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Sore throat - acute - Management
How should I manage someone with persistent sore throat?

  • Reconsider the initial diagnosis.
  • Consider an alternative diagnosis or further investigation if the individual has not responded to a course of antibiotics.
  • Consider cancer if the sore throat is persistent, especially if there is a neck mass.
  • Refer urgently anyone with:
    • An unexplained persistent sore or painful throat. 'Persistent' refers to a time frame of 3 to 4 weeks.
    • Red, or red and white patches, or ulceration or swelling of the oral/pharyngeal mucosa for more than 3 weeks.
    • Pain on swallowing or dysphagia for more than 3 weeks.
  • Suspect infectious mononucleosis if sore throat and lethargy persist into the second week, especially if the person is 15–25 years of age. Request a full blood count, differential white cell count and blood film to look for mononuclear leucocytosis, and a Monospot test to look for heterophile antibodies if the person wishes to be tested.
  • Consider non-infectious causes of sore throat (for example, gastro-oesophageal reflux disease, chronic irritation from cigarette smoke, alcohol, or hayfever).
Clarification / Additional information
  • Suspected cancer [Jones, 1998; Manni, 1998; Franco and Har-El, 1999; Dhillon and East, 2006]:
    • Hypopharyngeal cancer (includes the pyriform sinus, lateral pharyngeal wall, posterior pharyngeal wall, and post cricoid region): this may present with a unilateral, well-localized, persistent sore throat; a vague discomfort on swallowing; and referred pain to the ear; or as a neck mass due to cervical node metastases. Dysphagia is a late symptom. There may be weight loss. It is not directly visible on examination.
    • Oropharyngeal cancer (includes the tonsils and faucial pillars, base of the tongue, soft palate, and uvula): there may be sore throat, otalgia, and progressive dysphagia; trismus or a foreign body; or mass sensation in the throat. Many people complain of the sensation of a 'lump at the back of the throat'. An ulcer is usually visible on examination. It often presents with a neck mass due to metastases to the cervical nodes.
Basis for recommendation
  • The basis for these recommendations is expert advice from national guidance [National Collaborating Centre for Primary Care, 2005] and standard textbooks [Jones, 1998; Pagana and Pagana, 2002; Johannsen et al, 2005].
  • The National Institute for Health and Clinical Excellence (NICE) guidance recommends referring urgently everyone with an unexplained, persistent sore or painful throat [NICE, 2005]. Our expert reviewers suggested a time frame of 3 to 4 weeks for 'persistent' and also recommended a time frame of 3 weeks for people with red, or red and white patches, or ulceration or swelling of the oral/pharyngeal mucosa or pain on swallowing or dysphagia.

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