Workup for Sore Throat with Neck Pain and Fullness
This presentation demands urgent evaluation for life-threatening deep neck space infections and suppurative complications, not routine pharyngitis workup. When a patient describes their sore throat as predominantly neck pain and fullness rather than typical pharyngeal symptoms, you must immediately shift your diagnostic framework away from simple pharyngitis toward serious complications that can cause significant morbidity and mortality 1.
Critical Red Flags Requiring Immediate Imaging
This clinical presentation suggests complicated pharyngitis rather than uncomplicated sore throat, which standard guidelines explicitly exclude from routine management algorithms 1.
Obtain Contrast-Enhanced CT Neck Immediately If:
- Neck swelling or fullness (suggests peritonsillar abscess, retropharyngeal abscess, or Lemierre disease) 1, 2
- Severe unilateral neck pain (suggests deep space infection or suppurative lymphadenitis) 1
- Trismus or difficulty opening mouth (suggests peritonsillar abscess) 1
- Muffled "hot potato" voice (suggests peritonsillar abscess or supraglottic involvement) 3
- Dysphagia with drooling (suggests epiglottitis or deep space infection) 3
- Respiratory distress or stridor (suggests airway compromise) 3
Why CT Is Essential Here
The guideline explicitly states it does not cover "complicated pharyngitis (peritonsillar abscesses, Lemierre disease, Vincent's angina)" 1. Your patient's description of neck pain and fullness rather than pharyngeal symptoms places them squarely in this excluded category requiring imaging 1.
A case report illustrates this danger: a 30-year-old woman with progressive symptoms including neck swelling was seen twice in the ER with negative rapid strep tests and sent home with symptomatic therapy, only to return with severe Group C streptococcal pharyngitis requiring neck CT to exclude peritonsillar abscess 2.
Physical Examination Priorities
Look Specifically For:
- Asymmetric tonsillar enlargement with uvular deviation (peritonsillar abscess) 2
- Visible neck swelling or induration (deep space infection) 2
- Tender cervical lymphadenopathy, especially if fluctuant (suppurative lymphadenitis) 1
- Inability to fully open mouth (trismus from peritonsillar involvement) 2
- Respiratory rate and oxygen saturation (airway compromise assessment) 3
What NOT to Focus On
Do not waste time calculating Centor scores or performing rapid strep tests in this presentation 1. These tools are designed for uncomplicated acute pharyngitis to decide about antibiotics for Group A streptococcal infection 1. Your patient needs evaluation for surgical emergencies, not strep throat 1.
Laboratory Workup
Essential Initial Labs:
- Complete blood count with differential (leukocytosis suggests bacterial infection; thrombocytopenia may suggest Lemierre syndrome) 1
- Blood cultures if febrile (bacteremia from deep space infection or Lemierre disease) 1
- Throat culture (but do not delay imaging or treatment waiting for results) 2
Consider Additional Testing:
- Monospot or EBV serology if generalized lymphadenopathy or splenomegaly present (infectious mononucleosis can cause severe tonsillar hypertrophy with airway compromise) 1
- Inflammatory markers (CRP, ESR) if considering deep space infection 1
Common Pitfalls to Avoid
Do not assume negative rapid strep test excludes serious pathology. The case report demonstrates a patient with severe Group C streptococcal pharyngitis who had multiple negative rapid strep tests but progressive worsening requiring hospitalization 2. Group C and G streptococci can cause severe pharyngitis with complications including subdural empyema and septicemia, but won't be detected by Group A strep testing 1.
Do not send home with symptomatic treatment alone. Neck pain and fullness are not typical symptoms of viral pharyngitis, which usually presents with cough, coryza, and conjunctivitis 1. The absence of these viral features combined with neck symptoms should raise your suspicion for bacterial complications 1, 3.
Do not delay imaging for throat culture results. Peritonsillar abscess, retropharyngeal abscess, and Lemierre disease require urgent diagnosis and intervention to prevent airway compromise, mediastinitis, septic thrombophlebitis, and death 1.
Disposition and Management
- Admit for IV antibiotics and possible surgical drainage if imaging confirms abscess or deep space infection 1
- ENT consultation urgently for any confirmed suppurative complication 1
- Airway management preparation if any signs of respiratory compromise 3
The standard pharyngitis guidelines explicitly state they do not apply to your patient's presentation 1. This requires urgent evaluation for life-threatening complications, not routine strep throat management.