Sore Throat acute

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Sore Throat (acute)

• Lawrence Pike

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Definitions

• Pharyngitis
• predominantly inflammation of the oropharynx, but
  not the tonsils.
• Tonsillitis
• when the tonsils are particularly affected.
• Laryngitis
• few signs of infection visible but the patient
  complains of soreness lower down the throat often
  with a hoarse voice.

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Causes

• Viral (70-80)
• Group A beta-haemolytic streptococcus (20-30)

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Incidence

• Sore throat is estimated to account for 10 of
  all general practice consultations
• Asymptomatic carriage of streptococcus
• is common with rates of 6 - 40
• Carriers have low infectivity and are not at risk
  of developing complications such as rheumatic
  fever

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Symptoms

• Sore throat
• Pain on swallowing
• Fever
• Headache
• Malaise
• Hoarseness if laryngeal involvement

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Signs

• Redness of the pharynx and tonsils
• Presence of exudate
• Enlarged tonsils
• Swollen tender neck glands.
• Note that a streptococcal sore throat is
  impossible to diagnose on clinical grounds alone.

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Scarlet Fever

• A red punctate skin eruption with sandpaper-like
  texture
• Usually begins on chest and spreads to abdomen
  and extremities
• Prominent in skin creases
• Flushed face with circumoral pallor
• Strawberry tongue
• These indicate a streptococcal infection

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Investigations?

• Throat swabs cannot differentiate between
  "infection" and "carriage", are poorly sensitive,
  and are therefore of limited value. Results take
  up to 24 - 48 hours to be reported, and the test
  is relatively expensive.
• Rapid antigen tests to detect streptococcal
  antigen on a throat swab are not easily
  available.
• Anti-streptolysin O (ASO) titres can help to
  identify whether a patient has recently been
  infected with streptococcus, and may be useful
  for patients who remain unwell or develop
  complications.

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Differential Diagnosis

• Infectious mononucleosis (glandular fever)
• Epiglottitis (requires urgent admission)
• Gonococcal pharyngitis (rare)
• Diphtheria (very rare in U.K)
• Neutropaenia (e.g. ensure patient not on
  carbimazole)

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Complications

• Otitis media
• Sinusitis
• Peritonsillar abscess (quinsy)
• Suppurative cervical adenopathy
• Rheumatic fever
• Post streptococcal glomerulonephritis

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Management

• Sore throat (pharyngitis, tonsillitis,
  laryngitis) is usually a self-limiting illness,
  whether due to viral or bacterial infection.
• Explanation, reassurance and advice on
  symptomatic treatment is frequently all that is
  necessary when a patient consults with a sore
  throat, as only a third clearly want or expect an
  antibiotic.

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Management

• Prescription of an antibiotic increases patient
  reattendance rates for further episodes of sore
  throat.
• The patient is also exposed to the risk of side
  effects
• Increased risk of bacterial resistance in the
  community.
• Antibiotic therapy of sore throat reduces
  duration of symptoms by about 8 hours, although
  it is not known if symptom severity is also
  affected. The absolute benefit is small, with 90
  of both treated and untreated patients symptom
  free within one week.

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Management

• Antibiotic therapy has a small protective effect
  on the risk of developing sinusitis, otitis media
  and possibly peritonsillar abscess (quinsy).
• 30 children and 145 adults need treatment to
  prevent one case of acute otitis media.

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Management

• Benefit in reducing the incidence of rheumatic
  fever or post streptococcal glomerulonephritis is
  likely to be low.
• The incidence of rheumatic fever and post
  streptococcal glomerulonephritis has fallen in
  industrialised countries and does not appear to
  be related to antibiotic use. Although early
  studies showed that antibiotic treatment
  decreased the risk of these complications more
  recent studies have not shown benefit.

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Management

• Suggested indications for antibiotics are
• severely inflamed throat with marked systemic
  upset
• confirmed streptococcal infection
• scarlet fever
• patients with impaired immunity (splenectomy)
• past history of rheumatic fever or
  post-streptococcal glomerulonephritis.
• Antibiotic treatment is also usually advised
  during outbreaks of streptococcal infection in
  communities such as schools, hostels or prison
  (public health).

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Management

• If an antibiotic is necessary
• Penicillin is the treatment of choice, with
  erythromycin in patients with penicillin allergy.
  10 days treatment is recommended in order to
  eradicate possible streptococcus infection. DTB
  1995
• Tonsillectomy is occasionally recommended for
  recurrent attacks of tonsillitis. Consider only
  if seven documented throat infections in the
  preceding year, or three in each of three
  successive years.