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Batra K1, Safaya A2, Nair D3, Capoor M4

Key Words : Sore throat; tonsillitis; throat swab; core culture; tonsillectomy

A complaint of a 'sore throat' is an extremely common
presenting feature encountered by all otolaryngologists in
their practice. However, most available literature and
current concepts in the minds of otolaryngologists,
paediatricians and general practitioners are confusing
regarding how to differentiate between an ordinary sore
throat requiring only medical treatment, from an attack
of tonsillitis which may subsequently warrant surgical
intervention. Since performing a tonsillectomy is not a
particularly difficult task, frequently the decision is a
surgical one. This could be avoided in several cases if a
standard and straightforward protocol were to be followed.
Changing trends in antibiotic sensitivities of causative
organisms, coupled with a bewildering array and variety
of antimicrobial agents, add to the confusion even in the
line of medical treatment to be followed.
It was with the specific purpose of clarifying these very
confusing issues that a prospective study was undertaken
in the ENT department at Safdarjung Hospital to try and
objectify when to take the surgical option, what antibiotics
to use after determining which are the commonly
encountered pathogens and to try and pick out some
commonly encountered predisposing factors, leading to
Review of Literature
Celsus1 was the first to report the removal of tonsils and
since then, many changes have been brought about in
surgical technique and the indications to make the
procedure safer than before.

Anatomy and Physiology

The lingual tonsils anteriorly, palatine tonsils laterally and
pharyngeal tonsils (adenoids) posterosuperiorly form a ring
of lymphoid tissue about the upper end of the pharynx
and are known as the Waldeyer's ring. All the structures
have a similar histology and presumably similar function
as well. The palatine tonsils form the largest accumulation
of lymphoid tissue in this ring and constitute a compact
body with a definite thin capsule on the deep surface.
Tonsillar crypts lined with stratified squamous epithelium
extend deeply into the tissue. Adenoids are covered by
pseudostratified columnar epithelium which, grow until
the fifth year of life often causing some degree of airway
obstruction. This subsequently atrophies as the
nasopharynx grows and the airway improves.
Both the tonsils and adenoids are predominantly B-cell
organs. Ample evidence proves their role in inducing
secretory immunity and regulating secretory
immunoglobulin production. They are favorably located
for mediating the immunologic protection of the upper
aerodigestive tract due to their exposure to airborne
antigens. However, no major immunologic deficiencies
result from the removal of either the tonsils or adenoids.
Although studies have shown lower serum IgA levels in
post-tonsillectomy patients than in age matched controls,
but this immunologic change did not appear clinically
Most infections around Waldeyer's ring are polymicrobial
in nature and often it is difficult interpreting data of samples

Pool Officer, 2Senior ENT Specialist, 3Specialist,Department of Microbiology, 4Senior Resident, Department of Microbiology,
Safdarjang Hospital and VM Medical College New Delhi

Sore Throat - A Review of Presentation and Etiology


Fig. 1 Protocol for Management of Sore Throat

and differentiating between organisms that are colonized

and those that are invaders. Group A streptococcus has
been the most common cause of acute pharyngotonsillitis,
its importance lying not only in its frequency of
occurrence, but due to its two serious sequelae i.e. acute
rheumatic fever and post-streptococcal glomerulonephritis.
Clinical features of a sore throat associated with fever
higher than 38.5 deg C (101.3 deg F), odynophagia, otalgia,
Table I. Age & Sex Distribution of 50 Patients of Sore

cervical lymphadenopathy, enlarged tonsils with yellowish

white spots and maybe even a membrane or exudates
combined give a high clinical suspicion of GABHS as a
causative organism2. This should be verified by the time
honoured throat swab culture which has a 90% sensitivity
and specificity 99% under ideal conditions2. Swabbing is
done from the posterior pharyngeal and tonsillar areas.
Patients with respiratory complications such as coryza
and cough are less likely to have a streptococcal pharyngitis.
A true infection is demonstrated by a positive throat culture
and at least a two-dilutional rise in antistreptolysin O titre
(ASLO). A GABHS carrier would show a positive culture
Table II : Duration & Frequency of Attacks of Sore

Indian Journal of Otolaryngology and Head and Neck Surgery Vol. 56 No. 1, January - March 2004


Sore Throat - A Review of Presentation and Etiology

Table III : Associated Complaints

Table IV : Tonsillar Grading & Lymphadenopathy in

Patients with Sore Throat

Table V : Bacteriological Culture in 50 Patients of

Sore Throat: Throat Swab Vs Fine Needle Aspiration
Vs Core Culture

*NPO - no pathogenic organism isolated Table VI:

Predisposing/Contributing Factors in Throat

but no change in dilutional titre.3

Other organisms isolated maybe Streptococcus
pneumoniae (19%), H. influenzae (13%), Moraxella
catarrhalis (36%).
Treatment Protocol
Penicillin has been the drug of choice for treatment of
streptococcal pharyngotonsillitis for almost five decades.
It has proved to be safe, efficacious and inexpensive.
Initially, in the early eighties, intramuscular form (Penicillin
G benzathine) was used, but subsequently oral
formulations were shown to be equally effective and so
this route was preferred. The main drawback is the 10%
cases that prove to be allergic and the problem with
compliance due to its three/four times a day dosing. The
intramuscular form, being painful, itself causes compliance
Bacterial failures range from 10-30% (i.e. failure to
eradicate the organism of the original infection), while
clinical failures range from 5-15% (i.e. patients who remain
symptomatic despite treatment).
Thus, alternatives to be used include:
1) Amoxycillin - has a narrower spectrum and
gastrointestinal side effects, but is less expensive.
2) Macrolides - Erythromycin is a good alternative in
allergic patients, but the GI side effects are intolerable

for some. US-FDA labels a 5 day course of

Azithromycin as an effective alternative.
3) Cephalosporins- a 10 day course of a first generation
drug (Cefadroxil/cephalexin) is superior to penicillin in
eradication of GABHS.
4) Amoxycillin-Clavulanate potassium - resistant to
degradation from beta-lactamase produced by copathogens that may colonise the tonsillopharyngeal area.
It is very useful for treating recurrent streptococcal
pharyngitis. The two main limiting factors are its
expense and the diarrhea caused by it.
Thus, a simple protocol would be to start with amoxicillin
after throat swab has been sent for culture. In cases of
allergic reactions, erythromycin or azithromycin maybe
used. Recurrent infections are best treated with amoxicillinclavulanate or a cephalosporin. Recommended durations
of therapy are 10 days for all antibiotics except
azithromycin, where a 5 day course suffices.
Aims and Objectives
1. To study some of the predisposing factors in cases of
sore throat and tonsillitis.
2. A review of the common presenting signs and
symptoms, with a view to formulating a treatment
protocol based on symptomatology.
3. To develop a lucid treatment protocol to decide when

Indian Journal of Otolaryngology and Head and Neck Surgery Vol. 56 No. 1, January - March 2004

Sore Throat - A Review of Presentation and Etiology

to employ the medical and surgical modalities.

As an ongoing process, 50 patients with a primary
complaint of sore throat, with or without fever and other
related complaints were selected for this study. All of these
patients were examined in detail in the out-patient's
department and then a prepared questionnaire, including
predisposing factors and treatment history, was filled out
in each case. Each of these patients was subjected to a
throat swab and those showing GABHS were also
subjected to assessment of ASLO titres and repeat swabs.
All this was done in most cases before starting any form
of antimicrobial therapy.
Depending on the response to treatment, persistence of
symptoms and other factors, 20 patients were kept on
medical treatment, while 30 patients underwent a
tonsillectomy (with or without an adenoidectomy). All
patients taken up for surgery, had a fine needle aspiration
for culture done on the operating table just prior to removal
of tonsils, while the tonsils were sent in each case for
core culture (one being spirit washed and the other was
sent as such) in sterile containers for microbiological
evaluation. A post-therapy/post-operative swab was taken
in each case.
All the findings were compiled in a master chart for easy
reference and observation.
The fifty patients taken up for this study were broadly
divided into two groups - Group A who underwent surgery
and Group B who received only medical treatment.
(i) Age & sex distribution :
The youngest patient was 3 years while the oldest was 44
years of age. 24 patients (48%) were below the age of 10
years, while only 6 patients (12%) were above 30 years.
The highest incidence was found to be in the 6-10 year
age group with 19 patients (38%) belonging to this age
The sex distribution showed a slight male preponderance
with 29 (42%) males as opposed to 21 (42%) females.
The distribution is depicted in Table I.
(ii) Presenting symptoms and signs :
The main complaint of course was that of 'sore throat' in
all of the 50 patients, but the duration and frequency of


attacks varied greatly. In 26 (52%) cases, the symptom

had been present for less than 2 years, 22 (44%) had the
symptom for less than the preceding 6 years, while only
2 (4%) said the complaint had been present for more than
6 years. 93% of the patients who were treated with surgery
had the problem for the last 6 years, while in the medical
group, this was 100%.
The frequency of attacks ranged between 3 per year up
to a maximum of 14 per year. 64% (32) patients had
between 3 and 6 attacks per year, while only 10% (5) had
less than 3 per year and 26% (13) had 7 or more than 7
episodes per year. The distribution by frequency is depicted
in Table II.
The associated complaints that were looked for included
fever, a history of mouth breathing or nasal obstruction,
swelling of the neck and pain on swallowing. The
observations are recorded in Table III.
Several patients obviously had more than one associated
complaint, but in both groups of patients, fever and pain
on swallowing were the commonest. More of the patients
who were ultimately treated surgically had complaints of
pain on swallowing and swelling of the neck reflective of
concomitant cervical lymphadenopathy, than the group
given only medical treatment.
The most notable clinical findings in both groups were
that of cervical lymphadenopathy and that of tonsillar
exudates or pus point or debris on the tonsils.
Table IV shows distribution by grading of tonsillar size,
tonsillar exudate and cervical lymphadenopathy which in
most cases was the upper deep cervical and occasional
superficial group node.
Significantly the 4 patients who did show an exudate over
the tonsil, or pus points at the time of presentation, all
underwent surgery as the ultimate modality of treatment.
(iii) Microbiology :
In a significant 27 (54%) patients, an initial throat swab
did not grow any pathogenic organism. Positive swabs
were mostly of GABHS or of Staphylococcus aureus.
The fine needle aspiration yielded a good culture in 7 cases,
while core culture yielded growth in 25 of the 30 cases
i.e. even in cases where the pre-operative throat swab
had been negative. The 8 weeks post-operative throat

Indian Journal of Otolaryngology and Head and Neck Surgery Vol. 56 No. 1, January - March 2004


Sore Throat - A Review of Presentation and Etiology

swabs showed no recolonization/infection with GABHS.

The results are tabulated in Table V,
(iv) Predisposing/contributing factors :
Associated factors specifically looked for in history
included any association with chips/fried foods, cold
drinks, ice-creams, sweets and smoking (passive or
active). Table VI shows the results obtained.
A significant number i.e. 36 (72%) gave a history of attacks
being precipitated by the intake of cold drinks (aerated
drinks as well as juices). Another significant factor was
the fairly high incidence of passive smoking which was
44% in these patients.

A sore throat episode is defined as the occurrence of sore
throat as a complaint.4 This soreness is generally described
by the patient as pain in the throat without the effort of
swallowing and also a painful swallow. This common
complaint generally afflicts children below the age of 10
years, although adults are not immune to this problem
either. It was observed during the course of this study,
that the complaint of a painful throat was associated with
complaints of a difficult and painful swallow and fever.
Besides symptoms, a sore throat is also diagnosed on the
basis of the presence of signs of inflammation like
congested anterior pillars, tonsillar hypertrophy, exudate
on the tonsils, congested tonsils and a generalized
congestion of other structures of the throat. The
complaints may be there for a discrete period involving
either a day or a succession of days, provided that no
interruption in their sequence exceeds 9 days. Anything
that occurs after a gap of 10 days is considered a new
Classically, differentiation of an ordinary sore throat from
that of an episode of acute streptococcal tonsillitis is made
on the basis of standard Centor criteria 5 followed
elsewhere. Oral temperature of 38.3 C (101F) or above,
or tonsillar or pharyngeal exudates, or more than 2 cm
size tender anterior cervical lymph node or a positive throat
swab constitures tonsillitis. Paradise et al4 have also defined
tonsillitis on the basis of the association of a sore throat
with one or more of these criteria.
Presence of 3 or 4 of these criteria has a predictive value
of 40 to 60% and the absence has a negative predictive
value of approximately 80% 5 . Since a wide range of

organisms, commonest being the viruses, cause acute

pharyngitis, the actual incidence of the diagnosed true
tonsillitis, is in the range of only 5 to 15% GABHS in
adults and approximately 30% in paediatric cases. In most
cases, however, treatment is in the form of antibiotics
given to prevent the development of known dreaded
complications of streptococcal infection of the throat
namely rheumatic fever, glomurelonephritis etc. Antibiotics
are also prescribed because the parents of the suffering
children and the adult patients expect some form of medical
therapy for the sore throat. In very few cases do parents
or patients themselves ask for a tonsillectomy to start with,
unless the episodes have been so frequent that the
attendants and the patient need to get rid of the perceived
source of the repeated infections. The antibiotics
prescribed were usually amoxicillin either plain or in a
combination with clavulinic acid as a first line, unless the
patient had a sensitivity problem with the drug. Those
cases were then treated with either a course of
erythromycin or azithromycin as an alternative or in some
cases a cephalosporin (usually Cefadroxil). These
antibiotics were found to be effective in most cases, with
post-therapy swabs corroborating the clinical response
In our study, a significant number of patients (32 i.e 62%)
who finally underwent surgery had between 3 to 6 episodes
of sore throat per year, which clearly shows that increased
frequency of attacks does have a prominent role in
deciding the outcome of the therapy. In some the frequency
of the attacks was even higher, thus giving an indication
that increased number of attacks have to do with the
virulence of the organism or the lowered immunity of the
patient, in both cases a subject where conservative
management may not be of much help and a surgical
treatment should be kept in mind at the outset.
In the study conducted by Woolford et al (2000) 6, the
patients prepared for surgery were kept under observation
and those remaining asymptomatic for 6-9 months did
not ultimately undergo the procedure, rather only those
with frequent attacks were finally operated.
Paradise et al4 recommend observation of two episodes
of moderate severity after presentation or recurrent attacks
before deciding on tonsillectomy in view of their finding
that clinicalhistories may frequently be exaggerated. They
recommend taking at least 7 episodes in one year; 5 in
two consecutive years or 3 in three consecutive years as

Indian Journal of Otolaryngology and Head and Neck Surgery Vol. 56 No. 1, January - March 2004

Sore Throat - A Review of Presentation and Etiology

a criterion.
Capper & Canter (2000)7 in their study also found that
frequency of tonsillitis was the most frequently stated
indication for a tonsillectomy.
Besides the frequency of the attacks, what was found to
be predictive of the selection of a surgical modality of
treatment was the associated symptoms of fever (95%)
and significant pain on swallowing (85%) with each
episode. The clinical grading of tonsillar size was also a
mild predictor with most operated cases revealing Grade
II(35%) or III(60%) tonsillar hypertrophy. The same
study by Woolford et al also found that keeping these
criteria as a yardstick for the decision for surgery was
fairly predictive and these patients benefited from surgery.
What was more significant was the presence of tonsillar
exudates or debris at the time of presentation. All the 4
patients presenting with this ultimately underwent a
tonsillectomy. 70% of the patients undergoing surgery
had anterior cervical lymphadenopathy at the time of
presentation, which was thus a fairly good predictor of
the severity of the episode and subsequent possibility of
surgery. Borderline cases need to be reviewed before
In some cases the antibiotics were not started until the
throat culture report was received as positive and
antibiotics started only according to the sensitivity reports.
There were, however, also some cases where the swab
reports did not indicate any pathogenic organism but the
patients had the typical complaints of sore throat according
to the criteria used by us. One of the main reasons for
resorting to techniques like repeating the throat swabs
thrice or using Fine Needle Aspiration culture (FNA) was
because we observed that it was not possible to detect
organisms on the surface of the tonsil in all the suspected
cases. This fact was confirmed after a core culture of the
removed tonsil was done and the offending organism was
isolated. The fine needle aspiration culture material yielded
better culture growths (when positive) and its use as a
routine culture technique in adults on an OPD basis needs
to be investigated further. A throat swab is from the
tonsillar surface and it has been demonstrated that drainage
of the tonsillar crypts is impaired by recurrent tonsillar
infection which impedes progress of the bacteria to the
surface resulting in a negative swab.8 Toner et al (1986)9
also found in their study a reduced organism recovery
rate from tonsil swabs of the surface as compared with


core isolates, this being true for both aerobes and

anaerobes. The relative frequency of the offending
organism is maintained, so a surface is usually a good
indicator of the core organism when it is positive,
Investigation of possible predisposing factors revealed
some interesting facts. As many as 36 (72%) of the patients
gave a positive history of association of the episodes with
the intake of cold drinks and 17 (34%) had a definite
association with the intake of fried foods especially chips.
These factors could possibly be acting by altering the
bacterial microflora or lowering host immunity by altering
local factors. Another significant etiological factor appears
to be the fairly strong association of these sore throat
episodes with smoking, be it passive or active (in the case
of some of the adults). 44% of the patients gave a positive
history of passive smoking.
Ice creams and sweets seemed to predisposing in only
22% and 26% cases respectively, thus this did not show
a strong association with the presenting complaint as the
others. There would thus appear either to be some basis
in the age old concept of avoidance of cold and fried things
during an episode of a sore throat, or this maybe reflective
of a biased history provided by the patients and the
attendants. No comparisons were possible with other
similar studies since these predisposing factors have not
apparently been delved into very deeply in the literature
reviewed by us. Paradise et al only considered demographic
profile details in the history and they found no statistically
significant association of any of the factors considered.
So, what then would be the appropriate treatment protocol
for cases of sore throat and tonsillitis ? A schematic
representation of the guideline is given in Figure 1.

Although sore throat continues to be one of the commonest
complaints encountered by otolaryngologists on a regular
basis, its definition, diagnosis and management continues
to be somewhat hazy. All cases of sore throat do not require
antibiotic therapy, nor do all ultimately need surgeries in
the form of tonsillectomies. However, it would be fair to
say that frequent attacks associated with clinical features
of lymphadenopathy, fever, tonsillar hypertrophy and
exudates and a positive throat culture (especially for
GABHS), would require more aggressive treatment - first
in the form of antibiotic therapy, failing which a
tonsillectomy would have to be performed.

Indian Journal of Otolaryngology and Head and Neck Surgery Vol. 56 No. 1, January - March 2004

Cold drinks and fried stuffs along with passive smoking

would appear to have an etiological/predisposing role to
play in this condition.
A rational and systematic approach to this condition would
ensure that antimicrobial abuse and unwarranted
tonsillectomies do not take place.
Throat swab culture and fine needle aspirate cultures are
useful adjuncts in planning treatment protocols of this


Paradise J.L., Bluestone CD. et al (1978): History of recurrent

sore throat as an indication for tonsillectomy. The New Engl. J.
of Med. Vol. 298, 8, 409-413.


Cooper RJ, Hoffman RT (2001) : Principles of Appropriate

Antibiotic Use for Acute Pharyngitis in Adults: Background,
Ann Intern Med. 134: 509-577.


Woolford T.J., Ahmed A., Willat D J. et al (2000): Spontaneous

resolution of tonsillitis of tonsillitis in children on the waiting
list for tonsillectomy, clin. Otolaryngol. 25, 428-430.


Capper R., Canter RJ. (2001) : Is there agreement among

general practitioners, paediatricians and otolaryngologists about
the management of children with recurrent tonsillitis, Clin.
Otolaryngol, 26, 371-378.


The cause of tonsillitis, Everett M.T. (1979) : The practitioner,

Vol.223, 253-260


Toner J.G., Stewart T.J., Campbell J.B. et al (1986): Tonsil

flora in the very young tonsillectomy patient. Clin. Otolaryngol.
11, 171-174.



Wiatrak B.J., Woolley A.L. in Cumming's Otolaryngology &

head & Neck Surgery, Vol.5, Paed. Otolaryngol, chapter 12,
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beta hemolytic streptococcal pahryngitis, Am Fam. Physician.
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in children, Curr Opin Otolaryngol Head Neck Surg, 3:369.

Address for Correspondence :

Dr Kadambari Batra
J-37, Sector 25,
Noida - 201301