Sore throat

Everyone gets a sore throat, and almost always for a harmless reason: a virus, too many hours in dry air, an evening of shouting, smoke around you. Within a week that kind of soreness goes on its own, and most people need neither an antibiotic nor tests. But sore throat has a narrow band of situations counted in hours, and a few causes that are hardly ever mentioned — and those are what make the subject worth reading about. If the pain is concentrated in the tonsils, they are enlarged and coated, and this happens several times a year, it is more likely to be tonsillitis: that is a separate illness with its own page. Here the subject is a sore throat as such.

When it is counted in hours

An ordinary sore throat gets in the way of eating, but not of breathing and not of swallowing your own saliva. As soon as that changes, the situation stops being ordinary. Call an ambulance if you or your child:

• cannot swallow even saliva, so it pools in the mouth or dribbles out;
• has a changed voice — muffled and strangled, as though speaking around a hot potato;
• has a swollen, tender neck, with a firm sore lump on one side, and it hurts to turn the head;
• cannot open the mouth, or can open it only a couple of centimetres;
• is breathing with effort, with a whistle or a harsh rasping sound, and is only easier sitting up and leaning forwards;
• has soreness building very fast, a high fever, and is visibly getting worse.

Behind that set sit an abscess beside the tonsil or deep in the neck, and swelling of the epiglottis — situations in which the airway can close. A child who is sitting bolt upright, straining the neck forwards and drooling should not be laid flat, and nobody should try to look down the throat with a spoon: the attempt can make the breathing worse. Across Europe the single number 112 works, and many countries also have their own local emergency medical number; call it and stay beside the person.

Virus or streptococcus

Nine cases out of ten in adults are viral, and it shows: the sore throat comes with a runny nose, hoarseness and a cough, builds up gradually and starts easing within two or three days. An antibiotic here does not shorten the illness by a single day.

A streptococcal infection behaves differently. It starts abruptly, the pain is severe and gets in the way of swallowing, the fever is high, the tonsils are bright red and coated, the neck glands are large and tender — and there is precisely no runny nose and no cough. The two cannot be told apart from the description alone with any certainty: that is what a rapid streptococcus test and a throat swab are for, and they are done precisely so that nobody takes an antibiotic blindly.

It is worth avoiding both extremes here. "An antibiotic is never needed for a sore throat" is untrue: with a confirmed streptococcus, a course reduces how infectious you are, eases the symptoms and lowers the risk of uncommon but unpleasant complications, and it has to be finished rather than stopped when the pain goes. "An antibiotic is always needed" is untrue as well, and the price of that idea is a wrecked gut flora and bacteria that resist the treatment you will need later on.

The teenager who has had a sore throat for three weeks

If the soreness does not clear within a week, the fever holds, the neck glands have become large and firm, and heavy tiredness, aching and a complete absence of energy have joined in, glandular fever is worth thinking about. It is a viral infection that turns up mostly in teenagers and young adults; the throat can look exactly as it does with a streptococcus, tonsils coated, but the illness drags on for weeks and the exhaustion outlasts it.

It is sorted out with a blood test. It is worth knowing about for two reasons. First: in glandular fever the spleen enlarges, which is why contact sports and heavy lifting are dropped for some weeks — the risk is not in the throat but in a blow to the abdomen. Second: some antibiotics of the penicillin group produce a striking rash in glandular fever, which then follows the person around for years in their records as an allergy, although no allergy ever happened. That is one more argument against starting an antibiotic without a test.

A sore throat in someone who has just started a new medicine

Here is the rare cause worth keeping in mind, because it is mentioned almost nowhere. If a sore throat with a high fever and ulcers in the mouth appears in someone who recently started a new long-term medicine — from thyroid treatment, some anti-inflammatories, some psychiatric or anti-epileptic drugs — that is a reason for a full blood count the same day, not a reason to treat the throat with gargles.

The reason is that one uncommon adverse reaction to such medicines is a sharp fall in the number of neutrophils, the blood cells responsible for defence against bacteria. The first sign is precisely a severe sore throat with fever, because the throat has the hardest time of it. In itself the condition is rare, but it develops quickly and is picked up by a simple test. If you take a medicine of that kind, you should have been told when it was prescribed: sore throat and fever mean a blood test immediately. Do not wait for Monday morning, and do not start an antibiotic before the test is done.

When soreness takes far too long to go

Soreness that does not behave like an infection deserves attention of its own. These should put you on guard:

• pain on one side only that lasts more than three weeks and does not go with a cold, particularly in someone who smokes and someone who drinks regularly;
• hoarseness of more than three weeks with no obvious cause;
• a firm, fixed lump in the neck that is not painful and does not shrink;
• a sense of something in the way when swallowing that keeps increasing, with food starting to catch;
• an ulcer in the throat or mouth that has not healed in more than three weeks, pain running to one ear, weight loss.

None of these signs means the person has cancer — most such appointments end with a harmless diagnosis. But that combination is exactly when the throat should be looked at by a doctor and, if needed, examined with an instrument, rather than given another month. Smoking and alcohol are the main risk factors here, and they add to each other.

What actually eases it

While the body deals with the infection, the job is to eat, drink and sleep. These help:

• drinking. Warm or cool, whichever appeals; the amount matters rather than the temperature, because a dry lining hurts more;
• soft, unirritating food. Acidic, spicy and very hot things, and dry hard biscuits, all make the soreness worse;
• a painkiller. Paracetamol or an anti-inflammatory at the usual dose, with your own conditions taken into account; aspirin is not given to children or teenagers;
• gargling with warm salty water, half a teaspoon in a glass, spitting it out. For adults and for children old enough not to swallow it, this brings relief for a while;
• slightly humid air and stopping smoking, at least for the length of the illness, including the smoke you breathe from other people;
• lozenges and sprays with a local anaesthetic or antiseptic. They make swallowing bearable for a few minutes but do not shorten the illness; young children are not given hard lozenges or sweets, because they are an object that can be choked on.

It is worth booking an ordinary, non-urgent appointment if the soreness has not started to settle within a week, if your throat hurts often and for long stretches, if a high fever holds for more than three days, if the patient is a child under two who refuses to drink, and also in pregnancy and in conditions that weaken the immune system.

Online consultation

An online doctor can work out what your particular sore throat resembles: a virus, a streptococcus, a glandular fever that is dragging on, or a cause that is not an infection at all. They can judge whether any of your signs belong to the group that calls for an ambulance rather than an appointment, say whether a rapid test and a blood test are worth doing and what exactly to ask for at the laboratory. They can explain how to make swallowing hurt less today, whether an antibiotic is right in your case and how to finish it properly, and advise on what to do if your throat goes sore several times a year.

This material is for information only and does not replace medical advice.