Sore throat (pharyngitis): causes, red flags and when to see a GP

NICE CKS describes sore throat as pain at the back of the mouth, with acute pharyngitis meaning inflammation of the throat behind the soft palate and tonsillitis meaning inflammation of the tonsils. The NHS lists the symptoms as a painful throat, especially when swallowing, a dry scratchy throat, redness in the back of the mouth, bad breath, a mild cough and swollen neck glands. Children get the same symptoms plus a high temperature and being less active.

The NHS also gives the less ordinary signs that change the picture: severe pain with a very high temperature, trouble swallowing or breathing, drooling and a high-pitched breathing sound.

NICE CKS says common causes in primary care are the common cold, influenza, streptococcal infection and infectious mononucleosis (glandular fever). Non-infectious causes are uncommon and include reflux, chronic cigarette smoke and hay fever.

For 999 or A&E the NHS lists difficulty breathing or being unable to swallow, drooling (which can mean you cannot swallow), a high-pitched sound as you breathe (stridor) and severe symptoms that are getting worse quickly. For glandular fever the NHS adds being unable to swallow even your own spit, severe breathing difficulty and severe stomach pain; for 111, difficulty and pain when swallowing.

The NHS says to ask for an urgent GP appointment or call 111 if you are worried about your symptoms, you have a very high temperature or feel hot, cold or shivery, you have signs of dehydration such as peeing less than usual or dark, strong-smelling pee, or you have a weakened immune system, for example because of diabetes or chemotherapy.

CKS describes immediate admission for stridor, breathing difficulty, clinical dehydration, or a condition such as acute epiglottitis, and referral for a suspected serious cause such as cancer or HIV.

• Difficulty breathing, noisy or high-pitched breathing.

• Unable to swallow, or drooling.

• Severe symptoms getting worse quickly.

• Very high temperature, shivering, or signs of dehydration.

• Weakened immunity from diabetes, chemotherapy or other causes.

• A sore throat that is not improving after a week, or a lump or mouth ulcer lasting more than 3 weeks.

The usual questions are how long, how severe, whether swallowing is painful, fever, cough, recent contacts, rash, tiredness, smoking and previous episodes. Examination looks at the throat and tonsils, the neck glands, temperature and hydration. CKS says FeverPAIN and Centor clinical scores are used to help decide whether to prescribe antibiotics.

CKS lists recurrent tonsillitis, defined as more than 7 episodes in one year, 5 per year for 2 years or 3 per year for 3 years, as a reason for specialist assessment for tonsillectomy.

The NHS suggests gargling with warm salty water (half a teaspoon of salt dissolved in a glass of warm water, spat out, not for children), drinking plenty of water, eating cool or soft foods, avoiding smoking and smoky places, sucking ice cubes, ice lollies or hard sweets (not for young children because of choking), and resting.

A pharmacist can suggest paracetamol or ibuprofen, medicated lozenges containing a local anaesthetic, antiseptic or anti-inflammatory, and anaesthetic spray, although the NHS says there is little proof sprays help on their own. Some medicines are not safe for everyone, for example in pregnancy. For tonsillitis the NHS says not to give aspirin to children under 16.

The NHS says you will only be given antibiotics by a pharmacist or GP if you could have a bacterial infection. CKS says viral or bacterial sore throat is self-limiting, with symptoms resolving at much the same rate regardless of whether the cause is streptococcal, and uses clinical scores to judge when antibiotic treatment is appropriate.

Anyone who is prescribed antibiotics should take the whole course as directed.

A pharmacist is the first stop for most adults and children aged 5 and over; the NHS says a pharmacist can offer the same antibiotic treatment as a GP if needed. A GP for a child under 5, a sore throat that does not improve after a week, frequent sore throats, or a lump or ulcer lasting over 3 weeks. NHS 111 or urgent GP care for the urgent signs, and 999 for breathing or swallowing difficulty.