44. Sore throat

Question 1

Index conditions.

a) Inflammation/infection
b) Mass

Answer 1

a) Tonsillitis, laryngitis, pharyngitis, epiglottitis, glandular fever, diphtheria
b) Neoplasms, paratonsillar abscess (quinsy), AIDS related conditions

Question 2

Tonsillitis.

a) Cause, risk factors
b) Presentation
c) Centor criteria (mnemonic: CENTOR)
d) Primary care management
e) Indications for hospital admission
f) Tonsillectomy - indication
g) Other complications of GABS

Answer 2

a) Viral (eg. EBV), bacterial (eg. GABS)

b) Sore throat, odynophagia, fever, headache, malaise, voice changes (concurrent laryngitis)
- note: inflammation of the throat, without tonsil inflammation = pharyngitis

c) CENTOR:
- Cough absent,
- Exudate present,
- Nodes (anterior cervical; may be tender),
- Temperature (> 38C),
- young OR old (more likely in 3 - 14 year olds)

(GABS likely if 3-4 criteria positive - immediate or backup antibiotic)

d) Centor 0-2/ FeverPain 0-3.
- Usually viral (supportive), fluids, bed rest, analgesia
- May do EBV screen (Monospot)
- No antibiotic

Centor 3-4/ FeverPain 4-5.
- Backup/ immediate phenoxymethylpenicillin 5 - 10 days (alternative: clarithromycin/ erythromycin in pregnancy)

e) - Airway/breathing difficulty
- Suspicion of quinsy/ other abscess
- Clinical dehydration
- Sepsis
- Immunocompromised/ at risk of complications

f) Tonsillectomy criteria:
- 7 episodes in last year, or
- 5 in each of last 2 years, or
- 3 in each of last 3 years

g) Glomerulonephritis, Scarlet fever, sepsis, rheumatic fever, guttate psoriasis flare-up

Question 3

Peritonsillar abscess (quinsy).

a) Cause
b) Symptoms
c) Signs o/e
d) Management

Answer 3

a) Bacterial usually (GABS) - progression from tonsillitis to peritonsillitis and then abscess; may also be caused by glandular fever (EBV)

b) - Severe unilateral throat pain
- Fever.
- Drooling
- Odynophagia/ dysphagia.
- Earache on the affected side.
- Neck stiffness/ torticollis
- Altered voice quality (‘hot potato voice’)

c) - Hallitosis.
- Lymphadenopathy and fever
- Trismus (difficulty opening the mouth).
- Tonsillar enlargement, oedema, mass may be visible
- UVULA DEVIATION away from lesion

d) - A-E: IV fluids, bloods, blood cultures, analgesia
- Urgent ENT review
- IV phenoxymethylpenicillin (or ceph/ macrolide)
- Single-dose IV steroid
- Surgical intervention probably needed: incision/drainage +/- tonsillectomy

Question 4

Epiglottitis/supraglottitis

a) Cause
b) Triad of clinical features
c) Differentials
d) Management of suspected epi/supraglottitis

Answer 4

a) Bacterial - eg. strep

b) - Pharyngeal: sore throat, drooling/ spitting saliva (cannot swallow), odynophagia
- Systemic: fever, dehyration, lymphadenopathy, malaise, tachycardia
- Airway: increased WOB, tripod sign, voice changes (eg. hot potato voice)/unable to speak, STRIDOR (late sign = airway emergency)

c) UA obstruction - croup, inhaled foreign body
- Sore throat - tonsillitis, quinsy, glandular fever
- Rare - retropharyngeal abscess

d) A-E.
- Airway: Urgent admission with airway support (ENT/anaesthetic) - stabilise airway!!
- Oxygen as required
- DO NOT examine throat
- Laryngoscopy/naso-endoscopy to diagnose
- If not possible, XR neck: thumbprint sign (however, if airway compromise risk - do not send off to radiology without airway support)
- Nebulised adrenaline may help stridor
- Circulation: IV access, bloods (FBC, CRP, U+Es, blood cultures), IV fluids
- Broad-spectrum IV antibiotics and IV steroids

Question 5

Investigations for sore throat.

a) In primary care
b) In secondary care
c) When to not examine throat

Answer 5

a) - Usually no investigation required
- ?EBV - FBC and monospot test
- Recurrent /persistent infection: swab and culture
- ASOT for active/recent strep infection

b) - ?naso-endoscopy
c) Upper airway obstruction: stridor, suspected epiglottitis, croup, etc.

Question 6

Glandular fever.

a) Virus and transmission
b) Latency - where?
c) Classic triad
d) Other common features
e) Investigations if > 12 and immunocompetent
f) Investigations if < 12 or immunocompromised
g) Management

Answer 6

a) EBV - spread through saliva (eg. kissing, sharing toothbrushes and glasses, etc.); rarely via blood/semen
b) In memory B cells
c) Fever, sore throat (tonsillitis), lymphadenopathy (usually posterior cervical; could be diffuse)
d) Prodrome (malaise, fatigue, myalgia, chills, sweats, anorexia, headache), splenomegaly (50%), RUQ pain +/- hepatomegaly, non-specific rash (in 5%; commonly post- amoxicillin), jaundice (6–8%).

e) - FBC (atypical lymphocytosis); also screens for leukaemia/lymphoma
- Monospot test (heterophile antibodies)
- LFTs (usually raised ALT/AST)

f) - EBV serology, HIV serology; consider CMV and toxoplasmosis
- FBC - screen for leukaemia/lymphoma
- LFTs (usually raised ALT/AST)

g) - Reassure that usually lasts 2 - 3 weeks but counsel that may last longer in some people
- NSAIDs/ paracetamol, fluids
- Continue with work/school/activity
- Avoid contact sport for 4 weeks (risk of splenic rupture)
- TCI if: dehydration, stridor, systemic upset, abdo pain

Question 7

Head and neck cancer: 2 week wait guidelines

a) Oral cancer
b) Laryngeal cancer
c) Thyroid cancer

Answer 7

a) - Persistent unexplained ulceration (> 3 weeks)
- Lump on lip or mouth consistent with oral cancer
- Persistent unexplained lump in the neck
- Erythroplakia or erythroleukoplakia

b) Aged over 45 with:
- Persistent unexplained hoarseness, or
- An unexplained lump in the neck

c) - Unexplained thyroid mass

Question 8

Sore throat: history

a) HPC
b) Ass sx
c) PMHx
d) DHx
e) FHx
f) SHx

Answer 8

a) - Onset - sudden or gradual, provoked?
- Timing - intermittent
- Exacerbating factors - swallowing (odynophagia)
- Relieving factors - pain relief

b) - Coryzal symptoms
- Strep throat (CENT) - cough (absence), exudate, nodes (tender CLNs), temperature
- Glandular fever - malaise, abdo pain
- Scarlet fever - rash, strawberry tongue
- Red flags: dysphagia, wt loss/anorexia, bleeding, anaemia, night sweats, stridor/dyspnoea

c) - Previous tonsillitis/ tonsillectomy
- Previous courses of ABx for sore throat
- Glandular fever
- Malignancy
- Chronic diseases

d) - Recent amoxicillin (rash)
- Allergies

e) ?

f) - Smoking, alcohol
- Occupation

Question 9

Sore throat: examination

a) In general
b) Who should not have throat examined?

Answer 9

a) - Examine throat and ears
- Temperature
- Lymph nodes
- General health

b) Anyone with stridor