Pharyngitis
🌟 Introduction
- Sore throat is a very common presentation in primary care and emergency settings. Most cases are viral and self-limiting, but bacterial causes (especially Group A Streptococcus, GAS) must be considered. 🔬
🦠 Aetiology
- Viral: Rhinovirus, adenovirus, coronavirus, influenza, parainfluenza (most common).
- Bacterial: Group A Streptococcus (Strep. pyogenes) → key concern due to potential complications (scarlet fever, rheumatic fever, post-streptococcal GN).
- Less common: Mycoplasma pneumoniae, Epstein–Barr virus (infectious mononucleosis). ⚠️
🩺 Clinical Features
- Symptoms: Sore throat, odynophagia, fever, ± coryzal symptoms (suggest viral).
- Exam: Tonsillar erythema, exudates, tender anterior cervical lymphadenopathy. Always check vital signs + airway first.
- Red flags: Drooling, stridor, muffled voice, severe trismus → think deep neck space infection or epiglottitis 🚨.
❗ Important Differentials
- Peritonsillar Abscess (Quinsy): Trismus, unilateral swelling, uvular deviation, “hot-potato” voice.
- Retropharyngeal Abscess: More common in children; drooling, torticollis, airway risk.
- Epiglottitis: Rare now with Hib vaccination; high fever, stridor, tripod position → emergency.
- Other: Tracheitis, infectious mononucleosis (EBV, esp. if rash after amoxicillin). 🧾
🛠️ Management
- Supportive: Fluids, rest, analgesia (paracetamol/ibuprofen). NICE supports a single dose of dexamethasone for severe sore throat to shorten symptom duration.
- Antibiotics: Only modest benefit (~16h reduction in symptoms). Reserve for high risk / severe presentations.
- Safety-netting: Advise patient to return if red-flag symptoms develop (airway compromise, worsening pain, systemic illness). 🛑
📊 CENTOR Score (or FeverPAIN in UK)
- Criteria:
- Tonsillar exudate +1
- Tender anterior cervical nodes +1
- Absence of cough +1
- Fever >38°C +1
- Age: 3–14y (+1), 15–44y (0), ≥45y (–1)
- Interpretation:
- 0–2 → low likelihood GAS → no antibiotics.
- 3–4 → consider antibiotics or delayed prescription. ⏳
💡 In UK practice, FeverPAIN score is often preferred. Both support delayed/back-up antibiotic prescriptions as a safe strategy to reduce overuse.
💊 Antibiotic Choices (NICE 2023)
- First-line: Phenoxymethylpenicillin 500mg QDS (or 1g BD) for 5–10 days.
- Penicillin allergy (non-pregnant): Clarithromycin 250–500mg BD for 5 days.
- Penicillin allergy in pregnancy: Erythromycin 250–500mg QDS or 500–1000mg BD for 5 days.
🔑 Teaching Pearls
- Do not prescribe amoxicillin in suspected EBV → causes a widespread rash. 🌸
- Consider public health notification if scarlet fever suspected (GAS notifiable disease in UK).
- Suppurative complications (quinsy, deep neck infection) are rare but serious → always assess airway risk first.
- Antibiotic stewardship is vital → most sore throats resolve within 7–10 days without antibiotics. 🌱
