CPD Sore Throat Module

Ref: IHL-CPD-STSM-001 OBJECTIVES By the end of this module you will:

• Understand what a sore throat is

• Understand and explain the causes of sore throat

• Identify symptoms which may require referral

• Understand the differential diagnoses for sore throats

• Know the drug treatment and self-care options available WHAT IS A CAUSES OF SORE THROAT A SORE THROAT

Sore throat, also known as , is usually self-limiting and does not last more than 1 week. It is generally viral in nature. A sore throat lasting more than a week should be referred for further investigation. A sore throat presents with pain and irritation in the throat which can worsen on swallowing. Viral E.g. , flu, chicken pox, Infections* glandular Bacterial E.g. Streptococcus pyogenes, Infections Group A streptococcus

Allergies E.g. Pollen, dust, moulds, pet dander

Dryness E.g. Dry indoor air caused by heating

Irritants E.g. tobacco smoke, chemicals

Medicines E.g. cytotoxics, carbimazole, clozapine, captopril, penicillamine, sulfasalazine DANGER AETIOLOGY SYMPTOMS *70 – 90% of sore throat cases are caused by viral infections. The second most common cause is bacterial infection in which testing is recommended. In people with a sore throat there are certain “danger Acute throat infections most commonly occur in symptoms” that may suggest a sinister pathology: children aged 5–10 years and in young adults aged 15–25 years. Approximately 36% of patients with sore throats will visit the community pharmacy each year • Inspiratory stridor (harsh, vibratory sound produced for treatment and advice in the UK whereas only 6% when breathing in due to partial airway obstruction) visit their GP. It is estimated that on average each • Fever of unknown aetiology lasting 5 days or more adult will experience two to three episodes of a sore • Change in voice, muffled speech, “hot potato” voice throat each year. Rarely an abscess or may (speaking as if a hot object is being held in the mouth), cause sore throat, however while these complications stifled cries are uncommon they are of particular concern because • Dysphagia -True difficulty in swallowing (i.e. caused by they may compromise the airway. mechanical blockage over pain) • Dyspnoea (difficult breathing) • Blood in saliva (may indicate tonsillar cancer) • Visible bulge in pharynx • Ulcers in throat • Polymorphous rash

NOTE: Admit immediately to hospital any patient who has stridor, breathing difficulty, or dehydration. Refer urgently patients with suspected cancer of the throat. The swelling is of concern as it can block the windpipe, particularly in infants and children. The most common pathogen indicated in Epiglottitis occurring in children DIFFERENTIAL is Haemophilus type B (HiB). However, with widespread paediatric vaccination it has now become rare DIAGNOSES in children but HiB is still a cause in adults and unvaccinated children.

NOTE: People with suspected epiglottitis should not have their throat examined unless there are facilities for Abscess immediate intubation because of the possibility An abscess in the pharyngeal area is uncommon. It is of precipitating complete airway obstruction or typically caused by the pathogen GABHS. A mass of puss cardiopulmonary arrest. may form beneath or near one of the tonsils which is called In children symptoms appear as: a peritonsillar abscess. Often an abscess is caused by • Posture bent forward. a streptococcal infection that has spread from the tonsils • Shallow breathing without marked increase in into deeper tissue. In children, an abscess can form in the respiration rate. tissue at the back of the throat which is called • Inspiratory stridor and hoarseness may occur a retropharyngeal abscess. but the barking and aphonia that occur Epiglottitis with are rare. • The child may be reluctant to talk and/or muffled The epiglottis is a thin flap of cartilage that closes voice and cry. the entrance to the voice box and windpipe during swallowing thereby protecting the glottis. Infection In adults: of the epiglottis can cause severe pain and swelling • There is severe sore throat with painful swallowing. and thus sore throat is the prominent symptom. Predictors of airway compromise include sitting erect, stridor, and dyspnea. • Oropharyngeal cancer (includes the tonsils and faucial Streptococcal Sore Throat pillars, base of the tongue, soft palate, and uvula): there may be sore throat, otalgia, and progressive dysphagia; • Cannot be diagnosed on clinical features alone trismus or a foreign body; or mass sensation in the • May cause mild symptoms but it can also cause severe throat. Many people complain of the sensation of a ‘lump pharyngeal pain, painful swallowing, headache, and a at the back of the throat’. An ulcer is usually visible on high temperature. examination. It often presents with a neck mass due to • Abdominal pain, nausea and vomiting are common in metastases to the cervical nodes. children. • Associated symptoms common in children: fever, nasal discharge, enlarged cervical lymph glands, and otitis media. • A patchy grey-yellow exudate is often present on the tonsils and the uvula is often oedematous. The cervical lymph nodes are enlarged and tender.

Laryngeal and tonsillar carcinoma

• Rare cancer that starts in the voice box which is called the . • Hypopharyngeal cancer (includes the pyriform sinus, lateral pharyngeal wall, posterior pharyngeal wall, and post cricoid region): this may present with a unilateral, well-localized, persistent sore throat; a vague discomfort on swallowing; and referred pain to the ear; or as a neck mass due to cervical node metastases. Dysphagia is a late symptom. There may be weight loss. It is not directly visible on examination. TESTING MANAGEMENT Regardless of the cause of your sore throat, If symptoms are severe or if danger symptoms these self-care strategies can help you ease are present, tests may be required: your symptoms:

• Flexible fibre optic laryngoscopy

• X-rays of the neck Self-Care • Rapid strep screening (paediatrics)

• Throat culture (for adults) • Take plenty of rest. • Drink fluids and prevent dehydration. • Avoid caffeine and alcohol. • Consume warm liquids e.g. broth, caffeine-free tea or warm water with honey. • Gargle with salt water. • Humidify the air. Use a cool-air humidifier to eliminate dry air that may further irritate a sore throat or sit for several minutes in a steamy bathroom. • Avoid irritants. Keep your home free from cigarette smoke and cleaning products that can irritate the throat. DRUG TREATMENT REFERRAL

Antibiotics should not be used to secure symptomatic relief in sore throat. Ibuprofen 400mg three times daily is recommended for relief of fever, headache and throat pain in adults with sore throat. Admission is required for conditions that are immediately In adults who are intolerant to ibuprofen, paracetamol life-threatening e.g. epiglottitis. Non-urgent referral for 1g four times daily when required is recommended for tonsillectomy may be required in some cases of recurrent symptom relief. tonsillitis. Other symptoms and conditions may require referral and expert advice such as the following: Local analgesics are licensed for the symptomatic • Pyrexia that does not resolve with use of paracetamol relief of sore throat e.g. flurbiprofen lozenges and • Drooling benzydamine gargle. • No improvement after 7 days Products containing Capsicum tincture, acetic acid • High risk patients e.g. HIV, AIDS, leukaemia, and Quassia wood may offer symptomatic relief for aplastic anaemia sore throats. • Patients with a spleen injury or disorder, Capsicum are used in gargles for throat irritation or who have undergone a splenectomy or infection. Quassia wood has antibacterial and • History of sleep apnoea, daytime drowsiness, antifungal properties, but has limited evidence for and failure to thrive (children) its effectiveness. Acetic acid is mildly antiseptic, • Five or more episodes per year of sore throat due to with broad spectrum activity against streptococci, tonsillitis. The episodes should have been disabling and have prevented normal functioning. staphylococci, pseudomonas and enterococci. TEST YOURSELF

1. Which one of the following statements about benzydamine 0.15% spray for use in sore throats is FALSE? a. This medicinal product contains 10 vol % ethanol b. Benzydamine use is not advisable in patients with hypersensitivity to acetylsalicylic acid or other NSAIDs c. Bronchospasm may be precipitated in patients suffering from or with a previous history of bronchial asthma d. Benzydamine is contraindicated in asthmatic patients e. Should not be used by pregnant women 2. Which one of the following is not 5. Which one of the following statements a viral cause of sore throat? about epiglottitis is FALSE? a. Chicken Pox a. It can be life threatening b. Croup b. It may be caused by a bacterial infection c. Influenza c. It may be caused by throat injury d. Mononucleosis d. Vaccination does not reduce risk e. Strep throat of contracting epiglottitis in children e. Epiglottitis can occur at any age 3. Which ONE of the following patients with a sore throat does not need to be referred? 6. What self-care measures can a patient suffering with a sore throat take? a. Patient with five or more episodes per year of sore throat due to tonsillitis b. Patient that has a lump that causes difficulty swallowing 7. List and explain the drug treatments that c. Patient that has had a sore throat for 5 days can be offered to patients. d. Patient that presents with an earache e. Patient that presents with rash and joint pain 6.8. ListWhich 2 causes medicines of cough may cause a sore throat?

4. In which one of the following scenarios 9. Which tests are recommended in should you refer the patient to A&E? patients who present with a sore throat with danger symptoms? a. A child with a sore throat and unusual drooling indicative of inability to swallow 10. List the causes of a sore throat. b. An adult with a sore throat who has difficulty opening their mouth c. A child with a sore throat and fever d. An adult with blood in saliva or phlegm e. A child with a frequently recurring sore throat ANSWERS 1. ANSWER D Benzydamine 0.15% spray should be used with caution in patients with asthma. 2. ANSWER E “Strep throat” is caused by the bacteria (not ) Streptococcus pyogenes, also known as group A streptococcus which are highly contagious. 3. ANSWER E Generally with sore throat allow at least one week for symptoms to resolve following OTC products. 4. ANSWER A While all of the scenarios require referral and follow up with GP the paediatric case with unusual drooling is dangerous as it could obstruct the narrow airways of a child.

5. ANSWER D Routine Haemophilus influenzae type b (Hib) vaccination for infants has signigicantly reduced rates of epiglottitis so that it is now rare in children. 6. What self-care measures can a patient suffering with a sore throat take? • Take plenty of rest. • Drink fluids and prevent dehydration. • Avoid caffeine and alcohol. • Consume warm liquids e.g. broth, caffeine-free tea or warm water with honey. • Gargle with salt water. ANSWERS ANSWERS • Humidify the air. Use a cool-air humidifier to eliminate 8. Which medicines may cause a sore throat? dry air that may further irritate a sore throat or sit for • cytotoxics several minutes in a steamy bathroom. • carbimazole • Avoid irritants. Keep your home free from cigarette smoke and cleaning products that can irritate the throat • clozapine • captopril 7. List and explain the drug treatments that • penicillamine can be offered to patients. • sulfasalazine should not be used to secure symptomatic relief in sore throat. • methotrexate Ibuprofen 400mg three times daily is recommended for 9. Which medicines may cause a sore throat? relief of fever, headache and throat pain in adults with • Flexible fibre optic laryngoscopy sore throat. • X-rays of the neck In adults who are intolerant to ibuprofen, paracetamol 1g four times daily when required is recommended for • Rapid strep screening (paediatrics) symptom relief. • Throat culture (for adults) Local analgesics are licensed for the symptomatic relief 10. Which medicines may cause a sore throat? of sore throat e.g. flurbiprofen lozenges and benzydamine gargle. • Viral Infections* Products containing Capsicum tincture, acetic acid and • Bacterial Infections Quassia wood may offer symptomatic relief for sore throats. • Capsicum are used in gargles for throat irritation or • Dryness infection. Quassia wood has antibacterial and antifungal properties, but has limited evidence for its effectiveness. • Irritants Acetic acid is mildly antiseptic, with broad spectrum • Medicines activity against streptococci, staphylococci, pseudomonas and enterococci Name of Product: Sanderson’s Throat Specific Mixture. Active Ingredient(s): Each 5 ml contains: 0.025 ml of Capsicum Tincture (Capsicum annuum L. var. minimum (Miller) Heiser), corresponding to 7.5 to 12.5 micrograms capsaicinoids calculated as capsaicin. Extraction solvent: ethanol 90% v/v. 0.025 ml of extract (as liquid extract) from Squill bulb (Drimia maritima(L.) Stearn) (1:1). Extraction solvent: ethanol 65% v/v. 37.5 mg of Acetic acid. Product licence number: PL 0415/5000R. Name and address of the product licence holder: Infohealth Laboratories Limited, 28 Chipstead Valley Road, Coulsdon, Surrey. CR5 2RA. United Kingdom. Supply classification: GSL. Indications: For symptomatic relief of sore throat, hoarseness, loss of voice and catarrh, and as a preventative gargle when these symptoms begin to appear or are expected to appear. Sanderson’s Throat Specific Mixture is indicated in adults and children aged 8 years and over. Precautions: This product contains small amounts of alcohol (less than 100 mg per 5 ml dose). This product has a sharp biting taste. If symptoms worsen or persist after 7 days, a doctor should be consulted. Patients should be advised not to exceed the stated dose. If dyspnoea, fever or purulent sputum occurs, a doctor should be consulted. Contra-Indications: Hypersensitivity to the active substances or to any of the excipients listed in section 6.1 of the SmPC. Cardio-pulmonary disorders or breathing difficulties. History of alcohol abuse, liver disease or renal impairment. Raised intracranial pressure. Pregnancy & lactation: The safety of this product during pregnancy and lactation has not been established, therefore use during pregnancy and lactation is not recommended. No studies on the effects on fertility have been performed. Effects on ability to drive and use machines: No studies on the effect on the ability to drive or use machines have been performed. This product contains alcohol (see section 4.4). Dosage: Adults, the elderly and children over 8 years: Gargle with 10 ml (two 5 ml spoonfuls) in an equal amount of water hourly. Also swallow slowly one 5 ml spoonful undiluted, three times daily.If symptoms of sore throat, hoarseness, loss of voice or catarrh are expected to appear, gargle well with 10 ml (two 5 ml spoonfuls) in twice the amount of water in the morning before breakfast and last thing at night. Do not use for more than 7 consecutive days. Not recommended for children under 8 years of age. Cost: Clear glass bottles of 100ml £4.19; 200ml £5.29. Reporting of suspected adverse reactions: Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the Yellow Card Scheme at: www.mhra.gov.uk/yellowcard. Date: July 2017

The content was Independently produced by: Ref: IHL-CPD-STSM-001 Nadia Bukhari BPharm, FRPharmS, FHEA, PGDip CPD Senior teaching Fellow in Pharmacy Practice, UCL School of Pharmacy Oksana Pyzik MPharm, MRPharmS Teaching Fellow in Pharmacy Practice, UCL School of Pharmacy © Infohealth Laboratories