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'I keep getting a sore throat'

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'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 ... – PowerPoint PPT presentation

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Title: '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
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