Sore Throat Information PDF

## SORE THROAT Most (90%) sore throat, which present in the pharmacy will be caused by viral infection, with only one in ten being due to bacterial infections. Clinically, it is almost impossible to differentiate between the two. Most infections are self-limiting. ### Information to Be Collected...

## SORE THROAT Most (90%) sore throat, which present in the pharmacy will be caused by viral infection, with only one in ten being due to bacterial infections. Clinically, it is almost impossible to differentiate between the two. Most infections are self-limiting. ### Information to Be Collected - **Age** - Establishing who the patient is will influence the choice of treatment & whether referral is necessary. - Streptococcal (bacterial) sore throat is more likely in children of school age. - **Duration** - Most sore throats are self-limiting & will be better within 7-10 days. - If a sore throat has been present for longer, then the patient should be referred. - **Severity** - If the sore throat is being extremely painful, especially in the absence of cold, cough & catarrhal symptoms, then referral should be recommended if there is no improvement within 24-48 hours. ### Associated Symptoms - A cold, catarrh & a cough may be associated with a sore throat. - There is may also be a fever & general aches & pains. These are in keeping with a minor self-limiting viral infection. - Hoarseness of longer than 3 weeks duration & difficulty in swallowing (dysphagia) are both indications for referral. ### Previous History - Recurrent bouts of infection (tonsillitis) would mean that referral is best. - If the patient is diabetic, sugar-free medication might be preferred. ### Smoking Habit - Smoking will exacerbate a sore throat, & if the patient smokes it can be a good time to offer advice & information about quitting. ### Present Medication - The pharmacist should establish whether any medication has been tried to treat the symptoms. - If one or more medicines have been tried **without improvement**, then referral to the doctor should be considered. - Current prescriptions are important & the pharmacist should question the patient carefully about them. - Steroid inhalers (beclomethasone or budesonide) can cause hoarseness & candidal infections of the throat & the mouth. Generally, they tend to do this at high doses. This can be prevented by: - Rinsing the mouth with water after using the inhaler. - Checking the inhaler technique. Poor technique with metered-dose inhalers can lead to a large amount of the inhaled drug being deposited at the back of the throat. - Using a spacer is a good solution for poor inhaler technique especially in children. - Any patient taking carbimazole (antithyroid agent) & presenting with a sore throat should be referred. A rare side effect of carbimazole is agranulocytosis. - The same principle applies to any drug, which can cause agranulocytosis. - A sore throat in such patients can be the first sign of a life-threatening infection. ### Symptoms for Direct Referral 1. **Hoarseness** - This is caused when there is inflammation of the vocal cords in the larynx. Laryngitis is typically caused by a self-limiting viral infection. - It is usually associated with a sore throat & a hoarse, diminished voice. - Antibiotics are of no value & symptomatic advice, including resting voice, should be given. - The infection usually settles within a few days & referral is necessary. - When this infection occurs in babies, infants or small children it can cause croup & present with difficulty in breathing & stridor. In this situation referral is essential. - When hoarseness persists for more than 3 weeks, especially when it is not associated with an acute infection, referral is necessary. - There are many causes of persistent hoarseness, some of which are serious. For example, laryngeal cancer can present & hoarseness may be the only early symptom. 2. **Dysphagia** - Difficulty in swallowing can occur in severe throat infections. - It can happen when an abscess develops in the region of the tonsils as a complication of tonsillitis. This will usually result in a hospital admission where an operation to drain abscess may be necessary & high-dose parenteral antibiotics may be given. - Glandular fever. - Most bad sore throats will cause discomfort on swallowing but not true difficulty & do not necessarily need referral unless there are other reasons for concerns. - Dysphagia when not associated with a sore throat always needs referral. 3. **Appearance of Throat** - It's commonly thought that the presence of white spots, exudates or pus on the tonsils is an indication for referral or a means of differentiating between viral & bacterial infection. - Unfortunately, the appearance can be the same in both types of infection & sometimes the throat can appear almost normal without exudates in a streptococcal infection. - **A) Thrush** - An exception not to be forgotten is candidal (thrush) infection, which produces white plaques. - These are rarely confined to throat alone & are most commonly seen in babies or very elderly. - It is an unusual infection in younger adults & may be associated with more serious disorders, which interfere with the body's immune system for example leukaemia, human immunodeficiency virus (HIV) & acquired immune deficiency syndrome (AIDS), or with immunosuppressive therapy (steroids). - The plaques may be seen in the throat & on the gums & tongue. When they are scraped off, the surface is raw & inflamed. - Referral is advised if thrush is suspected & the throat is sore & painful. - **B) Glandular fever** - This is a viral infection caused by Epstein-Barr virus. - It's well known because of its tendency to leave its victims deliberated for some months afterwards & its association with the controversial condition ME (myalgic encephalomyelitis). - The infection occurs in teenagers & young adults, with peak incidence between ages of 14-21. - It is known as 'kissing disease'. - A severe sore throat may follow a week or two of general malaise. - The throat may become very inflamed with creamy exudates present. - There may be difficulty in swallowing (dysphagia) because of the painful throat. - Glands in the neck & axillae may be enlarged & tender. - Referral is necessary for accurate diagnosis. - The diagnosis can be confirmed with a blood test, although this may not become positive until a week or after the onset of the illness. - Antibiotics are of no value; in fact if ampicillin is given during the infection a measles-type rash is likely to develop. - Treatment is aimed at symptomatic relief. ### Treatment Timescale - If the sore throat has not improved within 7 days, the patient should see the doctor. ### Management - **A) Oral Analgesics:** Paracetamol, aspirin & ibuprofen provide rapid & effective relief of pain in sore throat. Patients can be advised to take analgesic regularly to sustain pain relief. - **Flurbiprofen lozenges:** - They are licensed for sore throat in adults & children aged 12 & above. - They contain 8.75 mg of flurbiprufen, & one lozenge is sucked or dissolved in the mouth every 3-6 hours as required, to a maximum of 5 lozenges. - Flurbiprofen can be used for up to 3 days at a time. - **B) Mouthwashes & Sprays:** - **1. Antiseptics:** A range of antiseptic mouthwashes is available over the counter, & research suggests that some preparations are more effective than others. - Those containing chlorhexidine, hexetidine, povidone-iodine & cetylpyridinium chloride have been shown to have an effective antimicrobial action. - Such preparations are unlikely to have antiviral activity, but would be useful where there was bacterial involvement. - Mouthwashes & gargles are popular treatments. - **2. Anti-inflammatory:** Benzydamine is an anti-inflammatory agent, which is absorbed through skin & mucosa & has been shown to be effective in reducing pain & inflammation in conditions of mouth & throat. - Side effects have occasionally been reported & include mouth & throat numbness & stinging. - Benzydamine spray can be used in children of 6 & over, whereas the mouthwash may be only recommended for children aged over 12. - **3. Local anaesthetic:** Phenol has a local anaesthetic effect when applied to the mucosa & can be effective in reducing pain in sore throat. Phenol-based mouthwashes & sprays are available over the counter. Benzocaine is also available as a throat spray. - **C) Lozenges & Pastilles:** These can be divided into four categories: - **1- Antiseptic (cetylpyridinium chloride)** - **2- Antifungal (dequalinium)** - **3- Local anaesthetic (Benzocaine)** - Lozenges containing cetylpyridinium chloride have shown to have effective antibacterial action. - Local anaesthetic lozenges will numb the tongue & throat & can help to ease soreness & pain. - Benzocaine can cause sensitization. - **Cautions:** Iodized throat lozenges should be avoided in pregnancy because they have the potential to affect the thyroid gland of the foetus. - **4- Oral analgesic: Flurbiprofen lozenges** ### Practical Points - **1. Diabetics:** Mouthwashes & gargles are suitable, & can be recommended. Sugar-free pastilles are available but the sugar content of such products is now not considered so important in short-term use. - **2. Mouthwashes & gargles:** Patients should be reminded that mouthwashes & gargles should **not be swallowed**. - The potential toxicity of OTC products of this type is low & it is unlikely that problems would result from swallowing small amounts. - However, there is small risk of systemic toxicity from swallowing products containing iodine. Manufacturers' recommendations about whether to use the mouthwash **diluted or undiluted** should be checked & appropriate advice given to the patient. ## ALLERGIC RHINITIS The symptoms of allergic rhinitis (hay fever) occur after an inflammatory response involving the release of histamine, which is initiated by allergens being deposited on the nasal mucosa. Allergens include grass and tree pollens, and fungal mould spores. - **Perennial allergic rhinitis** occurs when symptoms are present all year around, and is caused by the house-dust mite, animal dander and feathers. - Some patients may suffer from **perennial rhinitis**, which becomes worse in the summer. ### Information to Be Collected - **Age** - Symptoms may start by any age, although its onset is commoner in children and young adults. - There is frequently a family history of atopy in allergic rhinitis sufferers. Thus children of allergic rhinitis sufferers are more likely to have the condition. - The condition improves or resolves as the child gets older. - The age of the patient must be taken into account if any medicine is recommended. - **Duration** - Sufferers will often present with seasonal rhinitis as soon as the pollen count becomes high. - Symptoms may start in April when pollens appear. - Hay fever peaks between May and July, when grass pollen levels are highest. - Anyone presenting with 'summer cold', for several weeks, may be suffering from hay fever. - Fungal spores are also a cause and are present slightly later, often until September. - People can suffer from what they think are mild cold symptoms for a long period, without knowing they have perennial rhinitis. ### Symptoms - **A) Sneezing** - In hay fever, the allergic response starts with sneezing, then rhinorrhoea, progressing to nasal congestion. - Classically, symptoms of hay fever are more severe in the morning and in the evening. This is because pollen rises during the day after being released in the morning, & then settles at night. - Patients may describe a worsening of the condition on windy days as pollen is scattered, and a reduction in symptoms when it rains or after rain, as the pollen clears. - Conversely, in those allergic to fungal mould spores, the symptoms worsen in damp weather. - **B) Rhinorrhoea** - A runny nose is a commonly experienced symptom of allergic rhinitis. - The discharge is thin, clear and watery, but can change to thicker, coloured, purulent one. - This suggests a secondary infection, although the treatment for allergic rhinitis is not altered. There is no need for antibiotics. - **C) Nasal congestion** - The inflammatory response caused by the allergen produces vasodilation of the nasal blood vessels so results in nasal congestion. - Severe congestion may result in headache and occasionally earache. - Secondary infection such as otitis media and sinusitis can occur. - **D) Nasal itching** - This commonly occurs. Irritation is sometimes experienced on the roof the mouth. - **E) Eye symptoms** - The eyes may be itchy and also watery; it is thought that these symptoms are a result of tear duct congestion, and also a direct effect of pollen grains being caught in the eye, setting off a local inflammatory response. - Irritation of the nose by pollen probably contributes to eye symptoms too. - People who suffer severe symptoms of allergic rhinitis may be hypersensitive to bright light (photophobic) and find that wearing dark glasses is helpful. ### Previous History - There is commonly a history of hay fever going back over several years. - It can occur at any age, so the absence of any previous history does not necessarily indicate that allergic rhinitis is not a problem. - The incidence of hay fever has risen during the last decade. - Pollution, particularly in urban areas, is thought to be partly responsible for the trend. - Perennial rhinitis can usually be distinguished from seasonal rhinitis by questioning about the timing and the occurrence of symptoms. - People who have had hay fever before will often consult the pharmacist when symptoms are exacerbated in the summer months. ### Danger symptoms - When tightness of the chest, wheezing, shortness of breath or coughing are present, then immediate referral is advised. - These symptoms may herald the onset of an asthmatic attack. - **A) Wheezing:** Difficulty with breathing, possibly with cough, suggests an asthmatic attack. - Some sufferers only experience asthma attacks during the hay fever season (seasonal asthma). - These episodes can be quite severe and require referral. - Seasonal asthmatics often do not have appropriate medication at hand as their attacks occur so infrequently, which puts them at greater risk. - **B) Earache and facial pain:** Allergic rhinitis can be complicated by secondary bacterial infection in the middle ear (otitis media) or the sinuses (sinusitis). - Both these conditions cause persisting severe pain. Referral is advised. - **C) Purulent conjunctivitis:** Irritant watery eyes are a common accompaniment to allergic rhinitis. - Occasionally this allergic conjunctivitis is complicated by a secondary infection. - When this occurs, the eye becomes more painful (gritty sensation) and redder, and the discharge changes from being clear and water to coloured and sticky (purulent). Referral is needed. ### Medication - Pharmacist must establish any prescription or OTC medicines are being taken by the patient. - Potential interactions between prescribed medication & antihistamines can be identified. - It would be useful to know if any medicines have been tried already to treat the symptoms, especially where there is a previous history of allergic rhinitis. - The pharmacist should be aware of the risk of drowsiness by some antihistamines combined with other medicines. This can lead to increased danger in certain occupations and driving. - Failed medication: If symptoms are not controlled with OTC preparations then referral to may be worthwhile. ### Treatment Timescale - Improvement in symptoms should occur within a few days. - If no improvement is noted after 5 days, the patient might be referred to the doctor. ### Management - Management include antihistamines, nasal decongestants and sodium cromoglycate. - Over the counter antihistamines can be very effective in the treatment of allergic rhinitis. - It is reasonable for the pharmacist to recommend treatment for hay fever. - Patients with symptoms, which don't respond to OTC products can be referred to the doctor at a later stage. - Pharmacists have an important role in ensuring that patients know how to use prescribed medicines correctly (e.g., steroid nasal sprays) which must be used continuously for the patients to benefit). - **1) Antihistamines:** Most pharmacists consider these drugs to be 1st line for mild to moderate & intermittent allergic rhinitis. They are effective in reducing sneezing & rhinorrhoea, less in reducing nasal congestion. - **Non-sedating OTC antihistamines** include cetirizine, acrivastine and loratadine. - They may be recommended for other allergic disorders such as seasonal rhinitis, perennial rhinitis and urticaria. - For sale OTC, loratadine for children over 2 years, cetirizine for children over 6 years and acrivastine over 12 years. - All are effective in reducing the troublesome symptoms of hay fever and have the advantage of causing less sedation than some of the older antihistamines. - While drowsiness is an extremely unlikely side effect of any of the three drugs, patients might be well advised to try the treatment for day before driving or operating machinery. - Acrivastine is taken 3 times daily. - Long duration of action requires only once daily dosage. - Cetirizine has a long half-life and its full effects may take a day or longer to develop. This drug may be most effective when taken continuously during hay fever season since its long half-life may make intermittent treatment of symptoms less effective. - Azelastine (non-sedating antihistamine): is a nasal spray used in allergic rhinitis. It is should begin 2-3 weeks before the start of hay fever season. It is suitable for children over 5 years. - **Older antihistamines** include phenylephrine, promethazine and diphenhydramine. - They have a greater tendency to produce sedative effects. - The shorter t1/2 of diphenhydramine (5-8 hours compared to promethazine's 8-12 hours) should mean less likelihood of a morning hangover/drowsiness. - Other older antihistamines are relatively less sedative, e.g., chlorpheniramine & clemastine. - Patients may develop tolerance to their sedative effects after regular use. - Antihistamines competitively block histamine release at receptor level, and also have anticholinergic activity. - Anticholinergic activity is very much lower among the newer. - **Interactions:** - The potential sedative effects of older antihistamines are increased by alcohol, sedatives & anxiolytics. - The plasma concentration of non-sedating antihistamines may be increased by ritonavir. - Plasma concentration of loratadine may be increased by amprenavir. - Concurrent administration with certain drugs (erythromycin, antiarrythmics, neuroleptics (chlorpromazine), tricyclic antidepressants (amitriptyline) and drugs which may cause electrolyte imbalance, such as diuretics.) predisposes to cardiotoxicity. - Patients should always be reminded not to exceed the recommended dose of these antihistamines. - There have been reports of an interaction between phenytoin & chlorpheniramine, in which phenytoin levels were raised to toxic levels while the patients were taking chlorpheniramine. - It has been suggested that antihistamines might inhibit liver metabolism of phenytoin. - Antihistamines can antagonize the effects of betahistine. - **Side effects:** - The major side effect of the older antihistamines is their potential to cause drowsiness. - Their anticholinergic activity may result in a dry mouth, blurred vision, constipation and `urinary retention. - These effects will be increased if the patient is taking another drug with anticholinergic effects (TCADs, neuroleptics). - Antihistamines are best avoided by patients with closed angle glaucoma, since the anticholinergic effects produced can cause an increase in intra-ocular pressure. - They should be used with caution in patients with liver disease or prostatic hypertrophy. - At very high doses, antihistamines have CNS excitatory effects. - Such effects seem to be more likely to occur in children. - At toxic levels, there have been reports of fits being induced. - As a result, so antihistamines should be used with care in epileptic patients. - **2) Nasal decongestants:** The decongestants are sympathomimetics such as pseudoephedrine and phenylpropanolamine. - Decongestants may be used to reduce nasal congestion alone or in combination with an antihistamine. - They are useful in patients using a 'preventer' such as cromoglycate or beclomethasone where congestion can prevent the drug from reaching the nasal mucosa. - The pharmacist should be aware that these drugs (e.g., pseudoephedrine), when taken orally, have the potential to keep patients awake, because of their CNS stimulating effects. It may therefore be reasonable to suggest that patient avoids taking dose of the medicine near bedtime. - Topical decongestant can cause rebound congestion, especially with prolonged use. - They should not be used for more than a week. - Since it's best restricted to 7 days or fewer, they will be inappropriate if symptoms continue. - **Eye drops** containing an antihistamine and sympathomimetic, or mask cells stabelizers may be of value in troublesome eye symptoms. - The sympathomimetic acts as vasoconstrictor, reducing irritation and redness. - Some patients find that the vasoconstrictor causes painful stinging when first applied. - Eye drops which containing a vasoconstrictor should not be used in patients who have glaucoma or who wear soft contact lenses. - **3) Sodium cromoglycate:** It can be effective as a prophylactic if used correctly. - It should be started 2-3 weeks before the hay fever season is likely to begin, and then used continuously through the season. - It seems to have no significant side effects, although nasal irritation may occur. - The eye drops should be used 4 times/day. The eye drops contain the preservative benzalkonium chloride & shouldn't be used by wearers of soft contact lenses. - **4) Steroids:** Beclometasome & fluticasone spray can be used for the treatment of seasonal allergic rhinitis. - It is the treatment of choice for moderate to severe nasal symptoms that are continuous. - They reduce the inflammation that has occurred as a result of allergen's action. - Must be taken daily and full effectiveness appears after 1-2 weeks of starting treatment - Combination with antihistamine may be more effective than either alone - Nose & throat dryness and irritation as well as nosebleeds have occasionally been reported. - These sprays can be used in patients over 18 years for up to 3 months. - They shouldn't be recommended for pregnant women or anyone with glaucoma. ### OTC Treatment in Practice - **Mild intermittent symptoms:** Respond to oral 2nd generation antihistamine - If not effective, start nasal steroid - **Moderate to severe persistent symptoms:** - For Nasal Congestion give Nasal steroids - For ocular symptoms give topical antihistamine ### When to Refer - Persistent moderate to severe symptoms lasting 2-4 weeks &/or affecting the quality of life - Symptoms suggestive of asthma - Symptoms of infection - Special population (children < 12 years, and pregnancy)