical Scoring

Use the Centor criteria (or similar validated scores like McIsaac or FeverPAIN) to stratify the probability of bacterial pharyngitis before prescribing antibiotics. 3, 5

Centor Criteria (4 points total):

• Tonsillar exudates
• Tender anterior cervical lymphadenopathy
• Absence of cough
• History of fever

Risk-Stratified Antibiotic Approach:

• Low risk (<3 points): Antibiotics are NOT indicated—manage with symptomatic treatment only 5
• Moderate risk (3 points): Consider delayed prescription strategy (patient fills prescription only if symptoms worsen or fail to improve) 5
• High risk (>3 points): Antibiotics can be started immediately 5

Important caveat: Even when bacterial pharyngitis is confirmed, antibiotics provide only modest symptom reduction (approximately 16 hours shorter duration) and primarily prevent complications rather than dramatically improving symptoms. 6

Step 3: Antibiotic Selection When Indicated

If antibiotics are prescribed, penicillin V is the first-line choice: 250-500 mg twice or three times daily for 10 days. 3, 2

• Alternative: Amoxicillin 500 mg twice daily for 10 days 2, 7
• For penicillin allergy: First-generation cephalosporin, clindamycin, azithromycin, or clarithromycin 2
• Treatment duration must be at least 10 days for any infection caused by Streptococcus pyogenes to prevent acute rheumatic fever 3, 7
• Take antibiotics at the start of a meal to minimize gastrointestinal intolerance 7

Step 4: Consider Adjunctive Corticosteroids (Selective Use Only)

Corticosteroids in conjunction with antibiotics can be considered in adult patients with severe presentations (3-4 Centor criteria), but are NOT routinely recommended. 3

• A single dose of corticosteroids may provide additional symptom relief in severe cases 3
• No evidence of benefit in children 3
• Effect is smaller when administered orally versus parenteral routes 3

Management of Persistent Sore Throat (≥14 Days)

A sore throat lasting beyond 2 weeks is atypical and warrants evaluation for non-infectious causes and serious pathology—do not simply continue antibiotics. 8, 2

Timeline for Concern:

• Most viral and bacterial pharyngitis resolves within 7 days 8, 2
• Even untreated streptococcal pharyngitis shows resolution of fever within 3-4 days 8, 2
• Symptoms persisting beyond 3 weeks mandate evaluation, as this exceeds the expected course of benign viral infections 8

Evaluation Approach for Persistent Cases:

• Laryngoscopy is necessary to directly visualize the larynx and pharynx, typically using transnasal flexible fiberoptic scope 8
• Consider non-infectious etiologies: gastroesophageal reflux disease, neoplastic processes (especially laryngeal cancer), chronic carrier state 8, 2
• Do not apply Centor or FeverPAIN scores to persistent cases—these tools are validated only for acute presentations 2

Key Complications Prevented by Antibiotics

Suppurative Complications (High-Certainty Evidence):

• Acute otitis media: Antibiotics reduce incidence within 14 days (number needed to treat approximately 50) 6
• Peritonsillar abscess (quinsy): Antibiotics reduce incidence within 2 months 6
• Acute sinusitis: No significant protective effect demonstrated 6

Non-Suppurative Complications:

• Acute rheumatic fever: Antibiotics reduce incidence within 2 months, though overall prevalence is now very low in developed countries 6
• Acute glomerulonephritis: Insufficient evidence to determine protective effect 6

Important note: Prevention of suppurative complications is NOT a specific indication for antibiotic therapy in routine sore throat management—the decision must weigh modest benefits against antibiotic resistance, side effects, and costs. 3

Common Pitfalls to Avoid

• Do not prescribe antibiotics empirically without clinical assessment—over 60% of adults with sore throat receive unnecessary antibiotics 8
• Do not use zinc gluconate—conflicting evidence and higher adverse effects make this not recommended 3
• Do not routinely use herbal treatments or acupuncture—insufficient reliable evidence for efficacy 3
• Do not assume persistent sore throat is just "slow to resolve" viral infection—delays diagnosis of serious conditions like cancer 8
• Do not wait the full 3 months before seeking evaluation for persistent symptoms—a 1-month duration already warrants assessment 8