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Sore Throat Module 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 pharyngitis, 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. common cold, flu, chicken pox, Infections* glandular fever 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 epiglottitis 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 influenza 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 cough and aphonia that occur Epiglottitis with croup 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 larynx. • 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.
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