What are the causes and treatment options for a chronic sore throat in an adult patient with no significant past medical history?

Chronic Sore Throat: Causes and Evaluation

Primary Directive

Chronic sore throat (>2 weeks duration) is fundamentally different from acute pharyngitis and requires systematic evaluation for non-infectious causes, serious complications, and malignancy—not empiric antibiotics. 1, 2

Critical Red Flags Requiring Urgent Evaluation

Immediately assess for life-threatening complications before pursuing other diagnoses:

• Peritonsillar abscess: Look for unilateral tonsillar swelling, uvular deviation, trismus, "hot potato voice," and severe dysphagia 2, 3
• Retropharyngeal abscess: Assess for neck stiffness, neck tenderness or swelling, drooling, and difficulty swallowing 2, 3
• Epiglottitis: Evaluate for drooling, stridor, sitting forward position, and respiratory distress—this is an airway emergency 2, 3
• Lemierre syndrome: Consider in adolescents and young adults with severe pharyngitis and high fever, caused by Fusobacterium necrophorum progressing to septic thrombophlebitis 4, 2, 3

Common Causes of Chronic Sore Throat

Infectious Causes

• Chronic tonsillopharyngitis: Most common infectious cause in the Indian tertiary care study of 1,580 patients 5
• Submandibular sialadenitis: Third most common cause identified 5
• Tuberculosis (Koch's pneumonitis): Consider in endemic areas or high-risk patients 5
• HIV-related infections: Including candidal pharyngitis, which should prompt HIV testing 6, 5

Non-Infectious Causes (More Likely in Chronic Presentations)

• Gastroesophageal reflux disease (GERD): Second most common cause; presents as chronic throat irritation without classic heartburn 1, 2, 5
• Laryngopharyngeal reflux disorder: Fourth most common cause, distinct from GERD 5
• Malignancy: Critical diagnosis not to miss, particularly in adults >40 years with isolated persistent symptoms and risk factors (smoking, alcohol use) 1, 2
• Allergy: Chronic postnasal drip causing pharyngeal irritation 5
• Oral submucous fibrosis: Consider in patients with betel nut chewing 5
• Stylalgia (Eagle syndrome): Elongated styloid process causing pharyngeal pain 5

Systemic Conditions

• Diabetes mellitus: Predisposes to chronic pharyngeal infections 5
• Hypothyroidism: Can cause chronic throat discomfort 5
• Uremia: Chronic kidney disease-related pharyngitis 5
• Arthritides: Including Sjögren's syndrome causing dry throat 5
• Dietary deficiencies: Vitamin deficiencies causing mucosal changes 5

Psychiatric and Behavioral

• Psychiatric illnesses: Somatization, anxiety, or depression manifesting as chronic throat symptoms 5
• Chronic smoking: 39% of chronic sore throat patients in one study were smokers 5
• Alcohol addiction: 31% of patients had alcohol dependence 5

Diagnostic Approach

What NOT to Do

• Do not prescribe empiric antibiotics: The 2-week duration makes bacterial pharyngitis extremely unlikely, and antibiotics provide no benefit for chronic presentations 1, 2, 3
• Do not apply Centor or FeverPAIN scores: These are validated only for acute presentations (<14 days) and are inappropriate for chronic symptoms 4, 1, 2
• Do not dismiss with reassurance alone: Absence of other symptoms does not rule out serious pathology 1
• Do not perform routine rapid strep testing: Clinical context has shifted away from acute bacterial pharyngitis 2

Recommended Evaluation

• Direct laryngoscopy: Use transnasal flexible fiberoptic scope to visualize larynx and pharynx for masses, inflammation, or structural abnormalities 3
• Consider HIV testing: Particularly if candidal infection, recurrent infections, or risk factors present 6, 5
• Evaluate for GERD/LPR: Trial of proton pump inhibitors may be both diagnostic and therapeutic 1, 2, 5
• Imaging if indicated: CT neck with contrast for suspected abscess or mass 2
• Biopsy suspicious lesions: Any persistent unilateral mass or ulceration requires tissue diagnosis 2

Symptomatic Management During Workup

• Ibuprofen or acetaminophen: First-line for pain relief regardless of underlying etiology 1, 2, 3
• Exercise caution with NSAIDs in elderly: Risk of cardiovascular, renal, and gastrointestinal toxicity 2

Key Clinical Pitfall

The most dangerous error is assuming this represents simple streptococcal pharyngitis and prescribing antibiotics. Most viral and bacterial pharyngitis resolves within 7 days, with >80% achieving complete resolution by this timeframe. 1 Even untreated streptococcal pharyngitis shows fever disappearing within 3-4 days. 1 Persistence beyond 2 weeks is atypical and mandates investigation for alternative diagnoses, particularly malignancy in adults with risk factors. 1, 2