Sore Throat (acute)Sore Throat (acute)

Lawrence PikeLawrence Pike

DefinitionsDefinitions

• PharyngitisPharyngitis– predominantly inflammation of the oropharynx, predominantly inflammation of the oropharynx,

but not the tonsils. but not the tonsils.

• TonsillitisTonsillitis– when the tonsils are particularly affected. when the tonsils are particularly affected.

• LaryngitisLaryngitis– few signs of infection visible but the patient few signs of infection visible but the patient

complains of soreness lower down the throat complains of soreness lower down the throat often with a hoarse voice.often with a hoarse voice.

CausesCauses

• Viral (70-80%) Viral (70-80%)

• Group A beta-haemolytic Group A beta-haemolytic streptococcus (20-30%) streptococcus (20-30%)

IncidenceIncidence

• Sore throatSore throat is estimated to account is estimated to account for 10% of all general practice for 10% of all general practice consultations consultations

• Asymptomatic carriageAsymptomatic carriage of of streptococcusstreptococcus– is common with rates of 6 - 40%is common with rates of 6 - 40%– Carriers have low infectivity and are not at Carriers have low infectivity and are not at

risk of developing complications such as risk of developing complications such as rheumatic feverrheumatic fever

SymptomsSymptoms

• Sore throatSore throat

• Pain on swallowingPain on swallowing

• FeverFever

• HeadacheHeadache

• MalaiseMalaise

• Hoarseness if laryngeal involvement Hoarseness if laryngeal involvement

SignsSigns

• Redness of the pharynx and tonsilsRedness of the pharynx and tonsils

• Presence of exudatePresence of exudate

• Enlarged tonsilsEnlarged tonsils

• Swollen tender neck glands. Swollen tender neck glands.

• Note that a streptococcal sore throat Note that a streptococcal sore throat is impossible to diagnose on clinical is impossible to diagnose on clinical grounds alone. grounds alone.

Scarlet FeverScarlet Fever

• A red punctate skin eruption with A red punctate skin eruption with sandpaper-like texturesandpaper-like texture

• Usually begins on chest and spreads to Usually begins on chest and spreads to abdomen and extremitiesabdomen and extremities

• Prominent in skin creasesProminent in skin creases• Flushed face with circumoral pallorFlushed face with circumoral pallor• Strawberry tongueStrawberry tongue• These indicate a streptococcal infectionThese indicate a streptococcal infection

Investigations?Investigations?

• Throat swabsThroat swabs cannot differentiate between cannot differentiate between "infection" and "carriage", are poorly sensitive, "infection" and "carriage", are poorly sensitive, and are therefore of limited value. Results take and are therefore of limited value. Results take up to 24 - 48 hours to be reported, and the test is up to 24 - 48 hours to be reported, and the test is relatively expensive. relatively expensive.

• Rapid antigen testsRapid antigen tests to detect streptococcal to detect streptococcal antigen on a throat swab are not easily available. antigen on a throat swab are not easily available.

• Anti-streptolysin O (ASO) titresAnti-streptolysin O (ASO) titres can help to can help to identify whether a patient has recently been identify whether a patient has recently been infected with streptococcus, and may be useful infected with streptococcus, and may be useful for patients who remain unwell or develop for patients who remain unwell or develop complications.complications.

Differential DiagnosisDifferential Diagnosis

• Infectious mononucleosisInfectious mononucleosis (glandular fever)(glandular fever)

• EpiglottitisEpiglottitis (requires urgent (requires urgent admission)admission)

• Gonococcal pharyngitisGonococcal pharyngitis (rare) (rare)

• DiphtheriaDiphtheria (very rare in U.K) (very rare in U.K)

• NeutropaeniaNeutropaenia (e.g. ensure patient (e.g. ensure patient not on carbimazole)not on carbimazole)

ComplicationsComplications

• Otitis media Otitis media

• Sinusitis Sinusitis

• Peritonsillar abscess (quinsy) Peritonsillar abscess (quinsy)

• Suppurative cervical adenopathy Suppurative cervical adenopathy

• Rheumatic fever Rheumatic fever

• Post streptococcal glomerulonephritisPost streptococcal glomerulonephritis

ManagementManagement

• Sore throat (pharyngitis, tonsillitis, Sore throat (pharyngitis, tonsillitis, laryngitis) is usually a self-limiting illness, laryngitis) is usually a self-limiting illness, whether due to viral or bacterial infection. whether due to viral or bacterial infection.

• Explanation, reassurance and advice on Explanation, reassurance and advice on symptomatic treatment is frequently all symptomatic treatment is frequently all that is necessary when a patient consults that is necessary when a patient consults with a sore throat, as only a third clearly with a sore throat, as only a third clearly want or expect an antibiotic. want or expect an antibiotic.

ManagementManagement

• Prescription of an antibiotic increases patient Prescription of an antibiotic increases patient reattendance rates for further episodes of sore reattendance rates for further episodes of sore throat. throat.

• The patient is also exposed to the risk of side effectsThe patient is also exposed to the risk of side effects• Increased risk of bacterial resistance in the Increased risk of bacterial resistance in the

community. community. • Antibiotic therapy of sore throat reduces duration of Antibiotic therapy of sore throat reduces duration of

symptoms by about 8 hours, although it is not known symptoms by about 8 hours, although it is not known if symptom severity is also affected. The absolute if symptom severity is also affected. The absolute benefit is small, with 90% of both treated and benefit is small, with 90% of both treated and untreated patients symptom free within one week.untreated patients symptom free within one week.

ManagementManagement

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

treatment to prevent one case of acute treatment to prevent one case of acute otitis media. otitis media.

• ] ]

ManagementManagement

• Benefit in reducing the incidence of Benefit in reducing the incidence of rheumatic fever or post streptococcal rheumatic fever or post streptococcal glomerulonephritis is likely to be low. glomerulonephritis is likely to be low. – The incidence of rheumatic fever and post The incidence of rheumatic fever and post

streptococcal glomerulonephritis has fallen in streptococcal glomerulonephritis has fallen in industrialised countries and does not appear to industrialised countries and does not appear to be related to antibiotic use. Although early be related to antibiotic use. Although early studies showed that antibiotic treatment studies showed that antibiotic treatment decreased the risk of these complications more decreased the risk of these complications more recent studies have not shown benefit.recent studies have not shown benefit.

ManagementManagement

• Suggested indications for antibiotics are:Suggested indications for antibiotics are:– severely inflamed throat with marked systemic severely inflamed throat with marked systemic

upsetupset– confirmed streptococcal infection confirmed streptococcal infection – scarlet feverscarlet fever– patients with impaired immunity (splenectomy)patients with impaired immunity (splenectomy)– past history of rheumatic fever or post-past history of rheumatic fever or post-

streptococcal glomerulonephritis. streptococcal glomerulonephritis. – Antibiotic treatment is also usually advised during Antibiotic treatment is also usually advised during

outbreaks of streptococcal infection in communities outbreaks of streptococcal infection in communities such as schools, hostels or prison (public health). such as schools, hostels or prison (public health).

ManagementManagement

• If an antibiotic is necessary If an antibiotic is necessary – Penicillin is the treatment of choice, with Penicillin is the treatment of choice, with

erythromycin in patients with penicillin allergy. erythromycin in patients with penicillin allergy. 10 days treatment is recommended in order to 10 days treatment is recommended in order to eradicate possible streptococcus infection. [DTB eradicate possible streptococcus infection. [DTB 1995] 1995]

• Tonsillectomy is occasionally recommended Tonsillectomy is occasionally recommended for recurrent attacks of tonsillitis. Consider for recurrent attacks of tonsillitis. Consider only if seven documented throat infections only if seven documented throat infections in the preceding year, or three in each of in the preceding year, or three in each of three successive years.three successive years.