Sore throat (pharyngitis) is one of the most common complaints in primary care and emergency departments. Most cases are viral, but some causes—like epiglottitis or peritonsillar abscess (PTA)—can be life-threatening and require rapid intervention.
Your uploaded chart provides a structured clinical approach using:
- Red flags
- Key physical exam clues
- Centor criteria
- Dangerous vs. common causes
This article breaks those concepts into a clear, academic, learner-friendly format.
Red Flags in Sore Throat
These symptoms suggest a dangerous cause and require urgent evaluation:
Major Red Flags
- Fever
- Drooling
- Voice change ("hot-potato voice")
- Abdominal pain (in strep children)
- Uvula not midline
- Foreign body sensation
- Stridor
- Airway obstruction risk
- Severe headache
- Neck stiffness
- Toxic appearance
A sore throat with any of the above is not simple pharyngitis.
The First 3 Questions (Based on the Chart)
Your chart emphasizes three quick screening questions:
1. Is the voice muffled? Is the patient drooling?
→ Think Epiglottitis (airway emergency)
2. Is the uvula deviated from the midline?
→ Think Peritonsillar abscess (PTA)
3. Are Centor criteria positive?
→ Think Strep throat (Group A Streptococcus)
These questions help decide whether the cause is dangerous, bacterial, or viral.
Likely Viral vs. Bacterial vs. Severe Causes
Your chart divides sore throat causes into categories:
A. Severe, High-Risk Causes
1. Epiglottitis (Airway Emergency)
History/Exam:
- Fever
- Drooling
- Muffled voice
- Difficulty swallowing
- Tripod posture
Workup:
- Neck X-ray (thumb sign)
- Avoid throat exam if respiratory distress
Treatment:
- Secure airway
- ENT consult
- IV antibiotics
2. Foreign Body (FB)
History/Exam:
- FB sensation
- Stridor
- Difficulty swallowing
Workup:
- Clinical evaluation
- CT neck if unclear
Treatment:
- ENT consult
- Endoscopic removal
3. Gonorrhea / Chlamydia Pharyngitis
History/Exam:
- Oral sexual exposure
- Tonsillar discharge
Workup:
GC/Chlamydia cultureTreatment:
Ceftriaxone + azithromycin (or doxycycline)4. Ludwig’s Angina (Rapidly Progressive Infection)
History/Exam:
- Dental infection
- Submandibular swelling
- Difficulty swallowing
- Airway compromise risk
Workup:
CT neckTreatment:
- Airway management
- IV antibiotics
- ENT consult
5. Peritonsillar Abscess (PTA)
History/Exam:
- Fever
- Uvula deviated
- Trismus
- Muffled “hot-potato” voice
Workup:
- Clinical
- Ultrasound if needed
Treatment:
- Needle aspiration
- Antibiotics
- Steroids
- ENT referral
B. Common Causes
1. Streptococcal Pharyngitis (Strep Throat)
Evaluated using Centor criteria (see section below).
Workup: Clinical ± rapid strep test
Treatment:
- Penicillin (oral or IM)
- Consider steroids for severe pain
2. Infectious Mononucleosis (Mono)
History/Exam:
- Lymphadenopathy
- Splenomegaly
- Rash after penicillin
- Adolescents/young adults
Workup: Monospot test
Treatment: Supportive care
Avoid contact sports (splenic rupture risk)
3. Viral Pharyngitis
History/Exam:
- Fever
- Cough
- Congestion
- Rhinorrhea
Workup: Exclusion
Treatment:
- NSAIDs
- Fluids
- Rest
Centor Criteria for Strep Throat (Chart-Based)
Centor criteria help estimate the probability of Group A Streptococcal infection.
| Criterion | Points |
|---|---|
| Fever | +1 |
| Exudates | +1 |
| Tender anterior cervical lymph nodes | +1 |
| No cough | +1 |
Score Interpretation (from chart)
| Score | Strep Probability | Next Step |
|---|---|---|
| 0–1 | <10% | Nothing |
| 2–3 | 17–35% | Test |
| 4 | >50% | Treat |
Important Note (from chart):
Treatment recommendations vary, and many physicians no longer strictly use these older guidelines.
Summary Table of Causes
| Disease | Key Findings | Workup | Treatment |
|---|---|---|---|
| Epiglottitis | Fever, drooling, muffled voice | Neck X-ray | Airway, ENT, IV ABx |
| FB | Stridor, FB sensation | Clinical / CT | ENT removal |
| GC/Chlamydia | Oral sex, discharge | Cultures | Ceftriaxone + azith/doxy |
| Ludwig’s Angina | Dental infection, neck swelling | CT neck | Airway + IV ABx |
| Mono | Lymphadenopathy, splenomegaly | Monospot | Supportive |
| PTA | Fever, uvula deviation | Clinical/US | Aspiration + Antibiotics |
| Strep | Centor criteria + | Clinical | PCN ± steroids |
| Viral | Cough, congestion | Exclusion | Symptomatic care |
Documentation Essentials (From Chart)
Document the following:
General
- Normal phonation (voice)
- Airway status
HEENT
- Uvula midline
- Tonsil size
- Exudates
- Absence of drooling
- Non-erythematous, non-enlarged tonsils
Neck
- Supple
- No cervical lymphadenopathy
Clear documentation supports proper diagnosis and safe discharge.
Sore Throat: High-Yield Clinical Pearls
- Drooling + muffled voice = airway emergency (epiglottitis/PTA)
- Uvula deviation ALWAYS means peritonsillar abscess
- No cough + fever + tender nodes = possible strep
- Mono patients get rash after penicillin (important exam question!)
- Oral sex → consider GC/Chlamydia pharyngitis
- Ludwig’s angina can close the airway quickly—ACT FAST
FAQs About Sore Throat
1. What is the most dangerous cause of sore throat?
Epiglottitis and Ludwig’s angina because they can obstruct the airway.
2. When should a patient with sore throat be hospitalized?
If they have drooling, airway threat, uvula deviation, trismus, neck swelling, or systemic toxicity.
3. Do all sore throats need antibiotics?
No—most are viral. Careful evaluation using Centor criteria helps guide treatment.
4. When is imaging required?
With suspected PTA, deep-neck infection, or foreign body.
5. Why avoid giving penicillin in mono?
It causes a characteristic rash.
6. When should steroids be used?
Severe strep throat or PTA (as adjunct).
