Saidala 24: Throat (sore)

Introduction

A sore throat, medically termed pharyngitis, refers to pain, irritation, or scratchiness in the throat that often worsens when swallowing. It is one of the most frequent reasons for doctor visits and antibiotic prescriptions worldwide. A sore throat may be a symptom of viral or bacterial infection, irritation, or systemic illness. While most cases are benign and self-limiting, some can be serious, particularly those caused by Group A Streptococcus (GAS) or infections that spread to surrounding tissues.

The professional evaluation of sore throat involves identifying the underlying cause, ruling out life-threatening conditions (such as epiglottitis), and providing appropriate treatment—whether symptomatic care, antimicrobials, or other interventions.

Common Causes of Sore Throat

1. Viral Infections (Most Common – 70–90%)

Rhinovirus, coronavirus, adenovirus → common cold with sore throat.
Influenza virus → fever, myalgia, sore throat.
Epstein-Barr virus (EBV) → infectious mononucleosis, prolonged severe sore throat with lymphadenopathy.
Coxsackievirus → herpangina, painful ulcers in children.
Symptoms: gradual onset, cough, rhinorrhea, conjunctivitis, hoarseness, mild fever.
Usually self-limiting.

2. Bacterial Infections

Group A Streptococcus (GAS) – main bacterial cause.
- Sudden onset sore throat, fever, tonsillar exudates, tender cervical lymph nodes.
- Absence of cough.
- Can lead to rheumatic fever, scarlet fever, glomerulonephritis if untreated.
Other bacteria: Mycoplasma pneumoniae, Chlamydia pneumoniae, Neisseria gonorrhoeae, Corynebacterium diphtheriae (rare but severe).

3. Non-Infectious Causes

Allergies – postnasal drip causing throat irritation.
Gastroesophageal reflux disease (GERD) – stomach acid irritates throat.
Dry air or irritants (smoke, pollutants).
Overuse of voice – shouting, singing.

4. Serious but Less Common Causes

Peritonsillar abscess – severe unilateral sore throat, trismus, “hot potato” voice.
Epiglottitis (usually Haemophilus influenzae type b in children, but rare now due to vaccination) – rapid onset sore throat, drooling, stridor, life-threatening airway obstruction.
Tumors – chronic sore throat with weight loss, hoarseness, risk factors such as smoking.

Clinical Presentation

Pain or scratchiness in the throat.
Pain on swallowing (odynophagia).
Redness of the throat or tonsils.
Swollen lymph nodes in the neck.
Fever, headache, malaise (bacterial).
Cough, runny nose, hoarseness (viral).

Diagnostic Evaluation

Clinical Assessment

Centor Criteria (for predicting GAS):
- Fever > 38 °C (+1)
- Absence of cough (+1)
- Tender anterior cervical lymphadenopathy (+1)
- Tonsillar exudates (+1)
- Age 3–14 years (+1), 15–44 years (0), ≥45 years (–1)
- Score 0–1: unlikely GAS, supportive care.
- Score 2–3: test with throat swab.
- Score 4–5: likely GAS, consider antibiotics.

Laboratory/Imaging

Rapid antigen detection test (RADT): quick test for GAS.
Throat culture: gold standard but takes 24–48 hours.
Blood tests: monospot test for EBV.
Imaging: neck X-ray or CT if abscess suspected.

Treatment

1. General Symptomatic Measures

Rest and adequate hydration.
Warm saline gargles.
Lozenges and throat sprays for pain relief.
Humidified air to soothe throat.
Avoid smoking and irritants.

2. Pharmacological Management

Analgesics and Antipyretics

Paracetamol (acetaminophen): 500–1000 mg every 6 hours as needed (max 4 g/day).
Ibuprofen: 200–400 mg every 6–8 hours as needed (max 1200 mg/day OTC, up to 2400 mg/day under medical supervision).

Local Anesthetics

Lidocaine 2% spray or lozenge: applied to throat up to 3–4 times daily.
Benzocaine lozenges: as needed.

3. Antibiotics (for confirmed or strongly suspected bacterial pharyngitis)

First-Line for GAS

Penicillin V: 500 mg orally every 8–12 hours for 10 days.
Amoxicillin: 500 mg orally every 8 hours or 875 mg twice daily for 10 days.

Alternative for Penicillin Allergy

Azithromycin: 500 mg on day 1, then 250 mg daily for 4 days.
Clarithromycin: 250 mg orally twice daily for 10 days.
Clindamycin: 300 mg orally every 8 hours for 10 days.

4. Special Conditions

Infectious Mononucleosis (EBV)

No role for antibiotics (unless secondary infection).
Symptomatic management with analgesics.
Corticosteroids (prednisone 40–60 mg daily for 5–7 days) in severe tonsillar swelling threatening airway.

Peritonsillar Abscess

Needle aspiration or incision and drainage.
IV antibiotics:
- Ampicillin-sulbactam 3 g every 6 hours.
- If allergic: Clindamycin IV 600–900 mg every 8 hours.

Epiglottitis

Airway management is priority (intubation if needed).
IV ceftriaxone 2 g daily for 7–10 days.
Hospitalization mandatory.

Pediatric Considerations

Children with GAS: Amoxicillin is often preferred for palatability.
Avoid aspirin (risk of Reye’s syndrome).
Viral sore throat: supportive treatment only.

Prognosis

Viral sore throat: resolves in 5–7 days with symptomatic care.
Streptococcal pharyngitis: resolves in a few days with antibiotics; treatment prevents complications.
Chronic or recurrent sore throat: may require ENT evaluation.

Red Flags (Require Urgent Referral)

Difficulty breathing or stridor.
Drooling and inability to swallow (possible epiglottitis).
Severe unilateral throat pain with trismus (possible abscess).
Persistent sore throat beyond 3 weeks.
Weight loss, night sweats, hemoptysis (possible malignancy).

Summary of Key Treatments with Doses

Paracetamol: 500–1000 mg every 6 hours (max 4 g/day).
Ibuprofen: 200–400 mg every 6–8 hours (max 2400 mg/day).
Penicillin V: 500 mg PO every 8–12 hours × 10 days.
Amoxicillin: 500 mg PO every 8 hours or 875 mg PO BID × 10 days.
Azithromycin: 500 mg day 1, then 250 mg daily × 4 days.
Clarithromycin: 250 mg PO BID × 10 days.
Clindamycin: 300 mg PO every 8 hours × 10 days.
Prednisone: 40–60 mg PO daily × 5–7 days (severe mononucleosis).
Ceftriaxone (epiglottitis): 2 g IV daily × 7–10 days.
Ampicillin-sulbactam (abscess): 3 g IV every 6 hours.

Saidala 24

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Sunday, August 17, 2025

Throat (sore)