How should I manage a patient presenting with sore throat, including assessment for red‑flag signs and treatment of viral, streptococcal, infectious mononucleosis, peritonsillar abscess, deep‑space infections, epiglottitis, atypical, fungal, granulomatous, and neoplastic causes?

Management of Sore Throat: A Comprehensive Algorithmic Approach

Most patients with sore throat require only symptomatic treatment with ibuprofen or acetaminophen, as 65-85% of cases are viral and self-limiting within 7 days; antibiotics should be reserved exclusively for microbiologically confirmed Group A streptococcal infection in appropriately risk-stratified patients, while immediately recognizing red-flag signs that indicate life-threatening complications requiring urgent intervention. 1, 2, 3

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STEP 1: Immediate Red-Flag Assessment (Rule Out Life-Threatening Conditions)

Before any routine evaluation, assess for these emergent conditions:

Critical Red Flags Requiring Immediate Intervention

• Severe difficulty swallowing or breathing – evaluate immediately for airway compromise 1, 2
• Drooling with inability to swallow secretions – suggests epiglottitis or severe deep-space infection 3
• Severe unilateral throat pain with trismus and uvular deviation – indicates peritonsillar abscess (quinsy) requiring drainage 3
• Neck swelling or stiffness with high fever – consider retropharyngeal or parapharyngeal abscess 2, 3
• Persistent high fever with severe neck pain in adolescents/young adults – evaluate for Lemierre syndrome (suppurative thrombophlebitis of internal jugular vein) 3, 4

If any red flags present: Proceed directly to imaging (CT neck with contrast), ENT consultation, and hospital admission. Do not delay for routine testing. 2, 3

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STEP 2: Risk Stratification Using Modified Centor/McIsaac Criteria

For patients without red flags, use this validated scoring system:

Calculate the Score (0-5 points total)

Clinical Feature	Points	Citation
Fever (documented temperature)	+1	[1]
Tonsillar exudates (patchy or confluent)	+1	[1,3]
Tender anterior cervical adenopathy	+1	[1,3]
Absence of cough	+1	[1,3]
Age 3-14 years	+1	[1]
Age 15-44 years	0	[1]
Age ≥45 years	-1	[1]

Testing and Treatment Algorithm Based on Score

• Score ≤0: GAS probability 1-2.5% – No testing needed; provide symptomatic treatment only 1, 3
• Score 1: GAS probability 5-10% – No testing indicated; symptomatic treatment only 1, 3
• Score 2: GAS probability 11-17% – Consider testing based on clinical judgment; may proceed with RADT 1, 3
• Score 3: GAS probability 28-35% – Testing strongly recommended with RADT before antibiotics 1, 3
• Score ≥4: GAS probability 51-53% – Testing mandatory with RADT; treat only if positive 1, 3

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STEP 3: Diagnostic Testing Strategy

When to Test

• Test only patients with Centor score ≥2 3
• Do NOT test patients with clear viral features: cough, rhinorrhea, hoarseness, conjunctivitis, diarrhea, anterior stomatitis, discrete ulcerative lesions, or viral exanthem 1, 3
• Do NOT test children <3 years unless specific risk factors present (GAS pharyngitis uncommon in this age group) 1

Testing Method

• Rapid Antigen Detection Test (RADT) is preferred – a positive result is diagnostic and requires no confirmation 1, 3
• Backup throat culture is NOT routinely needed after negative RADT in adults or children 1, 3
• Do NOT use biomarkers (C-reactive protein, procalcitonin) for routine sore throat assessment 3

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STEP 4: Antibiotic Therapy (Only for Confirmed GAS)

First-Line Treatment

Penicillin V 250 mg orally twice or three times daily for 10 days – this is the gold standard; shorter courses lack sufficient evidence 1, 2

Penicillin Allergy Alternatives

• First-generation cephalosporin 1
• Clindamycin 1
• Clarithromycin 1
• Azithromycin 1

Critical Antibiotic Stewardship Principles

• Never prescribe antibiotics without microbiological confirmation – clinical features alone cannot distinguish GAS from viral pharyngitis 1, 2, 3
• Do NOT prescribe antibiotics for scores 0-2 without positive testing 1
• Antibiotics do NOT prevent complications (ear infections, sinusitis) in low-risk patients 1, 2
• Antibiotics are NOT needed to prevent rheumatic fever in patients without prior rheumatic fever history 1, 2
• Up to 20% of children are asymptomatic GAS carriers – positive tests in viral illness represent carriage, not active infection 1

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STEP 5: Symptomatic Management (All Patients)

Analgesics (First-Line for All)

Ibuprofen or acetaminophen (paracetamol) are strongly recommended as the most effective treatments for pain relief, regardless of etiology 1, 2

• Aspirin is contraindicated in children (Reye syndrome risk) 1

Adjunctive Measures

• Adequate hydration 5
• Rest guided by patient's energy level (do NOT enforce strict bed rest) 5
• Topical anesthetics may provide additional relief 4

What NOT to Use

• Zinc gluconate is NOT recommended 1
• Herbal treatments and acupuncture have inconsistent evidence and cannot be reliably recommended 1
• Corticosteroids are NOT routinely recommended in pediatric GAS pharyngitis 1
• Corticosteroids may be considered in adults with Centor score 3-4 for severe symptoms, but this is not standard practice 2

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STEP 6: Condition-Specific Management

Infectious Mononucleosis (Epstein-Barr Virus)

Clinical presentation: Pharyngitis with generalized lymphadenopathy, splenomegaly, posterior cervical or auricular adenopathy, palatal petechiae, and profound fatigue in patients 10-30 years 1, 5

Diagnosis:

• Atypical lymphocytosis ≥20% OR atypical lymphocytosis ≥10% plus total lymphocytosis ≥50% 5
• Positive heterophile antibody test (false negatives common early in infection) 5

Management:

• Symptomatic treatment with analgesics, antipyretics, adequate hydration 5
• Activity guided by patient's energy level (do NOT enforce bed rest) 5
• Withdraw from contact/collision sports for at least 4 weeks after symptom onset (splenic rupture risk) 5
• Corticosteroids only for respiratory compromise or severe pharyngeal edema 5
• Acyclovir and antihistamines are NOT recommended 5
• Note: 23.4% of severe IM cases may develop peritonsillar abscess requiring surgical drainage 6

Peritonsillar Abscess (Quinsy)

Clinical presentation: Severe unilateral throat pain, trismus, uvular deviation, "hot potato" voice, drooling 3

Management:

• Needle aspiration or incision and drainage 2
• Broad-spectrum antibiotics covering polymicrobial infection 1
• ENT consultation 2
• Consider abscess tonsillectomy for definitive treatment 6

Retropharyngeal/Parapharyngeal Abscess

Clinical presentation: Neck swelling, stiffness, high fever, difficulty swallowing, potential airway compromise 2, 3

Management:

• CT neck with contrast for diagnosis 3
• IV broad-spectrum antibiotics 7
• Surgical drainage 7
• Hospital admission with airway monitoring 2

Epiglottitis

Clinical presentation: Drooling, severe dysphagia, respiratory distress, "tripod" positioning, muffled voice 7, 4

Management:

• Do NOT examine throat or lay patient flat (may precipitate complete airway obstruction) 7
• Immediate ENT and anesthesia consultation 7
• Secure airway in controlled setting (operating room) 7
• IV antibiotics covering Haemophilus influenzae and Streptococcus species 7

Lemierre Syndrome

Clinical presentation: Persistent high fever, severe neck pain, pharyngitis in adolescent/young adult, potential septic emboli 1, 3, 4

Management:

• CT neck with contrast showing internal jugular vein thrombophlebitis 4
• Prolonged IV antibiotics (4-6 weeks) covering anaerobes (Fusobacterium necrophorum) 4
• Anticoagulation is controversial; consult infectious disease 4

Fungal Pharyngitis (Candidiasis)

Clinical presentation: White plaques on oropharynx, immunocompromised host, recent antibiotic or corticosteroid use 7

Management:

• Oral fluconazole or nystatin suspension 7
• Address underlying immunosuppression 7

Neoplastic Causes

Clinical presentation: Persistent unilateral throat pain >2-3 weeks, unilateral tonsillar enlargement, weight loss, night sweats, tobacco/alcohol use 7

Management:

• ENT referral for biopsy 7
• Imaging (CT or MRI neck) 7

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STEP 7: Follow-Up and Patient Education

When to Return

• Symptoms worsening after 48 hours 1
• Development of red-flag signs (difficulty breathing, drooling, severe unilateral pain) 2, 3
• Symptoms persisting beyond 7 days 1

Patient Counseling Points

• Most sore throats are viral, self-limiting within 7 days, and do NOT require antibiotics 1, 2
• Antibiotics do NOT speed recovery in viral pharyngitis 1
• Even bacterial pharyngitis often resolves without antibiotics 8
• Ibuprofen or acetaminophen are the most effective treatments for symptom relief 1, 2

What NOT to Do

• Do NOT perform routine post-treatment testing (test of cure) 1
• Do NOT test asymptomatic household contacts 1
• Do NOT prescribe antibiotics based on patient pressure or expectations alone 8

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Common Pitfalls to Avoid

• Testing patients with clear viral symptoms (cough, rhinorrhea, conjunctivitis) leads to false-positive results in carriers and unnecessary antibiotic use 1, 3
• Prescribing empiric antibiotics without microbiological confirmation – up to 70% of sore throat patients receive antibiotics, but only 20-30% have GAS 1
• Assuming all positive GAS tests represent active infection – 20% of children are asymptomatic carriers 1
• Missing life-threatening complications by not maintaining high suspicion for peritonsillar abscess, Lemierre syndrome, epiglottitis in severe presentations 2, 3
• Testing children <3 years routinely when GAS pharyngitis is uncommon in this age group 1
• Using corticosteroids routinely in pediatric GAS pharyngitis 1
• Attributing abdominal pain to GAS carriage – carriers do not experience symptoms from colonizing bacteria; concurrent abdominal pain is due to viral illness 1