On this page
Referral and warning signs
When to refer
Refer if: Signs of airway obstruction (stridor, difficulty breathing). Inability to swallow saliva (drooling). Signs of deep neck space infection (neck swelling, trismus). Suspected peritonsillar/retropharyngeal abscess. Severe symptoms or dehydration. Failure to improve despite antibiotics (if given for suspected GAS).
Red flags
- Difficulty breathing / Stridor.
- Drooling / Inability to swallow.
- Trismus (difficulty opening mouth).
- Muffled ('hot potato') voice.
- Unilateral neck swelling.
- Signs of sepsis.
Signs and symptoms
- Sore throat / Throat pain (especially on swallowing).
- Mild fever.
- Malaise, loss of appetite.
- Headache.
- Redness of the pharynx.
- Runny nose, cough, conjunctivitis, hoarseness, diarrhoea (suggest viral cause).
- Tonsillar exudates, tender cervical lymph nodes, high fever, absence of cough (suggest bacterial cause - Strep throat / Pharyngo-tonsillitis - See ENT017).
Risk factors
- Exposure to viral or bacterial pathogens.
- Close contact settings (schools, households).
- Smoking.
- Immunosuppression (may lead to opportunistic infections like Candida).
Diagnosis
Clinical assessment
Diagnosis based on history of sore throat and examination of the pharynx. Differentiating viral from bacterial (Group A Strep - GAS) clinically can be difficult but presence of cough/rhinorrhoea suggests viral.
Differential diagnosis
- Pharyngo-Tonsillitis (significant tonsillar involvement).
- Peritonsillar Abscess (unilateral swelling, trismus).
- Epiglottitis (drooling, stridor, toxic appearance - RARE).
- Laryngitis (hoarseness).
- Oral Thrush (Candida pharyngitis).
- Infectious Mononucleosis (EBV) (exudate, lymphadenopathy, fatigue, splenomegaly).
- Gonococcal pharyngitis.
- Diphtheria (grey membrane - RARE with vaccination).
Investigations
- Usually clinical diagnosis.
- Throat Swab for Rapid Strep Antigen Detection Test (RADT): If GAS suspected (helps guide antibiotic use).
- Throat Culture: Gold standard for GAS, but takes longer.
- Monospot test / EBV serology (if mononucleosis suspected).
- FBC (may show lymphocytosis in viral/mono, neutrophilia in bacterial).
Diagnostic criteria
Clinical diagnosis. Centor criteria or FeverPAIN score can help predict likelihood of GAS but not definitive.
Management
Non-pharmacological management
- Viral Pharyngitis (Majority of cases):
- - Reassurance.
- - Rest.
- - Adequate fluid intake (warm fluids like tea may soothe).
- - Salt water gargles (adults).
- - Avoid irritants (smoke).
Pharmacological treatment
- Symptomatic Relief:
- - Analgesia/Antipyretics: Paracetamol 1g Q6H PRN (Adult); 10-15mg/kg/dose (Child). OR Ibuprofen. (LOC: HC2)
- - Lozenges or throat sprays (limited evidence).
- Antibiotics (ONLY if Group A Strep strongly suspected or confirmed):
- - Aim is to prevent rheumatic fever.
- - See Management under Pharyngo-Tonsillitis (ENT017) - Phenoxymethylpenicillin or Benzathine Penicillin G. Erythromycin if penicillin allergic. (LOC: HC2)
Monitoring
Symptoms usually resolve within 3-7 days (viral). Follow up if symptoms worsen or persist > 7-10 days, or if GAS treated and fever persists.
Complications
- Usually self-limiting (viral).
- Suppurative complications of GAS: Peritonsillar abscess, Retropharyngeal abscess, Otitis media, Sinusitis.
- Non-suppurative complications of GAS (Immune-mediated): Acute Rheumatic Fever (ARF), Post-Streptococcal Glomerulonephritis (PSGN).
Prevention
- Good hygiene (handwashing).
- Avoid close contact with infected individuals.
- Prompt treatment of confirmed GAS infection.
Patient education
- Likely cause (usually viral).
- Self-care measures (fluids, rest, analgesia).
- Antibiotics usually not needed.
- Rationale for antibiotics IF Group A Strep suspected/confirmed (rheumatic fever prevention).
- Importance of completing antibiotic course if prescribed.
- When to seek further medical attention (worsening symptoms, red flags).
Uganda-specific notes
Viral pharyngitis very common. Overuse of antibiotics should be avoided. Rheumatic fever still occurs, so treating confirmed/highly suspected GAS is important. Diphtheria possible in unimmunized populations.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 21, Section 21.3.3