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    Sore Throat – Diagnostic and Therapeutic

    Cardinal Presentations / Presenting Problems, Ears, Eyes, Nose, and Throat, Infections

    Last Updated Jan 19, 2022
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    By Nicholas Sparrow, Raman Ubhir

    Context

    • Sore throat is a common complaint in the emergency department.
    • Most common cause is a viral infection which is often self limiting.5
    • Another common cause is Group A Strep (GAS), accounts for approximately 15% of sore throats.5
    • Important to think of which patients to swab.
    • Also important to keep in mind some red flags and important differentials to consider.

    Diagnostic Process

    Considerations for history

    • Sick contacts including COVID contacts.
    • Other infectious symptoms (e.g., fever, cough, nasal congestion, coryza, conjunctivitis).
    • Sexual history.
    • Allergies, smoking, and vaccinations.

    Some important signs on physical exam

    Signs of upper airway obstruction

    • Respiratory distress.
    • Stridor.
    • Drooling.
    • Hoarse or muffled voice.

    Signs of deep neck infection

    • Neck pain, stiff neck.
    • Severe sore throat – asymmetric.
    • Uvula deviation or bulging of pharyngeal wall, soft palate.
    • Trismus.
    • Toxic appearance.

    Investigations

    Decision aid

    • Consider using the Centor Score (Modified/McIsaac) to help decide whether to swab for GAS, especially if low pre-test probability.
    • Negative predictive value approx. 80% for score less than two.5

    Investigations

    • Rapid strep test +/- culture.
    • Culture in high risk patients or in areas with high burden of acute rheumatic fever. (Eg. children living in northern Canada, Indigenous and Pacific Islander children consider confirming negative strep test with negative culture4).
    • Consider COVID swab.
    • Consider STI testing if high risk (e.g., acute HIV infection can cause sore throat).
    • Consider monospot test (prolonged sore throat and fatigue).
    • If considering deep neck infection and patient stable consider neck imaging (CT neck soft tissue with IV contrast or alternatively soft tissues x-rays of the neck).
    • Consider CBC, CRP and blood cultures and venous gas in the septic looking patient.

    Some important differentials to consider5

    • Peritonsillar abscess.
    • Common cause: GAS, oral anaerobes.
    • Common patient: Teens.
    • Features: unilateral odynophagia/pharyngitis, uvula shift, muffled voice.
    • Retropharyngeal abscess.
    • Common cause: Staph. Aureus, oral anaerobes, GAS.
    • Common patient: Infants – teens.
    • Features: posterior pharynx swelling, stridor, dysphagia, drooling, stiff neck, cervical lymphadenopathy.
    • Lateral pharyngeal abscess/cellulitis.
    • Common cause: oral anaerobes.
    • Common patient: Teens.
    • Features: jaw or neck swelling, pain, fever, trismus, dysphagia.
    • Can be associated with rare but serious complication of Lemierre syndrome (septic thrombophlebitis of internal jugular vein).
    • Ludwig Angina.
    • Common cause: oral anaerobes.
    • Common patient: Teens and adults.
    • Features: swollen tongue and floor of mouth (tender), Fever, dysphagia, odynophagia, stiff neck, dyspnea, airway obstruction.
    • Epiglottitis.
    • Common cause: H. Influenza b (rare due to vaccination), GAS, Strep. Pneumoniae, Staph. Aureus.
    • Common patient: 2-5 year old.
    • Features: toxic appearance, stridor, increased work of breathing, sudden onset fever, “thumb sign” on neck x-ray.

    Recommended Treatment

    1. Nonpharmacologic treatment – symptomatic relief & fluid intake

    • Soothing drinks (cold water, warm tea).
    • Popsicles.
    • Hard candy.
    • Avoid smoking.

    2. Pharmacologic treatment

    • Acetaminophen.
    • NSAIDS – e.g., Ibuprofen.
    • Consider dexamethasone 10mg adult or 0.6mg/kg child.1
    • For GAS treat with amoxicillin (e.g., for children 50 mg/kg by mouth once daily, max 1g/day for 10 days).4
    • For other more severe bacterial causes discussed in important differentials airway management, e.g., intubation if needed, consider drainage of abscesses, consider ENT consult, disposition will depend on severity and many patients will need empiric IV antibiotics.

     

    Quality Of Evidence?

    Justification

    Use single dose of corticosteroid to reduce swelling and time to symptom resolution for sore throat. Moderate quality recommendation: Recent Cochrane review of multiple RCTs found moderate grade evidence supporting reduction of mean symptom duration.3

    Moderate

    Use of clinical decision making tools may decrease unnecessary tests and overprescribing antibiotics. Low quality recommendation – Recent review of literature reported few studies with variable results, one RCT showing reduction in unnecessary tests but no significant reduction in antibiotic prescribing, another retrospective study showing significant reduction but limited by study design (poor physician compliance to tool).2

    Low

    Related Information

    Reference List

    1. Aertgeerts B, Agoritsas T, Siemieniuk RAC, et al. Corticosteroids for sore throat: a clinical practice guideline. BMJ. 2017 Sep 20;358:j4090.


    2. Banerjee S, Ford C. Clinical Decision Rules and Strategies for the Diagnosis of Group A Streptococcal Infection: A Review of Clinical Utility and Guidelines [Internet]. Canadian Agency for Drugs and Technologies in Health; 2018 May 23.


    3. de Cassan S, Thompson MJ, Perera R, Glasziou PP, Del Mar CB, Heneghan CJ, Hayward G. Corticosteroids as standalone or add-on treatment for sore throat. Cochrane Database Syst Rev. 2020 May 1;5(5):CD008268.


    4. Sauve L, Forrester AM, Top KA. Group A streptococcal pharyngitis: A practical guide to diagnosis and treatment. Paediatr Child Health. 2021 Jul 28;26(5):319-320.


    5. Tanz RR. Sore Throat. Nelson Pediatric Symptom-Based Diagnosis. 2018;1-14.e2.


    6. https://www.mdcalc.com/centor-score-modified-mcisaac-strep-pharyngitis#evidence


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