Most adults presenting to the Emergency Department with a sore throat have uncomplicated tonsillitis or a viral infection. However, a small proportion have a serious deep neck-space infection or rapidly progressive airway disease.
The key challenge for the emergency clinician is to distinguish common uncomplicated illness from potentially life-threatening conditions such as:
Adult supraglottitis is particularly important because the throat examination may appear relatively normal despite severe symptoms. Early recognition, senior airway support and appropriate escalation are therefore essential.
This article summarises the RCEMLearning and ENT UK approach to the assessment and management of adults presenting with an acute severe sore throat.
Assessment should begin with an immediate evaluation of the airway, breathing and circulation.
Do not allow apparently normal oxygen saturations or a reassuring oral examination to delay escalation when the patient has symptoms suggesting upper-airway compromise.
Key symptoms include:
A patient who describes severe throat pain but has minimal visible abnormality on oral examination requires particular caution.
The examination should assess both the oropharynx and the neck while avoiding unnecessary distress in a patient with possible airway obstruction.
Important clinical findings include:
The patient’s vaccination history should also be reviewed, particularly when supraglottitis is suspected.
Investigations should be guided by the suspected diagnosis and the patient’s clinical condition.
The guideline identifies the following possible investigations:
Patients with suspected deep neck infection may require imaging such as a contrast-enhanced CT scan. A dental panoramic radiograph may also be considered where an odontogenic source is suspected.
Investigations must not delay airway management in a patient with signs of impending obstruction.
Tonsillitis and glandular fever are common causes of severe sore throat.
Typical features may include:
Treatment may include:
Discharge may be appropriate when the patient is clinically stable and able to swallow safely.
Patients who cannot swallow fluids, have significant dehydration, worsening systemic illness or signs of airway compromise require further assessment and escalation.
A peritonsillar abscess is a collection of pus between the tonsillar capsule and the surrounding tissues.
The guideline reports an approximate incidence of 12 cases per 100,000 people.
Important findings include:
The combination of peritonsillar swelling and a deviated uvula should raise strong suspicion of quinsy.
Management includes:
Drainage may be performed by needle aspiration or incision, depending on local practice and specialist assessment.
The airway should be reassessed regularly, particularly where there is extensive swelling, drooling, respiratory difficulty or rapid clinical deterioration.
Deep neck-space infection is less common but may cause significant morbidity and airway compromise.
The guideline reports an incidence of approximately 5 cases per 100,000 people.
Features suggesting a neck abscess include:
The source may be tonsillar, pharyngeal or dental.
Patients with suspected deep neck-space infection should be managed cautiously.
Recommended actions include:
These patients may require operative drainage and specialist airway management.
Supraglottitis is inflammation of the supraglottic structures. The term is generally preferred because isolated epiglottic inflammation is uncommon without involvement of surrounding supraglottic tissues.
Although rare, supraglottitis is potentially life-threatening and may progress rapidly.
The guideline highlights supraglottitis in:
Other possible underlying conditions include:
A classic warning pattern is:
Severe throat pain with a relatively normal oral examination.
Other features may include:
Stridor may occur, but its absence does not exclude serious supraglottic inflammation.
A patient may be critically unwell before obvious airway obstruction develops.
Suspected supraglottitis should be treated as a time-critical airway emergency.
The patient should be transferred promptly to an environment where advanced airway management can be performed.
This may be:
The patient should be managed calmly and unnecessary movement or distress should be avoided.
The guideline recommends:
Heliox may be considered where available.
The recommended regimen is:
Adrenaline 1:1000, 1 mL diluted in 4 mL of sodium chloride 0.9%, administered by nebuliser.
This may help reduce upper-airway swelling while definitive specialist assessment is arranged.
Urgent support should include:
ENT cover may not be physically available on site, making early communication particularly important.
The airway should be approached as a potentially difficult airway.
Endotracheal intubation may be required, but this should be undertaken by an experienced clinician with an agreed rescue plan.
If intubation fails and the patient cannot be oxygenated, emergency front-of-neck access may be necessary.
Repeated or poorly planned attempts at airway instrumentation may worsen swelling, bleeding and obstruction.
The guideline recommends:
Dexamethasone 6–8 mg intravenously as an initial dose, followed by reassessment to determine whether further treatment is required.
The guideline recommends:
Ceftriaxone 2 g intravenously once daily
with consideration of:
Metronidazole 500 mg three times daily.
Local antimicrobial guidance, allergy status and microbiology advice should also be considered.
The following findings should prompt urgent senior review:
These signs should not be managed as routine uncomplicated tonsillitis.
Discharge may be considered for uncomplicated tonsillitis or glandular fever when the patient:
Patients should be advised to return urgently if they develop:
https://www.entuk.org/_userfiles/pages/files/resources/adult_sore_throat_clinical_guideline.pdf
A severe sore throat with a normal oral examination should raise concern for supraglottitis.
A deviated uvula with unilateral peritonsillar swelling suggests quinsy.
Neck swelling with restricted neck movement should prompt consideration of a deep neck-space abscess.
Supraglottitis is a rapidly progressive airway emergency requiring immediate resuscitation-area management, senior ENT and anaesthetic support, difficult-airway preparation, corticosteroids and intravenous antibiotics.
Investigations and imaging must never delay management of a threatened airway.
Most adult sore throats are uncomplicated, but the emergency clinician must actively search for signs of quinsy, deep neck-space infection and supraglottitis.
The safest approach is to prioritise airway assessment, recognise red flags early and escalate promptly. In particular, severe odynophagia, drooling, hoarseness or systemic illness despite a relatively normal throat examination should be treated as possible supraglottitis until proven otherwise.
Clinical disclaimer: This educational article is intended for healthcare professionals and examination preparation. Clinical management should follow local hospital policies, current antimicrobial guidance and senior specialist advice.