One of the most common A&E presentations is a sore throat, and while sore throat seems like a pretty straightforward complaint, it is important to properly assess and identify the cause in order to adequately treat it!  

Causes of Sore Throat

Common causes of sore throat:

• Viral tonsilitis
• Acute bacterial tonsilitis
• Glandular fever
• Peritonsillar abscess (Quinsy)
• Herpetic stomatitis

Uncommon causes of sore throat:

• Epiglottitis
• Diphtheria
• Supraglottitis
• Parapharyngeal abscess
• Candidal infection (oral/oropharyngeal thrush)

Malignant causes of sore throat:

• Oral cancer, SCC
• Oropharyngeal cancer, SCC
• Lymphoma

Other systemic causes of sore throat:

• Autoimmune diseases (Behçet’s disease, Pemphigoid, sarcoidosis)
• Crohn’s disease
• STD

Viral Tonsillitis

It is usually caused by the common cold (e.g. rhinovirus, adenovirus, influenza). Patients often present with a sore throat, low-grade fever and difficulty swallowing. They have associated coryzal symptoms (e.g. blocked nose or runny nose, sniffling, cough). Characteristically, the oropharynx is erythematous, and the tonsils are swollen.

Management is largely supportive e.g. rest, hydration, adequate analgesia. Symptoms tend to improve within 5 days

Bacterial Tonsillitis

It is usually caused by streptococci infection. Patients present with a sore throat, high-grade fever and difficulty swallowing. Characteristically, the tonsils are bilaterally enlarged, with white exudates. Patients often have reactive lymphadenopathy in the neck.

Management includes oral antibiotics, hydration, and adequate analgesia.

Image from: https://www.entkidsadults.com/pediatric-ent/tonsils-and-tonsillectomy/bacterial-tonsillitis-viral-tonsillitis/

Glandular Fever

It is also known as infectious mononucleosis. It is caused by the Epstein-Barr Virus (EBV). Patients present with a sore throat, neck lymphadenopathy, fatigue and low-grade fever. Patients with glandular fever also complain of abdominal pain as EBV can cause hepatitis and splenomegaly. On examination, the patient can have enlarged tonsils with exudates, but a characteristic feature of glandular fever is a palatal rash Management includes hydration, and adequate analgesia. Antibiotics should only be given if there’s concern of concurrent bacterial infection.

General advice includes hand/oral hygiene, avoiding contact sport as there is an increased risk of splenic rupture

Quinsy (Peri-tonsillar abscess)

Quinsy (peritonsillar collection): is the collection of pus at the back of the throat, specifically lateral to the tonsils. Pus accumulates between the tonsillar capsule and the superior constrictor muscle of the pharynx. This pushes the tonsil medially toward the midline.

For the untrained eye, it might be difficult to differentiate quinsy from a severe episode of acute tonsillitis or peritonsillar cellulitis. Patients with quinsy present with unilateral sore throat, fever, and change in their voice (hot potato voice). When examining them, they might find it difficult to open the mouth (trismus), but if you can see further into the oropharynx, there will be a unilateral swelling, with the uvula deviated to the opposite side.

Quinsy can result as a complication of a poorly treated episode of acute tonsillitis.

• The bacteria spreads from the tonsils to the peritonsillar tissues, causing inflammation (peritonsillar cellulitis) and/or a collection of pus (Quinsy).
• It is important to involve the ENT team to drain the abscess because it can spread and cause parapharyngeal and/or retropharyngeal extension, which can compromise the airway.

Image from: https://entsho.com/quinsy

Symptomatic difference among various causes of sore throat:

Physical examination difference among various causes of sore throat:

Herpetic stomatitis

Herpetic stomatitis: is a viral infection of the mouth that causes sores and ulcers. These may extend to involve peri-tonsillar area and presents with a sore throat.  Treatment is mainly supportive with analgesia and hydration.

Diphtheria

Diphtheria: is a highly contagious rare infection of the throat and or skin. It should only be suspected in unvaccinated patients with a history of foreign travel. It presents with a severe sore throat and a white membranous exudate coating the tonsils “diphtheric patch” shown below.

Image from: https://specialist-ent.com/o-c-p-faucial-diphtheria/

Epiglottitis and Supraglottitis

Epiglottitis and supraglottitis: These are serious life-threatening rapidly progressing bacterial infections of the larynx. They could present with a sore throat that is usually associated with any of the following:

• Change in voice
• Odynophagia
• Drooling
• Stridor
• Fever
• Distress

Assessing these patients should only happen in a controlled setting with both anaesthetics and ENT teams available around.

Candidal Infection

Candidal infection: This should be suspected in immunocompromised patients with a sore throat. Seeing oral thrush is enough to commence treatment as per the local trust microbiology guidelines. This is usually in the form of antifungals.

Suggestive symptoms in history

Symptoms suggestive of quinsy in the History:

• Unilateral worsening sore throat
• Odynophagia (pain when swallowing)
• Fever
• Hot potato voice (muffled voice)
• Trismus (difficulty opening mouth)
• History of previous quinsy

Symptoms suggestive of malignant causes in the history:

• Unilateral sore throat
• Referred otalgia
• Weight loss and loss of appetite
• Neck lump
• Unilateral tonsillar enlargement
• B symptoms

Symptoms suggestive of other systemic causes in the history:

• Urogenital rash or ulcerations
• Skin rash of desquamation
• Oral vesicles
• Family history
• Associated autoimmune comorbidity

Important notes

• Referral to ENT team is indicated if the patient is unable to eat or drink, quinsy is suspected and/or having airway symptoms (e.g. stridor, stertor)
• They may require IV antibiotics and hydration if they have poor oral intake
•  Patients with quinsy should be referred to ENT team urgently for aspiration or incision and drainage to prevent spread of collection
• USC referral to ENT if malignancy is questioned and the patient is too well to be in a hospital
• Medical/dermatological opinion should be sought if other systemic causes are suspected
• Patients with glandular fever can have splenomegaly, and advice about contact sport is important!

Resources and useful links

1. NCBI Summary – Tonsillitis
2. ENT SHO – Quinsy
3. NICE CKS – Glandular Fever
4. CDC – Candidiasis
5. Specialist ENT – Faucial Diphtheria

Written by Miss Dema Motter and Mr Hussein Ben Amer
Edited by Divya Jayarajan (Medical Student)