Sore Throat

Acute Sore Throat

Most acute sore throats are due to viral infection, requiring advice and reassurance in Primary Care. Throat swabs or rapid antigen testing are not routinely recommended (SIGN). Use of antibiotics for streptococcal sore throat decrease symptom duration by less than 1 day (NICE 2018). CKS has a useful summary of the management of acute sore throat.

Diagnosis:

• Clinical examination cannot be relied upon to differentiate between viral and bacterial sore throat
• Throat swabs or rapid antigen testing should not be carried out routinely in sore throat  
• There is insufficient evidence to support a recommendation on the routine use of antibiotics in acute sore throat
  
  Scenarios or complications to consider include:

• Immunosuppression (consider FBC and same day specialist assessment)
• Drugs with the potential for leucopoenia (particularly DMARDs and carbimazole)
• Red flag symptoms or signs (epiglottitis, stridor, peritonsillar or other abscess)
• Systemic sepsis or clinically significant dehydration
• Other causes (glandular fever, candidiasis, or the rarities such as diphtheria or Kawasaki Disease).

For urgent Referral to St John’s Tel 01506 523 000 and ask for On Call ENT:

• Sore throat associated with stridor or respiratory difficulty is an absolute indication for inpatient admission
• If patient is unable to swallow fluids

For further advice on prescribing please see Primary Care Management.

Persistent Sore Throat

It is common for sore throats due to infection to take some time to settle. Where there is a clear explanation for symptoms (persistent or post infection), and particularly when the person is otherwise low risk (<40, non-smoking) then it is appropriate to make a clinical judgement about duration of symptoms before referring.

The Scottish Referral Guidelines for Suspected Cancer advise referral for PERSISTENT pain (in the throat or on swallowing) lasting longer than 3 weeks.

Scottish data clearly shows:

• That PERSISTENT pain is key
• INTERMITTENT pain has much less predictive significance
• UNILATERAL PERSISTENT PAIN (particularly in older people who smoke) is the most concerning.

The Head and Neck Cancer Risk Calculator http://www.orlhealth.com/risk-calculator-2.html is validated in the Scottish population and will reliably indicate those needing to be referred to exclude cancer. It is incorporated into the SCI Gateway template.

Please see RefHelp for specific advice about any accompanying hoarseness or other significant symptoms ENT-Cancers.aspx.

Who to refer:

For emergency (same day) referral to St John’s Tel 01506 523 000 and ask for On Call ENT:

• Sore throat associated with stridor or respiratory difficulty is an absolute indication for same day inpatient admission
• If patient is unable to swallow fluids

Persistent sore throat:

Persistent pain in the throat or swallowing lasting more than 3 weeks noting the following:

• Clinical judgement should be used, particularly in those who are low risk (<40 especially) with no other red flags and a clearly infected cause
• PERSISTENT rather than INTERMITTENT pain is key
• UNILATERAL (i.e. localising) symptoms are more significant.

The easiest and most reliable way to risk-assess for a persistent sore throat is to use the validated Head and Neck Cancer Risk Calculator: http://www.orlhealth.com/risk-calculator-2.html.

Please see more detail on referral thresholds on the Neck Lump and Throat Cancer Risk Assessment page.

Who not to refer:

Sore throats with no red flags, a short duration (<3 weeks) or a clear infective cause.

How to refer:

SCI Gateway, Lauriston / St John’s, ENT – Throat.

Primary Care Management of Acute Sore Throat

Antibiotics should NOT be used:

• for symptomatic relief
• specifically to prevent the development of rheumatic fever or acute glomerulonephritis
• routinely to prevent cross infection in the general population
• specifically to prevent suppurative complications

Paracetamol is the drug of choice for analgesia in sore throat. Routine use of non-steroidal anti-inflammatory agents (NSAIDs) is not recommended

Consider prescribing antibiotics if any of the following are present:

• Systemic toxicity
• Recurrent tonsillitis,
• Immunocompromised
• Debilitated or prolonged (more than 7 days) illness. In other cases consider withholding prescription, or give delayed prescription

Consider glandular fever (infectious mononucleosis) if sore throat persists or patient is debilitated and not responding to antibiotics.Persistent Sore Throat
It is common for sore throats due to infection to take some time to settle. Where there is a clear explanation for symptoms (persistent or post infection), and particularly when the person is otherwise low risk (<40, non-smoking) then it is appropriate to make a clinical judgement about duration of symptoms before referring.
The Scottish Referral Guidelines for Suspected Cancer advises referral for PERSISTENT pain (in the throat or on swallowing) lasting longer than 3 weeks.

Scottish data clearly shows:

• That PERSISTENT pain is key
• INTERMITTENT pain has much less predictive significance
• UNILATERAL PERSISTENT PAIN (particularly in older people who smoke) is the most concerning.​

Indications for Tonsillectomy