Sore throat

Infection or irritation of the pharynx or tonsills Can present as acute pharyngitis or tonsillitis or exudative tonsillitis Usually infectious with 50-80 % due to viruses Common condition with highest incidence in children and young adults Bacterial pharyngitis is more common in winter ( or early spring ) while enteroviral infection is more common in the summer and autumn ( BMJ Best Practice ) Self limiting condition which generally resolves within 2 weeks It is difficult to distinguish viral and bacterial causes of pharyngitis on the basis of history and physical examination alone

Rhinovirus Coronavirus Parainfluenza Adenovirus Herpes simplex type 1 Epstein – Barr virus Haemophilus influnza type B Enterovirus Measles virus HIV-1 Group A Streptococcus ( GAS ) Fusobacterium necrophorum Candida albicans Neisseria gonorrhoea Neiseria meningitides Cornybacterium diptheria & C ulcerans Acranobacterium haemolyticum Yersinia enterocolitica Francisella tularensis Chlamydophilia pneumoniae Mycoplasma pneumoniaea

Irritation eg smoke or NG tube Hayfever GORD Kawasaki disease Radiotherapy or chemotherapy related mucositis Leukaemia Aplastic anaemia Drug related – drugs causing agranulocytosis , neutropenia and thrombocytopenia

Complications particularly suppurative after an episode of sore throat in primary care are rare Fear of complications by both patients and the GP -often used to justify high antibiotics prescribing rate Complications from GABH ( group A streptococcus ) pharyngitis that were historically common but are now mostly rare in developed world It is estimated that up to 60 % of patients presenting in primary care in UK with sore throat are prescribed antibiotics ( higher rate up to 71.5 % by trainee doctors )

Self care-Consider paracetamol for pain or fever or if preferred and suitable ibuprofen Advice about the adequate intake of fluids Medicated lozenges may only help to reduce pain by a small amount Be aware that no evidence was found on non-medicated lozenges , mouthwashes or local anaesthetic mouth spray used on its own

Assessment- Examine throat and neck Tonsills for exudate , enlargement , erythema Lymph nodes Associated symptoms
○ headache
○ nausea
○ vomiting
○ abdominal pain Temperature Hydration status CV and Respiratory status Associated medical problems Previous h/o Rheumatic fever Immunocompromised Contact with GAS person Sexual activity or abuse

FeverPain-Fever ( during previous 24 hrs) Purulence ( pharyngeal / tonsillar exudate ) Attend rapidly ( 3 days or less ) Severely inflamed tonsills No cough or coryza Centor-Tonsillar exudate Anterior cervical lymphadenopathy or lymphadenitis History of fever ( over 38 °) Absence of cough

GAS pharyngitis-Is common in children and adolescents 5-15 yrs More frequent in winter Sudden onset Headache Cough/ Rhinorrhoea is not usually associated with GAS infection Fever Pharyngeal exudates Cervical adenopathy

DD-Common cold – rhinorrhoea , nasal congestion and cough Influenza Pharyngoconjunctival fever Acute herpetic pharyngitis
 Epiglottitis Retropharyngeal , peritonsillar and 
lateral abscess Lemierre syndrome
 Infectious mononucleosis Diptheria Measles Bechet’s syndrome Stevens-Johnson syndrome Kawasaki disease Hand-foot-mouth disease Oropharyngeal cancer Apthous ulcer Tularemia

Major suppurative complications of acute sore throat ( quinsy , otitis media , sinusitis , impetigo or cellulitis ) occurred in approximately 1 % of patients regardless of whether they were given antibiotics , not given antibiotics or given delayed antibiotics ( BMJ 2013 ) Signs and symptoms of patients with GAS and non-GAS pharyngitis are generally similar. No signs or symptoms clearly distinguish GAS from non-GAS infection ( Family Practice 2017 )

LINKS AND RESOURCES

PATIENT INFORMATION

NHS inform Scot- self help guide https://www.nhsinform.scot/illnesses-and-conditions/ears-nose-and-throat/sore-throat

A useful guide to antimicrobial prescribing for the public from NICE – helpful to show the data when antibiotic is not indicated https://www.nice.org.uk/guidance/ng84/informationforpublic

NHS on sore throat https://www.nhs.uk/conditions/sore-throat/

CDC on sore throat https://www.cdc.gov/antibiotic-use/community/for-patients/common-illnesses/sore-throat.html

Treating your infection -a useful self care leaflet developed in collaboration with various societies like RCGP , British Society for Antimicrobial therapy http://www.wales.nhs.uk/sitesplus/documents/888/Treating%20your%20infection%20EAAD%20leaflet%20%28English%29.pdf

Self-care Forum on sore throat http://dev.selfcareforum.org/wp-content/uploads/2013/03/190227-SCF-Fact-Sheet-No-10-Sore-Throat-v102.pdf

INFORMATION FOR CLINICIANS

Management of sore throat and indications for tonsillectomy SIGN Quick reference guide https://www.sign.ac.uk/assets/qrg117.pdf

NICE : sore throat antimicrobial prescribing https://www.nice.org.uk/guidance/ng84/resources/visual-summary-pdf-4723226606 

Centor Score via MD Calc https://www.mdcalc.com/centor-score-modified-mcisaac-strep-pharyngitis

Fever PAIN Clinical Score https://ctu1.phc.ox.ac.uk/feverpain/index.php

An easy to use algorithm from Heart Foundation NZ https://www.heartfoundation.org.nz/shop/heart-healthcare/non-stock-resources/sore-throat-algorithm.pdf

This is  excellent work from Greater Glasgow and Clyde Paediatric guidelines on managing acute sore throat in children https://www.clinicalguidelines.scot.nhs.uk/ggc-paediatric-guidelines/ggc-guidelines/ent/acute-sore-throat/

 

References

1. BMJ Best Practice Acute Pharyngitis https://bestpractice.bmj.com/topics/en-gb/5
2. Predictors of suppurative complications for acute sore throat in primary care: prospective clinical cohort study BMJ 2013 ;347 :f6867
3. Thuy N Thai, Ariella P Dale, Mark H Ebell, Signs and symptoms of Group A versus Non-Group A strep throat: A meta-analysis, Family Practice, Volume 35, Issue 3, June 2018, Pages 231–238, https://doi.org/10.1093/fampra/cmx072
4. Pharyngitis Treatment & Management E Medicine April 2017
5. Use of antibiotics for sore throat and incidence of quinsy Br J Gen Pract 2007 ; 57 (534) :45-49
6. Ng  GJY, Tan  S, Vu  AN, Del Mar  CB, van Driel  ML. Antibiotics for preventing recurrent sore throat. Cochrane Database of Systematic Reviews 2015, Issue 7. Art. No.: CD008911. DOI: 10.1002/14651858.CD008911.pub2.
7. Management of sore throat and indications for tonsillectomy SIGN A national clinical guideline April 2010 https://www.sign.ac.uk/sign-117-management-of-sore-throat-and-indications-for-tonsillectomy
8. Anthea Dallas, Mieke van Driel, Simon Morgan, Amanda Tapley, Kim Henderson, Jean Ball, Chris Oldmeadow, Andrew Davey, Kate Mulquiney, Joshua Davis, Neil Spike, Lawrie McArthur, Parker Magin, Antibiotic prescribing for sore throat: a cross-sectional analysis of the ReCEnT study exploring the habits of early-career doctors in family practice, Family Practice, Volume 33, Issue 3, June 2016, Pages 302–308, https://doi.org/10.1093/fampra/cmw014
9. Sore throat- acute CKS NHS August 2017 https://cks.nice.org.uk/sore-throat-acute
10. Diagnostic Evidence Co-operative Oxford Point-of -care tests for group A Streptococcus Horizon Scan Report Oct 2015
11. Sore throat ( acute ) : antimicrobial prescribing : guidance ( NG84 ) NICE January 2018
12. Medicines Evidence Commentary : Sore throat : predictors of complications in primary care NICE https://www.evidence.nhs.uk/document?id=1618126&returnUrl=Search%3Fps%3D100%26q%3Dtonsil&q=tonsil
13. Allam A, Nijim H. Persistent Unilateral Sore Throat: Should It Be Included in the 2-Week Wait Referral Criteria by NICE. International Journal of Otolaryngology. 2019 ;2019:4920514. DOI: 10.1155/2019/4920514. https://europepmc.org/article/pmc/pmc6525844