GP - Sore throat/ pharyngitis/ tonsillitis

Question 1

Sore throat is a broad umbrella term encompassing mainly 2 conditions, what are they?

Answer 1

Pharyngitis

Tonsillitis

Question 2

What are the causes/ differential diagnoses of an acute sore throat?

Answer 2

Virus (most cases):

• Rhinovirus, coronavirus –> common cold
• Influenza –> flu
• Adenovirus –> pharyngoconjunctival fever (high grade fever + pharyngitis + conjunctivitis + enlarged cervical lymph nodes)
• EBV –> glandular fever (infectious mononucleosis)

Bacteria:

• Streptococcal pyogenes (Group A, Beta-haemolytic streptococcus) –> pharyngitis, tonsillitis, scarlet fever
• Haemophilus influenza type B –> epiglottitis (rare)

Non-infectious causes (uncommon)

• Chronic cigarette smoke
• GORD
• Oropharyngeal cancer
• Kawasaki disease

Question 3

Give 3 complications of strep throat

Answer 3

• Peritonsilar abscess (quinsy) - can cause airway compromise, aspiration of pus, sepsis
  
  • Fever, neck pain, trismus (reduced opening of the jaw), hot-potato voice, displaced uvula to unaffected side, enlarged displaced tonsil
  • Most common in children aged 2-4 yrs
• Retropharyngeal abscess
  
  • Severe sore throat that does not resolves after days
  • Trismus and neck swelling
• Scarlet fever (which is basically pharyngitis/ tonsillitis + maculopapular rash + strawberry tongue - typically affects children under 10 yrs old)
• Rheumatic fever
• Acute otits media
• Acute sinusitis

Question 4

How long does a sore throat usually last?

Answer 4

Self-limiting

Usually resolves within 2 weeks

Question 5

How do you diagnose the cause of a sore throat?

Answer 5

• Examine the person’s throat and neck:
  
  • Pharyngitis - pharyngeal exudate, red swollen pharynx, enlarged cervical lymph nodes
  • Tonsillitis - tonsillar exudate, red swollen tonsils, enlarged jugulodigastric node
• Ask about their symptoms:
  
  • Fever > 38 degree C
  • Sore throat
  • Pain on swallowing
  • Headache, N&V, abdo pain
  • Loss of voice

(Symptoms in BOLD are symptoms of strep throat)

• Assess fluid status - sore throat can cause dehydration due to pain on swallowing, esp in kids
  
  • Reduced skin turgor
  • Increased capillary refill time (more than 2 seconds)
  • Dry mucous membranes
  • Decrease in the number of wet nappies indicating decreased urine output in babies
• FeverPAIN or Centor criteria to determine the likelihood of a strep infection (and therefore the need for Abx treatment)
• Other common (non-streptococcal) infectious causes of acute sore throat, and their symptoms and signs:
  
  • Common cold - nasal congestion, nasal discharge, dry cough, sneezing
  • Flu - fever, headache, myalgia, fatigue, dry cough, reduced appetite
  • Pharyngoconjunctival fever - fever, pharyngitis, conjunctivits, rhinitis
  • Glandular fever - pharyngitis of longer than several days, adenopathy, splenomegaly
  • Epiglottitis - affects children; sore throat, fever, stridor, drooling, muffled voice, hoarseness, sit leaning forward
• Non-infectious causes of acute sore throat:
  
  • GORD - heartburn, acid taste in mouth, bad breath, worse when lying flat
  • Oropharyngeal cancer - hoarse voice, dysphonia, dysphagia, sore throat, neck mass
  • Kawasaki disease - cause unknown; affects children under 4 yrs;
    
    • Diagnosed by the presence of either 5/6 main symptoms, or 4 main symptoms if coronary aneurysms are identified on echo
      
      • Pyrexia of unknown origin lasting 5 days or more
      • Bilateral conjunctivitis
      • Changes in lips and oral cavity i.e. dryness and fissuring of lips, redness of oral cavity and pharynx
      • Cervical lymphadenopathy
      • Polymorphous rash
      • Changes in extremities i.e. redness of palms and soles, desquamation of skin, oedema of hands and feet

Question 6

What does the FeverPAIN or the Centor criteria do?

Answer 6

To predict the likelihood of a streptococcal infection and therefore the need for Abx treatment

Question 7

What is the FeverPAIN criteria?

Answer 7

• Fever > 38 degree C
• Purulence (pharyngeal/ tonsillar exudate)
• Attend rapidly (3 days or less)
• Inflamed tonsils
• No coryzal symptoms (no cough, sneeze, nasal discharge)

Other signs: anterior cervical lymphadenopathy, scarlatiniform rash (in children)

Each criterion is worth 1 point, and whether or not you give Abx depends on the score

If Group A strep (GAS) needs to be confirmed with certainty, arrange rapid antigen test for GAS - if negative, do throat swab and culture

Question 8

What is the Centor criteria?

Answer 8

• Tonsillar exudate
• Tender anterior cervical lymphadenopathy
• Hx of fever > 38 degree C
• No cough

Each criterion is worth 1 point, and whether or not you give Abx depends on the score

Question 9

How would you manage sore throat in primary care?

Answer 9

• If FeverPAIN score 0-1 or Centor score 0-2 –> Do NOT give Abx
• If FeverPAIN score 2-3 - consider no Abx prescription or delayed Abx prescription (if no impovement in 5 days or symptoms worsen)
• If FeverPAIN score 4-5 or Centre score 3-4 or GAS has been confirmed by rapid antigen test –> Strep throat is very likely –> Immediate Abx
  
  • 1st line - phenoxymethylpenicillin (if allergic, give clarithromycin)
  • Side effects - diarrhoea, nausea
• If systemically unwell, or has clinical features of a more serious illness, or has high risk of complications –> Immediate Abx –> hospital admission if severe systemic infection or severe complications
• Advise adequate fluid intake
• Advise the use of paracetamol and ibuprofen as antipyretic and analgesic
• Advise salt water gargling, medicated lozenges (strepsils) for pain relief
• Advise that children may return to school after their fever has resolved and they are no longer feeling unwell, or after taking Abx for at least 24 hrs
• Safety net: advise the person to seek follow-up if:
  
  • Symptoms has not improved after 3 days of Abx
  • Pain does not improve after 3 days or if fever is still > 38 degree C
  • They find it difficult to swallow saliva or liquids, or if they have difficulty breathing
• Arrange hospital admission for anyone with:
  
  • ​Epiglottitis (immediate admission)
  • Breathing difficulty
  • Dehydration
  • Peritonsillar abscess, retropharyngeal abscess
  • Sepsis
  • Kawasaki disease

Question 10

When do you refer patients to ENT?

Answer 10

• Recurrent tonsillitis (> 7 episodes per year; 5 episodes per year for 2 years; or 3 episodes per year for 3 years ) –> referral to ENT as they may need tonsillectomy
• Peritonsillar abscess (quinsy) - same day referral to ENT

Question 11

When would you admit patient to hospital?

Answer 11

• Children with suspected epiglottitis
• Breathing difficulty
• Severe dehyration
• Peritonsillar abscess, retropharyngeal abscess
• Systemically unwell or sepsis
• Kawasaki disease

Question 12

Name 2 conditions that can cause peritonsillar abscess as a complication?

Answer 12

Strep throat/ tonsillitis

Glandular fever

Question 13

What are the clinical features of peritonsillar abscess (quinsy)?

Answer 13

• SEVERE throat pain that lateralises to one side
• Uvula deviation to the unaffected side
• Trismus (lockjaw/ difficulty opening mouth)
• Reduced neck mobility
• Drooling
• Hot potato voice/ muffled voice

Question 14

What is the management for peritonsillar abscess in secondary care?

Answer 14

Needle aspiration or incision & drainage (send for culture) + IV Abx

Tonsillectomy to prevent recurrence