Sore throat management

Question 1

What are the common causes of sore throat?

Answer 1

Viral ~80% - adenovirus, rhinovirus, influenza, RSV, EBV

Bacterial ~5-17% - especially Group A Beta haemolytic streptococci and streptococcus pyogenes

Question 2

What are the suppurative complications?

Answer 2

Otitis media
Sinusitis
Peritonsillar abscess - quinsy (a complication of tonsillitis)

Question 3

What are the rare immunological consequences of GABHStrep?

Answer 3

Acute rheumatic fever:
a disease of children aged 5-14 predominantly
antibody cross reaction with the heart, joints, brain and skin causing:
- Rheumatic heart disease
- Polyarthritis
- Sydenham’s chorea

Acute Glomerulonephritis

Question 4

What are other causes of sore throat?

Answer 4

Tooth infections & dental abscess
Aphthous ulceration
Oropharyngeal thrush
Epstein Barr virus - Glandular fever 
Rare: oral cancer

Question 5

Sore throat usually resolves within?

Answer 5

3 days - 40%
7 days - 85%
irrespective of cause

Question 6

How long does antibiotics shorten the length of illness by?

Answer 6

Half a day

Question 7

Do antibiotics help with suppurative complications?

Answer 7

Yes but these are uncommon complications - no need to treat prophylactically

Question 8

Name three scores that help determine whether a sore throat is caused by streptococcus and suggests a management course

Answer 8

Modified Centor score - max score 5
FeverPAIN - max score 5
Centor - max score 4

Question 9

What is the Modified Centor Score?

Answer 9

Age 3-14 = +1 point
Age 14- 45 = 0
Age 45+ = -1
Exudate or swelling on tonsil = +1
Tender/ enlarged anterior cervical LN = +1
T >38 = +1
Absence of cough = +1 

Score of 5 - treat with abx
3-4 clinical consideration in partner with the pt

Question 10

What is the FeverPAIN score

Answer 10

Fever during previous 24 hours 
Purulence on tonsils
Attend rapidly - within 3 days of onset of symptoms 
Inflamed tonsils (severe)
No cough or coryza 

Score of 4-5 = 63-65% chance of isolating strep

Question 11

Centor criteria

Answer 11

Tonsillar exudate
Tendor anterior cervical lymphadenopathy
History of fever - >38
Absence of cough

Score of 1-3 try to resist abx

Question 12

What is scarlet fever

Answer 12

A notifiable disease in children which causes an erythematous rash and strawberry tongue

Question 13

Should we swab throats?

Answer 13

Over medicalises commensal bacteria
Increased cost to NHS - unnecessary
UK NICE guidelines - throat swab not routinely carried out in primary care for management of sore throat

Question 14

What medications should be used to reduce symptoms and prevent complications?

Answer 14

NSAIDs and paracetamol - to reduce symptoms
best taken together
can be used for >1 week

Consider naproxen and not diclofenac as alternative NSAID
NSAIDs contraindicated in pregnancy or stomach ulcer but safe in most asthmatics

Consider co-codamol as alternative to paracetamol

Question 15

With a score of 5 in the centor/ feverpain score, which antibiotic would you use?

Answer 15

Penicillin V - phenoxymethylpenicillin 500mh four times daily for 7 days (NOT 10)
NOT amoxicillin - greater resistance & too broad spectrum
If allergic to penicillin - cephalosporins - Doxycycline 200mg PO OD

Question 16

What is an increased risk of doxycycline?

Answer 16

C.difficile
Pseudomembranous colitis
Especially in the elderly

Question 17

How do you manage score of 3-4

Answer 17

Delayed prescribing with clear safety netting
e.g. severe fevers, unusual rash esp if non blanching, unable to swallow saliva or fluids or very concerned that it has got more severe

Question 18

Indications for tonsillectomy

Answer 18

7 or more in the last year
5 or more in each of last 2 years
3 or more in each of last 3 years
Aim to avoid if possible - tonsils are part of the immune system