Sore throat resident survival guide: Difference between revisions

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{{SK}} An approach to sore throat in adults, Sore throat approach in adults, Approach to pharyngitis in adults, Pharyngitis in adults
{{SK}} An approach to sore throat in adults, Sore throat approach in adults, Approach to pharyngitis in adults, Pharyngitis in adults
==Overview==
==Overview==
[[Sore throat]], also called as [[pharyngitis]], is a painful sensation in the back part of the throat due to [[inflammation]] of the [[pharynx]]. It is one of the most common complaints among [[Patient|patients]] visiting their [[primary care physician|primary care physicians]]. In the United States, approximately 12 million [[ambulatory care]] visits are due to [[Pharyngitis|sore throat]] annually. It mostly occurs in children and adolescents. The most common etiology is acute self- limiting [[Virus|viral]] infection. [[Group A streptococcal infection]] is the most common causative bacteria for [[Pharyngitis|acute pharyngitis]] in adults. As a physician, it is important to identify clinical signs for life-threatening [[airway obstruction]] and deep tissue infection and treat them promptly. This section provides a short and straight to the point overview of the [[Pharyngitis|sore throat]] in adults.
[[Sore throat]], also called as [[pharyngitis]], is a [[painful]] sensation in the back part of the throat due to [[inflammation]] of the [[pharynx]]. It is one of the most frequent complaints among [[Patient|patients]] visiting their [[primary care physician|primary care physicians]]. In the United States, approximately 12 million [[ambulatory care]] visits are due to [[Pharyngitis|sore throat]] annually. The majority of cases occur in children and adolescents. The etiology is acute self- limiting [[Virus|viral]] infection in the majority of individuals. [[Group A streptococcal infection]] is the usual causative [[bacteria]] for [[Pharyngitis|acute pharyngitis]] in adults. As a physician, it is important to identify clinical [[signs]] for life-threatening [[airway obstruction]] and deep tissue [[infection]] and treat them promptly. This section provides a short and straight to the point overview of the [[Pharyngitis|sore throat]] in adults.


==Causes==
==Causes==
===Life Threatening Causes===
Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated.
* [[Croup]]
* Acute [[epiglottitis]]


{| class="wikitable"
|+Differentiating [[croup]] and [[epiglottitis]]<ref name="pmid21091577">{{cite journal| author=Tibballs J, Watson T| title=Symptoms and signs differentiating croup and epiglottitis. | journal=J Paediatr Child Health | year= 2011 | volume= 47 | issue= 3 | pages= 77-82 | pmid=21091577 | doi=10.1111/j.1440-1754.2010.01892.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21091577  }}</ref><ref name="pmid11464324">{{cite journal| author=Stroud RH, Friedman NR| title=An update on inflammatory disorders of the pediatric airway: epiglottitis, croup, and tracheitis. | journal=Am J Otolaryngol | year= 2001 | volume= 22 | issue= 4 | pages= 268-75 | pmid=11464324 | doi=10.1053/ajot.2001.24825 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11464324  }}</ref>
!
![[Croup]]
![[Epiglottitis]]
|-
|Clinical features
|Acute [[stridor]] with [[coughing]] and lack of [[drooling]]
|Acute [[stridor]] with [[drooling]] and lack of [[coughing]]
|-
|Course
|Slow-developing airway obstruction - rare severe obstruction
|Rapidly courses with complete airway obstruction and [[shock]]
|-
|Imaging
|Steeple sign in an anterior-posterior [[neck]] [[x-ray]]
|Thumb sign in a lateral [[neck]] [[x-ray]]
|-
|Additional clinical features
(less reliable for diagnostic)
|Sore throat
*Barking cough
|Sore throat
*Sitting position
*Refusal of food or drink
*Inability to swallow
*[[Vomiting]]
|-
|Treatment
|[[Nebulization]] of [[racemic]] [[epinephrine]]:
*Preferred regimen: 0.5 mL of a 2.25% [[racemic]] [[epinephrine]] solution diluted in 3 mL of normal [[saline]]
| *Invasive airway management (oral [[intubation]] or [[tracheotomy]])
*[[Antibiotics]]
*[[Intensive care unit]]
|}


===Common Causes===
===Common Causes===
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* Group C and G Streptococcus infection<ref name="pmid23091044">{{cite journal| author=Shulman ST, Bisno AL, Clegg HW, Gerber MA, Kaplan EL, Lee G | display-authors=etal| title=Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. | journal=Clin Infect Dis | year= 2012 | volume= 55 | issue= 10 | pages= 1279-82 | pmid=23091044 | doi=10.1093/cid/cis847 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23091044  }} </ref>
* Group C and G Streptococcus infection<ref name="pmid23091044">{{cite journal| author=Shulman ST, Bisno AL, Clegg HW, Gerber MA, Kaplan EL, Lee G | display-authors=etal| title=Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. | journal=Clin Infect Dis | year= 2012 | volume= 55 | issue= 10 | pages= 1279-82 | pmid=23091044 | doi=10.1093/cid/cis847 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23091044  }} </ref>
* Arcanobacterium haemolyticum<ref name="pmid23091044">{{cite journal| author=Shulman ST, Bisno AL, Clegg HW, Gerber MA, Kaplan EL, Lee G | display-authors=etal| title=Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. | journal=Clin Infect Dis | year= 2012 | volume= 55 | issue= 10 | pages= 1279-82 | pmid=23091044 | doi=10.1093/cid/cis847 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23091044  }} </ref>
* Arcanobacterium haemolyticum<ref name="pmid23091044">{{cite journal| author=Shulman ST, Bisno AL, Clegg HW, Gerber MA, Kaplan EL, Lee G | display-authors=etal| title=Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. | journal=Clin Infect Dis | year= 2012 | volume= 55 | issue= 10 | pages= 1279-82 | pmid=23091044 | doi=10.1093/cid/cis847 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23091044  }} </ref>
*[[Fusobacterium necrophorum]]<ref name="pmid25686164">{{cite journal| author=Centor RM, Atkinson TP, Ratliff AE, Xiao L, Crabb DM, Estrada CA | display-authors=etal| title=The clinical presentation of Fusobacterium-positive and streptococcal-positive pharyngitis in a university health clinic: a cross-sectional study. | journal=Ann Intern Med | year= 2015 | volume= 162 | issue= 4 | pages= 241-7 | pmid=25686164 | doi=10.7326/M14-1305 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25686164  }} </ref>
*[[Fusobacterium necrophorum]] - which causes the [[Lemierre's syndrome]]<ref name="pmid25686164">{{cite journal| author=Centor RM, Atkinson TP, Ratliff AE, Xiao L, Crabb DM, Estrada CA | display-authors=etal| title=The clinical presentation of Fusobacterium-positive and streptococcal-positive pharyngitis in a university health clinic: a cross-sectional study. | journal=Ann Intern Med | year= 2015 | volume= 162 | issue= 4 | pages= 241-7 | pmid=25686164 | doi=10.7326/M14-1305 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25686164  }} </ref>
*[[Mycoplasma]] and [[Chlamydia (bacterium)|Chlamydia]] species<ref name="pmid2494921">{{cite journal| author=Huovinen P, Lahtonen R, Ziegler T, Meurman O, Hakkarainen K, Miettinen A | display-authors=etal| title=Pharyngitis in adults: the presence and coexistence of viruses and bacterial organisms. | journal=Ann Intern Med | year= 1989 | volume= 110 | issue= 8 | pages= 612-6 | pmid=2494921 | doi=10.7326/0003-4819-110-8-612 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2494921  }} </ref>
*[[Mycoplasma]] and [[Chlamydia (bacterium)|Chlamydia]] species<ref name="pmid2494921">{{cite journal| author=Huovinen P, Lahtonen R, Ziegler T, Meurman O, Hakkarainen K, Miettinen A | display-authors=etal| title=Pharyngitis in adults: the presence and coexistence of viruses and bacterial organisms. | journal=Ann Intern Med | year= 1989 | volume= 110 | issue= 8 | pages= 612-6 | pmid=2494921 | doi=10.7326/0003-4819-110-8-612 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2494921  }} </ref>
*[[Corynebacterium diphtheriae]]
*[[Corynebacterium diphtheriae]]
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Shown below is an algorithm summarizing the diagnosis of [[sore throat]] in adults<ref name="pmid11255529">{{cite journal| author=Snow V, Mottur-Pilson C, Cooper RJ, Hoffman JR, American Academy of Family Physicians. American College of Physicians-American Society of Internal Medicine | display-authors=etal| title=Principles of appropriate antibiotic use for acute pharyngitis in adults. | journal=Ann Intern Med | year= 2001 | volume= 134 | issue= 6 | pages= 506-8 | pmid=11255529 | doi=10.7326/0003-4819-134-6-200103200-00018 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11255529  }} </ref><ref name="pmid22566485">{{cite journal| author=Fine AM, Nizet V, Mandl KD| title=Large-scale validation of the Centor and McIsaac scores to predict group A streptococcal pharyngitis. | journal=Arch Intern Med | year= 2012 | volume= 172 | issue= 11 | pages= 847-52 | pmid=22566485 | doi=10.1001/archinternmed.2012.950 | pmc=3627733 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22566485  }} </ref><ref name="pmid10678338">{{cite journal| author=Webb KH, Needham CA, Kurtz SR| title=Use of a high-sensitivity rapid strep test without culture confirmation of negative results: 2 years' experience. | journal=J Fam Pract | year= 2000 | volume= 49 | issue= 1 | pages= 34-8 | pmid=10678338 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10678338  }}  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=10923583 Review in: J Fam Pract. 2000 Jul;49(7):660] </ref>:
Shown below is an algorithm summarizing the diagnosis of [[sore throat]] in adults<ref name="pmid11255529">{{cite journal| author=Snow V, Mottur-Pilson C, Cooper RJ, Hoffman JR, American Academy of Family Physicians. American College of Physicians-American Society of Internal Medicine | display-authors=etal| title=Principles of appropriate antibiotic use for acute pharyngitis in adults. | journal=Ann Intern Med | year= 2001 | volume= 134 | issue= 6 | pages= 506-8 | pmid=11255529 | doi=10.7326/0003-4819-134-6-200103200-00018 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11255529  }} </ref><ref name="pmid22566485">{{cite journal| author=Fine AM, Nizet V, Mandl KD| title=Large-scale validation of the Centor and McIsaac scores to predict group A streptococcal pharyngitis. | journal=Arch Intern Med | year= 2012 | volume= 172 | issue= 11 | pages= 847-52 | pmid=22566485 | doi=10.1001/archinternmed.2012.950 | pmc=3627733 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22566485  }} </ref><ref name="pmid10678338">{{cite journal| author=Webb KH, Needham CA, Kurtz SR| title=Use of a high-sensitivity rapid strep test without culture confirmation of negative results: 2 years' experience. | journal=J Fam Pract | year= 2000 | volume= 49 | issue= 1 | pages= 34-8 | pmid=10678338 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10678338  }}  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=10923583 Review in: J Fam Pract. 2000 Jul;49(7):660] </ref>:
{{Family tree/start}}
{{Family tree/start}}
{{familytree | | | | | | | | A01 |A01=<div style="float: left; text-align: left; height: 28em; width: 19em; padding:1em;"> Are there alarming clinical signs for upper airway obstruction or deep neck infection present?
{{familytree | | | | | | | | A01 |A01=<div style="float: left; text-align: left; height: 28em; width: 19em; padding:1em;"> Are there alarming clinical [[signs]] for upper airway obstruction or deep neck [[infection]] present?
* “Hot potato” voice
* “Hot potato” voice
* [[Drooling]]
* [[Drooling]]
Line 97: Line 54:
* Respiratory distress
* Respiratory distress
* “Tripod position”
* “Tripod position”
* [[Fever]] and chills
* [[Fever]] and [[chills]]
* Severe unilateral [[sore throat]]
* Severe unilateral [[sore throat]]
* Bulging of the pharyngeal wall or soft palate
* Bulging of the [[pharyngeal]] wall or [[soft palate]]
* History of penetrating trauma to the neck
* History of penetrating trauma to the [[neck]]
* [[Trismus|Lockjaw]]
* [[Trismus|Lockjaw]]
* [[Crepitus]]
* [[Crepitus]]
Line 107: Line 64:
{{familytree | | | B01 | | | | | | | | B02 | | |B01= Yes| B02= No}}
{{familytree | | | B01 | | | | | | | | B02 | | |B01= Yes| B02= No}}
{{familytree | | | |!| | | | | | | | | |!| }}
{{familytree | | | |!| | | | | | | | | |!| }}
{{familytree | | | C01 | | | | | | | | |C02| |C01= <div style="float: left; text-align: left;"> Stabilize ABC and refer patient urgently to emergency or inpatient care unit.<br>Consider the following differential diagnosis: <br>* [[Croup]]<br>* Acute [[epiglottitis]]|C02= <div style="float: left; text-align: left;"> Are clinical signs for viral upper respiratory infection (including [[conjunctivitis]], [[coryza]], [[cough]], [[exanthem|viral exanthem]] and voice hoarseness) present?}}
{{familytree | | | C01 | | | | | | | | |C02| |C01= <div style="float: left; text-align: left;"> Stabilize ABC and refer [[patient]] urgently to emergency or inpatient care unit.<br>Consider the following differential diagnosis: <br>* [[Croup]]<br>* Acute [[epiglottitis]]|C02= <div style="float: left; text-align: left;"> Are clinical [[signs]] for [[viral upper respiratory infection]] (including [[conjunctivitis]], [[coryza]], [[cough]], [[exanthem|viral exanthem]] and voice [[hoarseness]]) present?}}
{{familytree | | | | | | | | | | | |,|-|^|.| | }}
{{familytree | | | | | | | | | | | |,|-|^|.| | }}
{{familytree | | | | | | | | | | | D01 | | D02|D01= Yes| D02= No }}
{{familytree | | | | | | | | | | | D01 | | D02|D01= Yes| D02= No }}
{{familytree | | | | | | | | | | | |!| | |!| | }}
{{familytree | | | | | | | | | | | |!| | |!| | }}
{{familytree | | | | | | | | | | | E01 | | E02|E01= Manage patient with supportive care.| E02=<div style="float: left; text-align: left; height: 19em; width: 19em; padding:1em;">Does patient have clinical features of GAS throat infection?
{{familytree | | | | | | | | | | | E01 | | E02|E01= Manage [[patient]] with supportive care.| E02=<div style="float: left; text-align: left; height: 19em; width: 19em; padding:1em;">Does patient have clinical features of GAS throat [[infection]]?
* [[Fever]] (temperature ≥100.4 degrees F)
* [[Fever]] (temperature ≥100.4 degrees F)
* Acute onset of [[sore throat]]
* Acute onset of [[sore throat]]
* Inflammation and edema of tonsillopharyngeal and uvular mucosa
* [[Inflammation]] and edema of tonsillopharyngeal and [[uvular]] [[mucosa]]
* Tonsillar and peritonsillar yellow or white exudates
* [[Tonsillar]] and peritonsillar yellow or white exudates
* Painful cervical [[lymphadenopathy]]
* Painful cervical [[lymphadenopathy]]
* Scarlatiniform rash
* Scarlatiniform rash
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{{familytree | | | | | | | | | | |F01| | | | F02 | | | | F03 |F01= Yes| F02= Uncertain| F03= No}}
{{familytree | | | | | | | | | | |F01| | | | F02 | | | | F03 |F01= Yes| F02= Uncertain| F03= No}}
{{familytree | | | | | | | | | | |!| | | | | |!| | | | | |!| }}
{{familytree | | | | | | | | | | |!| | | | | |!| | | | | |!| }}
{{familytree | | | | | | | | | | |!| | | | |G02| | | | |!|G02= Apply [[Centor criteria]] for patient's clinical signs and symptoms. Is score ≥3? }}
{{familytree | | | | | | | | | | |!| | | | |G02| | | | |!|G02= Apply [[Centor criteria]] for patient's clinical [[signs]] and [[symptoms]]. Is score ≥3? }}
{{familytree | | | | | | | | | | |!| | |,|-|^|-|.| | | | |!| }}
{{familytree | | | | | | | | | | |!| | |,|-|^|-|.| | | | |!| }}
{{familytree | | | | | | | | | | |!| | |H01| |H02| | |!| | |H01= Yes|H02= No }}
{{familytree | | | | | | | | | | |!| | |H01| |H02| | |!| | |H01= Yes|H02= No }}
{{familytree | | | | | | | | | | |!| | | |!| | |!| | | | |!| }}
{{familytree | | | | | | | | | | |!| | | |!| | |!| | | | |!| }}
{{familytree | | | | | | | | | | |!| | | |!| | |!| | | | |!| | }}
{{familytree | | | | | | | | | | |!| | | |!| | |!| | | | |!| | }}
{{familytree | | | | | | | | | | |I01|-|'| | |`|-|-|-|-| I02 | I01= Perform [[Rapid antigen detection test]] (RADT)| I02= Consider other viral, bacterial or noninfectious causes of [[sore throat]]. The illness is mostly self-limiting and specific tests for diagnosis are not carried out. }}
{{familytree | | | | | | | | | | |I01|-|'| | |`|-|-|-|-| I02 | I01= Perform [[Rapid antigen detection test]] (RADT)| I02= Consider other [[viral]], [[bacterial]] or noninfectious [[causes]] of [[sore throat]]. The illness is mostly self-limiting and specific tests for diagnosis are not carried out. }}
{{familytree | | | | | | | |,|-|-|^|-|-|-|.| | | | }}
{{familytree | | | | | | | |,|-|-|^|-|-|-|.| | | | }}
{{familytree | | | | | | | |J01| | | | |J02| | |J01= Positive|J02= Negative }}
{{familytree | | | | | | | |J01| | | | |J02| | |J01= Positive|J02= Negative }}
{{familytree | | | | | | | |!| | | | | | |!| | | | }}  
{{familytree | | | | | | | |!| | | | | | |!| | | | }}  
{{familytree | | | | | | | H01 | | | | | H02 | | |H01= GAS [[pharyngitis]] confirmed - start antibiotics |H02= <div style="float: left; text-align: left; height: 25em; width: 19em; padding:1em;">Perform [[throat culture]] in patients with any of the following risk factors:
{{familytree | | | | | | | H01 | | | | | H02 | | |H01= GAS [[pharyngitis]] confirmed - start [[antibiotics]] |H02= <div style="float: left; text-align: left; height: 25em; width: 19em; padding:1em;">Perform [[throat culture]] in patients with any of the following risk factors:
* Patient with weak immune system or history of complications of GAS infection i.e. [[rheumatic fever|acute rheumatic fever]].  
* [[Patient]] with weak immune system or history of complications of GAS infection i.e. [[rheumatic fever|acute rheumatic fever]].  
* Patients in close contact with individuals who have a high risk of complications (i.e. infants and immunocompromised elderly population)
* [[Patients]] in close contact with individuals who have a high risk of [[complications]] (i.e. infants and immunocompromised elderly population)
* Young adults living in close proximity (i.e. college dormitories)
* Young adults living in close proximity (i.e. college dormitories)
* Patients residing in endemic areas of [[rheumatic fever|acute rheumatic fever]]
* [[Patients]] residing in endemic areas of [[rheumatic fever|acute rheumatic fever]]
* Patient with negative RADT but with [[Centor criteria]] scores ≥3 }}
* [[Patient]] with negative RADT but with [[Centor criteria]] scores ≥3 }}
{{Family tree/end}}
{{Family tree/end}}


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Shown below is an algorithm summarizing the treatment of sore throat in adults according to the Infectious Diseases Society of America guidelines<ref name="pmid23091044">{{cite journal| author=Shulman ST, Bisno AL, Clegg HW, Gerber MA, Kaplan EL, Lee G | display-authors=etal| title=Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. | journal=Clin Infect Dis | year= 2012 | volume= 55 | issue= 10 | pages= 1279-82 | pmid=23091044 | doi=10.1093/cid/cis847 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23091044  }} </ref><ref name="pmid26785402">{{cite journal| author=Harris AM, Hicks LA, Qaseem A, High Value Care Task Force of the American College of Physicians and for the Centers for Disease Control and Prevention| title=Appropriate Antibiotic Use for Acute Respiratory Tract Infection in Adults: Advice for High-Value Care From the American College of Physicians and the Centers for Disease Control and Prevention. | journal=Ann Intern Med | year= 2016 | volume= 164 | issue= 6 | pages= 425-34 | pmid=26785402 | doi=10.7326/M15-1840 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26785402  }} </ref>:
Shown below is an algorithm summarizing the treatment of sore throat in adults according to the Infectious Diseases Society of America guidelines<ref name="pmid23091044">{{cite journal| author=Shulman ST, Bisno AL, Clegg HW, Gerber MA, Kaplan EL, Lee G | display-authors=etal| title=Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. | journal=Clin Infect Dis | year= 2012 | volume= 55 | issue= 10 | pages= 1279-82 | pmid=23091044 | doi=10.1093/cid/cis847 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23091044  }} </ref><ref name="pmid26785402">{{cite journal| author=Harris AM, Hicks LA, Qaseem A, High Value Care Task Force of the American College of Physicians and for the Centers for Disease Control and Prevention| title=Appropriate Antibiotic Use for Acute Respiratory Tract Infection in Adults: Advice for High-Value Care From the American College of Physicians and the Centers for Disease Control and Prevention. | journal=Ann Intern Med | year= 2016 | volume= 164 | issue= 6 | pages= 425-34 | pmid=26785402 | doi=10.7326/M15-1840 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26785402  }} </ref>:
{{Family tree/start}}
{{Family tree/start}}
{{familytree | | | | | | | | A01 |A01=Does patient have strong clinical suspicion for viral URTI?}}  
{{familytree | | | | | | | | A01 |A01=Does [[patient]] have strong clinical suspicion for [[viral]] URTI?}}  
{{familytree | | | | |,|-|-|-|^|-|-|-|-|.| | | }}
{{familytree | | | | |,|-|-|-|^|-|-|-|-|.| | | }}
{{familytree | | | B01 | | | | | | | | B02 | | |B01=No|B02=Yes}}
{{familytree | | | B01 | | | | | | | | B02 | | |B01=No|B02=Yes}}
{{familytree | | | |!| | | | | | | | | |!| }}
{{familytree | | | |!| | | | | | | | | |!| }}
{{familytree | | | C01 | | | | | | | | |C02| |C01=Is patient having clinical picture suggestive of GAS [[acute pharyngitis|pharyngitis]] along with positive RADT?|C02=Manage patient with supportive care including analgesics, hot fluids, lozenges, and soft diet.}}
{{familytree | | | C01 | | | | | | | | |C02| |C01=Is [[patient]] having [[symptoms]] suggestive of GAS [[acute pharyngitis|pharyngitis]] along with positive RADT?|C02=Manage patient with supportive care including [[analgesics]], hot fluids, [[lozenges]], and soft diet.}}
{{familytree | |,|-|^|.| | | | | | | | | | }}
{{familytree | |,|-|^|.| | | | | | | | | | }}
{{familytree |D01 | | D02 | | | | | | |D01=Yes|D02=No }}
{{familytree |D01 | | D02 | | | | | | |D01=Yes|D02=No }}
{{familytree | |!| | |!| | | | | | | | }}
{{familytree | |!| | |!| | | | | | | | }}
{{familytree |E01| |E02| | | | | | |E01=<div style="float: left; text-align: left; height: 16em; width: 19em; padding:1em;">Treat patients with empirical antibiotic course for 10 days
{{familytree |E01| |E02| | | | | | |E01= <div style="float: left; text-align: left;">
* The drug of choice is 500mg oral [[penicillin]] V two or three times a day.
 
* Benzathin G [[penicillin]] intramuscular injection can be administered as a single dose.
Treat [[patients]] with empirical [[antibiotic]]:
* [[Cephalosporin|Cephalosporins]] or [[Macrolide|Macrolides]] should be given to patients experiencing allergic reactions with [[penicillin]]. |E02=<div style="float: left; text-align: left; height: 16em; width: 25em; padding:1em;"> Provide supportive care to the patients.  
* Preferred regimen (1):  adults: [[penicillin]] V 500mg q12h PO for 10 days; children: [[penicillin]] V 250mg q12h or q8h PO for 10 days;
* If the patients have risk factors suggestive of other causes (i.e. acute [[HIV infection]], [[gonorrhea]], or non-infectious causes), perform relevant investigations. }}
* Preferred regimen (2): [[amoxicillin]] 50mg/kg (max: 1gr) qd PO or 25/mg (max: 500mg) bid;
* Preferred regimen (2): Benzathine G [[penicillin]] 1.2mi UI single-dose IM;
 
If patients are allergic to [[penicillin]]:
* Alternative regimen (1): [[Cephalexin]] 20 mg/kg/dose (max: 500mg) bid PO for 10 days
* Alternative regimen (2): [[Cefadroxil]] 30 mg/kg (max: 1gr) qd PO for 10 days
* Alternative regimen (3): [[Clindamycin]] 7 mg/kg/dose (max: 500mg) tid PO for 10 days
* Alternative regimen (4): [[Azythromycin]] 12 mg/kg (max: 500mg) qd PO for 10 days
* Alternative regimen (5): [[Clarithromycin]] 7.5 mg/kg/dose (max: 250mg) bid PO for 10 days|E02= <div style="float: left; text-align: left;">
 
Provide supportive care to the [[patients]].  
* If the [[patients]] have [[risk factors]] suggestive of other [[causes]] (i.e. acute [[HIV infection]], [[gonorrhea]], or non-infectious causes), perform relevant investigations.
}}
{{Family tree/end}}
{{Family tree/end}}


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==Don'ts==
==Don'ts==
* The oral [[glucocorticoid|glucocorticoids]] should not be prescribed to patients as their adverse effects outweigh their benefits as an oral [[analgesics]]<ref name="pmid23091044">{{cite journal| author=Shulman ST, Bisno AL, Clegg HW, Gerber MA, Kaplan EL, Lee G | display-authors=etal| title=Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. | journal=Clin Infect Dis | year= 2012 | volume= 55 | issue= 10 | pages= 1279-82 | pmid=23091044 | doi=10.1093/cid/cis847 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23091044  }} </ref>. [[Glucocorticoids]] should only be considered in [[Patient|patients]] with significant [[odynophagia]] and [[dysphagia]].
* The oral [[glucocorticoid|glucocorticoids]] should not be prescribed to patients as their adverse effects outweigh their benefits as an oral [[analgesics]]<ref name="pmid23091044">{{cite journal| author=Shulman ST, Bisno AL, Clegg HW, Gerber MA, Kaplan EL, Lee G | display-authors=etal| title=Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. | journal=Clin Infect Dis | year= 2012 | volume= 55 | issue= 10 | pages= 1279-82 | pmid=23091044 | doi=10.1093/cid/cis847 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23091044  }} </ref>.
* [[Glucocorticoids]] should only be considered in [[Patient|patients]] with significant [[odynophagia]] and [[dysphagia]].


==References==
==References==
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[[Category:Resident survival guide]]
[[Category:Resident survival guide]]
[[Category:Up-To-Date]]
[[Category:Primary care]]

Latest revision as of 14:39, 25 September 2020

Sore throat Resident Survival Guide Microchapters
Overview
Causes
Diagnosis
Treatment
Do's
Don'ts


Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mydah Sajid, MD[2]

Synonyms and keywords: An approach to sore throat in adults, Sore throat approach in adults, Approach to pharyngitis in adults, Pharyngitis in adults

Overview

Sore throat, also called as pharyngitis, is a painful sensation in the back part of the throat due to inflammation of the pharynx. It is one of the most frequent complaints among patients visiting their primary care physicians. In the United States, approximately 12 million ambulatory care visits are due to sore throat annually. The majority of cases occur in children and adolescents. The etiology is acute self- limiting viral infection in the majority of individuals. Group A streptococcal infection is the usual causative bacteria for acute pharyngitis in adults. As a physician, it is important to identify clinical signs for life-threatening airway obstruction and deep tissue infection and treat them promptly. This section provides a short and straight to the point overview of the sore throat in adults.

Causes

Common Causes

Diagnosis

Shown below is an algorithm summarizing the diagnosis of sore throat in adults[10][11][12]:

 
 
 
 
 
 
 
Are there alarming clinical signs for upper airway obstruction or deep neck infection present?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Stabilize ABC and refer patient urgently to emergency or inpatient care unit.
Consider the following differential diagnosis:
* Croup
* Acute epiglottitis
 
 
 
 
 
 
 
 
Are clinical signs for viral upper respiratory infection (including conjunctivitis, coryza, cough, viral exanthem and voice hoarseness) present?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Manage patient with supportive care.
 
Does patient have clinical features of GAS throat infection?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
Uncertain
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Apply Centor criteria for patient's clinical signs and symptoms. Is score ≥3?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Perform Rapid antigen detection test (RADT)
 
 
 
 
 
 
 
 
 
 
 
Consider other viral, bacterial or noninfectious causes of sore throat. The illness is mostly self-limiting and specific tests for diagnosis are not carried out.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Positive
 
 
 
 
Negative
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
GAS pharyngitis confirmed - start antibiotics
 
 
 
 
Perform throat culture in patients with any of the following risk factors:
 
 

Treatment

Shown below is an algorithm summarizing the treatment of sore throat in adults according to the Infectious Diseases Society of America guidelines[5][13]:

 
 
 
 
 
 
 
Does patient have strong clinical suspicion for viral URTI?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Is patient having symptoms suggestive of GAS pharyngitis along with positive RADT?
 
 
 
 
 
 
 
 
Manage patient with supportive care including analgesics, hot fluids, lozenges, and soft diet.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Treat patients with empirical antibiotic:

  • Preferred regimen (1): adults: penicillin V 500mg q12h PO for 10 days; children: penicillin V 250mg q12h or q8h PO for 10 days;
  • Preferred regimen (2): amoxicillin 50mg/kg (max: 1gr) qd PO or 25/mg (max: 500mg) bid;
  • Preferred regimen (2): Benzathine G penicillin 1.2mi UI single-dose IM;

If patients are allergic to penicillin:

  • Alternative regimen (1): Cephalexin 20 mg/kg/dose (max: 500mg) bid PO for 10 days
  • Alternative regimen (2): Cefadroxil 30 mg/kg (max: 1gr) qd PO for 10 days
  • Alternative regimen (3): Clindamycin 7 mg/kg/dose (max: 500mg) tid PO for 10 days
  • Alternative regimen (4): Azythromycin 12 mg/kg (max: 500mg) qd PO for 10 days
  • Alternative regimen (5): Clarithromycin 7.5 mg/kg/dose (max: 250mg) bid PO for 10 days
 

Provide supportive care to the patients.

 
 
 
 
 
 

Do's

Don'ts

References

  1. 1.0 1.1 Huovinen P, Lahtonen R, Ziegler T, Meurman O, Hakkarainen K, Miettinen A; et al. (1989). "Pharyngitis in adults: the presence and coexistence of viruses and bacterial organisms". Ann Intern Med. 110 (8): 612–6. doi:10.7326/0003-4819-110-8-612. PMID 2494921.
  2. Bisno AL (2001). "Acute pharyngitis". N Engl J Med. 344 (3): 205–11. doi:10.1056/NEJM200101183440308. PMID 11172144.
  3. Arons MM, Hatfield KM, Reddy SC, Kimball A, James A, Jacobs JR; et al. (2020). "Presymptomatic SARS-CoV-2 Infections and Transmission in a Skilled Nursing Facility". N Engl J Med. 382 (22): 2081–2090. doi:10.1056/NEJMoa2008457. PMC 7200056 Check |pmc= value (help). PMID 32329971 Check |pmid= value (help).
  4. Llor C, Madurell J, Balagué-Corbella M, Gómez M, Cots JM (2011). "Impact on antibiotic prescription of rapid antigen detection testing in acute pharyngitis in adults: a randomised clinical trial". Br J Gen Pract. 61 (586): e244–51. doi:10.3399/bjgp11X572436. PMC 3080229. PMID 21619748.
  5. 5.0 5.1 5.2 5.3 5.4 Shulman ST, Bisno AL, Clegg HW, Gerber MA, Kaplan EL, Lee G; et al. (2012). "Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America". Clin Infect Dis. 55 (10): 1279–82. doi:10.1093/cid/cis847. PMID 23091044.
  6. Centor RM, Atkinson TP, Ratliff AE, Xiao L, Crabb DM, Estrada CA; et al. (2015). "The clinical presentation of Fusobacterium-positive and streptococcal-positive pharyngitis in a university health clinic: a cross-sectional study". Ann Intern Med. 162 (4): 241–7. doi:10.7326/M14-1305. PMID 25686164.
  7. Tindall B, Barker S, Donovan B, Barnes T, Roberts J, Kronenberg C; et al. (1988). "Characterization of the acute clinical illness associated with human immunodeficiency virus infection". Arch Intern Med. 148 (4): 945–9. PMID 3258508.
  8. McMillan JA, Weiner LB, Higgins AM, Lamparella VJ (1993). "Pharyngitis associated with herpes simplex virus in college students". Pediatr Infect Dis J. 12 (4): 280–4. doi:10.1097/00006454-199304000-00004. PMID 8387178.
  9. 9.0 9.1 Renner B, Mueller CA, Shephard A (2012). "Environmental and non-infectious factors in the aetiology of pharyngitis (sore throat)". Inflamm Res. 61 (10): 1041–52. doi:10.1007/s00011-012-0540-9. PMC 3439613. PMID 22890476.
  10. Snow V, Mottur-Pilson C, Cooper RJ, Hoffman JR, American Academy of Family Physicians. American College of Physicians-American Society of Internal Medicine; et al. (2001). "Principles of appropriate antibiotic use for acute pharyngitis in adults". Ann Intern Med. 134 (6): 506–8. doi:10.7326/0003-4819-134-6-200103200-00018. PMID 11255529.
  11. Fine AM, Nizet V, Mandl KD (2012). "Large-scale validation of the Centor and McIsaac scores to predict group A streptococcal pharyngitis". Arch Intern Med. 172 (11): 847–52. doi:10.1001/archinternmed.2012.950. PMC 3627733. PMID 22566485.
  12. Webb KH, Needham CA, Kurtz SR (2000). "Use of a high-sensitivity rapid strep test without culture confirmation of negative results: 2 years' experience". J Fam Pract. 49 (1): 34–8. PMID 10678338. Review in: J Fam Pract. 2000 Jul;49(7):660
  13. Harris AM, Hicks LA, Qaseem A, High Value Care Task Force of the American College of Physicians and for the Centers for Disease Control and Prevention (2016). "Appropriate Antibiotic Use for Acute Respiratory Tract Infection in Adults: Advice for High-Value Care From the American College of Physicians and the Centers for Disease Control and Prevention". Ann Intern Med. 164 (6): 425–34. doi:10.7326/M15-1840. PMID 26785402.
  14. Little P, Gould C, Williamson I, Warner G, Gantley M, Kinmonth AL (1997). "Reattendance and complications in a randomized trial of prescribing strategies for sore throat: the medicalizing effect of prescribing antibiotics". BMJ. 315 (7104): 350–2. doi:10.1136/bmj.315.7104.350. PMC 2127265. PMID 9270458.
  15. BRINK WR, RAMMELKAMP CH, DENNY FW, WANNAMAKER LW (1951). "Effect in penicillin and aureomycin on the natural course of streptococcal tonsillitis and pharyngitis". Am J Med. 10 (3): 300–8. doi:10.1016/0002-9343(51)90274-4. PMID 14819035.
  16. Lala I, Leech P, Montgomery L, Bhagat K (2000). "Use of a simple pain model to evaluate analgesic activity of ibuprofen versus paracetamol". East Afr Med J. 77 (9): 504–7. doi:10.4314/eamj.v77i9.46696. PMID 12862143.
  17. Tibballs J, Watson T (2011). "Symptoms and signs differentiating croup and epiglottitis". J Paediatr Child Health. 47 (3): 77–82. doi:10.1111/j.1440-1754.2010.01892.x. PMID 21091577.