What could be causing my throat pain?

Throat Pain: Causes and Diagnostic Approach

Viruses are the most common cause of acute throat pain, but you must obtain laboratory testing to distinguish bacterial from viral pharyngitis because clinical diagnosis alone is unreliable, even for experienced physicians. 1

Primary Causes by Category

Viral Causes (Most Common)

• Respiratory viruses cause the vast majority of pharyngitis cases, including rhinovirus, coronavirus, adenovirus, respiratory syncytial virus, influenza, and parainfluenza 2
• Herpes viruses (herpes simplex virus, Epstein-Barr virus, cytomegalovirus) can cause pharyngitis, with Epstein-Barr virus often accompanied by generalized lymphadenopathy and splenomegaly 1, 2
• Enteroviruses such as coxsackievirus and echoviruses may cause characteristic vesicles (herpangina) 1, 2

Bacterial Causes (Less Common but Important)

• Group A Streptococcus (GAS) is the most common bacterial cause, accounting for only 5-15% of adult pharyngitis cases 2
• GAS pharyngitis typically presents with sudden-onset severe sore throat, persistent fever, tonsillar exudates, tender anterior cervical lymphadenopathy, and absence of cough 2
• Other bacterial causes include Groups C and G streptococci (relatively common in college students and adults), Arcanobacterium haemolyticum (rare, may cause scarlet fever-like rash in teenagers), Neisseria gonorrhoeae (in sexually active persons), and rarely Mycoplasma pneumoniae or Chlamydophila pneumoniae 1, 2

Critical Diagnostic Principle

Clinical diagnosis of streptococcal pharyngitis cannot be made with certainty even by the most experienced physicians—bacteriologic confirmation is required. 1

• The signs and symptoms of streptococcal and viral pharyngitis overlap too broadly for accurate clinical diagnosis alone 1
• Even patients with all clinical features suggesting streptococcal infection are confirmed to have it only 35-50% of the time, particularly in children 1
• Therefore, except when obvious viral features are present, perform a laboratory test (rapid antigen detection test or throat culture) to determine whether GAS is present 1

Life-Threatening Causes Requiring Immediate Evaluation

If you have unusually severe signs or symptoms that are refractory to standard therapy, you require urgent evaluation for life-threatening complications including: 3

• Peritonsillar abscess: Look for unilateral tonsillar swelling, uvular deviation, trismus, "hot potato voice," and difficulty swallowing 3
• Retropharyngeal abscess: Assess for neck stiffness, neck tenderness or swelling, drooling, and difficulty swallowing 3
• Epiglottitis: Evaluate for drooling, stridor, sitting forward position, and respiratory distress—airway management is paramount 3
• Lemierre syndrome: Consider in adolescents and young adults with severe pharyngitis caused by Fusobacterium necrophorum, which can progress to life-threatening septic thrombophlebitis 3

Common Clinical Pitfall

Over 60% of adults with sore throat receive antibiotic prescriptions despite most cases being viral and self-limited 2

• Antibiotics are not indicated for viral pharyngitis and provide minimal benefit even for confirmed streptococcal infection 3
• Most viral pharyngitis symptoms last up to 2 weeks, with approximately 90% of patients symptom-free by one week even without treatment 4

When to Seek Further Evaluation

• Follow up if symptoms worsen (especially with headache or high fever) or have not improved within 3 to 5 days 4
• Persistent symptoms beyond 2 weeks are atypical and warrant evaluation for non-infectious causes and serious pathology 4