How to manage a 2-week sore throat with enlarged tonsils but no exudate in a patient?

Management of 2-Week Sore Throat with Enlarged Tonsils Without Exudate

This patient requires urgent evaluation for serious complications and non-infectious causes, not empirical antibiotics, because the 2-week duration makes typical bacterial or viral pharyngitis extremely unlikely. 1

Why This Is Not Simple Pharyngitis

The 2-week duration fundamentally changes the diagnostic approach:

• Most viral and bacterial pharyngitis resolves within 7 days, with >80% achieving complete symptom resolution by this timeframe 1
• Even untreated streptococcal pharyngitis shows fever and constitutional symptoms disappearing within 3-4 days, with throat soreness lasting at most 1-2 days longer than antibiotic-treated cases 1
• The European Society of Clinical Microbiology and Infectious Diseases guideline explicitly excludes cases with symptoms ≥14 days from their acute pharyngitis algorithms 1
• Standard scoring systems (Centor, FeverPAIN) are validated only for acute presentations and should not be applied to persistent cases 1

Immediate Evaluation Required

Evaluate urgently for life-threatening complications:

• Peritonsillar abscess (quinsy) - look for unilateral tonsillar swelling, uvular deviation, trismus, and "hot potato" voice 1
• Lemierre syndrome - particularly in adolescents and young adults with severe persistent pharyngitis and high fever, caused by Fusobacterium necrophorum 1
• Retropharyngeal abscess - assess for neck stiffness, drooling, respiratory distress 1

Consider non-infectious etiologies that present with persistent throat symptoms:

• Gastroesophageal reflux disease - can present as chronic throat irritation without typical heartburn 1
• Neoplastic processes - particularly important in adults with isolated persistent symptoms; tonsillar lymphoma can present as bilateral tonsillar hypertrophy with persistent sore throat and dysphagia 2
• Groups C and G streptococci can cause severe or recurrent pharyngitis, though evidence is limited 3

Diagnostic Testing Approach

Obtain throat culture or rapid antigen detection test (RADT) for Group A Streptococcus, even though the prolonged duration makes this diagnosis less likely 1

• If RADT is positive, it confirms streptococcal pharyngitis, but the clinical benefit of antibiotics at 2 weeks is negligible since the natural course has already exceeded the 1-2 day benefit window 1
• If RADT is negative, throat culture backup is generally not necessary in adults due to low incidence and low risk of rheumatic fever 1

If initial testing is negative and symptoms persist, strongly consider:

• Referral to ENT for direct visualization and possible biopsy, especially given the bilateral tonsillar enlargement without exudate 2
• Imaging (CT with contrast) if abscess or deep space infection is suspected 1

Symptomatic Management

Prescribe ibuprofen or paracetamol for pain relief regardless of etiology 1

• These remain first-line analgesics and are appropriate while pursuing diagnostic workup 1

Antibiotic Treatment (Only If Streptococcal Infection Confirmed)

If Group A Streptococcus is confirmed by testing:

• Penicillin V 250-500 mg orally twice or three times daily for 10 days remains first-line treatment 1
• Alternative options include amoxicillin 500 mg twice daily for 10 days 1
• For penicillin allergy: first-generation cephalosporin, clindamycin, azithromycin, or clarithromycin 1

However, at 2 weeks duration, antibiotic benefit for symptom reduction is negligible as the natural course has already exceeded the 1-2 day benefit window 1

Critical Pitfalls to Avoid

• Do not assume this is simple streptococcal pharyngitis and prescribe antibiotics empirically - the 2-week duration makes this diagnosis unlikely 1
• Do not dismiss the patient with reassurance alone - absence of other symptoms does not rule out serious pathology in a 2-week presentation 1
• Do not apply Centor or FeverPAIN scores - these tools are validated only for acute presentations 1
• Do not delay ENT referral if no clear infectious etiology is identified, as neoplastic processes require tissue diagnosis 2