Sore throat

Sore throat- review including the new NICE guidelines of January 2018 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 )


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