Acute Sore Thoat Management in Pharmacy
Patients with an acute sore throat are a common presentation to Emergency Departments in Ireland. A recent single centred respective study based in an Emergency Department (ED) in Dublin, found there was over 650 attendances annually, accounting for just below 2% of annual attendances to the department.1 Consequently this cohort of patients accounts for a significant proportion of the workload upon emergency services, and the provision of appropriate emergency care to them is vital.
These patients are usually diagnosed as either tonsillitis or pharyngitis. These diagnoses account for the vast majority of presentations. Both illnesses tend to be viral in origin, with Group A Beta Haemolytic streptococcus representing the most serious bacterial cause. Severe but rare diagnoses such as epiglottitis, retropharyngeal abscess and peritonsillar abscess/quinsy should be also considered. Clinical signs that can help differentiate benign causes from severe causes include significant systemic upset, stridor, the inability to swallow salvia, severe neck stiffness and the patient holding a tripod position.
The majority of simple tonsillitis and pharyngitis treatment can be carried out at a GP level or by over the counter medications such as paracetamol and NSAIDs. In the case of uncomplicated tonsillitis/pharyngitis, a pragmatic expectant policy is recommended. Patients who attend the ED are advised to avoid antibiotics and return to their GP if symptoms persist for a few days.2
There is an over tendency to prescribe antibiotics with one UK study finding that 64% of primary care patients are prescribed antibiotics for a sore throat.3 This is despite most evidence displaying that the majority of sore throats are secondary to a viral infection. 85% to 95% of throat infections in adults and children under the age of 5 are caused by viruses. While viruses account for 70% of throat infections in those aged 5 to 15 years.4 This over prescribing of antibiotics has numerous potential consequences including unnecessary exposure to antibiotic side effects and antibiotic resistance. Certain studies have in fact shown that treatment of sore throats with antibiotics only provides mild symptomatic relief, though they do reduce complications such as rheumatic fever. However they have no effect on incidence, in countries such as Ireland, where this disease is not common.5
To help differentiate between viral and bacterial causes there is a number of decision aid tools. Two of these are recommended by NICE, which are the FeverPAIN and CENTOR.6 FeverPAIN scores from zero to five with each of the following scoring one point:
- Fever over 38°C.
- Purulence (pharyngeal/tonsillar exudate)
- Attend rapidly (3 days or less)
- Severely Inflamed tonsils
- No cough or coryza
A score of 0-1 has a 13-18% chance of isolating streptococcus.6 The CENTOR scores zero to four with each of the following scoring one point:
- Tonsillar exudate
- Tender anterior cervical lymphadenopathy or lymphadenitis
- History of fever (over 38°C)
- Absence of cough
A score of less than or equal to 1 only has a 7% of being caused by streptococcus.6 Both tools help reduce the prescription of unnecessary antibiotics by giving the clinician confidence that with a low score, the likelihood of a streptococcus infection is low.
The antibiotic of choice for when one is required is Phenoxymethylpenicillin four times a day for ten days. If the patient is allergic to penicillin the second line option is clarithromycin.7 Antibiotics such as amoxicillin carry the risk of causing maculopapular exanthems in patients diagnosed with infectious mononucleosis and therefore should be avoided in patients presenting with sore throats.7 Other treatments that can be considered include paracetamol and NSAIDs. These medications can also be given rectally, which may be of benefit in patients with odynophagia. Topical mouthwashes or sprays, for example Benzydramine, may also provide symptomatic relief. When patients attend the ED, a commonly used treatment is Dexamethasone to treat severe odynophagia or stridor by reducing soft tissue swelling.
One diagnosis to always consider, especially in younger patients presenting with a sore throat is infectious mononucleosis. This can be tested by a Monospot being sent. Rostegaard et al in 2019 found that the cumulative risk of infectious mononucleosis prior to turning 30 years old was 13.3% for males and 22.4% for females.8 Consequently it is a very prevalent infection and carries with it, other side effects that need to be acknowledged. One such effect is splenomegaly which is of particular importance in sport playing children and young adults. Splenomegaly occurs as a consequence of lymphocytic infiltration enlarging the spleen below the level of the ribcage, leaving it susceptible to be ruptured.9 Patients with confirmed infectious mononucleosis should be advised to rest from contact sports and heavy lifting for at least one month, and return to the E if they develop sudden onset abdominal pain.10
Another complication of bacterial tonsillitis to consider is a peritonsillar abscess or quinsy. This is a unilateral swelling of pus behind the tonsil, where the swelling typically crosses the midline of the mouth. Patient symptoms may include a “hot potato voice” and trismus.11 These patients need to be treated by an ENT surgeon and may need either needle aspiration or incision and drainage.12
Finally, epiglottis thankfully is now a less rare complications since the introduction of the Haemophilus influenzae b vaccine. However this a life threatening emergency and should be considered if the following clinical symptoms are present: stridor, muffled voice, rapid clinical course and a history of diabetes.13 These patients will need urgent review by ENT and anaesthetics, and may benefit from treatments such as dexamethasone and adrenaline nebulisers.
To conclude, sore throats are a common presentation to the ED. The majority of these presentations are viral in origin and require symptomatic treatment and do not benefit from antibiotic treatment. Through the use of decision aid tools such as the FeverPAIN and CENTOR a clinician can isolate sore throat presentations that are more likely bacterial in origin. Certain diagnoses such as infectious mononucleosis, epiglottis and peritonsillar abscess need to be carefully considered in this cohort.
References available on request
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