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Sore Throat & Neck

Airway first — then the deep spaces that kill.

Open full pathway
Educational first-pass aid. Reassess the patient, confirm doses and use local protocols.

1 · First minutes

  1. Airway first. Tripod + drool = skilled airway, not a tongue blade.
  2. Hunt deep-space infection: epiglottitis, PTA, RPA, Ludwig, Lemierre.
  3. Centor/McIsaac gates GAS testing — it does not exclude the killers.

2 · Escalate now if

  • Drooling, tripoding, stridor, or sitting bolt upright
  • Trismus or a muffled / hot-potato voice
  • Floor-of-mouth swelling or an elevated tongue
  • Toxic appearance with delayed neck pain after pharyngitis (Lemierre)
  • Rapidly progressive swelling after ACE-inhibitor or allergen
  • Inability to swallow saliva

3 · Immediate workup

  • Airway assessment first; flexible nasopharyngoscopy by a skilled operator if stable and epiglottitis is possible
  • Do not force a complete oropharyngeal exam in stridor/drooling

4 · Don’t miss

  • Acute epiglottitis (supraglottitis)
    Drooling, tripoding, muffled voice, stridor — keep the patient sitting, call airway experts, do not force a tongue blade. Adult epiglottitis is now more common than pediatric in vaccinated populations. Lateral neck x-ray (thumbprint) only if stable.
  • Ludwig angina
    Floor-of-mouth brawny edema, tongue elevation, dental source — early airway and IV antibiotics covering oral flora.
  • Retropharyngeal abscess
    Fever, neck stiffness, drooling in a child (or adult after instrumentation) — CT neck with contrast once the airway is safe.
  • Lemierre syndrome
    Pharyngitis then septic thrombophlebitis of the IJ (Fusobacterium) — persistent fever, neck pain, pulmonary septic emboli. CT/US of the neck + blood cultures + prolonged antibiotics.
  • Diphtheria / angioedema / anaphylaxis
    Gray membrane, travel/unimmunized; or rapid swelling after ACE-inhibitor or allergen — airway + epinephrine as indicated.

5 · Disposition lane

Admit

PTA after drainage if toxic or unable to take fluids, severe pharyngitis in the immunocompromised, recovering deep-space infection on IV antibiotics.

Airway team / ICU / OT

Epiglottitis, Ludwig, RPA with airway threat, Lemierre with septic emboli, angioedema of the tongue/floor of mouth.