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Acute sore throat

Correspondence to: Dr Graham Worrall, Dr William H. Newhook Memorial Health Centre, Whitbourne, NL A0B 3K0; telephone 709 759-2300; fax 709 759-2387; e-mail gworrall{at}mun.ca

The pharynx is the garbage dump of the bronchial tubes and the nasal passages.
Sir William Osler

Acute sore throat accounts for about 4% of all FP visits; only a small proportion of people with sore throats seek medical attention.

• Sore throat is the second most common acute infection seen by FPs.
  
• Fewer than 1 in 10 people with sore throats go to see their FPs.
  
• Sore throat is predominantly a disease of youth and the early school years.
  
• Sore throats are more common in autumn and winter.
  

	Cause

TOP Cause Clinical course and diagnosis Sore throat decision rule Rapid antigen detection tests Antibiotic treatment Nonantibiotic management of sore... Footnotes References

 
The most important bacterial cause of a throat infection is group A β-hemolytic streptococcus (GABHS), which is responsible for about one-third of sore throats in children aged 5 to 15 years. In adults and in younger children, only 10% of sore throats are caused by GABHS. Carriers of GABHS do not need treatment.

• Viruses are responsible for 85% to 95% of adult sore throats.
  
• Viruses cause 70% of sore throats in children aged 5 to 16.
  
• Viruses cause 95% of sore throats in children younger than 5 years.
  
• The most common bacterial cause of sore throat is GABHS.
  
• At least 30% of GABHS cultured in primary care are due to carriers who are not sick and are at very low risk of infecting other people.
  

	Clinical course and diagnosis

TOP Cause Clinical course and diagnosis Sore throat decision rule Rapid antigen detection tests Antibiotic treatment Nonantibiotic management of sore... Footnotes References

 
In otherwise healthy people, a sore throat is usually self-limited and rarely produces serious aftereffects. Typical GABHS patients are children aged 5 to 15 who present with fairly acute onset of fever and sore throat.

• Headache, nausea and vomiting, malaise, dysphagia, and abdominal pain might be present.
  
• Cough and rhinorrhea are usually absent.
  
• Edema and erythema of the tonsils and pharynx are usually present.
  
• Anterior neck glands might be enlarged and tender.
  
• A non-adherent pharyngeal exudate might be present.
  

	Sore throat decision rule

TOP Cause Clinical course and diagnosis Sore throat decision rule Rapid antigen detection tests Antibiotic treatment Nonantibiotic management of sore... Footnotes References

 
The sore throat decision rule can identify both patients who are so likely to have GABHS that a confirmatory test is not needed and patients who are so unlikely to have GABHS that further testing is unrewarding. Using the rule will successfully identify most patients who need treatment for GABHS infection, while decreasing antibiotic use for sore throat by about 80%.

The 4 most useful features to look for in diagnosing GABHS are enlarged submandibular glands, a throat exudate, fever, and absence of cough and runny nose. Use the following sore throat rule to decide which adults are most likely to have GABHS infection:

• 0 or 1 feature present—GABHS is unlikely;
  
• 2 features present—diagnosis uncertain, consider further testing; and
  
• 3 or 4 features present—GABHS is likely.
  

	Rapid antigen detection tests

TOP Cause Clinical course and diagnosis Sore throat decision rule Rapid antigen detection tests Antibiotic treatment Nonantibiotic management of sore... Footnotes References

 
Office testing kits that determine whether a throat swab contains antistreptolysin antigen are now available and inexpensive. In patients with an indeterminate sore throat rule score, consider using such a test.

	Antibiotic treatment

TOP Cause Clinical course and diagnosis Sore throat decision rule Rapid antigen detection tests Antibiotic treatment Nonantibiotic management of sore... Footnotes References

 
In antibiotic trials, 90% of both treated and untreated patients were symptom-free by the end of 1 week. Antibiotics shortened the duration of symptoms, but by a mean of only 16 hours overall. Most patients get better without antibiotics; however, antibiotics do modestly reduce symptoms.

Antibiotics do protect against the following:

• acute rheumatic fever (number needed to treat [NNT] = 4000),
  
• subsequent acute otitis media (NNT = 29),
  
• subsequent acute sinusitis (NNT = 50), and
  
• subsequent peritonsillar abscess (NNT = 27).
  

Antibiotics do not protect against the following:

• acute glomerulonephritis and
  
• subsequent meningitis.
  

If you are going to use an antibiotic for a presumed GABHS sore throat, the drug of choice is still penicillin; GABHS remains very sensitive to penicillin (less than 1% resistance).

• In developed countries, GABHS remains very sensitive to penicillin V.
  
• Clinical rules or laboratory tests determine which patients are most likely to have GABHS infection.
  
• Consider delaying treatment for 2 to 3 days to allow time to observe the clinical course and receive laboratory test results.
  
• Immediate treatment might increase reinfection rates.
  
• Treat contacts only during institutional epidemics.
  
• Giving penicillin twice a day can be as effective as giving it 3 times a day.
  
• A 5-day course relieves symptoms as well as a 10-day course, but is less effective in eradicating GABHS infection.
  

	Nonantibiotic management of sore throats

TOP Cause Clinical course and diagnosis Sore throat decision rule Rapid antigen detection tests Antibiotic treatment Nonantibiotic management of sore... Footnotes References

 

• Consider nonantibiotic therapy as first-line placebo treatment.
  
• Nonsteroidal anti-inflammatory drugs relieve symptoms.
  

	Footnotes

TOP Cause Clinical course and diagnosis Sore throat decision rule Rapid antigen detection tests Antibiotic treatment Nonantibiotic management of sore... Footnotes References

 
Competing interests

None declared

Adapted from: Worrall G. There’s a lot of it about: acute respiratory infection in primary care. Abingdon, Engl: Radcliffe Publishing Ltd; 2006.

	References

TOP Cause Clinical course and diagnosis Sore throat decision rule Rapid antigen detection tests Antibiotic treatment Nonantibiotic management of sore... Footnotes References

 
Bean RB. Sir William Osler—Aphorisms from his bedside teachings and writings 1968.

Bisno AL, Gerber MA, Gwaltney JM Jr, Kaplan EL, Schwartz RH. Infectious Diseases Society of America. Practice guidelines for the diagnosis and management of group A streptococcal pharyngitis. Clin Infect Dis 2002;35(2):113-25.[Medline]

Del Mar CB, Glasziou PP, Spinks AB. Antibiotics for sore throat. Cochrane Database Syst Rev 2006;(4):CD000023.

Institute for Clinical Systems Improvement. Guidelines and more: respiratory illness in children and adults. Bloomington, MN: Institute for Clinical Sysytems Improvement; 2007. Available from: www.icsi.org/guidelines_and_more/. Accessed 2007 October 9.

McIsaac WJ, White D, Tannenbaum D, Low DE. A clinical score to reduce unnecessary antibiotic use in patients with sore throat. CMAJ 1998;158(1):75-83.[Abstract]

Snow V, Mottur-Pilson C, Cooper RJ, Hoffman JR, et al. American Academy of Family Physicians, American College of Physicians, Principles of appropriate antibiotic use for acute pharyngitis in adults. Ann Intern Med 2001;134(6):506-8.[Free Full Text]

Worrall G. Acute sore throat. In: Worrall G. There’s a lot of it about: acute respiratory infection in primary care. Abingdon Engl: Radcliffe Publishing Ltd; 2006. p. 24-36.

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