I keep getting a sore throat

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, DV, otitis media, sinusitis, flu
• Any actual evidence of benefit?

3
GP Consultation

• Presentation
• History
• Examination
• Diagnosis
• Viral, viral, viral
• Supportive
• ?Antibiotics
• PUNS ICE

4
Presentation

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

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 dont 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 whats
  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
• gt4 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 differIndications 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 200617(3)12-14
• Management of Infection Infestations, LHB,
  December 2008