Sore throat is pain in the back of the throat.
A sore throat can be very painful and is usually worsened by swallowing.
Many people with a sore throat refuse to eat or drink. Sometimes pain is also felt in the ear because nerves to the back of the throat run very close to nerves from the ear.
Causes of Sore Throat
A sore throat usually results from infection (see table Some Infectious Causes and Features of Sore Throat). The most common cause is
Tonsillopharyngitis
Much less common but more serious causes of sore throat are
Abscess
Infection of the epiglottis (epiglottitis)
Tumors
Abscess, epiglottitis, and tumors are of particular concern because they may block the airway.
Throat irritation and mild soreness can also be caused by dryness, irritants, gastroesophageal disease (GERD), and vocal strain (such as from yelling).
Tonsillopharyngitis
Tonsillopharyngitis is infection of the tonsils (patches of lymphoid tissue at the back of the throat) and the throat (pharynx). Doctors may use the term tonsillitis when the tonsils are particularly inflamed or the term pharyngitis when the tonsils are not particularly inflamed or when people who have no tonsils have a sore throat.
Tonsillopharyngitis is usually caused by a virus, typically one of the same viruses that causes the common cold. Most common colds begin with a mild sore throat. A less common viral cause is acute mononucleosis (caused by the Epstein-Barr virus), which occurs mainly in children and young adults. The coronavirus that causes COVID-19 and other coronaviruses can also cause a sore throat. Rarer still, sore throat can be part of the initial infection with human immunodeficiency virus (HIV) or due to chronic fungal infections in people with HIV infections, such as thrush.
About 10% of sore throats in adults (and slightly more in children) are caused by a type of Streptococcus bacteria (streptococci). Such streptococcal infections are often called strep throat. Strep throat is unusual in children younger than 2 years. If untreated, streptococcal infections can lead to serious complications such as rheumatic fever (now rare in developed countries), a kidney disorder called glomerulonephritis, or an abscess)
Rare bacterial causes include gonorrhea and diphtheria (in countries with low vaccination rates).
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Abscess
A collection of pus (abscess) may form beneath or near one of the tonsils (peritonsillar abscess). The usual cause is a streptococcal infection that has spread from the tonsils into deeper tissue. In young children, an abscess can form in the tissue at the back of the throat (retropharyngeal abscess).
Epiglottitis
The epiglottis is a small flap of tissue that closes the entrance to the voice box and windpipe during swallowing. The epiglottis can become infected by certain bacteria (epiglottitis). This infection causes severe pain and swelling. The swelling can close off the windpipe, particularly in infants and children. Epiglottitis used to occur mainly in children and usually was caused by Haemophilus influenzae type B (HiB) bacteria. Now, in areas where most children are vaccinated against HiB, epiglottitis is quite rare in children, but HiB is still a cause in adults and unvaccinated children.
Evaluation of Sore Throat
Not every sore throat requires immediate evaluation by a doctor. The following information can help people decide whether a doctor’s evaluation is needed and help them know what to expect during the evaluation.
Warning signs
In people with a sore throat, certain symptoms and characteristics are cause for concern. They include
Squeaking sound when breathing in (stridor)
Any sign of difficulty breathing (particularly when children sit upright and lean forward, with their neck tilted back and jaw thrust forward to try to help them breathe better)
Drooling
Muffled, “hot potato” voice (speaking as if a hot object is being held in the mouth)
Visible bulge in the back of the throat
When to see a doctor
People who have warning signs should go to the hospital right away.
People with a sore throat but no warning signs should call their doctor. People who have typical cold symptoms and mild to moderate discomfort may be advised to stay at home and treat their symptoms with over-the-counter (OTC) remedies. People with severe pain and/or other symptoms (such as fever, extreme fatigue, or a productive cough) typically should be seen right away.
What the doctor does
Doctors first ask questions about the person's symptoms and medical history and then do a physical examination. What doctors find during the history and physical examination helps them decide what, if any, tests need to be done (see table Some Infectious Causes and Features of Sore Throat).
During the medical history, doctors ask about the following:
Symptoms of a runny nose, cough, and difficulty swallowing, speaking, or breathing
Whether the person has had any general feeling of severe fatigue before the sore throat (suggesting mononucleosis)
Whether the person has had a previous episode of mononucleosis (people rarely get mononucleosis twice)
Whether people have any risk factors for gonorrhea (such as recent oral-genital sexual contact) or HIV infection (such as unprotected sex, multiple sex partners, or intravenous drug abuse)
During the physical examination, doctors focus on the nose and throat. However, if doctors suspect epiglottitis in children (because there are warning signs and no evidence of a cold), they do not examine the throat in their office because inserting a tongue depressor may cause a spasm that triggers complete airway blockage.
If epiglottitis is not suspected, doctors do the following:
Look in the mouth to see whether the throat and/or tonsils are red, whether there are white patches (exudate) on the tonsils, and whether there are any bulges suggesting an abscess
Examine the neck for enlarged, tender lymph nodes
Feel the abdomen for an enlarged spleen, which may occur in people with mononucleosis
Some Infectious Causes and Features of Sore Throat
Cause | Common Features* | Diagnostic Approach† |
|---|---|---|
Viral tonsillopharyngitis (infection of the tonsils and throat caused by a virus) | Usually mild to moderate throat pain and little or no fever Usually a runny nose and/or cough Throat and tonsils that are slightly to very red and that may be coated with a white discharge or pus Sometimes one or two enlarged lymph nodes in the neck | A doctor’s examination alone |
Often severe throat pain and fever Rarely a runny nose or cough Often a very red throat and tonsils that are coated with a white discharge or pus Usually one or two tender, enlarged lymph nodes in the neck | Testing of a sample taken from the throat with a swab | |
Mononucleosis (caused by the Epstein-Barr virus) | Often moderate to severe throat pain, high fever, and constant fatigue but no cold symptoms Usually in adolescents or young adults who have never had mononucleosis Often a very red throat and tonsils, coated with a white discharge or pus Typically many enlarged lymph nodes on both sides of the neck and sometimes an enlarged spleen detected during a doctor's examination | A blood test for antibodies to Epstein-Barr virus |
Severe throat pain, often fever, and no cold symptoms Sometimes a muffled voice that sounds as if a hot object is being held in the mouth ("hot potato" voice) Throat and tonsils that may be slightly to very red Typically substantial swelling on one side of the throat, detected during the examination | Usually removal of pus with a needle (for diagnosis and treatment) Sometimes CT of the neck | |
Epiglottitis‡ (infection of the epiglottis—the small flap of tissue that covers the opening to the voice box, or larynx) | Severe throat pain and difficulty swallowing that begin abruptly In children, often drooling and signs of severe illness (such as little or no eye contact, failure to recognize parents, and irritability) Sometimes (more often in children) respiratory symptoms, including
A throat that typically appears normal seen during the examination with a laryngoscope (however, examination can be dangerous and may not be advisable) | For most children and for adults who appear seriously ill, flexible fiberoptic laryngoscopy (insertion of a thin flexible tube into the throat to directly view the epiglottis), done in operating room Sometimes for people who do not have all the symptoms of epiglottitis and who do not appear seriously ill, x-rays of the neck |
* Features include symptoms and the results of the doctor's examination. Features mentioned are typical but not always present. | ||
† Although a doctor's examination is always done, it is mentioned in this column only if the diagnosis can sometimes be made by the doctor's examination alone, without any testing. | ||
‡ These causes are rare. | ||
CT = computed tomography. | ||
Testing
The need for tests depends on what doctors find during the history and physical examination, particularly whether warning signs are present.
Possible tests include
Rapid strep screening (for children)
Throat culture (for adults)
Flexible fiberoptic laryngoscopy
X-rays of the neck
A doctor's first concern is to recognize which people might have epiglottitis. Stridor and drooling are warning signs, particularly in people who appear ill or with difficulty breathing. In such cases, people should not have x-rays. Instead, the doctor looks down the throat with a thin, flexible viewing tube inserted through the nose (flexible fiberoptic laryngoscopy). Because children are more likely to have sudden, complete blockage of their airway when their throat is examined, doctors minimize this danger by doing this examination only in the operating room, where advanced airway equipment and personnel are available. Adults who do not appear seriously ill and have no respiratory symptoms may have neck x-rays to look for a swollen epiglottis or have flexible fiberoptic laryngoscopy done in the emergency department or a specialist's office.
Despite what many people think, it is difficult for doctors to distinguish a strep throat from a sore throat caused by a virus based only on appearance. Both may cause a very red throat with white patches. Thus, unless people clearly have just a cold, doctors usually do tests to diagnose strep throat. There are two types of test, a rapid strep antigen test and a throat culture. Both tests are done on a sample taken from the back of the throat with a swab. The rapid strep antigen test can be done in the doctor's office in about 20 minutes. The rapid test is usually done only in children. If results are positive, children are treated for strep throat with antibiotics. If results are negative, another sample is sent to the laboratory for culture (growing microorganisms on a special gel so that there are enough to identify). If adults need testing for strep throat, doctors usually do only a throat culture because adults may have another bacterial infection that would not be identified by the rapid antigen test.
An abscess is often noticeable during the doctor's examination. The doctor can both diagnose and treat the abscess by inserting a small needle into the swollen area after spraying the throat with an anesthetic. If pus comes out, an abscess is confirmed, and the doctor removes as much pus as possible. If the location and extent of an abscess are unclear, computed tomography (CT) of the neck is performed.
Doctors do blood tests for mononucleosis or HIV only when they suspect people have one of these infections.
Treatment of Sore Throat
Doctors treat any specific cause of sore throat. For example, people with strep throat or other bacterial infections are given antibiotics.
Key Points
Most sore throats are caused by viral tonsillopharyngitis and resolve without treatment.
Occasionally, sore throats are caused by certain bacteria (particularly streptococci) and result in strep throat.
It is difficult for doctors to distinguish viral from bacterial causes of tonsillopharyngitis without testing.
Abscess and epiglottitis are rare but serious causes of sore throat.
