Other diagnoses

Learning bite

Regardless of the underlying cause, always assess the patient for signs of airway obstruction or dehydration that may require admission.

Common cold

The majority of sore throats are viral in origin. Suggested by rhinorrhoea, coryza, and cough. Can be managed with simple analgesia and rest.

Scarlet fever

Scarlet fever is a GABHS exotoxin-mediated illness which occurs far more commonly in children. Other than standard antibiotic treatment for GABHS, consideration must also be made of hydration status and intravenous fluid rehydration may be required. It is a notifiable disease in England and Wales.

Peri-tonsillar Abscess (Quinsy)

Uncomplicated peritonsillar abscess may be managed in the ED although it is common practice for patients to be referred to an ear, nose and throat (ENT) specialist due to a lack of familiarity with treatment techniques.

Both needle aspiration and incision and drainage techniques may be employed, and have been found to be equally effective [21]. The clinician must be aware of the potential complications of both the problem e.g. Lemierres syndrome (extension of infection involving the jugular vein) and its management e.g. accidental puncture of the carotid artery.

Learning bite

Peritonsillar abscess can be treated equally effectively by either needle aspiration or incision and drainage, although the operator must be familiar with both the technique and the potential serious complications.

Patients should receive a broader antibiotic choice than standard pharyngotonsillitis as organisms other than Group A Streptococcus are also likely to be causative (follow local Microbiology guidance).

Infective Mononucleosis

Caused by the Ebstein Barr virus. Suggested by prolonged symptoms, fatigue, generalised lymphadenopathy and hepatosplenomegaly. More common teenagers and young adults. Advise patients that symptoms can take weeks to months to resolve. Patients should avoid kissing and sharing towels or kitchen utensils. They should avoid heavy lifting or contact sports for 1 month due to the risk of splenic rupture. Advise them to return to ED in the event of sudden onset abdominal pain [25].

Learning bite

HIV may present as a sore throat with myalgia, arthralgia, lymphadenopathy and lethargy during seroconversion. Patients being investigated for suspected Infectious Mononucleosis should be considered for HIV testing as well.

Epiglottitis/Supraglottitis

Since the advent of Hib vaccination, epiglottitis is now more commonly an infection affecting adults. The main complication of airway obstruction may be predicted by the presence of specific clinical features [22]:

• Stridor
• Muffled voice
• Rapid clinical course
• History of diabetes

Any patient presenting with these features should be urgently reviewed by anaesthetics and ENT.

A review of 106 patients with epiglottitis found that routine intubation was unnecessary as over 90% of patients recovered with a conservative watchful approach [23].

The main focus of treatment centres on observation for airway obstruction and administration of antibiotics a third-generation cephalosporin and metronidazole are recommended to cover the spectrum of organisms responsible. Adrenaline nebulisers and Dexamethasone is commonly given to reduce swelling.

Learning bite

Since the advent of Hib immunisation, epiglottitis has become more common in adults and, in the absence of high risk features, can normally be managed with antibiotics and careful observation.

Retropharyngeal Abscess

Although very uncommon, a combination of sore throat, fever, neck stiffness and stridor should alert the clinician to consider this diagnosis. Swelling or oedema of the posterior pharynx should prompt a consideration of advanced airway care and an urgent ENT opinion. Mortality rates are high when complications such as airway obstruction and mediastinitis arise.