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'I keep getting a sore throat'

'I keep getting a sore throat' . 50 year old male smoker Dr K. Sore Throats. Very common presentation Sore throats are self-limiting conditions 50% improve in 3 days [1d] 85% of people resolve in one week [3] Caused by viruses, bacteria and other factors

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'I keep getting a sore throat'

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  1. 'I keep getting a sore throat' 50 year old male smoker Dr K

  2. Sore Throats • Very common presentation • Sore throats are self-limiting conditions • 50% improve in 3 days [1d] • 85% of people resolve in one week [3] • Caused by viruses, bacteria and other factors • Important because might be streptococcal infection • Why? Potentially serious complications • Case History • Pressure to prescribe common to other conditions • viral URTI, D&V, otitis media, sinusitis, flu • Any actual evidence of benefit?

  3. GP Consultation • Presentation • History • Examination • Diagnosis • Viral, viral, viral • Supportive • ?Antibiotics • PUNS & ICE

  4. Sore throat Otalgia Headache and malaise Pyrexia Enlarged tonsils Pus Pharyngeal mucosa is inflamed Foetor Tender cervical lymphadenopathy Presentation

  5. History • Duration of symptoms • Systemic features (e.g. fever, malaise) • Rash • ±Dysphagia • ±Trismus

  6. Examination • Adults: Throat only • Children: Ears and throat • Temp • Erythema • Tonsil enlargement ± pus • Foetor • Cervical lymph nodes

  7. Centor Criteria • Fever • Absence of cough • Cervical lymph nodes (anterior and tender) • Exudate on tonsils • Positive: 3 out of 4 • Probability of GABHS 40 - 60% • Negative: 3 out of 4 • Probability not GABHS 80%

  8. PUN & ICE • “Most patients don’t come with a sore throat so find out why they came” • What do you expect me to do for you? • What is it that concerns you? • Why do you think an antibiotic will help?

  9. Aetiology: Acute • Viral • Adenoviruses • Coxsachie • Rhinoviruses • Parainfluenzae • (10-20%) [1a] • Bacteria • Group A beta-haemolytic streptoccocus 17% • Group B,C, and D streptococci 4% • Other (H. influenzae or S. aureus) 1% • Other • Tuberculosis • Candidiasis • Chemical irritation

  10. Aetiology: Chronic • Smoking • Irritation • Poor inhaler technique • Dust • Chemicals • Allergy • Candidiasis • Glandular Fever

  11. Streptococcal Infections • Gram-positive cocci • Classification: • Lancefield grouping: at least 6 (A, B, C, D, F, G) • By degree of haemolysis: alpha, beta, non-haemolytic • Asymptomatic carriage of GABHS is common, occuring in 6-40% of people [1b] • Risk of serious complications • Does not predispose to increased risk of serious complications (which are rare) • The Centor criteria helps predict those who may benefit from antibiotics

  12. GAHBS Complications • Otitis media and sinusitis • Glomerulonephritis • Erysipelas • Meningitis • Cellulitis • Lymphangitis / lymphadenitis • Pneumonia • Septicaemia • Toxic shock syndrome

  13. Management • Supportive: • Advice and reassurance • Analgesics • Adequate fluid intake • Antibiotics: • Pressure from patients to prescribe antibiotics • Patients given antibiotics are more likely to re-attend if they have another similar infection • Some doctors give a delayed script for use if symptoms are not resolving or getting worse  • When to prescribe, which antibiotic and what’s the evidence?

  14. Antibiotics Which? • Ampicillin • Contraindicated: causes a diffuse maculopapular rash in glandular fever • Penicillin V 500mg QDS for 10 days • Erythromycin 500mg BD/ 250mg QDS for 10 days if allergic [1] • Clarithromycin 250-500mg BD for 10 days if allergic [4] When? • Centor criteria 3 out of 4 • O/E: red, inflamed, enlarged tonsils with pus • Systemically unwell

  15. Antibiotics: Evidence? • 7 day course resolves symptoms 0.5 to 1 days earlier than 3 day course in streptococcal sore throat (651 patient trial) • Accelerates resolution by: • 2.5 days in patients with group A streptococcal sore throat • 1.5 days in non-group A streptococcal sore throat • 7 days protective against risk of abscess • Trend for protection against acute glomerulonephritis • Reduced acute otitis media to 25% • You need to treat 30 children to 145 adults to prevent one case of otitis media [4]

  16. Referral • Quinsy • Acute upper airways obstruction (inc acute epiglotittis) • Dysphagia with systemic upset • Hx of sleep apnoea, daytime somnolence or failure to thrive • >4 acute episodes in past year and affecting child's normal behaviour • Guttate psoirasis exacerbated by recurrent tonsillitis • Suspicion of a serious underlying disorder (e.g. leukaemia)

  17. Tonsillectomy • Opinions on this subject differ:Indications for tonsillectomy include: • More than 5 episodes of tonsillitis requiring antibiotics in a year (not just simply tonsillitis) [2] • Recurrent episodes of acute tonsillitis: • 3 or 4 attacks in 1 year [1a] • 5 attacks in 2 years [1a] • Recurrent tonsillitis with complications [1a] • Tonsillar or adenoidal hypertrophy causing airways obstruction [1a] • One or more episodes of quinsy [1a] • It is not indicated after one episode of qunisy since the chance of a recurrence of quinsy is only about 10%. [2]

  18. As most patients with a sore throat do not see a doctor it is worth asking why they came. [1]

  19. Sources • GP Notebook 2008 • Tonsillectomy, GP Notebook, 2008 • Onexamination.com, 2008 • MeReC Bulletin 2006;17(3):12-14 • Management of Infection & Infestations, LHB, December 2008

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