Throat pain

Throat pain

Throat pain is another common reason for primarycare visits, especially around the autumn and spring months. While pharyngitis is the predominant reason for throat pain, it could also be due to conditions such as postnasal drip, peritonsillar abscesses, epiglottitis, or infectious mononuclesosis. A careful history collection and a physical examination are important for making appropriate clinical decisions. Pharyngitis is caused by virus 90% of the time. Group A B hemolytic streptococcus (GABHS) causes 20% to 40% of pharyngitis cases in pediatrics and 5% to 15% in adults. Streptococcal pharyngitis is common in patients between 5 and 15 years old and rare in patients under 3 years old. Timely assessment and management are essential to prevent complications associated with GABHS. Similarly, viral pharyngitis must be distinguished from GABHS to prevent antibiotic overuse.

Stage-1

Abstract Conceptualization

Abstract Conceptualization

Stage-2

Active Experimentation

Active Experimentation

History collection

Collect a history onthe throat pain’s duration, any trouble breathing, fever, neck stiffness, otalgia, sinus pressure, past history of throat infection, chronic carriers of GABHS, sick contacts, and dysphagia.

Physical examination

Check the temperature. Are patients alert and oriented?

Are there tonsillar swelling or palpable anterior cervical nodes?

Is there any respiratory distress orairway occlusion?

Complete ENT examination to r/o AOM, sinusitis

Any neck stiffness, rashes, or facial swelling?

Any Signs and symptoms of viral illness?

Clinical Diagnosis

GABHS Pharyngitis

A throat culture is the golden test for confirming GABHS infection. However, it may take 48 hours to obtain the result, which is a major drawback. Rapid antigen dip tests are available for office use to identify GABHS.They have a high specificity but low sensitivity. There are several clinical-decision criteria usedto predict GABHS’s possibility, such asCentor, modified Centor (McIsaac), Breese, Wald, Attia, FeverPAIN, and Joachim. Sudden-onset sore throat, odynophagia, fever, and the absence of viral URTI signs and symptoms (cough, rhinorrhea, hoarseness, oral ulcers, or conjunctivitis) are symptoms supporting bacterial etiology. Pharyngeal and tonsillar erythema, tonsillar hypertrophy with or without exudates, palatal petechiae, anterior cervical lymphadenopathy, and scarlet form rash (scarlet fever) are clinical signs that indicate GABHS pharyngitis. Patients who indicate bacterial etiology will require antibiotic treatment. Clinicians must perform a rapid antigen dip test or throat culture when possible to confirm the diagnosis. Children with persisting clinical s/s of pharyngitis but a negative rapid testing should have afollow-up throat culture. When untreated, strep throat spontaneously resolves in most of the cases; however, it increases the risk of complications, such as rheumatic fever, mastoiditis, and peritonsillar abscess. According to CDC’s recommendation, people with group A strep pharyngitis or scarlet fever should stay home from work, school, or daycare until they are afebrile and after24 hours of appropriate antibiotic therapy (2).

Modified Centor Score

Temperature above 38 C 1
Absence of cough 1
Swollen, tender anterior cervical node 1
Tonsillar swelling or exudate 1
Age 3- 14 years 1
Age 15-44 years 1
Age above 45 or above 1

If total score is -1 to 1- Provide symptomatic treatment

Score 2 and above- Do RADT or throat culture, if positive, treat with antibiotic (4)

Pharmaceutical Management

Penicillin is the treatment of choice. To get a detailed list of pharmaceutical agents and dosages, please follow the link. Corticosteroid has only a weak recommendation forstreptococcus pharyngitis management (4).

Find a list prescription recommendations/ antibiotic choices for GABHS management in here: http://www.topalbertadoctors.org/download/367/acute_pharyngitis_pda.pdf

Chronic carriers: Asymptomatic group A strep carriers usually do not require treatment as it is unlikely for them to develop any suppurative or nonsuppurative complications; similarly, they are very unlikely to transmit GABHS to others.

Clinical Pearl

Avoid throat swabbing if an epiglottitis is suspected.

If a patient with throat pain develops diffused rashes after penicillin treatment, rule out EBV.

Recommend NSAIDs for pain management if viral pharyngitis is diagnosed.

Benzydamine oral rinse has been shown to significantly improve dysphagia and throat pain (5).

Stage-3

Concrete Experimentation

Concrete Experimentation

SOAP note

C/o throat pain x 3 days
Fever intermittent, 1001-101f
Sibling was recently diagnosed with GABHS
No SOB, lethargy, neck stiffness, or rashes
No cough, coryza, or recent h/o viral URTI

o/e
nad
no neck stiffness, rashes, no SOB
Pharynx- tonsillar erythema ++, exudate+
Anterior cervical node- palpable b/l
Temp-101.6F
No cough
Rapid antigen test-+

A

GABHS

P

Penicillin as directed

Fever management discussed

Discussed mode of transmission, prevention

If continued fever, lethargy, confusion, neck stiffness, should seek medical help

Stage-4

Reflection

Reflection

Student Activity

Reflect on your learning experience with throat pain management. Provide a case example to demonstrate your use of Kolb’s learning cycle while practising GABHS management.

Reference

Randel, A. (2018).IDSA Updates Guideline for Managing Group A Streptococcal Pharyngitis. AmericanFamilyPhysician.Sep1;88(5):338-40. Retrieved from https://www.aafp.org/afp/2013/0901/p338.html

Center for Disease Control and Prevention (2018). Pharyngitis. Retrieved from https://www.cdc.gov/groupastrep/diseases-hcp/strep-throat.html

Aertgeerts, B., Agoritsas, T., Siemieniuk, Burgers, J. Corticosteroids for sore throat: a clinical practice guideline. BMJ. September 20; 201: 358. Retrieved from https://www.bmj.com/content/358/bmj.j4090

Mathan,J., Ekart,J., Houlding, A., Payinda, G., Mills, C (2017).Clinical management and patient persistence with antibiotic course in suspected group A streptococcal pharyngitis for primary prevention of rheumatic fever: the perspective from a New Zealand emergency department. New Zeland Medical Journal. Jun 16;130(1457):58-68. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/28617790

European Society of Clinical Microbiology and Infectious Diseases (2012). Guideline for the management of acute sore throat. Clin Microbiol Infect. April 18; 1:1-28. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/22432746/

Wethington JF.Double-blind study of benzydamine hydrochloride, a new treatment for sore throat. Clin Ther. 1985;7(5):641-6. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/3902241