Airway and ENT emergencies
Sore throat emergencies
Overview and approach
Severe sore throat can reflect peritonsillar or deep-neck abscess, epiglottitis or rapidly progressing infection.
- Your framework: sore throat, fever, dysphagia and dysphonia plus stridor, increased work of breathing, drooling, tripod positioning or a sick patient = emergency. Emergencies: peritonsillar abscess (quinsy), retropharyngeal abscess, epiglottitis, bacterial tracheitis, diphtheria, Ludwig angina (deep soft-tissue infection of the floor of mouth), respiratory burn. Non-emergencies: tonsillitis (GAS)/pharyngitis, infectious mononucleosis1,2,3.
- Quinsy is pus between the tonsil capsule and the superior constrictor muscle, usually following a phase of peritonsillar cellulitis. Beta-haemolytic streptococci are the most frequent organisms8.
- Epiglottitis (supraglottitis) is a rapidly progressive cellulitis of the epiglottis and surrounding tissues. Hib still causes cases in unvaccinated children; in adults (and increasingly children) group A streptococcus is the commonest cause, with pneumococcus and Staphylococcus aureus less often7,8.
- Agranulocytosis and acute leukaemia can cause very painful necrotic throat ulcers that may bleed; HIV can present as recurrent tonsillitis or pharyngitis8.
Assessment and clinical features
Look for trismus, muffled voice, drooling, neck swelling, stridor, sepsis and dehydration; maintain a calm approach.
- Quinsy: age 20-40; sore throat progressing to quinsy with or without tonsillitis; locked jaw (trismus), fever, dysphonia, dysphagia, cervical adenopathy, stridor if severe1.
- Tonsillitis (GAS)/pharyngitis: fever, viraemic features, dysphonia, dysphagia.
- Quinsy signs: severe one-sided throat pain, drooling because even saliva hurts to swallow, a muffled voice, trismus that can make the throat hard to see, same-side earache and neck nodes, and a swollen tonsil pushing the base of the uvula across8.
- Epiglottitis in children: usually under 24 hours of high fever, severe sore throat, toxicity and drooling while sitting forward. In adults: often 1-2 days of severe sore throat, then breathlessness, drooling and stridor7.
- Key pearl: a throat that looks much less inflamed than the symptoms suggest means the problem lies below the tonsils7.
- Stridor and chest wall recession can lessen as a child tires; this is a sign of deterioration, not recovery7.
Telling the main emergencies apart7,8.
| Condition | Typical patient | Key signs |
|---|---|---|
| Quinsy | Young adults after tonsillitis | One-sided swelling, deviated uvula, trismus, muffled voice |
| Epiglottitis | Unvaccinated children; adults | Toxic, drooling, sitting forward, stridor; throat looks fairly normal |
| Retropharyngeal abscess | Young children | Neck held stiff or extended, drooling, severe dysphagia |
Differentials and investigations
Senior ENT/anaesthetic assessment; blood tests and imaging only when safe and not delaying airway control.
- See each emergency's own page: Peritonsillar abscess, Deep neck space infections. Imaging (CT with contrast) only with advanced airway capability available4.
- Infectious mononucleosis: consider EBV serology if the diagnosis is uncertain5.
- Epiglottitis: the diagnosis is usually clinical and confirmed by fibreoptic laryngoscopy in a controlled setting such as theatre, where the airway can be secured at the same time7.
- A lateral neck X-ray may show a swollen epiglottis (thumbprint sign), and blood cultures are often positive, but X-rays and bloods must not delay airway control or require moving the patient7.
Management and follow-up
Analgesia, IV support and antibiotics under local guidance; drainage and airway decisions belong with the specialist team.
- Quinsy: antibiotics, steroids to reduce inflammation (not routine in some sources), aspiration or incision and drainage (resus bed)1,2.
- Epiglottitis: keep upright, avoid agitation or oral examination, involve airway specialists, secure the airway in a controlled setting, IV broad-spectrum antibiotics2,3. Bacterial tracheitis: controlled airway, IV antibiotics, debridement. Diphtheria: isolation, airway planning, antitoxin and antibiotics.
- Tonsillitis/pharyngitis: pain relief (paracetamol and ibuprofen), antibiotics only if confirmed or suspected GAS or high rheumatic-fever risk (Therapeutic Guidelines summary: phenoxymethylpenicillin 500 mg twice daily for 10 days, or benzathine benzylpenicillin once)5,6; consider steroids and IV hydration for severe cases. Infectious mononucleosis: supportive; avoid contact sports while splenomegaly persists5.
Red flags and clinical pearls
Do not force examination or lie a distressed patient flat when airway compromise is suspected.
- Post-streptococcal complications: glomerulonephritis and acute rheumatic fever6.
- Trismus, drooling and a muffled 'hot potato' voice suggest abscess.
- Never use a tongue depressor or mirror to look at a suspected epiglottitis outside a controlled airway setting: it can trigger laryngospasm and complete obstruction7,8.
- Watching and waiting is risky in epiglottitis; even in adults it should be reserved for those without breathlessness or stridor7.
- A chronic sore throat, especially with weight loss, dysphagia, hoarseness, smoking or alcohol, needs examination to exclude cancer of the mouth or pharynx8.
References
- Cochrane: Needle aspiration vs incision and drainage for peritonsillar abscess
- StatPearls: Peritonsillar abscess
- BMJ Best Practice: Epiglottitis - treatment algorithm
- RCH: Sore throat
- RACGP: Infectious mononucleosis
- Therapeutic Guidelines: Antibiotic prescribing in primary care summary table 2024
- Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, Loscalzo J, editors. Harrison's Principles of Internal Medicine. 18th ed. New York: McGraw-Hill; 2012. Chapter 31, Pharyngitis, sinusitis, otitis, and other upper respiratory tract infections.
- Dhillon RS, East CA. Ear, Nose and Throat and Head and Neck Surgery: An Illustrated Colour Text. 4th ed. Edinburgh: Churchill Livingstone Elsevier; 2013. Chapter 3, The throat.
Last updated from Sen’s notes on 22 October 2026.