Chapter 73: Sore throat

A sore or painful throat is one of the commonest symptoms encountered in general practice. The most usual cause is viral pharyngitis, which is self-limiting and usually only requires symptomatic treatment.

Presentation

Sore throat may be present as part of a complex of the common upper respiratory infections, such as the common cold and influenza. However, sore throat often presents as a single symptom. The pain is usually continuous and aggravated by swallowing. In those under 4 years of age the presentation of acute pharyngitis or tonsillitis may be confusing as the presenting complaints may be vomiting, abdominal pain and fever rather than sore throat and swallowing difficulty.

It is appropriate to consider sore throat as acute or chronic. Most presentations come as acute problems, the causes of which are listed in TABLE 73.1.

A summary of the diagnostic strategy model is presented in TABLE 73.2.

Probability diagnosis

The majority of sore throats, mainly pharyngitis, will be caused by a virus. A viral infection is supported by the presence of coryza prodromata, hoarseness, cough, conjuctivitis and nasal stuffiness.

Serious disorders not to be missed

It is vital to be aware of Haemophilus influenzae infection in children, especially between 2 and 4 years, when the deadly problem of epiglottitis can develop suddenly. These patients present with a short febrile illness, respiratory difficulty (cough is not a feature) and are unable to swallow.

Apart from acute epiglottitis it is important not to overlook cancer of the oropharynx or tongue, or the blood dyscrasias, including acute leukaemia (see CHAPTER 26). The severe infections not to be missed include streptococcal pharyngitis with its complications, including quinsy, diphtheria and HIV infection (including AIDS).

A foreign body may stick in the supraglottic area and may not be seen on oral examination.

Pitfalls

There are many pitfalls, the classic being to diagnose the exudative tonsillitis of EBM as streptococcal tonsillitis and prescribe one of the penicillins, which may precipitate a severe rash. Primary HIV infection can present with a sore throat along with other symptoms. Adenovirus pharyngitis can also mimic streptococcal pharyngitis, especially in young adults.

Traumatic episodes are important but are often not considered, especially in children. They include:

• a foreign body—may cause a sudden onset of throat pain, then drooling and dysphagia

• vocal abuse—excessive singing or shouting can cause a sore throat and hoarseness

• burns—hot food and drink, acids or alkalis

Various irritants, especially cigarette smoke in the household and smoke inhalation from fires, can cause pharyngeal irritation with sore throat, especially in children.

The mouth and pharynx may become dry and sore from mouth breathing, which is often associated with nasal obstruction (e.g. adenoid hypertrophy, allergic rhinitis).

Tonsilloliths are concretions of debris entrapped within deep tonsillar crypts. They are a common cause of halitosis, vague sore throat and possibly recurrent bouts of tonsillitis.

Seven masquerades checklist

Depression may be associated with a sore throat. Diabetes and aplastic anaemia and drugs are indirectly associated through candidiasis, neutropenia and agranulocytosis respectively. NSAIDs can cause a sore throat. The possibility of thyroiditis presenting as a sore throat should be kept in mind.

Making a diagnosis

The issues of making a reliable diagnosis and prescribing antibiotics are rather contentious and at times difficult. It is difficult to distinguish clinically between bacterial and viral causes. The main issue is to determine whether the sore throat has a treatable cause by interpretation of the clinical and epidemiological data.

The appearance of the pharynx and tonsils is not always discriminating. A generalised red throat may be caused by a streptococcal or a viral infection, as may tonsils that are swollen with follicular exudates. On probability, most sore throats are caused by a virus and generally do not show marked inflammatory changes or purulent-looking exudates (see FIG. 73.1). Such throats should be treated symptomatically.

History

It is necessary to determine whether the patient has a sore throat, a deep pain in the throat or neck pain. Instruct the patient to point to exactly where the pain is experienced. Enquire about relevant associated symptoms such as metallic taste in mouth, fever, upper respiratory infection, other pain such as ear pain, nasal stuffiness or discharge and cough.

Note whether the patient is an asthmatic and uses a corticosteroid inhaler, or is a smoker, or exposed to environmental irritants. Check the immunisation history, enquiring especially about diphtheria.

The history should give a clue to the remote possibility that the painful throat is a manifestation of angina.

Examination

An inspection should note the general appearance of the patient, looking for ‘toxicity’, the anaemic pallor of leukaemia, the nasal stuffiness of infectious mononucleosis, the characteristic halitosis of a streptococcal throat.

Palpate the neck for soreness and lymphadenopathy, inspect the ears and check the sinus areas.

Then inspect the oral cavity and pharynx. Look for ulcers, abnormal masses and exudates. Note whether the uvula and soft palate, tonsils, fauces or pharynx are swollen, red or covered in exudate. The typical appearances of various conditions causing a sore throat are shown in FIGURES 73.1 to 73.7, and important causes to exclude in FIGURE 73.8.

Guidelines

• Small patches of exudate on the palate or other structure indicate Candida albicans (oral thrush) FIG. 73.2).

• A large whitish-yellow membrane virtually covering both tonsils indicates EBM (see FIG. 73.3).

• A generalised red, swollen appearance with exudate indicates GABHS infection (see FIG. 73.4 and 73.5).

Investigations

Investigations can be selected from:

• throat swab

• haemoglobin, blood film and white cell count

• mononucleosis test

• random blood sugar (? diabetes)

• biopsy of suspicious lesions

To swab or not to swab

Throat swabs are about 90% effective in isolating GABHS from the infected throat. Authorities are divided about management. Some recommend that throat cultures be performed for all sore throats and antibiotics given only when GABHS is found. Others regard throat cultures as being unnecessary and recommend therapy based on clinical judgments. Swabs are seldom helpful because the isolation of GABHS often represents asymptomatic carriage.⁴ Still others recommend throat cultures for selected patients only.⁵

Generally, throat cultures are not necessary except to verify the presence of S. pyogenes, especially in closed institutions such as boarding schools, or if diphtheria is suspected in the non-immunised. One study has found that toothbrushes harbour GABHS and should not be shared.⁶ A positive culture and a fourfold rise in the ASO titre are necessary for a precise diagnosis.

Epstein–Barr mononucleosis screening

It is important initially if tonsillar exudate is present to consider the possibility of EBM. If suspected, an IgM antibody test should be ordered, rather than the older tests, such as a Paul–Bunnell test.

Supportive symptomatic treatment

Supportive measures include:

• adequate soothing fluids, including icy poles

• analgesia: adults—2 soluble aspirin; children—paracetamol elixir (not alcohol base) or ibuprofen

• rest with adequate fluid intake

• soothing gargles (e.g. soluble aspirin used for analgesia)

• advice against overuse of OTC throat lozenges and topical sprays, which can sensitise the throat; limited use (3 days) of decongestants for nasal decongestion is helpful

An acute sore throat in a child usually means a viral or, less commonly, bacterial infection of the tonsillopharynx. A bacterial cause is more common in children aged 3–13 years than in children <3 years. Other causes to consider are:

• gingivostomatitis, especially primary herpes simplex

• epiglottitis

• laryngotracheobronchitis (croup)

• laryngitis

• oral candidiasis (more a bad taste than pain)

• aphthous ulcers

• foreign bodies

• postnasal drip (e.g. allergic rhinitis)

• irritation: low environmental humidity, smoke (e.g. household smoke)

Sore throat in the elderly may be caused by a viral infection but otherwise needs to be treated with considerable respect. It is important to exclude pharyngeal cancer which can present with the classic triad.

Oropharyngeal lesions may occur with herpes zoster but vesicles are usually present on the face.

A metallic taste in the mouth with or without a complaint of a sore throat indicates C. albicans and hence diabetes must be excluded.

Streptococcal tonsillopharyngitis

This infection may involve the pharynx only and vary from mild to severe, or it may involve both tonsils and pharynx. It is uncommon under 3 years or over 40 years.⁷

Guidelines for streptococcal throat

The four diagnostic features are:

• constitutional symptoms:

  • – fever ≥38°C

  • – toxicity

• tender anterior cervical lymphadenopathy

• tonsillar swelling and exudate

• absence of cough

Other symptoms include:

• difficulty in swallowing

• significant pain, including pain on talking

• foul-smelling breath

Examination

• Pharynx very inflamed and oedematous

• Tonsils swollen with pockets of yellow exudate on surfaces (see FIGS. 73.4 and 73.5)

• Very tender enlarged tonsillar lymph nodes

Treatment

Indications for antibiotic therapy:⁴

• severe tonsillitis with above features of GABHS

• existing rheumatic heart disease at any age

• scarlet fever

• peritonsillar cellulitis or abscess (quinsy)

• patients 2–25 years with presumptive GABHS from special communities (e.g. remote Indigenous) with a high incidence of acute rheumatic fever

One evidence-based review recommended that if a cold follows its natural course, no antibiotics will be helpful. If there is a sore throat with no cough, but fever >38˚C, tender neck glands and white spots in the throat, antibiotics are indicated.⁸ Treatment should be with penicillin or an alternative antibiotic (see TABLE 73.3).⁴

Antibiotic treatment has a variable effect on the resolution of symptoms. It does not protect against glomerulonephritis but does protect against rheumatic fever.⁷ Amoxycillin should be avoided in tonsillitis because of confusion caused should mononucleosis be present. Frequent fluids are advisable and paracetamol for pain.

Recurrent tonsillitis^4,7

Recurrent sore throat is common in childhood and usually has a viral cause. Recurrent tonsillitis tends to be overdiagnosed. A throat swab taken during an acute episode can be helpful.⁹ Only patients with more than five episodes of presumptive or proven bacterial tonsillitis in a year should be treated with prophylactic penicillin. The decision should be based on the severity of the episode, time lost from work or school, infectivity and response to antibiotics. Tonsillectomy in children results in only a modest reduction in the number of subsequent sore throats.¹⁰

Quinsy

Quinsy is a peritonsillar abscess characterised by marked swelling of the peritonsillar area with medial displacement of tonsillar tissue (see FIG. 73.6). It is usually caused by GABHS or anaerobes, occasionally Staphylococcus aureus. A typical picture of tonsillitis with severe unilateral throat pain and high fever is followed by increasing difficulty in swallowing and trismus.

Treatment

Antibiotics (e.g. procaine penicillin IM or clindamycin) plus aspiration or drainage in hospital under local anaesthetic if it is pointing. Oral penicillin treatment is likely to fail. Subsequent tonsillectomy may, but not always, be necessary. The cover can be broadened by adding metronidazole.⁴

Acute epiglottitis

In children this is a life-threatening infection. It may be overlooked in adults where, unlike children, the airway is usually not obstructed and the patient presents with a severe sore throat, dysphagia, drooling of saliva and a tender neck. Examination of the throat may appear quite normal. However, it is a severe infection requiring hospitalisation and parenteral antibiotics (e.g. cefotaxime).

Diphtheria

Due to the bacterium Corynebacterium diphtheriae, the potentially fatal form of this disease almost always occurs in non-immunised people. The clinical presentation may be modified by previous immunisation or by antibiotic treatment.

Clinical features

• Insidious onset

• Mild to moderate fever

• Mild sore throat and dysphagia

• Patient looks pale and ill

• Enlarged tonsils

• Pharynx inflamed and oedematous

• Pseudomembrane (any colour but usually grey–green) can spread beyond tonsils to fauces, soft palate, lateral pharyngeal wall and downwards to involve larynx (see FIG. 73.7)

• Enlarged cervical lymph nodes

• Soft tissue swelling of neck → ‘bull neck’ appearance

Management

• Throat swabs

• Antitoxin

• Penicillin or erythromycin 500 mg qid for 10 days

• Isolate patient

Epstein–Barr mononucleosis

The angiose form of EBM is a real trap and must be considered in patients aged 15–25 years (peak incidence) with a painful throat that takes about 7 days to reach its peak. Refer to CHAPTER 28.

Clinical features

• Sore throat

• Prodromal fever, malaise, lethargy

• Anorexia, myalgia

• Nasal quality to voice

• Skin rash

Examination

• Petechiae on palate (not pathognomonic)

• Enlarged tonsils with or without white exudates (looks, but isn’t, purulent)

• Peri-orbital oedema

• Lymphadenopathy, especially posterior cervical

• Splenomegaly (50%)

• Jaundice ± hepatomegaly (5–10%)

• Primary rash (5%)

• Secondary rash:

  • with ampicillin, amoxycillin (90–100%)

  • with penicillin (50%)

Note: This rash is not synonymous with penicillin hypersensitivity.

Diagnosis

• Blood film—atypical lymphocytes

• White cell count—absolute lymphocytosis

• Heterophil antibodies

  • or

  • Monospot test (Paul Bunnell)

  • or

• EBV IgM test (more specific)

Treatment⁴

Symptomatic, e.g. paracetamol for pain. Parenteral corticosteroids only in most severe cases.

Herpangina

An uncommon infection caused by the Coxsackie virus. Presents as small vesicles on soft palate, uvula and anterior fauces. These ulcerate to form small ulcers. The problem is benign and rapidly self-limiting.

Herpes simplex pharyngitis

In adults primary infection is similar to severe streptococcal pharyngitis but ulcers extend beyond the tonsils.

Other viral pharyngitis

Typically, the signs are fewer than with other causes. The typical case has mild redness without exudate and prominent (sometimes pale) lymphoid patches on the posterior pharynx (see FIG. 73.1). Tonsillar lymph nodes are usually not enlarged or tender. This picture is the commonest encountered in general practice.

Oral candidiasis typically presents as milky-white growths on the palate, buccal and gingival mucosae, pharynx and dorsum of the tongue (see FIG. 73.2). If scraped away, a bleeding ulcerated surface remains. A bad (metallic) taste is a feature but the patient may complain of a sore throat and tongue and dysphagia.

Causes or predisposing factors to consider:

• HIV infection

• diabetes mellitus

• broad-spectrum antibiotics

• corticosteroids, including inhalers

• dentures

• debility

Management

• Determine underlying cause.

  • Nystatin suspension, rinse and swallow qid

  • or

  • amphotericin 10 mg lozenge dissolved slowly in oral cavity, 6-hourly, for 7–14 days

• Acute epiglottitis in children (a medical emergency)

• Inaccessible foreign body

• Abscess: peritonsillar or retropharyngeal

• Recurrent attacks of tonsillitis and adenoid hypertrophy for an opinion about tonsillectomy and/or adenoidectomy

• Suspicion or evidence of HIV infection or diphtheria

• Patients not responding to treatment

• Patients with more generalised disorders that are not yet diagnosed⁹

• Repeated attacks of acute tonsillitis

• Enlarged tonsils and/or adenoids causing airway obstruction, including OSA

• Chronic tonsillitis

• More than one attack of peritonsillar abscess

• Biopsy excision for suspected new growth

Antibiotic treatment is aimed primarily at streptococcal pharyngitis and this is often based on clinical judgment.

Hand-out sheets from Murtagh’s Patient Education 7th edition:

• Tonsillitis