When Your Patient Has a Sore Throat

When Your Patient Has a Sore Throat

Introduction

When researchers tabulate the reasons patients seek out an emergency room visit, sore throat consistently ranks in the top ten.[1] It is also one of the top four ambulatory care complaints in the United States, causing perhaps as many as 18 million physician office visits yearly.[2,3] The most common cause of sore throat is a virus, but the pharmacist must not assume that sore throat is always a minor condition treatable with nonprescription products.

Sore throat may arise from many serious pathogens, such as group A beta-hemolytic streptococcal organisms, other bacteria, or fungi.[2] The term "sore throat" is nonspecific, describing any pain in the posterior oral or pharyngeal area (oropharynx).[4,5] Because these mucosal and submucosal tissues are richly lymphoid, they are highly susceptible to inflammation and infections. Also, the pharynx serves as a passage for both respiratory and digestive systems. Therefore, a variety of inhaled or ingested agents can produce the inflammation known as pharyngitis, which results in sore throat. Patients may complain of sore throat ranging in severity from minor, scratchy discomfort to severe pain that inhibits swallowing, eating or talking. The challenge is to ensure that patients with potentially serious medical conditions see a physician.

Etiologies of Sore Throat

Pharyngitis has many potential etiologies.[6]

Infectious Causes: Infectious causes of pharyngitis include viruses (up to 70% of cases), bacteria (responsible for most of the rest of cases), fungi and parasites.[6] Bacteria and viruses will be discussed in detail later in this article.

Medical Conditions: Very rarely, sore throat is due to a medical condition whose etiology is poorly understood. These conditions include Kawasaki disease, Stevens-Johnson disease, Behçet’s syndrome, recurrent aphthous stomatitis, and systemic lupus erythematosus.[6] Of these, the pharmacist is most likely to provide primary care for the patient with recurrent aphthous stomatitis (canker sores), and sore throat is not a common manifestation of this condition. The others on this list are also uncommon causes of sore throat. It would be difficult for a pharmacist to detect their existence on the basis of sore throat alone, but such patients would need referral for a full diagnostic workup.

Miscellaneous Causes: Miscellaneous causes of sore throat include burns, cancer, leukemia, irradiation, referred pain from the thyroid, chemotherapy, and polyps.[6] Cigarette smoke is another miscellaneous cause. Children in households with smokers often experience recurrent pharyngitis. The pharmacist should advise that smokers be asked to go outside when smoking.

Ingestion of irritating foods, such as hot peppers, can irritate the intraoral tissue lining. Patients who experience sore throat after eating such foods should be advised to avoid those foods. Inhalation of irritating chemical fumes or smoke from fires can also cause sore throat. Again, avoidance is the best approach.

Mouth-breathing results in xerostomia (dry mouth) and dry, sore throat. If the cause is nasal obstruction, the patient may try therapy with antihistamines (e.g., for chronic obstruction due to allergic rhinitis) or nasal decongestants (for acute obstruction due to the common cold). Dryness of the throat also may be caused by a low-humidity environment. Humidifiers or vaporizers, as well as drinking plenty of fluids to achieve optimal hydration, may help.

Overuse Syndromes: Patients with sore throat should be asked about overuse. Pain might occur with prolonged use of the vocal apparatus, especially when the patient is forced to take in many breaths of cold, dry air. The typical situation is cheering for a sports team over the course of several hours on a cold November night in the dry indoor environment of a gym or the cold, dry outdoor environment of a football stadium. Another example is instructing others in a loud voice over a long period.[7] Even prolonged singing, such as an hour-long Christmas cantata, can cause sore throat, especially in light of the rehearsal time that precedes the program.

Viral Sore Throat

Most sore throats are caused by viral assaults.[2,5] Although hundreds of viruses can produce sore throat, most cases are caused by rhinoviruses, the same agents responsible for the common cold. Usually they produce an acute pharyngitis that is not severe or prolonged. Further, the common cold is a malady that occurs only a few times each year. Thus, this type of sore throat fits the criteria for sore throat that can be treated with nonprescription products.

To help determine whether sore throat is associated with a rhinovirus, the pharmacist should ask about associated common cold symptoms, such as rhinorrhea, nasal blockage, and cough.[6] If the patient does not have any of these symptoms, the pharmacist should suspect other etiologies. This month’s patient information page helps consumers determine which types of sore throat are self-treatable.

Viral sore throat may also be caused by coronavirus, influenza, adenovirus, herpesvirus (simplex 1 and 2), reoviruses, measles and varicella viruses, and cytomegalovirus.[5] When a virus induces nasal blockage, the patient is forced to mouth breathe, which can worsen a sore throat.[6]

Infectious mononucleosis is another cause of viral sore throat, especially in adolescents or young adults.[2] The patient most often notices a severe sore throat (in as many as 80% of cases) that inhibits swallowing.

To recognize mononucleosis, the pharmacist should ask about ancillary symptoms such as anorexia, malaise, chills, headache, fever (as high as 104°F), regional lymphadenopathy, swelling around the eyes, nausea, and vomiting. Epstein-Barr virus causes the condition, which may result in six months of malaise.[6] These patients should be referred to a physician because a course of steroids may be necessary to reverse respiratory obstruction, fever and pharyngitis.

Strep Throat

Many patients see a physician for sore throat due to the fear of "strep throat," which requires antibiotic treatment.[8] Although many bacteria can cause pharyngitis, the most common and one of the most serious is group A beta-hemolytic streptococci (GABHS), the cause of "strep throat."

Pharmacists might use several clues to recognize GABHS infection. GABHS is most likely to cause pharyngitis in the late winter and early spring.[2,6] The cough and nasal congestion seen with rhinovirus is not common. Instead, the patient often complains of ancillary symptoms, such as chills, fever (as high as 105°F), headache, nausea, vomiting, and abdominal pain. Although rhinoviruses may cause headache, the other symptoms of "strep throat" are not often seen in the common cold. The patient may also exhibit scarlet fever, the appearance of a petechial rash that begins on the trunk and spreads to the cheeks, palms, and soles. It is most likely to be seen in the axillae. With the resolution of the rash, the skin may desquamate.

Traditionally, GABHS has been thought to be found mostly in patients aged 6–12 years; however, recent research explored its occurrence in those aged 30–65 years.[9] The authors examined 148 adults who presented to an emergency room with sore throat. They discovered that 44% had positive cultures for group A streptococci. Thus, pharmacists should not rule out strep throat when adults complain of sore throat.

Although GABHS-induced pharyngitis usually resolves without sequelae, it can cause devastating consequences (e.g., retro-pharyngeal abscess, peritonsillar abscess, or suppurative cervical lymphadenitis).[6] It can also produce acute rheumatic fever (in which the joints, heart, skin, CNS, and subcutaneous tissues all may be affected) and acute glomerulonephritis (producing gross hematuria, hypertension, edema and renal insufficiency).[5]

Patients suspected of having GABHS-induced sore throat should be referred to a physician. The ideal treatment is penicillin V 250 mg three or four times daily for 10 days.[6] This regimen prevents acute rheumatic fever and is inexpensive. Clarithromycin and azithromycin are broader-spectrum agents that usually are able to eliminate any causative bacteria in cases when GABHS is not the culprit.[6]

Sore Throat in Aerobics Instructors

The increasing popularity of aerobic exercise has led to an increase in the number of aerobics instructors. Unfortunately, the need to vocalize for instructional purposes occurs at the same time as the instructor is undergoing strenuous exertion. The dual stresses cause a peculiar injury known as vocal fold trauma, induced by the collision of vocal folds during projection and exercise.[7] Vocal fold trauma is characterized by hoarseness, dysphonia, aphonia, rough voice, and sore throat. If the pharmacist suspects that overuse coupled with trauma are the cause of sore throat, a period of voice rest is advised. Perhaps the patient might be persuaded to use a microphone as a substitute for a high-volume vocal pitch while leading sessions.

Patient Information

When you have sore throat, it may just be a slight tickling or scratching, or it may be so painful that you cannot easily talk, eat or drink. Your pharmacist can help you determine when to try a nonprescription product, and when to see a physician.

What Makes the Throat Hurt?

The throat is made up of soft tissue that is prone to develop swelling, which can cause pain. Painful swelling can be caused by many factors, such as swallowing irritating foods, cheering for a long period, breathing dry air, or breathing in cigarette smoke, chemical fumes, or smoke from fires. Postnasal drip also can irritate the throat.

When Can I Treat Sore Throat?

Talk to your pharmacist if you have a sore throat. In some situations, the pharmacist will recommend that you see a doctor.

Only occasional sore throat can be treated with over-the-counter products. Having sore throats again and again may indicate a serious condition, which should be checked by a doctor.

Only minor sore throat, such as that due to the common cold, can be self-treated. If your sore throat is severe, you should see a doctor. The cause may be streptococcal bacteria ("strep throat"). If not treated, strep throat can cause lifelong damage to the body or even death.

If your sore throat has lasted more than two days, you should see a physician. Serious sore throat can last for many days or weeks.

Certain symptoms indicate a serious condition if they occur with sore throat. For example, fever, headache, rash, swelling, nausea, or vomiting along with sore throat requires a physician appointment. You also should see a doctor if your sore throat is accompanied by tickling or pain in your ears.

Never treat a sore throat in children under the age of two years unless directed by a physician.

What Products Can I Use to Treat Sore Throat?

If sore throat does not fall into any of the serious categories listed above, it may be self-treated with several types of products.

Oral analgesics (such as acetaminophen, naproxen, ibuprofen and ketoprofen) may help sore throat. Aspirin, however, should be avoided. If a virus is causing your sore throat, aspirin use increases your risk of Reye’s Syndrome, a serious and often life-threatening disorder.

Topical anesthetics, which are generally available as sprays or lozenges, are another option for treating sore throat. They contain ingredients such as menthol, dyclonine, phenol, benzocaine, benzyl alcohol or hexylresorcinol. Whichever product you use to treat sore throat, be sure to follow the directions on the label in regard to the age of the patient, the maximum dosing per time period, warnings, and instructions for proper use.

Combining Products

You may use an oral analgesic at the same time as a topical anesthetic. However, if you are taking any other medications, you may not be able to take certain oral analgesics. To ensure that there is no drug interaction, consult your pharmacist.