A sore throat is hard to swallow

A sore throat is hard to swallow

A sore throat is hard to swallow

A sore throat — known medically as pharyngitis — is one of the commonest complaints that lead people to see their family physician. Most of us know the all too familiar symptoms: a burning, prickling, dry, sensation in the throat, particularly painful on swallowing. About one in 10 Canadians, many of them children aged five to 15, gets a sore throat at least once each year between January and March. The modern medical approach is to ease the symptoms and detect any sore throats due to a bacterial infection, especially those due to streptococci. A streptococcal throat infection can lead to serious complications — such as glomerulonephritis (a kidney disorder) and rheumatic fever (which can damage the heart). Despite the rarity of rheumatic fever in today’s Western world, there is still medical concern about the possibility of lasting heart defects following a strep throat infection.

Many possible reasons for a sore throat

The term pharyngitis describes an inflammation of the pharynx (throat) and surrounding tissues, including the larynx, adenoids and tonsils — if they haven’t been removed (SEE DIAGRAM). Throats can be irritated and become sore from prolonged use of the voice, swallowing a sharp object, cigarette smoke, seasonal allergies or eating spicy food. But pharyngitis is more usually due to a viral or, less commonly, a bacterial infection. Frequently a sore throat is the first hint of an oncoming illness such as measles or influenza and it often heralds or accompanies a common cold. Generally, as the measles, influenza or cold takes hold, and its identifying symptoms — such as a rash, cough or runny nose — become obvious, the throat gradually becomes less sore. But when a sore throat persists without being the forerunner or accompaniment of another disease, it is pharyngitis on its own.

Viral pharyngitis, the commonest but least harmful form, tends to cure itself spontaneously within five to seven days, generally requiring no treatment other than topical painkillers to ease the soreness, antipyretics to bring down any fever and soothing warm drinks.

Bacterial pharyngitis, less usual but more dangerous, may also vanish within a few days with or without treatment. But a bacterial throat infection, especially one due to Group-A beta hemolytic streptococci (the “strep” throat often seen in children over age four), needs prompt medical attention because it may lead to complications that threaten the heart, joints and kidneys.

Gonococci (the organisms responsible for gonorrhea) occasionally cause throat soreness — in those who practice orogenital sex. More rarely, pharyngitis may stem from a fungal infection or candidiasis, with typical white patches — oral “thrush” — visible in the mouth and throat. Oral thrush is quite common in the immuno-compromised, particularly among AIDS patients.

Sometimes pharyngitis is the chief or accompanying symptom of unusual diseases such as infectious mononucleosis, caused by the Epstein-Barr virus. Infectious mono starts with a sore throat — also enlarged tonsils, an exudate (seepage or coating on the tonsils), swollen lymph (neck) nodes, and possibly an enlarged spleen. Some of these symptoms mimic those of a strep throat. But, in contrast to a strep throat, mononucleosis doesn’t respond to antibiotics, and the accompanying pharyngitis may persist for weeks.

The very severe form of pharyngitis due to diphtheria — a bacterial infection that inflames the larynx and produces a lethal toxin — rarely occurs any more in immunized Western communities.

A strep throat can lead to serious complications

In children aged five to 15, the typical signs and symptoms of a streptococcal throat infection include: fever over 38[degrees]C; fiery red, inflamed tonsils; a painfully sore/raw throat; enlarged, tender neck glands (lymph nodes); a yellowish exudate on the tonsils; and a generally sick, listless state. Occasionally, there is a scarlet fever rash all over the body — a complication produced by some streptococcal strains. In older children and adults, streptococcal pharyngitis is usually heralded by the abrupt onset of a sore throat, fever and headache.

In the absence of complications, streptococcal pharyngitis is often self-limiting, the fever subsiding in a few days and all symptoms gone within a week. However, a strep throat may lead to lasting health problems. Primary complications of a strep throat include middle ear infections and sinusitis. Secondary, and more serious, complications include acute rheumatic fever and glomerulonephritis.

Glomerulonephritis is an inflammation of the kidneys caused by some strains of streptococci, not prevented by the usual antibiotic treatment of a strep throat. But most scientists agree that the long term outlook for children with this streptococcal complication is excellent, and it rarely produces lasting kidney damage.

Rheumatic fever was, and in many developing areas still is, a distinct danger arising from a childhood strep throat. Acute rheumatic fever is characterized by inflammation of the heart (carditis), joints (arthritis), nerves (“St. Vitus dance” — nerve impairment which produces involuntary jerky movements) and subcutaneous tissue (causing painful nodules under the skin). While most of these complications of rheumatic fever leave few or no lasting traces, the cardiac inflammation can permanently injure the heart, particularly the heart valves (causing a “heart murmur”). Anyone known to have rheumatic fever stays on penicillin for life (or at least up to age 18), to prevent recurrence of an illness which might further injure a heart already damaged by one bout of carditis. Rheumatic fever can be prevented by antibiotics which eradicate streptococci from the throat before serious complications set in. In the developed world, antibiotics have dramatically reduced the toll of rheumatic fever, a decline that curiously, and for unknown reasons, began before the widespread use of these drugs. Currently in Canada, rheumatic fever affects only two to five people per million per year. Nonetheless, physicians warn against complacency in treating a strep throat, particularly since there has been a slight upswing in U.S. rheumatic fever cases (in Utah, Pennsylvania and Ohio).

Accurate diagnosis the key to successful treatment

While seemingly straightforward, the task of distinguishing a viral from a bacterial throat infection isn’t always easy. Most practiced physicians suspect a streptococcal infection when they see a feverish child with a very sore throat, fiery red tonsils coated by an exudate, and enlarged neck nodes. But while many doctors think they can identify a strep throat by such signs, studies show they may be wrong in a mere visual assessment. Surveys comparing clinical (office) diagnosis against throat culture (bacterial growth) laboratory tests show that physicians are only right 50 per cent of the time in identifying a bacterial throat infection. Therefore, experts recommend taking a throat swab for laboratory culture from every inflamed throat that brings someone to the doctor. For any obviously feverish, sick child, antibiotics may be given immediately (while awaiting the lab results), in the hope of shortening the illness should it be streptococcal. If the lab results indicate a viral infection, the antibiotic therapy might be discontinued.

Timely antibiotic treatment can shorten the duration and prevent the potentially serious consequences of a bacterial throat infection. But since antibiotics may be needlessly prescribed for viral pharyngitis, many experts advocate waiting out the few hours needed to get back the lab results, before prescribing drugs. The American Heart Association strongly recommends treatment based on test results. The Association suggests that even those complaining of a mild sore throat should get a throat culture test. A brief delay in treatment — while awaiting the lab results — does not increase the risk. Studies show that even given a few days after the onset of streptococcal pharyngitis, antibiotics can prevent rheumatic fever.

In everyday practice, however, the proffered advice tends to be ignored. Antibiotics are frequently prescribed for what looks streptococcal before the culture results are in (sometimes without taking a throat swab at all!).

New rapid antigenic strep testing kits that can detect streptococci in a throat swab within minutes have recently become available in Canada. But while these kits may hasten diagnosis of a strep throat and help physicians decide who should be given antibiotics, the rapid test may not be reliable, especially not in unpracticed hands. Accurate only in 90 per cent of cases, the kits are costly to use. And against the benefits of a swift diagnostic result must be weighed the disadvantage of many false negatives (people who test negative although harbouring throat streptococci), especially carriers who have scanty bacterial numbers. Since laboratory culture is still the most reliable and universally used method, takes only 24 hours to do, and given a period of “grace” in which to prescribe antibiotics without any increased risk, most physicians opt for the older and better trusted throat culture technique.

Simple effective treatment usually works well

The trick in dealing with a sore throat is to know when to call the doctor. For a mild sore throat, when there is no fever — especially one accompanied by a runny nose, cough or diarrhea — there may be no need for medical help. The best treatment is bedrest, fluids and gentle gargling. But if there is fever a doctor should always be consulted. Antipyretics (fever-reducers) such as ASA/aspirin, and acetaminophen (e.g., Tylenol, Tempra, Panadol, Atasol) will bring down the temperature and reduce the pain. While relieving the pain and reducing the fever may make the person feel more comfortable and sleep better, these efforts don’t reduce the risk of complications. ASA should never be used to bring down fever in children or teens because of the risk of Reye’s Syndrome linked to ASA use — especially in influenza or chicken pox. (For more on Reye’s Syndrome see Health News, February 1983 issue.) In cases of confirmed streptococcal pharyngitis oral penicillin for 10 days is the standard treatment. In cases of doubtful compliance some experts recommend the injected form of penicillin, although the shot is painful when administered. Other antibiotics, such as erythromycin, are effective for those allergic to penicillin.

On a final note, the many sore throat sufferers who rush out to buy some of the countless over the counter remedies — such as antiseptic gargles, lozenges, sprays and throat rinses — may achieve no better results than those obtainable by a warm salt-water gargle, a hot cup of tea or their favourite “toddy.”

COPYRIGHT 1988 Strategic Inc. Communications Ltd.

COPYRIGHT 2008 Gale, Cengage Learning