Sore throat resident survival guide

Sore throat Resident Survival Guide Microchapters
Overview
Causes
Diagnosis
Treatment
Do's
Don'ts

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mydah Sajid, MD[2]

Synonyms and keywords: An approach to sore throat in adults, Sore throat approach in adults, Approach to pharyngitis in adults, Pharyngitis in adults

Overview

Sore throat, also called as pharyngitis, is a painful sensation in the back part of the throat due to inflammation of the pharynx. It is one of the most common complaints among patients visiting their primary care physicians. In the United States, approximately 12 million ambulatory care visits are due to sore throat annually. It mostly occurs in children and adolescents. The most common etiology is acute self- limiting viral infection. Group A streptococcal infection is the most common causative bacteria for acute pharyngitis in adults. As a physician, it is important to identify clinical signs for life-threatening airway obstruction and deep tissue infection and treat them promptly. This section provides a short and straight to the point overview of the sore throat in adults.

Causes

Life Threatening Causes

Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated.

• Croup
• Acute epiglottitis

Differentiating croup and epiglottitis

	Croup	Epiglottitis
Clinical features	Acute stridor with coughing and lack of drooling	Acute stridor with drooling and lack of coughing
Course	Slow-developing airway obstruction - rare severe obstruction	Rapidly courses with complete airway obstruction and shock
Imaging	Steeple sign in an anterior-posterior neck x-ray	Thumb sign in a lateral neck x-ray
Additional clinical features (less reliable for diagnostic)	Sore throat Barking cough	Sore throat Sitting position Refusal of food or drink Inability to swallow Vomiting
Treatment	Nebulization of racemic epinephrine: Preferred regimen: 0.5 mL of a 2.25% racemic epinephrine solution diluted in 3 mL of normal saline	Medical emergency: Invasive airway management (oral intubation or tracheotomy) Antibiotics Intensive care unit

Common Causes

• Viral upper respiratory tract infection (adenovirus, rhinovirus, coronavirus, enterovirus, influenza A and B, parainfluenza virus, respiratory syncytial virus, and severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2).
• Group A streptococcal (GAS) infection
• Group C and G Streptococcus infection
• Arcanobacterium haemolyticum
• Fusobacterium necrophorum - which causes the Lemierre's syndrome
• Mycoplasma and Chlamydia species
• Corynebacterium diphtheriae
• Acute HIV infection
• Neisseria gonorrhoeae
• Epstein-Barr virus and other herpes viruses such as: cytomegalovirus (CMV) and herpes simplex virus (HSV)
• Allergic rhinitis, sinusitis
• Gastroesophageal reflux disease
• Smoking
• Inhalation of dry air (particularly in winters)
• Vocal strain
• Medications: Angiotensin-converting enzyme inhibitors, chemotherapeutic drugs

Diagnosis

Shown below is an algorithm summarizing the diagnosis of sore throat in adults:

Are there alarming clinical signs for upper airway obstruction or deep neck infection present? “Hot potato” voice Drooling Stridor Respiratory distress “Tripod position” Fever and chills Severe unilateral sore throat Bulging of the pharyngeal wall or soft palate History of penetrating trauma to the neck Lockjaw Crepitus Neck stiffness

Yes

No

Stabilize ABC and refer patient urgently to emergency or inpatient care unit. Consider the following differential diagnosis: * Croup * Acute epiglottitis

Are clinical signs for viral upper respiratory infection (including conjunctivitis, coryza, cough, viral exanthem and voice hoarseness) present?

Yes

No

Manage patient with supportive care.

Does patient have clinical features of GAS throat infection? Fever (temperature ≥100.4 degrees F) Acute onset of sore throat Inflammation and edema of tonsillopharyngeal and uvular mucosa Tonsillar and peritonsillar yellow or white exudates Painful cervical lymphadenopathy Scarlatiniform rash History of GAS exposure

Yes

Uncertain

No

Apply Centor criteria for patient's clinical signs and symptoms. Is score ≥3?

Yes

No

Perform Rapid antigen detection test (RADT)

Consider other viral, bacterial or noninfectious causes of sore throat. The illness is mostly self-limiting and specific tests for diagnosis are not carried out.

Positive

Negative

GAS pharyngitis confirmed - start antibiotics

Perform throat culture in patients with any of the following risk factors: Patient with weak immune system or history of complications of GAS infection i.e. acute rheumatic fever. Patients in close contact with individuals who have a high risk of complications (i.e. infants and immunocompromised elderly population) Young adults living in close proximity (i.e. college dormitories) Patients residing in endemic areas of acute rheumatic fever Patient with negative RADT but with Centor criteria scores ≥3

Treatment

Shown below is an algorithm summarizing the treatment of sore throat in adults according to the Infectious Diseases Society of America guidelines:

Does patient have strong clinical suspicion for viral URTI?

No

Yes

Is patient having symptoms suggestive of GAS pharyngitis along with positive RADT?

Manage patient with supportive care including analgesics, hot fluids, lozenges, and soft diet.

Yes

No

Treat patients with empirical antibiotic: Preferred regimen (1): adults: penicillin V 500mg q12h PO for 10 days; children: penicillin V 250mg q12h or q8h PO for 10 days; Preferred regimen (2): amoxicillin 50mg/kg (max: 1gr) qd PO or 25/mg (max: 500mg) bid; Preferred regimen (2): Benzathine G penicillin 1.2mi UI single-dose IM; If patients are allergic to penicillin: Alternative regimen (1): Cephalexin 20 mg/kg/dose (max: 500mg) bid PO for 10 days Alternative regimen (2): Cefadroxil 30 mg/kg (max: 1gr) qd PO for 10 days Alternative regimen (3): Clindamycin 7 mg/kg/dose (max: 500mg) tid PO for 10 days Alternative regimen (4): Azythromycin 12 mg/kg (max: 500mg) qd PO for 10 days Alternative regimen (5): Clarithromycin 7.5 mg/kg/dose (max: 250mg) bid PO for 10 days

Provide supportive care to the patients. If the patients have risk factors suggestive of other causes (i.e. acute HIV infection, gonorrhea, or non-infectious causes), perform relevant investigations.

Do's

• Physicians should administer antibiotics with judicious care in patients with a sore throat due to the risk of developing adverse reactions and bacterial resistance in the community. A physician should only prescribe antibiotics in patients with high clinical suspicion for GAS or those with positive rapid antigen detection test and throat culture.
• Antibiotics reduce the severity of symptoms and fasten the rate of recovery in the patients. The primary goal of treatment with antibiotics is to reduce the incidence of complications with GAS infection.
• The Infectious Disease Society of America (IDSA) has recommended the use of aspirin, non-steroidal anti-inflammatory drugs (NSAIDs), or acetaminophen as supportive therapy for alleviation of pain. The randomized clinical trials have shown NSAIDs as a more effective option for the relief of symptoms compared to acetaminophen.
• If there are alarm signs such as stridor and coughing or drooling assess for croup or epiglottitis and give emergent medical support.

Don'ts

• The oral glucocorticoids should not be prescribed to patients as their adverse effects outweigh their benefits as an oral analgesics. Glucocorticoids should only be considered in patients with significant odynophagia and dysphagia.