1. Management of Sore Throat

2. Objectives:
Enumerate causes of a case presented with the complaint of sore throat.
Identify reasons that led patients to seek help for a sore throat.
Differentiate between viral and bacterial causes of sore throat.

3. Objectives: Discuss the common symptoms and signs of sore throat.
Identify different modalities and benefits of investigations in a case of throat.
Discuss appropriate management options for a case of sore throat.

4. Objectives:
Discuss appropriate management options for the case mentioned above
Identify indications for tonsillectomy.

5. Objectives:
Use the watchful waiting strategies for use of antibiotics and referrals to tonsillectomy.
Adopt both modification of help seeking behavior and opportunistic health promotion in such cases.

6. CASE SCENARIO
Khalid is a 20-year old college student. He presents with history of lethargy for 3 days and a sore throat that started today.
- He is also having runny nose and mild red itchy eyes.
- Throat is so sore that he can hardly swallow solid food.
- He does not have any known drug allergies and takes no regular medications.

7. On examination:
Temperature is 37.8°C, and tonsillar congestion present.
- He is well hydrated. There are no other signs or symptoms.
- He is anxious about his illness as he is sitting a final 2nd year exam next week.

8. What’s Sore Throat? It’s a painful inflammation of the mucous
membranes lining the pharynx. 

9. - Acute pharyngitis, tonsillitis, or acute exudative tonsillitis may all cause sore throat. These are considered together under the term ‘sore throat’.

10. Differential diagnosis
Pharyngitis.
Tonsillitis.
Epiglottitis.
Peritonsillar abscess.
Laryngitis.
GERD.

11. Etiology
viral cause (50 to 80%), including influenza and primary herpes simplex.
Bacterial causes, most common is (GABHS). Others are
Chlamydia pneumonia, Mycoplasma pneumonia, Haemophilus influenza, Neisseria meningitides
and Neisseria gonorrhoeae (5-36%).

12. Etiology Fungal cause, including Candida.
A sore throat can also be caused
by Irritants, Allergies, Stomach acid ‘GERD’, Injuries, Muscle strain, Dryness and Tumors.

13. Why are patients seeking help for a sore throat ?
- A UK study found that only one in 18 episodes of sore throat led to a GP consultation.
- Practitioners should be aware of underlying psychosocial influences in patients presenting with sore throat.

14. Why are patients seeking help for a sore throat ?
Affecting Function.
Relieve the symptoms.
Sick leave.
Medication ”Antibiotics”.
psychosocial factors.

15. Is it Virus or Bacteria ?
The Centor scoring system may help to differentiate between GABHS and viral causes on the basis of symptoms and clinical signs by categorizing
the individual patient’s risk level for GABHS infection.

16. Is it Virus or Bacteria ? The Centor score gives one point each for:
- Tonsillar exudate
- Tender anterior cervical lymph nodes
- History of fever
- Absence of cough

17. Is it Virus or Bacteria ?
The likelihood of GABHS infection increases with increasing score.
Streptococcal infection is most likely in the 5–15 year old age group and gets progressively less likely in younger or older patients.

18. Is it Virus or Bacteria ?
The score isn’t validated for use in children under three years.
The score should be used to assist the decision on whether to prescribe an antibiotic, but cannot
be relied upon for a precise diagnosis.

19. History Personal data: History of present illness • Site • Onset
• Character • Radiation
• Associations • Time course
• Exacerbating/relieving factors
• Severity

20. Constitutional symptoms
- Fever, chills , weight and appetite changes, joint pain, stomach pain, headache , enlargement neck gland , N/V - Respiratory System Cough , SOB, chest pain , hemoptysis ,phlegm

21. History Review of systems Past medical history Surgical history
Allergy and mediation
Travel and sexual history
Social history , Family history

22. Signs and symptoms Fever and/or chills Nausea and/or vomiting
Body aches
Headache
Cough
Runny nose or nasal congestion

23. Signs and symptoms Earache Sneezing Weakness Lack of appetite
Redness and/or swelling of the
tonsils and back of the throat

24. White patchy areas on the tonsils (exudate).
Swollen and/or tender lymph nodes in the neck.
A muffled or hoarse voice.

25. Physical exam General appearance ,VS Using a lighted instrument.
Inspection , Gently feeling (palpating).
Percussion.
Listening to breathing with a stethoscope.

26. Investigations Throat swab
- The sample will be checked in a lab for streptococcal bacteria
- Results are available within 2-3 days.
Test +
Test -
bacterial infection
viral infection

27. Throat swabs should not be carried out routinely in primary care management of sore throat.
May be used to establish an etiology of recurrent severe episodes in adults when considering referral for tonsillectomy.

28. Rapid antigen testing
- Sensitivities between 59 and 95% and specificities over 90%
- Samples are taken from a throat swab and results
are available within 10 minutes.

29. Complete blood count (CBC)
radiologic imaging
Allergy tests
You may be referred to
an ENT doctor or other specialist
if …..

30. Management
- Depends on the cause !

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

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

33. Pain relief
In children, an adequate dose of paracetamol should be used as first line treatment for pain relief.
Ibuprofen can be used as an alternative to paracetamol in children.

34. Viral Between 50 to 80% of infection.
Usually lasts five to seven days and doesn't require medical treatment.
Sore throat is of viral cause, including influenza and infectious mononucleosis.

35. Bacterial Use of antibiotics in sore throat
in which GABHS has been detected.
Oral penicillin V given 6-hourly
for 10 days is widely regarded
as the gold standard treatment

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

37. Antibiotics in recurrent sore throat
The reasons may include:
inappropriate antibiotic therapy
inadequate dose
or duration of previous therapy
Antibiotic prophylaxis for recurrent sore throat is not recommended.

38. There is no evidence that bacterial sore throats are more severe than viral ones or that the duration of the illness is significantly different in either case.

39. Information leaflet Patients should manage sore throat at home.
Advise patients to contact their GP if they have the following symptoms:
- Difficulty in breathing
- Difficulty in swallowing or opening their mouth
- Persistent high temperature
- Particularly severe illness, especially with symptoms mainly on one side of one side of the throat
- Sore throat which has been worsening for several days.

40. Emergency hospital admission
1- Sore throat with stridor 2- Progressive difficulty with swallowing, 3- Increasing pain, or severe systemic symptoms. 4- Peritonsillar cellulitis or abscess (quinsy) 5- Glandular fever (infectious mononucleosis) 6- Severe uncomplicated tonsillitis associated with dysphagia and dehydration.

41. If breathing difficulty is present, urgent referral to hospital is mandatory and attempts to examine the throat should be avoid
(Acute epiglottitis)

42. Tonsillectomy
Tonsillectomy is a surgical procedure in which each tonsil is removed from a recess in the side of
the pharynx called the tonsillar fossa.

43. Tonsillectomy
Tonsillectomy can prevent recurrent acute attacks of tonsillitis but not recurrent sore throats due to other causes.
Before considering tonsillectomy the diagnosis of recurrent tonsillitis should be confirmed.

44. Tonsillectomy
Watchful waiting is more appropriate than tonsillectomy for children with mild sore throats.
Tonsillectomy is recommended for recurrent severe sore throat in adults.

45. Indications for tonsillectomy:
Sore throats are due to acute tonsillitis.
The episodes of sore throat are disabling
and prevent normal functioning.
Seven or more well documented, clinically significant, adequately treated sore throats in the preceding year .

46. Indications for tonsillectomy:
Five or more such episodes in each of the preceding two years.
Three or more such episodes in each of the preceding three years.
These Indications are in both children and adults.

47. Complications of Tonsillectomy
Tonsillectomy requires a short admission to hospital and a general anesthesia.
It is occasionally complicated by bleeding.
Return to usual activities takes on average two weeks, with a corresponding loss of time from education or work.

48. Health promotion
Educate the patient about the disease and provide an information leaflet to help managing sore throat at home.
Advice the patient to lead a healthy lifestyle.
Promote immunization in children.

49. Health promotion
Advice the patient to lose weight, Control lipid levels and blood sugar and pressure if needed.
Promote screening for breast cancer in females.
Advice smoker patients to quit smoking and educate about complications of smoking.

50. Summery
The Centor clinical prediction score is used to assist the decision on whether to prescribe an antibiotic.
Throat swabs shouldn’t be carried out routinely in primary care management of sore throat.

51. Summery
Antibiotics should not be used to secure symptomatic relief in sore throat.
Tonsillectomy is recommended for recurrent severe sore throat in adults.

52. Reference
Management of sore throat and indications for tonsillectomy: SIGN Guidelines 117.

53. Now read and answer the Questions provided?
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