Sore throat

Most people with a sore throat do not consult the doctor – only about
5% do so and many will consult their pharmacist. Most sore throats
that present in the pharmacy will be caused by viral infection (90%),
with only one in ten being due to bacterial infection, so that treatment
with antibiotics is unnecessary in most cases. Clinically it is almost
impossible to differentiate between the two. The majority of infections
are self-limiting. Sore throats are often associated with other symptoms
of a cold.
Once the pharmacist has excluded more serious conditions, an
appropriate OTC medicine can be recommended.
What you need to know
Age (approximate)
Baby, child, adult
Duration
Severity
Associated symptoms
Cold, congested nose, cough
Difficulty in swallowing
Hoarseness
Fever
Previous history
Smoking habit
Present medication
Significance of questions and answers
Age
Establishing who the patient is will influence the choice of treatment
and whether referral is necessary. Streptococcal (bacterial) throat
infections are more likely in children of school age.
Duration
Most sore throats are self-limiting and will be better within 7–10 days.
If it has been present for longer, then the patient should be referred to
the doctor for further advice.
SORE THROAT 41
Severity
If the sore throat is described as being extremely painful, especially in
the absence of cold, cough and catarrhal symptoms, then referral
should be recommended when there is no improvement within
24–48 h.
Associated symptoms
Cold, catarrh and cough may be associated with a sore throat. There
may also be a fever and general aches and pains. These are in keeping
with a minor self-limiting viral infection.
Hoarseness of longer than 3 weeks’ duration and difficulty in
swallowing (dysphagia) are both indications for referral.
Previous history
Recurrent bouts of infection (tonsillitis) would mean that referral is
best.
Smoking habit (see also ‘Smoking cessation’)
Smoking will exacerbate a sore throat and if the patient smokes it can
be a good time to offer advice and information about quitting. Surveys
indicate that two-thirds of people who smoke want to stop.
Present medication
The pharmacist should establish whether any medication has been
tried already to treat the symptoms. If one or more medicines have
been tried without improvement, then referral to the doctor should
be considered.
Current prescriptions are important and the pharmacist should
question the patient carefully about them. Steroid inhalers (e.g. beclometasone
(beclomethasone) or budesonide) can cause hoarseness and
candidal infections of the throat and mouth. Generally they tend to do
this at high doses. Such infections can be prevented by rinsing the
mouth with water after using the inhaler. It is also worthwhile
checking the patient’s inhaler technique. Poor technique with
metered-dose inhalers can lead to large amounts of the inhaled drug
being deposited at the back of the throat. If you suspect this is the
problem, discuss with the doctor whether a device that will help
coordination or perhaps a different inhaler might be needed.
Any patient taking carbimazole and presenting with a sore throat
should be referred immediately. A rare side-effect of carbimazole is
agranulocytosis (suppression of white cell production in the bone
marrow). The same principle applies to any drug that can cause
42 RESPIRATORY PROBLEMS
agranulocytosis. A sore throat in such patients can be the first sign of a
life-threatening infection.
Symptoms for direct referral
Hoarseness
Hoarseness is caused when there is inflammation of the vocal cords in
the larynx (laryngitis). Laryngitis is typically caused by a self-limiting
viral infection. It is usually associated with a sore throat and a hoarse,
diminished voice. Antibiotics are of no value and symptomatic advice
(see ‘Management’ below), which includes resting the voice, should be
given. The infection usually settles within a few days and referral is
not necessary.
When this infection occurs in babies, infants or small children, it
can cause croup (acute laryngotracheitis) and present difficulty in
breathing and stridor (see p. 31). In this situation referral is essential.
When hoarseness persists for more than 3 weeks, especially when
it is not associated with an acute infection, referral is necessary. There
are many causes of persistent hoarseness, some of which are serious.
For example, laryngeal cancer can present in this way and hoarseness
may be the only early symptom. A doctor will normally refer
the patient to a ear, nose and throat (ENT) specialist for accurate
diagnosis.
Dysphagia
Difficulty in swallowing can occur in severe throat infection. It can
happen when an abscess develops in the region of the tonsils (quinsy)
as a complication of tonsillitis. This will usually result in a hospital
admission where an operation to drain the abscess may be necessary
and high-dose parenteral antibiotics may be given.
Glandular fever (infectious mononucleosis) is one viral cause of sore
throat that often produces marked discomfort and may cause dysphagia.
If this is suspected, referral is necessary for an accurate diagnosis.
Most bad sore throats will cause discomfort on swallowing but not
true difficulty and do not necessarily need referral unless there are
other reasons for concern. Dysphagia, when not associated with a sore
throat, always needs referral (see p. 73).
Appearance of throat
It is commonly thought that the presence of white spots, exudates
or pus on the tonsils is an indication for referral or a means of
differentiating between viral and bacterial infection, but this is not
always so. Unfortunately the appearance can be the same in both types
SORE THROAT 43
of infection and sometimes the throat can appear almost normal
without exudates in a streptococcal (bacterial) infection.
Thrush
An exception not to be forgotten is candidal (thrush) infection that
produces white plaques. However, these are rarely confined to the
throat alone and are most commonly seen in babies or the very elderly.
It is an unusual infection in young adults and may be associated with
more serious disorders that interfere with the body’s immune system,
e.g. leukaemia, HIV and acquired immune deficiency syndrome
(AIDS), or with immunosuppressive therapy (e.g. steroids). The
plaques may be seen in the throat and on the gums and tongue.
When they are scraped off, the surface is raw and inflamed. Referral
is advised if thrush is suspected and the throat is sore and painful. See
p. 304 for more information about oral thrush.
Glandular fever
Glandular fever is a viral throat infection caused by the Epstein–Barr
virus (EBV). It is well known because of its tendency to leave its victims
debilitated for some months afterwards and its association with the
controversial condition myalgic encephalomyelitis (ME). The infection
typically occurs in teenagers and young adults, with peak incidence
between the ages of 14 and 21. It is known as the ‘kissing disease’!
A severe sore throat may follow 1 or 2 weeks of general malaise. The
throat may become very inflamed with creamy exudates present. There
may be difficulty in swallowing because of the painful throat. Glands
(lymph nodes) in the neck and axillae (armpits) may be enlarged and
tender. The diagnosis can be confirmed with a blood test, although this
may not become positive until 1 week after the onset of the illness.
Antibiotics are of no value; in fact if ampicillin is given during the
infection, a measles-type rash is likely to develop in 80% of those with
glandular fever. Treatment is aimed at symptomatic relief.
When to refer
Sore throat lasting 1 week or more
Recurrent bouts of infection
Hoarseness of more than 3 weeks’ duration
Difficulty in swallowing (dysphagia)
Failed medication
44 RESPIRATORY PROBLEMS
Treatment timescale
Patients should see their doctor in 1 week if the sore throat has not
improved.
Management
Most sore throats are caused by viral infections and are self-limiting
in nature with 90% of patients becoming well within 1 week of the
onset of symptoms. The pharmacist can offer a selection of treatments
aimed at providing some relief from discomfort and pain until
the infection subsides. Oral analgesics are first-line. A systematic
review found that simple analgesics (paracetamol, aspirin and
ibuprofen) are very effective at reducing the pain from sore
throat. Lozenges and pastilles have a soothing effect. There is some
evidence that benzydamine spray is effective in relieving sore throat
pain.
Oral analgesics
Paracetamol, aspirin and ibuprofen have been shown in clinical trials
to provide rapid and effective relief of pain in sore throat. A systematic
review showed no benefit of adding other analgesic constituents. The
patient can be advised to take the analgesic regularly to sustain pain
relief. (For a discussion of doses, side-effects, cautions and contraindications
for simple analgesics, see p. 201.) Flurbiprofen lozenges were
reclassified from POM to P for sore throat for adults and children
aged 12 and over. They contain 8.75 mg of flurbiprofen and one
lozenge is sucked or dissolved in the mouth every 3–6 h as required,
to a maximum of five lozenges. Flurbiprofen lozenges can be used for
up to 3 days at a time.
Mouthwashes and sprays
Anti-inflammatory (e.g. benzydamine)
Benzydamine is an anti-inflammatory agent that is absorbed through
the skin and mucosa and has been shown to be effective in reducing
pain and inflammation in conditions of the mouth and throat. Sideeffects
have occasionally been reported and include numbness and
stinging of the mouth and throat. Benzydamine spray can be used in
children of 6 years and over, whereas the mouthwash may only be
recommended for children over 12.
SORE THROAT 45
Local anaesthetic (e.g. benzocaine)
Benzocaine and lidocaine are available in throat sprays.
Lozenges and pastilles
Lozenges and pastilles can be divided into three categories:
antiseptic (e.g. cetylpyridinium)
antifungal (e.g. dequalinium)
local anaesthetic (e.g. benzocaine).
Lozenges and pastilles are commonly used OTC treatments for sore
throats and, where viral infection is the cause, the main use of antibacterial
and antifungal preparations is to soothe and moisten the
throat. Lozenges containing cetylpyridinium chloride have been
shown to have antibacterial action.
Local anaesthetic lozenges will numb the tongue and throat and can
help to ease soreness and pain. Benzocaine can cause sensitisation and
such reactions have sometimes been reported.
Caution. Iodised throat lozenges should be avoided in pregnancy
because they have the potential to affect the thyroid gland of the fetus.
Practical points
Diabetes
Mouthwashes and gargles are suitable and can be recommended.
Sugar-free pastilles are available but the sugar content of such products
is not considered important in short-term use.
Mouthwashes and gargles
Patients should be reminded that mouthwashes and gargles should not
be swallowed. The potential toxicity of OTC products of this type is
low and it is unlikely that problems would result from swallowing
small amounts. However, there is a small risk of systemic toxicity from
swallowing products containing iodine. Manufacturers’ recommendations
about whether to use the mouthwash diluted or undiluted should
be checked and appropriate advice given to the patient.
Sore throats in practice
Case 1
A woman asks your advice about her son’s very sore throat. He is 15
years old and is at home in bed. She says he has a temperature and that
she can see creamy white matter at the back of his throat. He seems
lethargic and hasn’t been eating very well because his throat has been
so painful. The sore throat started about 5 days ago and he has been in
bed since yesterday. The glands on his neck are swollen.
46 RESPIRATORY PROBLEMS
The pharmacist’s view
It would be best for this woman’s son to be seen by the doctor. The
symptoms appear to be severe and he is ill enough to be in bed.
Glandular fever is common in this age group and is a possibility. In
the meantime you might consider recommending some paracetamol in
soluble or syrup form to make it easier to swallow. The analgesic and
antipyretic effects would both be useful in this case.
The doctor’s view
The pharmacist is sensible in recommending referral. The description
suggests a severe tonsillitis, which will be caused by either a bacterial or
viral infection. If it turns out to be viral, then glandular fever is a strong
possibility. The doctor should check out the ideas, concerns and expectations
of the mother and son and then explain the likely causes and
treatment. Often it is not possible to rule out a bacterial (streptococcal)
infection at this stage and it is safest to prescribe oral penicillin, or
erythromycin if the patient is allergic to penicillin. Depending on the
availability of laboratory services, the doctor may take a throat swab,
which would identify a bacterial infection. If the infection has gone on
for nearly 1 week, then a blood test can identify infectious mononucleosis
(glandular fever). Although there is no specific treatment for
glandular fever, it is helpful for the patient to know what is going on
and when to expect full recovery.
Case 2
A teenage girl comes into your shop with her mother. The girl has a
sore throat which started yesterday. There is slight reddening of the
throat. Her mother tells you she had a slight temperature during the
night. She also has a blocked nose and has been feeling general aching.
She has no difficulty in swallowing and is not taking any medicines,
either prescribed or OTC.
The pharmacist’s view
It sounds as though this girl has a minor URTI. The symptoms
described should remit within a few days. In the meantime, it would
be reasonable to recommend a systemic analgesic, perhaps in combination
with a decongestant.
The doctor’s view
The pharmacist’s assessment sounds correct. Because she has a
blocked nose, a viral infection is most likely. Many patients attend
their doctor with similar symptoms understandably hoping for a quick
cure with antibiotics, which have no place in such infections.
SORE THROAT 47
Case 3
A middle-aged woman comes to ask your advice about her husband’s
bad throat. He has had a hoarse gruff voice for about 1 month and has
tried various lozenges and pastilles without success. He has been a
heavy smoker (at least a pack a day) for over 20 years and works as
a bus driver.
The pharmacist’s view
This woman should be advised that her husband should see his doctor.
The symptoms that have been described are not those of a minor
throat infection. On the basis of the long duration of the problem
and of the unsuccessful use of several OTC treatments, it would be
best for this man to see his doctor for further investigation.
The doctor’s view
A persistent alteration in voice, with hoarseness, is an indication for
referral to an ENT specialist. This man should have his vocal cords
examined, which requires skill and special equipment that most family
doctors do not have. It is possible he may have a canceron his vocal
cords (larynx), especially as he is a smoker.