Sore Throat

Pharyngitis is the term doctors use to describe sore throat and it accounts for 10-15 percent of all pediatric office visits. Group A beta-hemolytic streptococcal pharyngitis (GABHS), more commonly known as strep throat, is a primary concern of a person with a sore throat. GABHS is more common in children than adults. In both kids and adults viruses are the most common cause of sore throat.

The most important concern in the person with a sore throat is to rule out some serious conditions associated with sore throat, including, most commonly GABHS. Certain factors will help predict if the cause of the sore throat is GABHS or a viral infection. The factors are not perfect and the use of a throat culture is needed in many cases in order to rule out strep throat.

Important factors to know about strep include:

• It most commonly affects children between 5-15 years old.
• It does not commonly affect children under three years old.
• It has an incubation period of 2-5 days. This means that if you have been in contact with someone who is infected and are infected your disease may not show up for 2-5 days.
• Respiratory secretions spread the infection.

Causes of sore throat

Viruses cause the majority of sore throats. Bacteria cause 5-15% of sore throats, but those between the ages of 5-15 have a higher incidence of bacterial causes of sore throat. In this group, 15-30 percent of sore throats may be caused by GABHS.

Certain factors can help determine if the sore throat is caused by a bacteria or a virus. Viruses that cause sore throat are more commonly accompanied by cough, stuffy nose, red eyes and fatigue.

Possible diagnoses

• Viral sore throat - there are over 200 viruses that cause the common cold and each presentation may be a little different. Many of these viruses are linked to sore throat. Below some specific viruses that cause sore throat will be discussed.
• Hand-foot and mouth disease. This is caused by a virus that is called the Cocsackie virus. It causes blisters on the hands and feet as well as in the mouth or throat.
• Infectious mononucleosis can also cause sore throat. This sore throat is typically severe and associated with pus (white patches) in the throat. This disease is associated with swollen lymph nodes - particularly the glands on the back of the neck. It sometimes comes with stomach pain due to an enlarged liver or spleen. Those who are treated with penicillin will usually develop a rash (90% of the time). It is most common in those who are 10-25 years old and is accompanied by fatigue and a lingering sore throat.
• HIV is a rare cause of sore throat. Individuals who have risk factors for HIV (multiple sexual partners, men who have sex with men, intravenous drug users) who present with a sore throat should have this diagnosis considered.
• Bacterial sore throat. The most common cause of bacterial sore throat is GABHS. Other bacteria can sometimes cause sore throat.
• Fungal infections rarely cause sore throats. Candida infections are a common cause of fungal sore throat. The individual will have a sore throat with a white coat on the tongue and in the oral cavity that looks like cottage cheese. The white coating will bleed if it is scraped off.
• Diphtheria is a rare cause of sore throat. It presents with a sore throat, fever, tender lymph nodes in the front on the neck and serosanguineous nasal discharge. It can be prevented by routine vaccinations.
• Kawasaki disease rarely occurs but affects children under five and presents with sore throat, tender lymph nodes, fever, eye discharge, red oral mucosa, strawberry tongue, cracked red lips, swelling of the hands and feet and red rash on the hands and feet, followed by peeling of the palms.
• Peritonsillar abscess is a serious cause of sore throat and presents with fever, feeling wiped out, a hot potato voice, difficulty swallowing, painful swallowing, ear pain and difficulty opening the mouth.
• Miscellaneous causes of sore throat include: persistent cough, smoking, gastroesophageal reflux, postnasal drip secondary to runny nose, allergies, foreign body and thyroiditis (inflamed thyroid gland).

Complications

Most sore throats are caused by a virus and go away on their own. It is important that all health care consumers are aware of when sore throats can be serious and when they are likely self-limiting.

Death is a risk of life, but it is rarely related to sore throat. Throat abscess (pus filled infection in the throat) may lead to breathing problems as the swelling in the throat reduces the ability to breath. Diphtheria can lead to respiratory failure. Untreated GABHS can affect the heart valves and has the potential to lead to heart failure.

These serious complications are rare. Rheumatic fever is one of the most common preventable complication of sore throat. It occurs after GABHS goes untreated. The general population is not as greatly affected, as people commonly believe. In fact it takes treating 3000 to 4000 people with antibiotics with strep throat to prevent one case of rheumatic fever. The incidence of rheumatic fever is about one case per one million people. Treatment with antibiotics do not guarantee prevention of rheumatic fever.

Rheumatic fever occurs about 3 weeks after an untreated GABHS infection. It is characterized by joint pain and swelling, erythema marginatum (pink rings on the trunk, arms and legs), heart murmur or subcutaneous nodules (painless, firm nodes over the bones or tendons often seen on the wrist, elbow or knees). If this is suspected an immediate evaluation with a health care provider is essential.

Peritonsillar abscess (pus behind the tonsils) can cause sore throat or can be a complication of GABHS. It is not common but is characterized by worsening sore throat, ear pain, inability to open the mouth, fever, and a hot potato voice.

A rash that feels rough, like sandpaper, is red and fades when you push in on it is likely scarlet fever. This rash will last about a week and will result in peeling of the skin. This is a common manifestation of streptococcal infection

Streptococcal infections have the potential to attack the kidneys. It may present 10-14 days after a strep throat. It is characterized by bloody urine and swelling (especially around the eyes). It is unclear if treating with antibiotics reduces the risk of kidney problems after strep throat.

Red Flags

• High fever
• Unable to handle secretions - drooling
• Difficult time opening the mouth
• Hot potato voice (muffled voice, sounds like you have a mouthful of hot potatoes)
• Uvula (piece of tissue that hangs down in the back of the throat) deviating to one side
• One swollen tonsil
• Difficultly breathing

Diagnosing strep throat

Key features of the history and the physical exam will help the health care provider determine the likelihood of streptococcal infection. There are a few key features that are most predictive of strep throat.

Recent exposure to streptococcus and white patches in the throat or on the tonsils are the two most important factors in predicting strep throat. Tonsils that are free from swelling or pus and non-tender lymph nodes in the neck are the best criteria for ruling out strep throati.

Clinical prediction rules have been developed for helping the health care provider determine who has strep and who does not. None of these rules are perfect, and it usually requires the work of a throat culture to definitively determine who has strep throat. None-the less, these key features can be useful in helping patients determining their risk for strep throat.

The prediction rule has been based off of five key criteria.

1. Fever above 100.4 degrees Fahrenheit
2. Swelling of the tonsils or pus on the tonsils
3. Sore throat in the absence of cough
4. Tender lymph nodes in the front of the neck
5. Age - One point is given if the age is between 3 and 14, and one point is taken away if over the age of 45.

Based on the number of criteria that are present one can take a guess as to how likely GABHS is. The person is given a score of -1 to 5 and utilizing that point total one can predict the likelihood of strep throat.

For example, if we look at the case study presented in chapter 2: A 20 year-old female comes to her doctor with tonsillitis. "My nose has been stuffy for the last couple of days and I have been coughing. I woke up this morning and my throat hurt really badly. I looked in my throat and my tonsils were swollen and there were white dots on them.

It is also determined that she did not have a fever. When the doctor felt the front of her neck, he determined that her lymph nodes were swollen and tender.

This patient receives one point for swollen tonsils with pus and one point for swollen lymph nodes. She has a point total of 2. Therefore, her risk of strep is about 17%.

Table 1: Percent change of having GABHS based on number of clinical criteria

-1 or 0 - 1%
1 - 10%
2 - 17%
3 - 35%
4 or 5 - 51%

As you can see from the chart, it is impossible to rule in or rule out strep throat just by doing an interview and physical examination. The CDC recommends that antibiotics not be given unless GABHS is found on strep culture. When there is a score of 4 or 5 many health care providers will treat instead of doing a culture and some clinicians even choose to treat if there is a score of 3 or more.

One fact that is not well know is that strep throat will go away on its own. Well, that is not entirely true. The symptom of sore throat will remit, but the bacteria may still persist. It has the potential to go to the heart and cause rheumatic fever, it is therefore important to treat strep throat even though the sore throat will go away.

When sore throat persists beyond five days strep throat is not likely. It is more likely mononucleosis, a sinus infection, allergies or post-nasal drip.

Diagnostic Testing

Who is a candidate for diagnostic testing?

1. All children with a sore throat
2. Selected adults with a sore throat. This includes adults with at least one feature suggestive of strep throat (swollen tonsils, pus on the tonsils, fever above 100.4 degrees Fahrenheit, swollen lymph nodes, sore throat in the absence of a cough)

What type of testing should be done?

1. A rapid strep test is indicated for most patients with a sore throat with a back up throat culture

If the rapid test reads positive, it is quite reliable. If it reads negative it may not be that reliable. Because of the tests ability to miss the diagnosis, it is recommended that the health care provider get a back up culture that is sent to the lab to confirm every negative rapid strep test. Some experts suggest you do not need a back up culture in the adult, but my experience suggests that you should do a back up culture in the adult.

The rapid test should not be used in those who had a positive strep test in the last 30 days as there still may be strep antigen fragments hanging around that could give a false positive test.
Other testing for sore throat

When sore throat persists another diagnosis to consider is mononucleosis. This is most common in those 10-25 years-old. It can be testing by checking the blood for antibodies to the Epstein-bar virus. During the first week of the illness, the test may not pick up the disease but by the second week the test picks up the disease over 80% of the time.

Testing for HIV and other sexually transmitted diseases may be warranted in the high-risk individuals. Individuals who have oral sex may need the throat tested for gonorrhea.

Some cases of sore throat warrant a broad culture that looks for other causes of sore throat such as other bacteria.
Treatment

Most cases of sore throat are either caused by a virus or GABHS. If strep throat is present treatment with antibiotics is important and if it is not present treatment of the symptoms is all that is necessary. Treatment of strep throat will reduce rheumatic fever, abscess formation, transmission and improve comfort. It is always important to stay alert for other complications of sore throat - even though they are rare.

There is a nine-day window that the clinician has to treat strep throat to prevent rheumatic fever after GABHS. Treatment will also speed healing. After starting treatment you should be feeling much better in 24-48 hours. Ideally treatment should be started within 48-72 hours.

Some clinicians choose to treat patients while they wait for the return of the culture. Realizing that resolution will be faster and it will provide comfort to some patients.

This is not a wise strategy to implement for all patients. This requires some professional judgment of the treating health care provider. Those who are suspected of having strep are better candidates for this method of treatment. The goal is to avoid excessive exposure to antibiotics. When antibiotics are prescribed without a confirmed diagnosis the patient should be encouraged to stop antibiotics immediately if the culture comes back negative.

There is no resistance to penicillin in the United States, so it is the drug of choiceii. Ten days of pills or a shot is equally effective in its management. People who will not take all of their medication should receive a shot.

Amoxicillin, which is a type of penicillin, is often used in place of penicillin in children, as the suspension of penicillin does not taste good. Amoxicillin suspension has a pleasant tasting bubble gum flavor.

Individuals who do not have angioedema (swelling deep in the skin near the eyes and lips) or hives as their allergic reaction to penicillin can be treated with first or second-generation cephalosporins. If they are, they need to be watched closely as allergic reactions with penicillin sometime cross over to an allergic reaction to cephalosporins.

Erythromycin is recommended in patients with a severe penicillin allergy. Due to side effects - mainly gastrointestinal - azithromycin or clarithromycin is sometimes substituted.

Recurrent GABHS can be treated with amoxicillin-clavulanate (Augmentin). It is not usually picked as a first line medication as it is a more expensive and has a wider spectrum of activity. A wider spectrum of activity means that it is able to cover many other types of infections. The routine utilization of broad-spectrum antibiotics for simple infections has the potential to increase the risk of antibiotic resistance.

Penicillin should be used for 10 days in the treatment of GABHS to assure that all the bacteria are killed and no straggling bacteria remain.

The use of probiotics are one strategy that will significantly reduce the risk of Clostridium difficile and other complications of antibiotic use. When you are on antibiotic it is critical to take probiotics to reduce the risk of this complications. Always keep a supply of probiotics on hand because you never know when you will need to go on antibiotics.

Treating the symptoms

Sore throat pain can be quite debilitating and managing that pain is a critical part of treatment. Symptomatic treatment often involves a combination of systemic medications and local acting medications.

Systemic medications include medications that are taken by mouth that can help relieve the pain of the sore throat and may also help other symptoms that accompany sore throats such as headache, fever and body aches. Systemic medications include: ibuprofen, acetaminophen, naproxen or acetaminophen/codeine (in severe cases). The use of medications to reduce pain and fever, in addition to reducing symptoms, may help shorten the course of disease by one to two days.

Topical medications are available in many over the counter formulations and some can be made at home. A common home remedy is salt-water gargles, which can be made by adding one-fourth of a teaspoon of salt to 6-8 ounces of warm water. This concoction can be gargled and spit out every 3-4 hours. Sugar-free or regular Popsicles can help ease the discomfort of a sore throat.

Multiple over the counter medications are available for treating sore throat. They come in sprays and lozenges.

Certain foods can help the throat feel better. For example, warm or cool liquids soothe and moisturize the throat. Nasal saline can moisturize the nasal passages and clean mucus out of the nose. This will reduce the amount of post-nasal drip, which will help reduce throat discomfort. Herbal teas may be helpful in the treatment of sore throat. Throat coat - a herbal tea - has a demulcent that is more effective at providing relief than regular tea.

Certain prescription medications have the potential to aid a sore throat. Viscous lidocaine is a medications that comes as a thick liquid that the health care provider can prescribe that will numb the throat. It can also be mixed with other liquids such as liquid Benadryl and/or Maalox to ease the discomfort.

Steroids are used in some patients with sore throats. This is a prescription given by the doctor and can be given by mouth or as a shot. Steroids reduce the inflammation of a severely inflamed throat.

Home remedies for a sore throat:

• Salt water gargles as outlined above.
• A cool mist humidifier should be used. Many sore throats are caused by or exacerbated by dryness; the moisture that a cool mist humidifier provides can improve symptoms.
• Suck on a sour drop. Lemon drops or another type of drop will stimulate saliva and reduce throat pain
• Drink tea with honey as this will coat the throat.

Follow up

Improvement in the sore throat caused by a bacteria or virus is typically noted in 2-3 days. When there is no improvement or a worsening of symptoms noted a follow up with your health care provider should be attained to rule out a more serious (cellulitis or abscess) or another underlying condition (mononucleosis or chronic post-nasal drip).

Rarely, other bacteria can cause sore throat. This is much more common in the adult than the child. This may be considered when there is a non-response to antibiotics or a negative GABHS culture and the patient is getting worse. The health care provider will often take a more broad culture to look for other bacteria that may be causing the sore throat.

At times further testing is indicated. This is not common, but may occur in the sore throat that is not explained by other causes. It is most often carried out by an ear, nose and throat specialist. A laryngoscope will be used to look for cancer, a foreign body, acid reflux or another cause of sore throat.
Recurrent Disease

When disease returns within one week of completing antibiotic therapy it is considered treatment failure. The main causes of this are:

• Not taking the medication as directed
• Resistance to the antibiotic
• Repeat infections

For those who are thought to have a resistant strain, a different antibiotic may be considered such as a cephalosporin, macrolide or amoxicillin-clavulanate.

In cases where there is repeat infection, family members should be checked to see if they are carriers of strep. If they have a positive strep culture, they should be treated.

What is a carrier?

A surprising number of people - 10 to 25 percent - are colonized with GABHSviii. When one is colonized, it means that the strep is living in the throat with out causing the person to be sick. Generally, those who are colonized do not need to be treated, but sometimes they do. Treatment should ensue when there is:

• A personal or family history of rheumatic fever
• Recurrent transmission between close contacts
• Significant anxiety about GABHS
• Consideration of removal of the tonsils to eradicate the carrier state

Tonsillectomy and Adenoidectomy

Tonsils and adenoids are often removed, but the surgery may be done too often. The tonsils are there for a reason. The tonsils, while they often get infected, help fight infections in the throat and nose and keep the infection from spreading.

There are risks with this procedure. Bleeding is the most common complications and can occur up to eight days after surgery. Sore throat after the procedure is common. The voice sometimes changes after the procedure. The most worrisome complication is death, but this only occurs in one of every 250,000 operations.

The tonsils and/or adenoids can be removed for multiple reasons including:

• Recurrent GABHS: For two-year olds, more than 4 episodes a year; for three year-olds more than 3 episodes per year; and those over 3-years-old, greater than 6 episodes a year is an indication for the tonsils and adenoids to be removed.
• Obstructive sleep apnea
• A severe infection that does not respond to antibiotics
• Recurrent peritonsillar abscess
• Potential cancer
• Persistent mouth breathers may be a candidate for removal of the adenoids
• Persistent swallowing problems if they are caused by large tonsils or adenoids

What you need to know

If you are diagnosed with strep throat:

• Do not infect others. Do not come in close contact with others for 24 hours after starting antibiotics.
• Removable oral appliances (e.g. retainers) should be cleaned completely.
• A new toothbrush should be used after 24 hours.
• Complete the entire course of antibiotics or resistance to that antibiotic may occur.
• Symptoms that do not improve by 72 hours or get worse after 48 hours require a medical evaluation.
• Do not take any antibiotics that are lying around the house for a sore throat without visiting the health care provider. Antibiotics will invalidate a throat culture.

Questions to Ask Your Health Care Provider

1. Is my sore throat related to a virus or a bacterium?
2. Do I need a culture to determine if there is a bacterial infection?
3. Which medications do you recommend to manage my symptoms?
4. Do you recommend any home remedies?
5. Will an antibiotic help my infection?
6. Are there any potential interactions between the medications that you are recommending and the current medications that I am on or any other health problems I may have?
7. When should I expect an improvement in my condition?
8. What complications should I look out for and how will they show up?