Ear, Nose & Throat
A 17 year old girl presents to the Emergency Department with a 2 day history of sore throat. Which of the following is a scoring system used to guide management in acute sore throat?
Answer:
The Centor criteria are: score 1 point for each (maximum score of 4)- Tonsillar exudate
- Tender anterior cervical lymphadenopathy or lymphadenitis
- History of fever (over 38°C)
- Absence of cough
Acute Sore Throat
Ear, Nose & Throat
Last Updated: 10th February 2023
Sore throat occurs when an acute upper respiratory tract infection affects the mucosa of the throat. Acute tonsillitis is an acute infection of the parenchyma of the palatine tonsils. Acute pharyngitis is inflammation of the part of the throat behind the soft palate (oropharynx). The clinical distinction between tonsillitis and pharyngitis is unclear in the literature, and the condition is often referred to simply as 'acute sore throat'.
Causes
- Common infectious causes of acute sore throat include:
- Rhinovirus, coronavirus, parainfluenza virus.
- Influenza types A and B.
- Streptococcal infection.
- Group A beta-haemolytic streptococcus (GABHS), also known as Streptococcus pyogenes, is the most common bacterial cause of sore throat and may cause pharyngitis, tonsillitis, or scarlet fever. Acute Group A streptococcal (GAS) pharyngitis/tonsillitis is common in children and adolescents aged 5 to 15 years and is more common in the winter (or early spring) in temperate climates.
- Group C and G beta-haemolytic streptococci may cause pharyngitis and tonsillitis and have been associated with foodborne outbreaks of pharyngitis.
- Streptococcal infection is suggested by fever > 38.5°C, exudate on the pharynx/tonsils, anterior neck lymphadenopathy, and absence of cough. A scarlatiniform rash may be present, especially in children.
- Adenovirus, leading to pharyngoconjunctival fever.
- Herpes simplex virus type 1 (and more rarely type 2), leading to acute herpetic pharyngitis.
- Epstein-Barr virus, leading to infectious mononucleosis (glandular fever).
- Fusobacterium necrophorum, which may cause pharyngitis or tonsillitis, and can (very rarely) lead to Lemierre syndrome (septic phlebitis of the internal jugular vein).
- Rarer infectious causes include:
- Haemophilus influenzae type b — can cause epiglottitis.
- Enteroviruses — can cause herpangina and hand, foot, and mouth disease.
- Measles virus.
- Candida albicans — causes candidal pharyngitis.
- Neisseria gonorrhoeae — can cause gonococcal pharyngitis.
- Corynebacterium diphtheria, C. ulcerans — cause diphtheria.
- Arcanobacterium haemolyticum — causes arcanobacterial pharyngitis.
- Yersinia enterocolitica — causes yersinial pharyngitis.
- Francisella tularensis — causes oropharyngeal tularaemia.
- Chlamydophila pneumoniae, Mycoplasma pneumonia — can cause chlamydial pharyngitis and mycoplasmal pharyngitis.
- HIV-1.
- Non-infectious causes are uncommon, and include:
- Physical irritation (e.g. from a nasogastric tube or from smoke).
- Hayfever.
- Gastroesophageal reflux disease.
- Kawasaki disease.
- Oral mucositis secondary to radiotherapy or chemotherapy, which may become secondarily infected.
- Haematological disorders:
- Leukaemia: ulceration and haemorrhage of the mucous membrane of the pharynx may occur.
- Aplastic anaemia: sloughing and ulceration of the mouth and pharynx may occur.
- Drugs which can cause blood disorders (e.g. neutropenia, agranulocytosis, thrombocytopenia) leading to infection and acute sore throat. These include cytotoxic drugs, carbimazole, clozapine, and sulfasalazine.
- Oropharyngeal cancer.
- Behcet's syndrome.
- Stevens Johnson syndrome.
Assessment
- Examine the person's throat and neck:
- Pharyngitis is often is associated with pharyngeal exudate and cervical lymphadenopathy
- Tonsillitis is associated with tonsillar exudate and enlargement and erythema of the tonsils. There may be anterior cervical lymphadenopathy.
- Ask the person about their symptoms. Non-specific symptoms may include:
- Headache, nausea, vomiting, and abdominal pain — may be present in children with pharyngitis, and all people with tonsillitis.
- Fever — this is common in pharyngitis and tonsillitis. Most people with acute tonsillitis have a fever >38°C.
- Dehydration - a sore throat may occasionally result in significantly reduced fluid intake.
Assessment
Diagnosis is clinical and investigations are not performed routinely.
If the diagnosis of GAS needs to be confirmed with certainty (such as in people at high risk of rheumatic fever, vulnerable people such as the very old or young, or people who are at risk of immunosuppression, or people with very severe symptoms), arrange a rapid antigen test for group A streptococcus. A negative antigen test in a person (particularly a child) with suspected GAS should be followed up with a throat culture.
Centor criteria:
The Centor criteria are: score 1 point for each (maximum score of 4)
- Tonsillar exudate
- Tender anterior cervical lymphadenopathy or lymphadenitis
- History of fever (over 38°C)
- Absence of cough
Each of the Centor criteria score 1 point (maximum score of 4). A score of 0, 1 or 2 is thought to be associated with a 3 to 17% likelihood of isolating streptococcus. A score of 3 or 4 is thought to be associated with a 32 to 56% likelihood of isolating streptococcus.
FeverPAIN criteria:
The FeverPAIN criteria are: score 1 point for each (maximum score of 5)
- Fever (during previous 24 hours)
- Purulence (pharyngeal/tonsillar exudate)
- Attend rapidly (within 3 days of onset of symptoms)
- Severely inflamed tonsils
- No cough or coryza
A score of 0 or 1 is associated with a 13% to 18% likelihood of isolating streptococcus. A score of 2 or 3 is associated with a 34% to 40% likelihood of isolating streptococcus. A score of 4 or 5 is associated with a 62% to 65% likelihood of isolating streptococcus.
Management of acute sore throat
Acute sore throat is self-limiting and often triggered by a viral infection of the upper respiratory tract. Symptoms can last for around 1 week, but most people will get better within this time without antibiotics, regardless of cause (bacteria or virus).
Consider the person's signs and symptoms, and use the FeverPAIN or Centor clinical prediction score to determine the likelihood of streptococcal infection (and therefore the need for antibiotic treatment):
- People who are unlikely to benefit from an antibiotic (FeverPAIN score of 0/1 or Centor score of 0/1/2):
- Do not offer an antibiotic prescription.
- Give advice about the usual course of acute sore throat;
- Managing symptoms, including pain, fever and dehydration, with self-care
- Seeking medical help if symptoms worsen rapidly or significantly, if symptoms do not start to improve after 1 week, or if the person becomes systemically very unwell.
- People who may be more likely to benefit from an antibiotic (FeverPAIN score of 2/3):
- Consider no antibiotic prescription with advice or a backup antibiotic prescription.
- When a backup antibiotic prescription is given, give advice about the antibiotic not being needed immediately but using the back-up prescription if symptoms do not start to improve within 3 to 5 days or if they worsen rapidly or significantly at any time.
- People who are most likely to benefit from an antibiotic (FeverPAIN score of 4/5 or Centor score of 3/4):
- Consider an immediate antibiotic prescription, or a backup antibiotic prescription with advice.
- People who are systemically very unwell, have symptoms and signs of a more serious illness or condition, or are at high-risk of complications:
- Offer an immediate antibiotic prescription with advice.
- Refer for specialist input if the acute sore throat is associated with a severe systemic infection or severe suppurative complications (such as quinsy or cellulitis, parapharyngeal abscess or retropharyngeal abscess)
Choice of antibiotic:
- First choice: phenoxymethylpenicillin for 5 - 10 days
- Alternative first choice: clarithromycin or erythromycin for penicillin allergy or intolerance
Complications
Complications of streptococcal pharyngitis/tonsillitis include:
- Local extension:
- Otitis media
- Acute sinusitis
- Peritonsillar abscess (quinsy)
- Peritonsillar cellulitis
- Parapharyngeal abscess
- Retropharyngeal abscess
- Acute epiglottitis
- Mastoiditis
- Streptococcal pneumonia
- Systemic
- Metastatic infection (e.g. brain abscess, endocarditis, meningitis, osteomyelitis or liver abscess)
- Streptococcal toxic shock syndrome
- Scarlet fever
- Rheumatic fever
- Post-streptococcal glomerulonephritis
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
