What are the likely causes and recommended management for an adult with sore throat or neck pain that worsens when speaking, in the absence of red‑flag symptoms?

Sore Throat or Neck Pain Worsening with Speaking

Most Likely Diagnosis

This presentation most strongly suggests viral laryngitis, which causes inflammation of the vocal cords and characteristically worsens with voice use. 1, 2

The key distinguishing feature is that pain worsening specifically with talking points to laryngeal involvement rather than simple pharyngitis. Hoarseness accompanying sore throat is a clinical red flag for viral infection and helps distinguish this from bacterial pharyngitis, which typically does not present with hoarseness. 2

Clinical Features Supporting Viral Etiology

Look for these specific accompanying symptoms that confirm viral laryngitis:

• Hoarseness or voice changes – the hallmark of laryngeal involvement 2
• Cough – commonly accompanies viral laryngitis 1, 2
• Runny nose (coryza) – indicates viral upper respiratory infection 1, 2
• Absence of high fever, tonsillar exudates, or tender anterior cervical lymph nodes – these suggest bacterial pharyngitis instead 3, 1

When to Consider Bacterial Pharyngitis

Test for Group A Streptococcus only if the patient meets ≥3 modified Centor criteria: 3

• Fever by history
• Tonsillar exudates
• Tender anterior cervical adenopathy
• Absence of cough

Do not test patients with clear viral features (cough, rhinorrhea, hoarseness). 1 Testing asymptomatic or clearly viral presentations leads to unnecessary antibiotic use in over 60% of cases. 3, 4

Red Flags Requiring Urgent Evaluation

Immediately assess for life-threatening conditions if any of these are present:

• Difficulty swallowing, drooling, or neck swelling – suggests peritonsillar abscess, retropharyngeal abscess, or epiglottitis 3, 4
• Persistent high fever with severe pharyngitis in adolescents/young adults – consider Lemierre syndrome 3, 4
• Respiratory distress or stridor – indicates airway compromise 2
• Unilateral tonsillar swelling with uvular deviation – peritonsillar abscess 4

Recommended Management for Viral Laryngitis

Symptomatic Treatment

• Acetaminophen or NSAIDs for pain and fever control 1, 2
• Voice rest – essential for laryngeal recovery 2, 5
• Adequate hydration 2, 5
• Throat lozenges containing topical anesthetics (ambroxol, lidocaine, benzocaine) for temporary relief 1
• Warm salt water gargles for patients able to gargle 1

What NOT to Do

• Do not prescribe antibiotics – they provide no benefit for viral pharyngitis and contribute to resistance 1, 2
• Do not use systemic corticosteroids routinely – they provide only minimal symptom reduction (approximately 5 hours) with potential adverse effects 1, 2
• Avoid aspirin in children due to Reye syndrome risk 1

Expected Timeline and Follow-Up

• Most viral laryngitis resolves within 7-10 days, with symptoms typically lasting 1-3 weeks maximum 2
• Reassure the patient that viral sore throat typically lasts less than 1 week and antibiotics are not needed 3, 1

When to Escalate Care

• Symptoms persisting beyond 2-3 weeks warrant re-evaluation for alternative causes 4, 2
• Symptoms persisting beyond 4 weeks require laryngoscopy to exclude malignancy or other serious pathology 4, 2
• Progressive worsening rather than improvement over days to weeks is concerning 4

Alternative Diagnoses for Persistent Cases

If symptoms extend beyond the expected viral course, consider:

• Gastroesophageal reflux disease (GERD) – a leading cause of chronic throat symptoms, requires proton-pump inhibitor for at least 2 months 4
• Upper airway cough syndrome – common cause of chronic throat irritation 4
• Chronic streptococcal carrier state – these patients harbor GAS without active infection and do not benefit from antibiotics 4
• Fusobacterium necrophorum – implicated in 10-20% of pharyngitis in adolescents, can progress to Lemierre syndrome 3, 4
• Laryngeal malignancy – must be excluded with laryngoscopy if symptoms persist beyond 3-4 weeks 4

Common Pitfalls to Avoid

• Prescribing antibiotics based on symptoms alone without testing – clinical features have inadequate predictive value for bacterial infection 1
• Assuming all persistent sore throats are "slow to resolve" viral infections – this delays diagnosis of serious conditions like cancer 4
• Using broad-spectrum antibiotics empirically – narrow-spectrum agents (penicillin/amoxicillin) are first-line when bacterial infection is confirmed 1
• Incomplete antibiotic courses – if bacterial pharyngitis is confirmed, ensure full 10-day treatment to prevent complications 1