Diagnosing and treating the acute sore throat

MODERN MEDICINE CPD ARTICLE NUMBER TWO: 1 point Diagnosing and treating the acute sore throat THOMAS E HAVAS, MB BS, FRACS, FRCS, FACS Acute sore th...
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MODERN MEDICINE CPD ARTICLE NUMBER TWO: 1 point

Diagnosing and treating the acute sore throat THOMAS E HAVAS, MB BS, FRACS, FRCS, FACS

Acute sore throat may present as part of a generalised viral upper respiratory tract infection, be a symptom of specific pharyngeal infection, or be part of a generalised systemic disorder. The diagnosis is mainly clinical. The doctor needs to keep clearly in mind the differential diagnoses appropriate to the age of the patient, and also an appropriate treatment regimen.

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Acute sore throat is one of the most common complaints encountered in general practice. The causes can be grouped as infection, irritation and systemic disease (Table). Of the infective causes, most are viral and the remainder are a variety of bacterial and fungal conditions, predominantly group A beta haemolytic streptococcal infection. rrhe majority of acute sore throats are due to viral illnesses. On clinical grounds it is very difficult to differentiate a viral from a bacterial infection. Nevertheless, pustular tonsillitis (aggregates of pus on the tonsils) is suggestive of bacterial infection, and diffuse mucosal hyperaemia plus or minus granular pharyngitis is usually viral in aetiology.

Clinical features The discomfort associated with a viral infection ranges from mild to extremely severe. Occasionally there may be associated odynophagia and rarely dysphagia and drooling. The virus most commonly associated with severe symptoms is Epstein-Barr virus. In patients with infectious mononucleosis (glandular fever), the tonsils and the pharynx are sometimes covered by a pseudomembranous exudate (Figure 1), the appearance of which may cause this illness to be mistaken for severe bacterial tonsillitis. In times gone by, it was confused with diphtheria. Viral pharyngitis is characterised by generalised erythema and swelling of the pharynx. Odynophagia and drooling tend not to be present, although dysphagia is Viral infections encountered occasionally. Examination of the neck may reveal bilatAt least 50% of acute sore throats are caused by viruses. They may eral upper deep cervical lymphadenopathy, and there may be genoccur during the prodrome of acute eralised signs such as hepatoviral upper respiratory tract infection or may continue while the sys- splenomegaly or lymphadenopathy in the axilla or groin. The clinical temic symptoms persist. A large number of viruses, including rhino- course is determined by the underlying virus and there may be accomvirus, Epstein-Barr virus, influenza virus, parainfluenza, adenovirus, panying systemic symptoms such as coxsackievirus and enterovirus, rigors, diffuse myalgia, vomiting and diarrhoea. have been implicated. Measles can be associated with an acute sore throat; the pharyngeal manifestation is characterised by the presence of small white spots Associate Professor Havas is a conjoint (Koplik's spots) that are about the associate professor, Otolaryngology Head size of a pinhead and surrounded by and Neck Surgery, University of New South Wales; Chairman, Department of an area of erythema. Koplik's spots may precede the onset of a typical Otolaryngology, Prince of Wales Hospital; and Consultant Otolaryngologist, Sydney morbilliform rash by four to five Children's Hospital, Randwick, Australia. days and fade as the rash appears. 1

MODERN MEDICINE OF SOUTH AFRICA / MAY 2004

A membranous pharyngitis may also occur in measles. With chickenpox, acute sore throat may occur in association with superficial vesicles or pustules within the oral cavity. There may be some ulceration with the vesicles, and there is always surrounding erythema and inflammation. Herpes simplex lesions of the pharynx usually give rise to small vesicles that rupture and form shallow painful ulcers. The episode is self-limiting and of short duration. Herpes zoster does not commonly affect the pharynx; however, if the virus is distributed in the ninth or tenth cranial nerve, the patient may present with a sore throat. The vesicles usually appear unilaterally and are extremely painful. Treatment: symptomatic relief The treatment of viral causes of sore throat is directed mainly at controlling the symptoms. For viral infections, hydration and temperature control, with paracetamol, aspirin (avoid in children) or ibuprofen, are indicated. If the sore throat is extreme, locally-acting antiseptic and/or analgesic preparations are sometimes helpful. In my experience, the most useful commercially available preparations are antiinflammatory gargles such as beraydamine hydrochloride.

Bacterial infections Tonsillitis The second most common cause of acute sore throat is bacterial tonsillitis. The most commonly identified causative agent is group A beta haemolytic streptococcus (Streptococcus pyogenes) that is isolated in roughly 30% of all cases of acute bacterial tonsillitis — in the remaining 70%, the agent is never firmly established. Other streptococci, Staphylococcus aureus and Haemo-

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FEVER AND PAIN IN CHILDREN

Believe it or not, fever is actually beneficial. It is the body's way of responding to a variety of potentially harmful conditions. Fever stimulates the body's own immune cells to locate and destroy invading organisms or cells. 1 What is a 'normal' temperature? 2 A normal body temperature is 37°C. A temperature of 37.7°C or higher is classified as fever. How should I take my child's temperature? 1 There are many ways to measure a child's temperature, but not all of them are accurate or easy. Oral and armpit temperatures underestimate the core temperature by approximately 0.5°C. Glass mercury thermometers carry the hazard of breaking and spilling toxic mercury. Armpit temperatures need a reading time of 7 minutes, which greatly decreases the convenience of this method. Rectal temperatures are the most accurate but cause great apprehension for parents and children. Insertion of the thermometer also carries the risk of perforation of the rectum. Tympanic infrared thermometers are now widely available and provide a very accurate temperature reading within seconds, without causing too much distress.

• All children younger than 3 months • If the child is weak or not responsive to his or her environment • If the child has difficulty breathing • A rash together with fever • A fever greater than 39.5°C • If the fever persists longer than 24 hours despite treatmer • If other signs and symptoms like headache, vomiting an stiff neck accompany the fever How do I treat fever?4-5 A medical professional should urgently evaluate babie younger than 3 months with a temperature greater tha 38.5°C. Children older than 3 months of age who have fev< and are uncomfortable but do not have signs of significar illness should be observed and treated with appropriat medicine to break the fever. Tepid sponging helps to reduce fever in children. Give yoi child plenty to drink to prevent dehydration. Rest is vital fc the body to recover. Keep the room cool and dress y o i child in light cotton pajamas so that body heat can escapi If your child feels cold, put on an extra blanket but remov it when the chills stop.

What are the causes of fever? 2 • Common infections: Children can suffer from many different types of infections, including colds and flu, sore throats, tonsillitis, earache, runny tummy, bronchitis and bladder infections. • Serious infections: Occasionally, more serious infections like pneumonia, appendicitis and meningitis can cause fever. • Medicine: Certain medications can cause fever including antibiotics and antihistamines. • Chronic illness: Chronic conditions can cause ongoing fevers in children, such as different types of cancers and joint disorders, e.g. rheumatoid arthritis. • Overdressing: Lastly, fever can occur in infants who are simply overdressed in hot weather or a hot environment.

GilAdcock Ingram

When should I get medical help? 3 It is natural to be worried about your child when he or she has a fever. You should get professional medical help, however, in the following situations:

References: 1. Pray WS Controversies Surrounding Fever. US Pharmacist 1998;23(5). 2 M s t o l Encycloptrfir FIM* U.S. Ntabunal Library of Medicine and the National Institutes of Health. Ccntom v-rfted on 15/12/2003 It liliir/-wwnlmr.ihjrv'me-Ji^us/erKv/artWc/')03090.htrn. 3. Medial Fr*yfcf*tfo fwer and children U.S. Material Ubrary of Medicine and II eNauonal Institutes of H Content rfriwd on 15.'t#2O03 Jthtllj://wwwr&fi.ruji.cyWmr^nepWencvMrlxie/Q'Jl980.htm. 4. PetenervSniUl A. TKN«l Asessmert d UTTJHIE .vtd Emergent ppdutrw Problems. ?5lh National Primary N i l * Pimflwitf Symposium lontentretifcaim ISfiafJOOiathttp^Awivirnjclgapejyr^iewari^'^l 5. tr? Children. M w t Your Child Has Jtrever. AmerxjiiAcadeirTyo(fjT^P1ty>dan;. Ctnteru wtrfsetJ 1 SI I M M i at hlto//vvvwtfatrilvdoctor.ora/Ol».xml.

Aspirin is not recommended for the treatment of fever i children because of the risk of Reye's Syndrome (liver damage Paracetamol is commonly used to relieve pain and feve The dose is calculated according to the child's age and weigh

Don't forget that fever is often accompanied by pain. Yoi child may have a sore throat or sore ear in addition to th fever. Ask your doctor or pharmacist about the red, yelloi and green formulations from Adcock Ingram for the treatmer of pain and fever in children of different age: Brought to you by Adcock Ingram.

Diagnosing and treating the acute sore throat

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The second most common cause of acute sore throat is bacterial tonsillitis.

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continued

is often accompanied by a sense of fullness in the throat and severe dysphagia, with pain radiating into the ears and, occasionally, anorexia. The voice may have a plummy quality. There are pains in the neck and there may be limitation of neck movement due to the upper deep cervical lymphadenopathy. The patient may complain of headaches and systemic such as general symptoms Figure 1. Inflamed tonsils covered with exudates in infectious mononucleosis. malaise and rigors due to fever. On examination, there may be circumoral pallor. philus influenzae, have been shown The tongue is furred and dry, and to be causative agents in acute ton- the breath fetid. The tonsils are sillitis, as have a variety of anaero- swollen and red and often spotted with purulent exudates from the bic bacteria. The bacteriology of acute tonsil- crypts (Figure 2) or, in severe cases, with a purulent litis is complicated by the fact that covered most, if not all, of the bacteria pseudomembrane. There is an acute thought to cause sore throat are har- stasis of viscid mucus due to the boured on the tonsillar surface of patient's reluctance to swallow. asymptomatic individuals without In the parenchymatous form of causing any clinical signs of infectonsillitis there is a livid swelling of tion. the tonsils accompanied by oedema As with all mucous membranes, of the uvula and soft palate. It is the tonsillar surface is covered by important to note that odynophagia severe enough to prevent patients stratified squamous epithelium interspersed with occasional ciliated from swallowing their own saliva cells. Overlying this epithelial sur- usually indicates a complication of face is afilm of mucus that is contin- acute bacterial tonsillitis, the most ually propelled forward by the common being quinsy (peritonsillar action of the cilia. To cause invasive abscess). disease, micro-organisms must In the differential diagnosis of attach firmly to the epithelial cells severe acute bacterial tonsillitis it is and avoid being transported away important to consider infectious with the mucus film. Once attached, mononucleosis. Early in the course the micro-organisms can proliferate, of this disease a Paul Bunnell forming colonies and releasing heterophile antibody titre may be extra-cellular toxins that can then negative and the blood film may not injure the underlying cells. In bacte- show the definitive characteristics of rial tonsillitis the progression from this infection (that is, a total colonisation to invasion appears to lymphocytosis with atypical cells). be related to alterations in the com- Therefore, consider requesting position of the mucosal film and in Epstein-Barr virus serology. the effectiveness of mucociliary Vincent's angina is essentially a action. sub-acute tonsillitis with ulceration; Acute bacterial tonsillitis is pre- it represents spread of acute necrotising ulcerative gingivitis to the dominantly a disease of childhood that reaches peak incidence in the oropharynx. It is uncommon and, fifth and sixth years of life. It compared with acute tonsillitis, it is of slower onset and usually accomoccurs relatively infrequently in panied by less soreness in the throat adolescents and adults. It may occur as a primary infection, origi- and less fever. A sloppy membrane nating in the tonsils, or as a sec- forms, usually in the ulcer, either on ondary infection associated with a the tonsils or elsewhere in the oral cavity. Vincent's organisms (a viral upper respiratory tract infecfusiform bacillus and a spirochaete) tion. The typical primary tonsillitis due may be cultured from direct throat swabs. to haemolytic streptococcal infection 0

MODERN MEDICINE OF SOUTH AFRICA / MAY 2004

Other bacterial infections Diphtheria is now rare and is unlikely to be confused with tonsillitis because it is a systemic disease with a circulating exotoxin. However, if anything, it is usually confused with acute membranous tonsillitis. It is important to remember that diphtheria is slow in onset and, at first, is accompanied by less constitutional disturbance and less local discomfort. The membrane of diphtheria, that may extend beyond the surface of the tonsil and onto the palate, is dirty grey. It is adherent and its removal causes bleeding. This is the characteristic difference between a true membrane and a pseudomembrane, as may be seen in infectious mononucleosis or bacterial tonsillitis. Gonococcal pharyngitis cannot be distinguished from other infections on clinical grounds alone; if the history suggests the possibility of gonococcal pharyngitis, swabs should be taken and appropriate cultures performed. (Secondary syphilis may also cause an acute sore throat.) Atypical bacteria such as

Mycoplasma pneumoniae may be associated with acute sore throat. Often the sore throat is part of a systemic disorder, the main part of the symptom complex being due to pneumonitis or pneumonia. Treatment

To swab or not to swab?

The routine use of throat swabs or bacteriology is not recommended because, in the absence of a pure growth or at least a heavy, nearpure growth, interpretation is very difficult. The oral cavity and the pharynx are always heavily colonised with a variety of bacteria, and if a mixed growth is obtained on swabs (as is often the case) it will provide no diagnostic information. If a viral infection follows an atypical course - in that the patient develops signs consistent with bacterial infection - a throat swab may be considered. Again, it is only of clinical use if a pure or a heavy nearpure growth is obtained from the swab.

When is an antibiotic indicated?

Tliroat infections, whether bacterial or viral, are usually self-limiting, and the risks and benefits of antibiotic therapy should be discussed

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