oPatientPlus articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use, so you may find the language more technical than the condition leaflets.
Sore throat is a symptom resulting from inflammation of the upper respiratory tract. Four regions are principally involved - the pharynx, the larynx, the tonsils and (rarely) the epiglottis.
Because sore throat is a symptom rather than a specific condition, estimates of incidence vary. The symptom is in any case likely to be under-reported, as it is often self-limiting and a clinician may not be consulted.
Sore throat is usually due to a viral infection. The most common bacterial agent is Group A beta-haemolytic streptococcus (GABS). Asymptomatic nasal carriage of Group A streptococci is very common, especially in very young children.
The symptom of soreness on swallowing may be accompanied by fever and symptoms of upper respiratory tract infection such as headache, malaise, rhinitis and cough. Hoarseness may be present if there is laryngeal involvement.
Specific enquiry should be made about:
- Duration and severity of symptoms
- Any self-medication/over-the-counter treatment
- History of any comorbidities, previous risk factors, relevant past history
- Presence of trismus
- Feeling systemically unwell
- Examination of the throat using a tongue depressor should not be attempted in patients with stridor, as epiglottitis may be present and examination may provoke laryngeal obstruction.
- Examination of the throat may reveal redness of the pharynx and tonsils, enlargement of the tonsils, presence of exudate and enlarged tender cervical lymph glands.
- Differentiating a viral sore throat from that caused by GABS on the basis of examination is difficult. The Centor Criteria may be helpful in this respect:
- Tonsillar exudate
- Tender anterior cervical lymph nodes
- Absence of cough
- History of fever
- The presence of three or four of these signs suggests that the possibility of the patient having GABS is 40-60%. Conversely, patients without three or four of the signs imply an 80% chance of a viral infection.
- Centor Criteria may also be helpful in managing patients with tonsillitis. The presence of three out of four of the signs increases the possibility of quinsy to 1:60 compared with 1:400 for patients who do not.
- A scarlet fever-like rash (red punctate skin eruption, prominent in the skin creases), a flushed face, circumoral pallor and a 'strawberry tongue' suggest the possibility of a streptococcal infection.
- Coxsackievirus infection
- Infectious mononucleosis
- Malignancy (pharynx, tonsils, larynx)
- Diphtheria (very rare since immunisation)
- Investigation in primary care is not usually necessary. Some authorities recommend investigation, as this reduces the overdiagnosis of bacterial sore throat. However, in the context of UK general practice, the turnaround time for swab and serum results makes it unlikely that the results would make much difference to the immediate management of the patient. However, if symptoms and/or signs are prolonged, severe or atypical, investigation should be considered.
- Rapid antigen tests may be helpful but research shows no clear benefit over using a clinical score alone.
- Throat swab - this may be helpful if Centor Criteria suggest bacterial infection or there is exudation or excessive erythema.
- FBC and glandular fever screening test - these may be helpful if glandular fever is suspected.
- Antistreptolysin O (ASO) titres - these may be useful in excluding recent streptococcal infection in patients who are systemically unwell or have prolonged symptoms.
It should be remembered that sore throat is a symptom of an underlying condition and efforts should be made to make an accurate diagnosis before considering treatment. The National Institute for Health and Care Excellence (NICE) recommends offering clinical assessment to all patients presenting with sore throat. For further details, see our separate articles on Laryngitis and Epiglottitis.
- Sore throat is usually a self-limiting condition and patients should be told to expect natural resolution in one week.
- The patient should be advised to rest and avoid social contact to guard against transmitting the infection.
- Antipyretic analgesics like paracetamol and ibuprofen are of value.
- Gargles are anecdotally helpful but the evidence base is lacking.
- One study confirmed the effectiveness of over-the-counter lozenges containing amylmetacresol and 2,4-dichlorobenzyl alcohol (Strepsils®).
- Studies looking at other remedies (for example, zinc lozenges, and Chinese and herbal medicines) found no clear evidence of benefit.
- NICE recommends three options: no antibiotics, delayed antibiotics and immediate prescription of antibiotics.
- A discussion with patients/parents/carers should take place as to which strategy is best for individual patients. This decision should be based on a clinical assessment of severity and the presence or absence of three or more Centor Criteria (presence of tonsillar exudate, tender anterior cervical lymphadenopathy or lymphadenitis, history of fever and an absence of cough). Reassessment should be offered if the condition does not settle or if it worsens.
- If a delayed prescription is given, patients should be advised to use it if symptoms worsen or if the sore throat does not settle in a week. Reassessment should be offered if symptoms persist despite treatment.
- Immediate antibiotic should be offered to patients who are systemically very unwell, have peritonsillar abscess or cellulitis, or a significant comorbidity (eg, heart, lung, renal, liver or neuromuscular disease, immunosuppression, cystic fibrosis).
- A Cochrane review found that there was a trend for protection against acute glomerulonephritis by antibiotics but insufficient cases were recorded to be sure of this effect. Several studies found benefit from antibiotics for acute rheumatic fever, which reduced this complication; however, rheumatic fever is rare in Western societies in the 21st century. Antibiotics reduced the incidence of acute otitis media to about one quarter compared with placebo and reduced the incidence of acute sinusitis to about a half of that in the placebo group. The incidence of quinsy was also reduced. Symptoms of headache, sore throat and fever were reduced by antibiotics to about a half but the greatest time for this to be evident was around 3.5 days when the symptoms of about 50% of untreated patients had settled. The review concluded that antibiotics confer relative benefits in the treatment of sore throat but the absolute benefits are modest and at the cost of treating many with antibiotics who will derive no benefit. Antibiotics shorten the duration of symptoms but by a mean of only one day about half way through the illness and by about 16 hours overall.
- For adult patients requiring antibiotics, phenoxymethylpenicillin 500 mg two to four times daily for 10 days is the first choice. Erythromycin 500 mg twice daily or 250 mg four times daily for 10 days is an alternative for patients allergic to penicillin. Lower doses will be required for children.
- Erythromycin can also be used for treatment failures, which sometimes occur with penicillin. The course need only be five days. 5% to 35% of patients do not have bacteriological eradication with penicillin. This may be due to to commensal infection with bacteria that produce beta-lactamase or poor penetration of penicillin into tonsillar tissues.
- Amoxicillin or ampicillin should be avoided, especially in adolescents and young adults because, if the diagnosis is really glandular fever, it will produce a rash, even in the absence of allergy to penicillin.
- Delayed prescriptions - a review of nine trials found that patient satisfaction was greater with immediate prescription, and that there was a small difference in the speed of relief of fever, pain and malaise in some of the studies, but not in others.
- NICE recommends three options: no antibiotics, delayed antibiotics and immediate prescription of antibiotics.
Referral criteriaNICE has produced guidance on the referral of children with recurrent episodes of acute sore throat, up to the age of 15 years.
- Refer same day for suspected quinsy, or if swelling is causing any airway obstruction, marked swallowing difficulty with dehydration and/or systemic upset.
- Refer urgently (eg, within two weeks) if there is a history of sleep apnoea (daytime sleepiness, failure to thrive), or suspicion of an underlying disorder such as leukaemia.
- Routine referral is appropriate if patients have five or more episodes of sore throat in the previous year - significant to affect day-to day activities - or if they have guttate psoriasis exacerbated by acute tonsillitis.
- Otitis media
- Peritonsillar abscess (quinsy)
- Cervical adenitis
- Scarlet fever
- Streptococcal toxic shock syndrome (rare)
- Rheumatic fever(rare in developed countries but still quite prevalent in developing countries)
- Post-streptococcal glomerulonephritis
- Guttate psoriasis - may flare up in the presence of a streptococcal infection
One study found that symptoms settled in 40% of patients within three days and 80% of patients within one week, irrespective of whether the cause was viral or streptococcal.
Further reading & references
- Aalbers J, O'Brien KK, Chan WS, et al; Predicting streptococcal pharyngitis in adults in primary care: a systematic review of the diagnostic accuracy of symptoms and signs and validation of the Centor score. BMC Med. 2011 Jun 1;9:67. doi: 10.1186/1741-7015-9-67.
- Donkor ES; Understanding the pneumococcus: transmission and evolution. Front Cell Infect Microbiol. 2013;3:7. doi: 10.3389/fcimb.2013.00007.
- Sore throat - acute; NICE CKS, October 2012 (UK access only)
- Respiratory tract infections; NICE Clinical Guideline (July 2008)
- Little P, Hobbs FD, Moore M, et al; Clinical score and rapid antigen detection test to guide antibiotic use for sore throats: randomised controlled trial of PRISM (primary care streptococcal management). BMJ. 2013 Oct 10;347:f5806. doi: 10.1136/bmj.f5806.
- McNally D, Simpson M, Morris C, et al; Rapid relief of acute sore throat with AMC/DCBA throat lozenges: randomised Int J Clin Pract. 2009 Oct 22.
- Pelucchi C, Grigoryan L, Galeone C, et al; Guideline for the management of acute sore throat. Clin Microbiol Infect. 2012 Apr;18 Suppl 1:1-28. doi: 10.1111/j.1469-0691.2012.03766.x.
- Spinks A, Glasziou PP, Del Mar CB; Antibiotics for sore throat. Cochrane Database Syst Rev. 2013 Nov 5;11:CD000023.
- Brook I; Overcoming penicillin failures in the treatment of Group A streptococcal pharyngo-tonsillitis. Int J Pediatr Otorhinolaryngol. 2007 Oct;71(10):1501-8. Epub 2007 Jul 17.
- Spurling GK, Del Mar CB, Dooley L, et al; Delayed antibiotics for respiratory infections. Cochrane Database Syst Rev. 2007 Jul 18;(3):CD004417.
- NICE 'referral advice' recommendations database; National Institute for Health and Care Excellence
- Nahary L, Tamarkin A, Kayam N, et al; An investigation of antistreptococcal antibody responses in guttate psoriasis. Arch Dermatol Res. 2008 Sep;300(8):441-9. Epub 2008 Jul 22.
Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.
Dr Laurence Knott
Dr Jan Sambrook
Dr Helen Huins