Textbook of Urgent Care Medicine, Chapter 15, Sore Throat

Published on October 26, 2026

Original author: William Gluckman

Originally published in 2014. Substantially updated and clinically reviewed in 2026 to reflect current evidence, guidelines, and urgent care practice.

Keywords: sore throat; acute pharyngitis; group A Streptococcus; streptococcal pharyngitis; peritonsillar abscess; epiglottitis; infectious mononucleosis; Lemierre syndrome; urgent care

INTRODUCTION

Sore throat is a common complaint seen in the urgent care setting.

Most sore throats are caused by viral pharyngitis. Group A Streptococcus (GAS) causes approximately 20% to 30% of pharyngitis in children and 5% to 15% in adults, and identifying patients who should be tested helps limit unnecessary antibiotics.

Other causes include irritation from postnasal drip, smoking, gastroesophageal reflux disease, or ingestion of a caustic substance.

The urgent care clinician must also recognize less common but potentially life-threatening conditions, including epiglottitis, deep neck-space infection, Ludwig angina, and Lemierre syndrome.

PRESENTATION

Patients typically present with painful or sore throat and fever, and may report jaw, neck, or ear pain.

TRIAGE PEARLS

If any of the following are present, the clinician should be notified immediately. Prompt management and early transfer to an emergency department are required because of the risk of rapid airway compromise.

• Drooling
• Tripod position
• Tachycardia
• Tachypnea
• Stridor
• Hypoxia
• Hypotension
• Inability to swallow liquids or tolerate secretions
• Muffled or markedly altered voice
• Rapidly progressive floor-of-mouth, submandibular, or neck swelling
• Toxic appearance or rapidly worsening symptoms

HISTORY PEARLS

• Exposure to known strep throat (i.e., in school or in a family member or friend)
• Ability to tolerate liquids: If the patient is not able to drink or tolerate secretions, this may indicate a serious infection such as epiglottitis, the presence of an esophageal foreign body, or an abscess.
• Immunization history: Haemophilus influenzae type b vaccination has made pediatric epiglottitis less common, but epiglottitis still occurs in vaccinated children and is now encountered more often in adults than in the pre-vaccine era.
• Ask about duration and progression. Persistent fever, worsening symptoms after initial improvement, or new unilateral neck pain or swelling after pharyngitis should raise concern for a deep neck-space infection or Lemierre syndrome.
• If infectious mononucleosis is suspected, ask about marked fatigue, posterior cervical lymphadenopathy, abdominal discomfort, and recent athletic activity. Prior EBV infection makes a new primary EBV infection unlikely, but routine EBV testing is not required for every sore throat.
• Key symptoms:
• Constitutional symptoms: Symptoms such as cough and sneezing make strep throat less likely.
• Trismus, or difficulty opening jaw: This symptom may represent abscess formation.
• Stiff neck: This symptom may be a sign of retropharyngeal abscess.
• Sexual history and sites of exposure may identify risk for gonococcal pharyngitis or acute HIV infection. Pharyngeal gonorrhea may be asymptomatic.
• Pediatric patients:
• Common associated symptoms such as headache and stomachache (along with fever) are often presenting symptoms in pediatric patients.
• Vesicles or ulcerations of the posterior pharynx, especially with hand or foot lesions, favor enteroviral disease and usually do not require GAS testing when the clinical picture is clearly viral.

PHYSICAL EXAM PEARLS

How does the patient look? Do they seem comfortable or toxic? Are they drooling or spitting? Do they prefer to be in the tripod position?

Examine the mouth and pharynx systematically, but do not force an oropharyngeal examination or intentionally induce gagging in a patient with suspected epiglottitis or impending airway compromise. Keep the patient calm and in a position of comfort while arranging emergency airway-capable transfer.

• Evidence of vesicles or ulcerations in the pharynx points to a viral origin.
• Evaluate for postnasal drip.
• Examine the uvula for swelling (uvulitis) and note any deviation.
• Examine the teeth to make sure the pain is not odontogenic in nature.

Examine under the tongue and palpate the submandibular region when safe. Floor-of-mouth elevation, a woody or indurated submandibular swelling, drooling, or tongue displacement should raise concern for Ludwig angina and prompt immediate ED transfer.

The presence of or the amount of exudate does not determine severity of infection or help distinguish bacterial from viral causes.

The presence of palatal petechiae and tender anterior cervical lymphadenopathy makes group A Streptococcus a more likely causative organism.

Peritonsillar abscess is suggested by unilateral peritonsillar swelling, trismus, muffled “hot potato” voice, and displacement of the uvula away from the affected side. Airway symptoms, toxic appearance, inability to tolerate oral intake, or extension beyond the peritonsillar space should prompt ED/ENT management.

Pain out of proportion to the oropharyngeal examination, neck stiffness, torticollis, posterior pharyngeal bulging, or systemic toxicity may indicate a retropharyngeal or other deep neck-space infection.

Epiglottitis should be considered with severe sore throat or dysphagia out of proportion to visible pharyngeal findings, drooling, muffled voice, stridor, or respiratory distress. Do not delay airway-capable transfer for diagnostic imaging in an unstable patient.

Scarlet fever may produce a fine, diffuse scarlatiniform “sandpaper” rash and strawberry tongue in a patient with GAS infection.

TESTING PEARLS

The 2025 IDSA guideline update suggests using a clinical scoring system, such as Centor or modified Centor/McIsaac criteria, to help determine which children and adults should be tested for GAS. Clinical scores are most useful for identifying low-risk patients; they should not be used by themselves to make a definitive diagnosis or to justify routine empiric antibiotics.

Patients with clear viral features such as cough, rhinorrhea, hoarseness, oral ulcers, or conjunctivitis generally do not need GAS testing.

For patients without clear viral features, confirm GAS with an appropriate diagnostic test. A positive rapid antigen detection test (RADT) or throat culture confirms GAS pharyngitis.

• In symptomatic children age 3 years or older, a negative RADT should be backed up with a throat culture when a high-sensitivity molecular test has not already provided definitive testing.
• In adults, routine throat culture after a negative RADT is not recommended because acute rheumatic fever is very rare.
• Throat culture remains the reference standard. Follow the manufacturer and local laboratory policy for molecular GAS assays, because test performance and the need for backup culture vary by platform.

For suspected pharyngeal gonorrhea, FDA-cleared nucleic acid amplification tests (NAATs) are available for pharyngeal specimens. Use an assay cleared or validated for the specimen type and follow current CDC STI guidance.

If infectious mononucleosis is clinically suspected, a CBC with differential may show lymphocytosis and atypical lymphocytes. Heterophile antibody testing can be useful, but the CDC does not recommend the Monospot test for general use; EBV-specific serology is helpful when the presentation is atypical or the diagnosis remains uncertain.

CT of the neck with IV contrast may be required when a deep neck-space infection, complicated peritonsillar abscess, or Lemierre syndrome is suspected. Patients who need this level of evaluation generally belong in an emergency department or hospital setting.

Imaging should not delay airway management in suspected epiglottitis. Stable patients may undergo targeted imaging or flexible laryngoscopy in a monitored setting with airway expertise available.

DIAGNOSIS PEARLS

Most acute sore throats are viral and resolve without antibiotic treatment. GAS remains the principal common bacterial indication for antibiotics in uncomplicated pharyngitis.

Peritonsillar cellulitis and peritonsillar abscess can look similar. Fluctuance is not always present; trismus, muffled voice, unilateral swelling, and uvular deviation increase suspicion for abscess. Ultrasound or CT may help when the diagnosis is uncertain and the patient is stable.

Retropharyngeal and other deep neck-space infections should be considered when there is neck stiffness, torticollis, posterior pharyngeal fullness, drooling, respiratory symptoms, or toxicity. Do not rely on a normal-appearing oropharynx to exclude these infections.

Epiglottitis remains uncommon but potentially fatal. Adults may present with severe dysphagia or odynophagia before respiratory distress becomes obvious.

In adolescents and young adults, worsening pharyngitis followed by high fever, rigors, unilateral neck pain or swelling, or pulmonary symptoms should raise concern for Lemierre syndrome from septic internal jugular thrombophlebitis, most often associated with Fusobacterium necrophorum.

Infectious mononucleosis is suggested by fever, pharyngitis, fatigue, and posterior cervical lymphadenopathy. Splenomegaly may be present even when it is not palpable.

TREATMENT AND DISPOSITION PEARLS

• Pain relief
• Acetaminophen
• Nonsteroidal anti-inflammatory drugs
• Avoid routine opioid treatment for uncomplicated sore throat. Reserve opioids, if used at all, for unusual severe pain after safer options have been considered.
• Salt water gargles
• A single dose of dexamethasone may modestly shorten time to pain relief in selected patients with moderate to severe sore throat, but benefit is variable and corticosteroids should not be routine treatment for uncomplicated pharyngitis.

Treat confirmed GAS pharyngitis with penicillin or amoxicillin. Do not treat viral pharyngitis with antibiotics.

• Penicillin V: adults and adolescents 500 mg orally twice daily for 10 days; children 250 mg orally twice or three times daily for 10 days.
• Amoxicillin: 50 mg/kg once daily (maximum 1,000 mg) for 10 days, or 25 mg/kg twice daily (maximum 500 mg per dose) for 10 days.
• Benzathine penicillin G is an option when adherence to a 10-day oral regimen is doubtful: 600,000 units IM once for patients weighing <27 kg and 1.2 million units IM once for patients weighing ≥27 kg.
• For penicillin allergy, select an alternative based on whether the allergy is immediate-type. Avoid cephalexin or cefadroxil in immediate hypersensitivity. Macrolide and clindamycin resistance varies geographically and temporally.

If infectious mononucleosis is suspected, avoid unnecessary ampicillin or amoxicillin because a rash commonly develops. Routine antivirals and corticosteroids are not recommended for uncomplicated mononucleosis. Athletes should avoid athletic activity for the first 3 weeks after symptom onset and return gradually only when clinically well and afebrile; timing of contact sports requires shared decision-making because of splenic rupture risk.

Selected uncomplicated peritonsillar abscesses may be managed with needle aspiration or incision and drainage by a clinician experienced with the procedure and with immediate access to suction and rescue care. Many urgent care centers should instead refer to the ED or ENT, particularly when there is airway concern, inability to tolerate fluids, significant comorbidity, uncertain diagnosis, or extension beyond the peritonsillar space. Antibiotic therapy should accompany drainage or specialist-directed medical management.

Patients suspected of having epiglottitis should be transported by EMS to an emergency department with airway and otolaryngology/anesthesia capability. Keep the patient in a position of comfort and avoid unnecessary pharyngeal manipulation.

For confirmed uncomplicated pharyngeal gonorrhea in adolescents and adults, CDC recommends ceftriaxone 500 mg IM once for persons weighing <150 kg and 1 g IM once for persons weighing ≥150 kg. If chlamydia is identified, treat it as recommended. Pharyngeal gonorrhea requires a test of cure 7 to 14 days after treatment.

Suspected Lemierre syndrome requires emergency evaluation, blood cultures, contrast-enhanced imaging of the neck (and chest when indicated), and IV antibiotics with anaerobic coverage; it is not an outpatient urgent care diagnosis.

Consider treatment failure or an alternate diagnosis when confirmed streptococcal pharyngitis is not improving after approximately 48 to 72 hours of appropriate therapy.

Viral pharyngitis will resolve spontaneously.

Irritative-type throat pain from allergic postnasal drip benefits from increasing fluid intake, antihistamines, and nasal steroids.

MEDICOLEGAL PEARLS

Document airway assessment and the presence or absence of drooling, stridor, muffled voice, trismus, neck swelling, and ability to handle secretions when the presentation is more than a simple sore throat.

As with all conditions requiring antibiotics, remember to evaluate for the possibility of drug-drug interactions, allergies, and interactions between drugs and herbal remedies.

When GAS is considered, document the clinical score or features used to decide whether testing was indicated, the test performed, and the follow-up plan for any pending culture.

Document the presence or absence of findings concerning for peritonsillar abscess, deep neck-space infection, epiglottitis, or Ludwig angina when clinically relevant.

In adolescents and young adults with persistent or worsening pharyngitis, document assessment for unilateral neck pain/swelling or systemic toxicity that could suggest Lemierre syndrome.

REFERENCES

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