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Sore Throat & Neck

Airway first — then the deep spaces that kill.

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Your objective: explain the approach, recognize important warning signs, then test your recall.

Abbreviations explained
ACS
Acute coronary syndrome
OMI
Occlusion myocardial infarction
ECG
Electrocardiogram
PE
Pulmonary embolism
POCUS
Point-of-care ultrasound
QTc
QT interval corrected for heart rate
LBBB
Left bundle branch block
RBBB
Right bundle branch block
hs-cTn
High-sensitivity cardiac troponin
CTA
Computed tomography angiography
ICU
Intensive care unit
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The jobAirway first — then the deep spaces that kill.

  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.
  4. Throat pain with exertional features in a vasculopath still needs an ECG.

Most sore throats are viral.

The ED task is to find the airway and deep-space infections: epiglottitis, peritonsillar and retropharyngeal abscess, Ludwig angina, and Lemierre syndrome. Do not force a tongue-blade exam in a drooling, tripod patient. Centor/McIsaac gates testing for GAS — it does not rule out the killers.

Acute epiglottitis (supraglottitis) Critical

Key: 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 Critical

Key: Floor-of-mouth brawny edema, tongue elevation, dental source — early airway and IV antibiotics covering oral flora.

Retropharyngeal abscess Critical

Key: Fever, neck stiffness, drooling in a child (or adult after instrumentation) — CT neck with contrast once the airway is safe.

Lemierre syndrome Critical

Key: Pharyngitis then septic thrombophlebitis of the IJ (Fusobacterium) — persistent fever, neck pain, pulmonary septic emboli. CT/US of the neck + blood cultures + prolonged antibiotics.

Peritonsillar abscess Emergent

Key: Trismus, uvular deviation, hot-potato voice — drain + antibiotics. Distinguish from epiglottitis before you put a needle in.

Diphtheria / angioedema / anaphylaxis Critical

Key: Gray membrane, travel/unimmunized; or rapid swelling after ACE-inhibitor or allergen — airway + epinephrine as indicated.

ACS presenting as throat pain Emergent

Key: Especially women, diabetics, and the elderly — ECG if the story is exertional or accompanied by diaphoresis/dyspnea.

Viral pharyngitis / GAS Common

Key: Centor/McIsaac to gate testing; treat confirmed GAS. Most do not need antibiotics.

Tick what your patient has — the banner updates as you go.

Tempo

hours (epiglottitis, angioedema) vs days (PTA, viral)

Drooling, trismus, voice change, inability to swallow saliva

Dental pain or recent extraction (Ludwig)

Immunization (Hib, diphtheria); travel; ACE-inhibitor use

Sexual history (gonococcal pharyngitis); immunosuppression

Work of breathing and preferred posture — do not lie the unstable patient down

Floor of mouth, tongue elevation, neck crepitus or swelling

Tonsillar asymmetry, uvular deviation, trismus

IJ tenderness; lung findings (septic emboli)

Skin

rash of scarlet fever, membrane of diphtheria

Bedside

  • 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

Labs

  • Centor-gated RADT/culture for GAS in typical pharyngitis
  • CBC, blood cultures if toxic; throat NAAT for gonorrhea when indicated

Imaging

  • CT neck with contrast for deep-space abscess once the airway is secure
  • Lateral neck x-ray only in a stable patient if it will not delay airway care
Medication safety reminder

Use this as a first-pass prompt; verify all medications, doses, concentrations, contraindications, weight, pregnancy status, and local protocols before administration.

Check indication, allergy, route, renal/hepatic risk, interactions, monitoring, and local formulary.

Discharge

  • Viral or confirmed GAS pharyngitis with a safe airway, taking fluids, reliable follow-up. Analgesia; antibiotics only for GAS or a drained PTA on an oral regimen per local protocol.

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.

Use objective reassessment and the local pathway.

Before the next decision · reassess and hand over

Use these learning prompts with the presentation’s pathway. They are not discharge criteria.

  1. Reassess: compare symptoms, observations and examination with the initial assessment and response to treatment.
  2. Warning signs for Sore Throat & Neck:
    • 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. Reconsider: check unresolved findings and alternative explanations, including the pitfalls below.
  4. Escalate: communicate deterioration, uncertainty or needs beyond the current setting.
  5. Plan the transition: identify outstanding results, responsibility for follow-up, patient understanding and specific return advice.
Review this presentation’s disposition pathway →Practice a handover →

Clinical Pearls

  • Tripod + drool = airway team, not a throat swab.
  • Ludwig is a floor-of-mouth disease — look up from below the mandible.
  • Pharyngitis that “got better” then the patient became septic with neck pain = Lemierre until CT/US of the IJ is negative.
  • Centor gates GAS testing; it is not a license to skip the airway exam.

Pitfalls

  • A tongue-blade exam in epiglottitis can precipitate complete obstruction.
  • Centor scores do not exclude epiglottitis, PTA, or Lemierre.
  • Adult epiglottitis is often missed because we still think of it as a pediatric Hib disease.
  • Needle aspiration of a “PTA” that is actually a carotid aneurysm or an epiglottic problem is disastrous — confirm anatomy.
  • Sore throat + chest discomfort in a vasculopath is ACS until the ECG says otherwise.
PRACTICE REFRESHER

Rapid recall

Test your first action and the dangerous diagnoses before revealing the answer.

01 · First move

Before you scroll, what needs to happen first?

02 · Immediate threats

Name at least two diagnoses that cannot wait.

PRIVATE TO THIS DEVICE

Your learning note

Capture a weak point, a teaching pearl, or a question to take to your next shift.

Review schedule starts when marked reviewed
Fever & SepsisShortness of BreathChest Pain

Foundational references below. No separate topic-specific guideline check is recorded here.

  • Rosen’s Emergency Medicine, 10th ed. (2023) — sore throat
  • IDSA 2012 GAS pharyngitis guideline; Centor/McIsaac
  • Tintinalli’s 9th ed. — deep neck infections
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