Sore throat is one of the commonest symptoms in general practice. It can
be cause by either bacterial, virus or fungal infection. It usually involves
the upper respiratory tract. The most usual cause is a viral pharyngitis or
acute tonsillitis where based on National Morbidity Survey (UK) nine episodes
per year of both of this disease were diagnosed for every 100 patients and sore
throat itself account for about 5% of consultations in general practice per
Pharyngitis is the inflammation of the pharynx or tonsils. Adults with
pharyngitis typically complain of sore throat, particularly when swallowing.
Fever is often present with bacterial pharyngitis and may occur in association
with headache or malaise. Patients may note “swollen glands” or anterior neck
pain related to lymphadenopathy.
Many patients with viral pharyngitis also have signs and symptoms
associated with a viral upper respiratory infection (nasal congestion, coryza,
hoarseness, sinus discomfort or tenderness, ear pain, or cough).
The major goal of the evaluation of adults with sore throat or acute
pharyngitis is to exclude potentially dangerous causes, to identify any
treatable causes, and to improve symptoms. Identifying group A streptococcus
(GAS) is important because timely treatment with antibiotics helps prevent
poststreptococcal complications such as acute rheumatic fever 32. The
evaluation includes a thorough history, focused physical examination, and
diagnostic testing in selected patients.
Patients calling in to the physician’s office who can reliably report
that they have no fever and who have a cough in addition to their sore throat
symptoms would not meet criteria for diagnostic testing. Such patients can be
advised to stay home and monitor themselves for warning signs. They should be
cautioned to present for evaluation if fever develops, if they have difficulty
swallowing or if they develop any unusually severe signs and symptoms
(secretions, drooling, dysphonia, muffled “hot potato” voice, or neck
Identifying patients with GAS
Centor criteria — The Centor criteria are a widely used and accepted
clinical decision tool 38-40. These criteria are:
?Tender anterior cervical adenopathy
?Fever by history
?Absence of cough
The likelihood of having GAS increases with the
number of Centor criteria. However, the Centor criteria are most useful in
identifying patients for whom neither microbiologic tests nor antimicrobial
therapy are necessary. Patients with fewer than three (0 to 2) Centor criteria
are unlikely to have GAS and, in general, should not receive either antibiotic
treatment or diagnostic testing.
Patients who do not have GAS — In the vast majority
of patients with a negative evaluation for GAS, the pharyngitis will resolve in
a few days without sequelae and no further diagnostic measures are required
2. Symptomatic treatment should be offered
Patients needing further evaluation — Adults who
test negative for GAS and do not improve with symptomatic treatment within five
to seven days or who have worsening symptoms, should be reassessed for a
previously unsuspected diagnosis (eg, infectious mononucleosis or primary HIV
infection) or a suppurative complication (eg, peritonsillar abscess).