CPDSore Throat Module

Ref: IHL-CPD-STSM-001

OBJECTIVESBy the end of this module you will:

• Understand what a sore throat is

• Understand and explain the causes of sore throat

• Identify symptoms which may require referral

• Understand the differential diagnoses for sore throats

• Know the drug treatment and self-care options available

WHAT IS A SORE THROAT

Sore throat, also known as pharyngitis, is usually self-limiting and does not last more than 1 week. It is generally viral in nature.

A sore throat lasting more than a week should be referred for further investigation.

A sore throat presents with pain and irritation in the throat which can worsen on swallowing.

CAUSES OF A SORE THROAT

Viral Infections*

E.g. common cold, flu, chicken pox, glandular fever

Allergies E.g. Pollen, dust, moulds, pet dander

Irritants E.g. tobacco smoke, chemicals

Bacterial Infections

E.g. Streptococcus pyogenes, Group A streptococcus

Dryness E.g. Dry indoor air caused by heating

Medicines E.g. cytotoxics, carbimazole, clozapine, captopril, penicillamine, sulfasalazine

DANGER SYMPTOMS

• Inspiratory stridor (harsh, vibratory sound produced when breathing in due to partial airway obstruction)

• Fever of unknown aetiology lasting 5 days or more• Change in voice, muffled speech, “hot potato” voice

(speaking as if a hot object is being held in the mouth), stifled cries

• Dysphagia -True difficulty in swallowing (i.e. caused by mechanical blockage over pain)

• Dyspnoea (difficult breathing)• Blood in saliva (may indicate tonsillar cancer)• Visible bulge in pharynx• Ulcers in throat • Polymorphous rash

In people with a sore throat there are certain “danger symptoms” that may suggest a sinister pathology:

NOTE: Admit immediately to hospital any patient who has stridor, breathing difficulty, or dehydration. Refer urgently patients with suspected cancer of the throat.

AETIOLOGY*70 – 90% of sore throat cases are caused by viral infections. The second most common cause is bacterial infection in which testing is recommended. Acute throat infections most commonly occur in children aged 5–10 years and in young adults aged 15–25 years. Approximately 36% of patients with sore throats will visit the community pharmacy each year for treatment and advice in the UK whereas only 6% visit their GP. It is estimated that on average each adult will experience two to three episodes of a sore throat each year. Rarely an abscess or epiglottitis may cause sore throat, however while these complications are uncommon they are of particular concern because they may compromise the airway.

The swelling is of concern as it can block the windpipe, particularly in infants and children. The most common pathogen indicated in Epiglottitis occurring in children is Haemophilus influenza type B (HiB). However, with widespread paediatric vaccination it has now become rare in children but HiB is still a cause in adults and unvaccinated children.

NOTE: People with suspected epiglottitis should not have their throat examined unless there are facilities for immediate intubation because of the possibility of precipitating complete airway obstruction or cardiopulmonary arrest.

In children symptoms appear as:• Posture bent forward.• Shallow breathing without marked increase in

respiration rate.• Inspiratory stridor and hoarseness may occur

but the barking cough and aphonia that occur with croup are rare.

• The child may be reluctant to talk and/or muffled voice and cry.

In adults:• There is severe sore throat with painful swallowing.

Predictors of airway compromise include sitting erect, stridor, and dyspnea.

An abscess in the pharyngeal area is uncommon. It is typically caused by the pathogen GABHS. A mass of puss may form beneath or near one of the tonsils which is called a peritonsillar abscess. Often an abscess is caused by a streptococcal infection that has spread from the tonsils into deeper tissue. In children, an abscess can form in the tissue at the back of the throat which is called a retropharyngeal abscess.

The epiglottis is a thin flap of cartilage that closes the entrance to the voice box and windpipe during swallowing thereby protecting the glottis. Infection of the epiglottis can cause severe pain and swelling and thus sore throat is the prominent symptom.

Epiglottitis

DIFFERENTIAL DIAGNOSES

Abscess

• Cannot be diagnosed on clinical features alone• May cause mild symptoms but it can also cause severe

pharyngeal pain, painful swallowing, headache, and a high temperature.

• Abdominal pain, nausea and vomiting are common in children.

• Associated symptoms common in children: fever, nasal discharge, enlarged cervical lymph glands, and otitis media.

• A patchy grey-yellow exudate is often present on the tonsils and the uvula is often oedematous. The cervical lymph nodes are enlarged and tender.

• Rare cancer that starts in the voice box which is called the larynx.

• Hypopharyngeal cancer (includes the pyriform sinus, lateral pharyngeal wall, posterior pharyngeal wall, and post cricoid region): this may present with a unilateral, well-localized, persistent sore throat; a vague discomfort on swallowing; and referred pain to the ear; or as a neck mass due to cervical node metastases. Dysphagia is a late symptom. There may be weight loss. It is not directly visible on examination.

Streptococcal Sore Throat

Laryngeal and tonsillar carcinoma

• Oropharyngeal cancer (includes the tonsils and faucial pillars, base of the tongue, soft palate, and uvula): there may be sore throat, otalgia, and progressive dysphagia; trismus or a foreign body; or mass sensation in the throat. Many people complain of the sensation of a ‘lump at the back of the throat’. An ulcer is usually visible on examination. It often presents with a neck mass due to metastases to the cervical nodes.

MANAGEMENTRegardless of the cause of your sore throat, these self-care strategies can help you ease your symptoms:

Self-Care

• Take plenty of rest.• Drink fluids and prevent dehydration.• Avoid caffeine and alcohol.• Consume warm liquids e.g. broth,

caffeine-free tea or warm water with honey.• Gargle with salt water.• Humidify the air. Use a cool-air humidifier to eliminate

dry air that may further irritate a sore throat or sit for several minutes in a steamy bathroom.

• Avoid irritants. Keep your home free from cigarette smoke and cleaning products that can irritate the throat.

TESTING

• Flexible fibre optic laryngoscopy

• X-rays of the neck

• Rapid strep screening (paediatrics)

• Throat culture (for adults)

If symptoms are severe or if danger symptoms are present, tests may be required:

Antibiotics should not be used to secure symptomatic relief in sore throat.

Ibuprofen 400mg three times daily is recommended for relief of fever, headache and throat pain in adults with sore throat.

In adults who are intolerant to ibuprofen, paracetamol 1g four times daily when required is recommended for symptom relief.

Local analgesics are licensed for the symptomatic relief of sore throat e.g. flurbiprofen lozenges and benzydamine gargle.

Products containing Capsicum tincture, acetic acid and Quassia wood may offer symptomatic relief for sore throats.

Capsicum are used in gargles for throat irritation or infection. Quassia wood has antibacterial and antifungal properties, but has limited evidence for its effectiveness. Acetic acid is mildly antiseptic, with broad spectrum activity against streptococci, staphylococci, pseudomonas and enterococci.

DRUG TREATMENT REFERRAL

Admission is required for conditions that are immediately life-threatening e.g. epiglottitis. Non-urgent referral for tonsillectomy may be required in some cases of recurrent tonsillitis. Other symptoms and conditions may require referral and expert advice such as the following:• Pyrexia that does not resolve with use of paracetamol• Drooling• No improvement after 7 days• High risk patients e.g. HIV, AIDS, leukaemia,

aplastic anaemia• Patients with a spleen injury or disorder,

or who have undergone a splenectomy• History of sleep apnoea, daytime drowsiness,

and failure to thrive (children)• Five or more episodes per year of sore throat due to

tonsillitis. The episodes should have been disabling and have prevented normal functioning.

a. This medicinal product contains 10 vol % ethanol

b. Benzydamine use is not advisable in patients with hypersensitivity to acetylsalicylic acid or other NSAIDs

c. Bronchospasm may be precipitated in patients suffering from or with a previous history of bronchial asthma

d. Benzydamine is contraindicated in asthmatic patients

e. Should not be used by pregnant women

TEST YOURSELF

1. Which one of the following statements about benzydamine 0.15% spray for use in sore throats is FALSE?

6. What self-care measures can a patient suffering with a sore throat take?

6. List 2 causes of cough

7. List and explain the drug treatments that can be offered to patients.

9. Which tests are recommended in patients who present with a sore throat with danger symptoms?

8. Which medicines may cause a sore throat?

10. List the causes of a sore throat.

a. It can be life threateningb. It may be caused by a bacterial infection c. It may be caused by throat injuryd. Vaccination does not reduce risk

of contracting epiglottitis in childrene. Epiglottitis can occur at any age

5. Which one of the following statements about epiglottitis is FALSE?

a. Patient with five or more episodes per year of sore throat due to tonsillitis

b. Patient that has a lump that causes difficulty swallowing c. Patient that has had a sore throat for 5 daysd. Patient that presents with an earachee. Patient that presents with rash and joint pain

a. A child with a sore throat and unusual drooling indicative of inability to swallow

b. An adult with a sore throat who has difficulty opening their mouth

c. A child with a sore throat and feverd. An adult with blood in saliva or phlegme. A child with a frequently recurring sore throat

4. In which one of the following scenarios should you refer the patient to A&E?

3. Which ONE of the following patients with a sore throat does not need to be referred?

a. Chicken Pox b. Croup c. Influenzad. Mononucleosise. Strep throat

2. Which one of the following is not a viral cause of sore throat?

1. ANSWER D Benzydamine 0.15% spray should be used with caution in patients with asthma.

2. ANSWER E “Strep throat” is caused by the bacteria (not virus) Streptococcus pyogenes, also known as group A streptococcus which are highly contagious.

3. ANSWER E Generally with sore throat allow at least one week for symptoms to resolve following OTC products.

4. ANSWER A While all of the scenarios require referral and follow up with GP the paediatric case with unusual drooling is dangerous as it could obstruct the narrow airways of a child.

5. ANSWER D Routine Haemophilus influenzae type b (Hib) vaccination for infants has signigicantly reduced rates of epiglottitis so that it is now rare in children.

6. What self-care measures can a patient suffering with a sore throat take?

• Take plenty of rest.

• Drink fluids and prevent dehydration.

• Avoid caffeine and alcohol.

• Consume warm liquids e.g. broth, caffeine-free tea or warm water with honey.

• Gargle with salt water.

ANSWERS

ANSWERS

7. List and explain the drug treatments that can be offered to patients.

Antibiotics should not be used to secure symptomatic relief in sore throat.

Ibuprofen 400mg three times daily is recommended for relief of fever, headache and throat pain in adults with sore throat.

In adults who are intolerant to ibuprofen, paracetamol 1g four times daily when required is recommended for symptom relief.

Local analgesics are licensed for the symptomatic relief of sore throat e.g. flurbiprofen lozenges and benzydamine gargle. Products containing Capsicum tincture, acetic acid and Quassia wood may offer symptomatic relief for sore throats. Capsicum are used in gargles for throat irritation or infection. Quassia wood has antibacterial and antifungal properties, but has limited evidence for its effectiveness. Acetic acid is mildly antiseptic, with broad spectrum activity against streptococci, staphylococci, pseudomonas and enterococci

• Humidify the air. Use a cool-air humidifier to eliminate dry air that may further irritate a sore throat or sit for several minutes in a steamy bathroom.

• Avoid irritants. Keep your home free from cigarette smoke and cleaning products that can irritate the throat

8. Which medicines may cause a sore throat?

• cytotoxics

• carbimazole

• clozapine

• captopril

• penicillamine

• sulfasalazine

• methotrexate

9. Which medicines may cause a sore throat?

• Flexible fibre optic laryngoscopy

• X-rays of the neck

• Rapid strep screening (paediatrics)

• Throat culture (for adults)

10. Which medicines may cause a sore throat?

• Viral Infections*

• Bacterial Infections

• Allergies

• Dryness

• Irritants

• Medicines

ANSWERS

CPD

Name of Product: Sanderson’s Throat Specific Mixture. Active Ingredient(s): Each 5 ml contains: 0.025 ml of Capsicum Tincture (Capsicum annuum L. var. minimum (Miller) Heiser), corresponding to 7.5 to 12.5 micrograms capsaicinoids calculated as capsaicin. Extraction solvent: ethanol 90% v/v. 0.025 ml of extract (as liquid extract) from Squill bulb (Drimia maritima(L.) Stearn) (1:1). Extraction solvent: ethanol 65% v/v. 37.5 mg of Acetic acid. Product licence number: PL 0415/5000R. Name and address of the product licence holder: Infohealth Laboratories Limited, 28 Chipstead Valley Road, Coulsdon, Surrey. CR5 2RA. United Kingdom. Supply classification: GSL. Indications: For symptomatic relief of sore throat, hoarseness, loss of voice and catarrh, and as a preventative gargle when these symptoms begin to appear or are expected to appear. Sanderson’s Throat Specific Mixture is indicated in adults and children aged 8 years and over. Precautions: This product contains small amounts of alcohol (less than 100 mg per 5 ml dose). This product has a sharp biting taste. If symptoms worsen or persist after 7 days, a doctor should be consulted. Patients should be advised not to exceed the stated dose. If dyspnoea, fever or purulent sputum occurs, a doctor should be consulted. Contra-Indications: Hypersensitivity to the active substances or to any of the excipients listed in section 6.1 of the SmPC. Cardio-pulmonary disorders or breathing difficulties. History of alcohol abuse, liver disease or renal impairment. Raised intracranial pressure. Pregnancy & lactation: The safety of this product during pregnancy and lactation has not been established, therefore use during pregnancy and lactation is not recommended. No studies on the effects on fertility have been performed. Effects on ability to drive and use machines: No studies on the effect on the ability to drive or use machines have been performed. This product contains alcohol (see section 4.4). Dosage: Adults, the elderly and children over 8 years: Gargle with 10 ml (two 5 ml spoonfuls) in an equal amount of water hourly. Also swallow slowly one 5 ml spoonful undiluted, three times daily.If symptoms of sore throat, hoarseness, loss of voice or catarrh are expected to appear, gargle well with 10 ml (two 5 ml spoonfuls) in twice the amount of water in the morning before breakfast and last thing at night. Do not use for more than 7 consecutive days. Not recommended for children under 8 years of age. Cost: Clear glass bottles of 100ml £4.19; 200ml £5.29. Reporting of suspected adverse reactions: Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any

suspected adverse reactions via the Yellow Card Scheme at: www.mhra.gov.uk/yellowcard. Date: July 2017

Ref: IHL-CPD-STSM-001The content was Independently produced by: Nadia Bukhari BPharm, FRPharmS, FHEA, PGDip Senior teaching Fellow in Pharmacy Practice, UCL School of Pharmacy Oksana Pyzik MPharm, MRPharmS Teaching Fellow in Pharmacy Practice, UCL School of Pharmacy © Infohealth Laboratories