Sore Throats, Tonsillitis, Pharyngitis, Laryngitis

Pharmacy staff are often consulted about sore throats, especially as the winter months approach. Many of these can be handled with over-the-counter medications, while others will require medical treatment. The pharmacy staff has an important role to play in helping the patient to understand and correctly implement the treatment plan, as well as referring appropriately.

TONSILLITIS

The symptoms of tonsillitis include:

  • Fever
  • Sore throat and sometimes difficulty in swallowing
  • Halitosis or bad breath
  • Swollen red tonsils that may be pitted and covered in white spots or pus
  • Lymph nodes in the neck and under the jaw may be enlarged and tender.

Treatment
Bacterial tonsillitis is not always easy to distinguish from a viral infection, so a patient may not necessarily be prescribed an antibiotic. Symptomatic treatment would include oral analgesics (i.e. Panado®, Calpol®, throat lozenges (i.e. Strepsils®, Medikeel®, Andolex® C) or sprays (i.e. Andolex®, Orochlor®)

Clinical features that would indicate a streptococcal (bacterial) tonsillitis are:

  • A persistent high fever
  • Enlarged and tender cervical lymph nodes.
  • Follicles on the tonsils (large white/creamy patches on the inflamed tonsils).
  • Patient not getting better within 72 hours.
  • These patients will require an antibiotic, so refer them to their doctor for a full examination and further treatment.

Complications
Peritonsillar abscess (Quinsy) is more common in adults. The patient will be ill with a high fever and malaise. There is usually marked dysphagia (pain and difficulty swallowing). One tonsil will be noticeably enlarged, and the submandibular glands will be enlarged and very tender. These patients require urgent admission for intravenous antibiotics and drainage of the abscess.

PHARYNGITIS

The patient comes in complaining of a sore throat, with or without swollen glands. There may be an associated upper respiratory tract infection. There are a number of possible causes. Pharyngitis can be bacterial or viral in origin, and it is not always easy to distinguish between the two clinically. Often the patient’s overall presentation helps with the diagnosis:

  • Allergic rhinitis: the postnasal drip from allergic rhinitis can cause pharyngitis. The patient typically has an itchy, runny nose, sneezing, and sometimes itchy red eyes. The pharyngeal mucosa often has a granular appearance in these patients. Treatment with a topical antihistamine spray (i.e.Rhinolast® , Sinumax® Allergy Nasal spray) will help to control the rhinitis. In more severe cases an oral antihistamine (i.e. Allergex®, Clarityne®) may be required to control symptoms. A topical steroid nasal spray (i.e. Clenil® AQ Nasal spray, Flomist®, Flixonase®) may also be required.
  • Viral pharyngitis: a patient with a clear rhinitis, sneezing, a mild temperature and sore throat, is more likely to be viral. Treat symptomatically with a topical decongestant (i.e. Otrivin®, ENT®, Iliadin nasal spray®) or an oral antihistamine/decongestant combination e.g. Clarityne D OD Extended Release®, depending on the severity of the nasal symptoms. Gargling, which mechanically clears postnasal drip, inflammatory debris, etc. from the throat, is both soothing and therapeutic. A topical agent may be required if the throat is very painful, e.g. Andolex Throat Spray®.
  • Bacterial pharyngitis is usually due to a streptococcal infection. Typical features would be fever; a very red, inflamed throat and tender, enlarged lymph nodes in the head and neck area. A penicillin or cephalosporin antibiotic is usually prescribed by the doctor for this type of infection.
  • Epstein- Barr Virus (“Glandular Fever”): be aware of this as a possible cause of pharyngitis in teenagers and young adults, particularly if the sore throat has been present for several weeks and the lymph glands in the head and neck area, as well as the rest of the body, are enlarged. Glandular fever can present as a mild, subacute febrile illness in one of three ways: generalised lymphadenopathy; pharyngotonsillitis with regional lymphadenopathy and characteristic petechiae on the palate; and persistent fever. Being viral, it will not resolve with antibiotics. Treatment is symptomatic.

LARYNGITIS

Laryngitis presents with a hoarse, croaky voice. The patient may also complain of a sore throat. The primary infection is usually viral in origin, but can also be secondary to a postnasal drip.

Treatment
The mainstay of treatment is resting the voice i.e. no singing or shouting and preferably no talking! The voice should return to normal within a week. Gargling and topical anaesthetic sprays e.g. Andolex® may help give symptomatic relief but will not speed up the recovery time.
Any patient whose hoarseness lasts longer than two weeks must see a doctor as this is a definite indication for an indirect laryngoscopy (a procedure that examines the vocal chords).
If there is a postnasal drip then treat either with a decongestant e.g Vibrocil® – S for 3-4 days, or with a steroid nasal spray e.g. Flixonase® if there is an allergic component.

CONCLUSION

Although many of the conditions discussed above require medical treatment, pharmacy staff still has an important role to play. Ensure the patient understands the reason for the different medications and how to use them, including any possible side-effects. In cases where an antibiotic has not been given, the pharmacist can help the patient to understand the reason why. Refer the patient back to the doctor if there is no improvement in symptoms, or there are worrying features (e.g. hoarseness lasting longer than two weeks). A patient with Quinsy (peritonsillar abscess) must be referred for medical attention – admission is usually required for intravenous antibiotics and drainage.

References on request

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