SORE THROAT - A REVIEW OF PRESENTATION AND ETIOLOGY

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1 SORE THROAT - A REVIEW OF PRESENTATION AND ETIOLOGY Batra K 1, Safaya A 2, Nair D 3, Capoor M 4 Key Words : Sore throat; tonsillitis; throat swab; core culture; tonsillectomy INTRODUCTION A complaint of a 'sore throat' is an extremely common presenting feature encountered by all otolaryngologists in their practice. However, most available literature and current concepts in the minds of otolaryngologists, paediatricians and general practitioners are confusing regarding how to differentiate between an ordinary sore throat requiring only medical treatment, from an attack of tonsillitis which may subsequently warrant surgical intervention. Since performing a tonsillectomy is not a particularly difficult task, frequently the decision is a surgical one. This could be avoided in several cases if a standard and straightforward protocol were to be followed. Changing trends in antibiotic sensitivities of causative organisms, coupled with a bewildering array and variety of antimicrobial agents, add to the confusion even in the line of medical treatment to be followed. It was with the specific purpose of clarifying these very confusing issues that a prospective study was undertaken in the ENT department at Safdarjung Hospital to try and objectify when to take the surgical option, what antibiotics to use after determining which are the commonly encountered pathogens and to try and pick out some commonly encountered predisposing factors, leading to tonsillitis. Review of Literature Celsus 1 was the first to report the removal of tonsils and since then, many changes have been brought about in surgical technique and the indications to make the procedure safer than before. Anatomy and Physiology The lingual tonsils anteriorly, palatine tonsils laterally and pharyngeal tonsils (adenoids) posterosuperiorly form a ring of lymphoid tissue about the upper end of the pharynx and are known as the Waldeyer's ring. All the structures have a similar histology and presumably similar function as well. The palatine tonsils form the largest accumulation of lymphoid tissue in this ring and constitute a compact body with a definite thin capsule on the deep surface. Tonsillar crypts lined with stratified squamous epithelium extend deeply into the tissue. Adenoids are covered by pseudostratified columnar epithelium which, grow until the fifth year of life often causing some degree of airway obstruction. This subsequently atrophies as the nasopharynx grows and the airway improves. Both the tonsils and adenoids are predominantly B-cell organs. Ample evidence proves their role in inducing secretory immunity and regulating secretory immunoglobulin production. They are favorably located for mediating the immunologic protection of the upper aerodigestive tract due to their exposure to airborne antigens. However, no major immunologic deficiencies result from the removal of either the tonsils or adenoids. Although studies have shown lower serum IgA levels in post-tonsillectomy patients than in age matched controls, but this immunologic change did not appear clinically significant. Bacteriology Most infections around Waldeyer's ring are polymicrobial in nature and often it is difficult interpreting data of samples 1 Pool Officer, 2 Senior ENT Specialist, 3 Specialist,Department of Microbiology, 4 Senior Resident, Department of Microbiology, Safdarjang Hospital and VM Medical College New Delhi

2 Sore Throat - A Review of Presentation and Etiology 15 Fig. 1 Protocol for Management of Sore Throat and differentiating between organisms that are colonized and those that are invaders. Group A streptococcus has been the most common cause of acute pharyngotonsillitis, its importance lying not only in its frequency of occurrence, but due to its two serious sequelae i.e. acute rheumatic fever and post-streptococcal glomerulonephritis. Clinical features of a sore throat associated with fever higher than 38.5 deg C (101.3 deg F), odynophagia, otalgia, Table I. Age & Sex Distribution of 50 Patients of Sore Throat cervical lymphadenopathy, enlarged tonsils with yellowish white spots and maybe even a membrane or exudates combined give a high clinical suspicion of GABHS as a causative organism 2. This should be verified by the time honoured throat swab culture which has a 90% sensitivity and specificity 99% under ideal conditions 2. Swabbing is done from the posterior pharyngeal and tonsillar areas. Patients with respiratory complications such as coryza and cough are less likely to have a streptococcal pharyngitis. A true infection is demonstrated by a positive throat culture and at least a two-dilutional rise in antistreptolysin O titre (ASLO). A GABHS carrier would show a positive culture Table II : Duration & Frequency of Attacks of Sore Throat

3 16 Sore Throat - A Review of Presentation and Etiology Table III : Associated Complaints Table V : Bacteriological Culture in 50 Patients of Sore Throat: Throat Swab Vs Fine Needle Aspiration Vs Core Culture Table IV : Tonsillar Grading & Lymphadenopathy in Patients with Sore Throat *NPO - no pathogenic organism isolated Table VI: Predisposing/Contributing Factors in Throat but no change in dilutional titre. 3 Other organisms isolated maybe Streptococcus pneumoniae (19%), H. influenzae (13%), Moraxella catarrhalis (36%). Treatment Protocol Penicillin has been the drug of choice for treatment of streptococcal pharyngotonsillitis for almost five decades. It has proved to be safe, efficacious and inexpensive. Initially, in the early eighties, intramuscular form (Penicillin G benzathine) was used, but subsequently oral formulations were shown to be equally effective and so this route was preferred. The main drawback is the 10% cases that prove to be allergic and the problem with compliance due to its three/four times a day dosing. The intramuscular form, being painful, itself causes compliance problems. 2 Bacterial failures range from 10-30% (i.e. failure to eradicate the organism of the original infection), while clinical failures range from 5-15% (i.e. patients who remain symptomatic despite treatment). Thus, alternatives to be used include: 1) Amoxycillin - has a narrower spectrum and gastrointestinal side effects, but is less expensive. 2) Macrolides - Erythromycin is a good alternative in allergic patients, but the GI side effects are intolerable for some. US-FDA labels a 5 day course of Azithromycin as an effective alternative. 3) Cephalosporins- a 10 day course of a first generation drug (Cefadroxil/cephalexin) is superior to penicillin in eradication of GABHS. 4) Amoxycillin-Clavulanate potassium - resistant to degradation from beta-lactamase produced by copathogens that may colonise the tonsillopharyngeal area. It is very useful for treating recurrent streptococcal pharyngitis. The two main limiting factors are its expense and the diarrhea caused by it. Thus, a simple protocol would be to start with amoxicillin after throat swab has been sent for culture. In cases of allergic reactions, erythromycin or azithromycin maybe used. Recurrent infections are best treated with amoxicillinclavulanate or a cephalosporin. Recommended durations of therapy are 10 days for all antibiotics except azithromycin, where a 5 day course suffices. Aims and Objectives 1. To study some of the predisposing factors in cases of sore throat and tonsillitis. 2. A review of the common presenting signs and symptoms, with a view to formulating a treatment protocol based on symptomatology. 3. To develop a lucid treatment protocol to decide when

4 Sore Throat - A Review of Presentation and Etiology 17 to employ the medical and surgical modalities. MATERIAL AND METHODS As an ongoing process, 50 patients with a primary complaint of sore throat, with or without fever and other related complaints were selected for this study. All of these patients were examined in detail in the out-patient's department and then a prepared questionnaire, including predisposing factors and treatment history, was filled out in each case. Each of these patients was subjected to a throat swab and those showing GABHS were also subjected to assessment of ASLO titres and repeat swabs. All this was done in most cases before starting any form of antimicrobial therapy. Depending on the response to treatment, persistence of symptoms and other factors, 20 patients were kept on medical treatment, while 30 patients underwent a tonsillectomy (with or without an adenoidectomy). All patients taken up for surgery, had a fine needle aspiration for culture done on the operating table just prior to removal of tonsils, while the tonsils were sent in each case for core culture (one being spirit washed and the other was sent as such) in sterile containers for microbiological evaluation. A post-therapy/post-operative swab was taken in each case. All the findings were compiled in a master chart for easy reference and observation. OBSERVATIONS The fifty patients taken up for this study were broadly divided into two groups - Group A who underwent surgery and Group B who received only medical treatment. (i) Age & sex distribution : The youngest patient was 3 years while the oldest was 44 years of age. 24 patients (48%) were below the age of 10 years, while only 6 patients (12%) were above 30 years. The highest incidence was found to be in the 6-10 year age group with 19 patients (38%) belonging to this age group. The sex distribution showed a slight male preponderance with 29 (42%) males as opposed to 21 (42%) females. The distribution is depicted in Table I. (ii) Presenting symptoms and signs : The main complaint of course was that of 'sore throat' in all of the 50 patients, but the duration and frequency of attacks varied greatly. In 26 (52%) cases, the symptom had been present for less than 2 years, 22 (44%) had the symptom for less than the preceding 6 years, while only 2 (4%) said the complaint had been present for more than 6 years. 93% of the patients who were treated with surgery had the problem for the last 6 years, while in the medical group, this was 100%. The frequency of attacks ranged between 3 per year up to a maximum of 14 per year. 64% (32) patients had between 3 and 6 attacks per year, while only 10% (5) had less than 3 per year and 26% (13) had 7 or more than 7 episodes per year. The distribution by frequency is depicted in Table II. The associated complaints that were looked for included fever, a history of mouth breathing or nasal obstruction, swelling of the neck and pain on swallowing. The observations are recorded in Table III. Several patients obviously had more than one associated complaint, but in both groups of patients, fever and pain on swallowing were the commonest. More of the patients who were ultimately treated surgically had complaints of pain on swallowing and swelling of the neck reflective of concomitant cervical lymphadenopathy, than the group given only medical treatment. The most notable clinical findings in both groups were that of cervical lymphadenopathy and that of tonsillar exudates or pus point or debris on the tonsils. Table IV shows distribution by grading of tonsillar size, tonsillar exudate and cervical lymphadenopathy which in most cases was the upper deep cervical and occasional superficial group node. Significantly the 4 patients who did show an exudate over the tonsil, or pus points at the time of presentation, all underwent surgery as the ultimate modality of treatment. (iii) Microbiology : In a significant 27 (54%) patients, an initial throat swab did not grow any pathogenic organism. Positive swabs were mostly of GABHS or of Staphylococcus aureus. The fine needle aspiration yielded a good culture in 7 cases, while core culture yielded growth in 25 of the 30 cases i.e. even in cases where the pre-operative throat swab had been negative. The 8 weeks post-operative throat

5 18 Sore Throat - A Review of Presentation and Etiology swabs showed no recolonization/infection with GABHS. The results are tabulated in Table V, (iv) Predisposing/contributing factors : Associated factors specifically looked for in history included any association with chips/fried foods, cold drinks, ice-creams, sweets and smoking (passive or active). Table VI shows the results obtained. A significant number i.e. 36 (72%) gave a history of attacks being precipitated by the intake of cold drinks (aerated drinks as well as juices). Another significant factor was the fairly high incidence of passive smoking which was 44% in these patients. DISCUSSION A sore throat episode is defined as the occurrence of sore throat as a complaint. 4 This soreness is generally described by the patient as pain in the throat without the effort of swallowing and also a painful swallow. This common complaint generally afflicts children below the age of 10 years, although adults are not immune to this problem either. It was observed during the course of this study, that the complaint of a painful throat was associated with complaints of a difficult and painful swallow and fever. Besides symptoms, a sore throat is also diagnosed on the basis of the presence of signs of inflammation like congested anterior pillars, tonsillar hypertrophy, exudate on the tonsils, congested tonsils and a generalized congestion of other structures of the throat. The complaints may be there for a discrete period involving either a day or a succession of days, provided that no interruption in their sequence exceeds 9 days. Anything that occurs after a gap of 10 days is considered a new episode. 4 Classically, differentiation of an ordinary sore throat from that of an episode of acute streptococcal tonsillitis is made on the basis of standard Centor criteria 5 followed elsewhere. Oral temperature of 38.3 C (101 F) or above, or tonsillar or pharyngeal exudates, or more than 2 cm size tender anterior cervical lymph node or a positive throat swab constitures tonsillitis. Paradise et al 4 have also defined tonsillitis on the basis of the association of a sore throat with one or more of these criteria. Presence of 3 or 4 of these criteria has a predictive value of 40 to 60% and the absence has a negative predictive value of approximately 80% 5. Since a wide range of organisms, commonest being the viruses, cause acute pharyngitis, the actual incidence of the diagnosed true tonsillitis, is in the range of only 5 to 15% GABHS in adults and approximately 30% in paediatric cases. In most cases, however, treatment is in the form of antibiotics given to prevent the development of known dreaded complications of streptococcal infection of the throat namely rheumatic fever, glomurelonephritis etc. Antibiotics are also prescribed because the parents of the suffering children and the adult patients expect some form of medical therapy for the sore throat. In very few cases do parents or patients themselves ask for a tonsillectomy to start with, unless the episodes have been so frequent that the attendants and the patient need to get rid of the perceived source of the repeated infections. The antibiotics prescribed were usually amoxicillin either plain or in a combination with clavulinic acid as a first line, unless the patient had a sensitivity problem with the drug. Those cases were then treated with either a course of erythromycin or azithromycin as an alternative or in some cases a cephalosporin (usually Cefadroxil). These antibiotics were found to be effective in most cases, with post-therapy swabs corroborating the clinical response observed. In our study, a significant number of patients (32 i.e 62%) who finally underwent surgery had between 3 to 6 episodes of sore throat per year, which clearly shows that increased frequency of attacks does have a prominent role in deciding the outcome of the therapy. In some the frequency of the attacks was even higher, thus giving an indication that increased number of attacks have to do with the virulence of the organism or the lowered immunity of the patient, in both cases a subject where conservative management may not be of much help and a surgical treatment should be kept in mind at the outset. In the study conducted by Woolford et al (2000) 6, the patients prepared for surgery were kept under observation and those remaining asymptomatic for 6-9 months did not ultimately undergo the procedure, rather only those with frequent attacks were finally operated. Paradise et al 4 recommend observation of two episodes of moderate severity after presentation or recurrent attacks before deciding on tonsillectomy in view of their finding that clinicalhistories may frequently be exaggerated. They recommend taking at least 7 episodes in one year; 5 in two consecutive years or 3 in three consecutive years as

6 Sore Throat - A Review of Presentation and Etiology 19 a criterion. Capper & Canter (2000) 7 in their study also found that frequency of tonsillitis was the most frequently stated indication for a tonsillectomy. Besides the frequency of the attacks, what was found to be predictive of the selection of a surgical modality of treatment was the associated symptoms of fever (95%) and significant pain on swallowing (85%) with each episode. The clinical grading of tonsillar size was also a mild predictor with most operated cases revealing Grade II(35%) or III(60%) tonsillar hypertrophy. The same study by Woolford et al also found that keeping these criteria as a yardstick for the decision for surgery was fairly predictive and these patients benefited from surgery. What was more significant was the presence of tonsillar exudates or debris at the time of presentation. All the 4 patients presenting with this ultimately underwent a tonsillectomy. 70% of the patients undergoing surgery had anterior cervical lymphadenopathy at the time of presentation, which was thus a fairly good predictor of the severity of the episode and subsequent possibility of surgery. Borderline cases need to be reviewed before surgery. In some cases the antibiotics were not started until the throat culture report was received as positive and antibiotics started only according to the sensitivity reports. There were, however, also some cases where the swab reports did not indicate any pathogenic organism but the patients had the typical complaints of sore throat according to the criteria used by us. One of the main reasons for resorting to techniques like repeating the throat swabs thrice or using Fine Needle Aspiration culture (FNA) was because we observed that it was not possible to detect organisms on the surface of the tonsil in all the suspected cases. This fact was confirmed after a core culture of the removed tonsil was done and the offending organism was isolated. The fine needle aspiration culture material yielded better culture growths (when positive) and its use as a routine culture technique in adults on an OPD basis needs to be investigated further. A throat swab is from the tonsillar surface and it has been demonstrated that drainage of the tonsillar crypts is impaired by recurrent tonsillar infection which impedes progress of the bacteria to the surface resulting in a negative swab. 8 Toner et al (1986) 9 also found in their study a reduced organism recovery rate from tonsil swabs of the surface as compared with core isolates, this being true for both aerobes and anaerobes. The relative frequency of the offending organism is maintained, so a surface is usually a good indicator of the core organism when it is positive, Investigation of possible predisposing factors revealed some interesting facts. As many as 36 (72%) of the patients gave a positive history of association of the episodes with the intake of cold drinks and 17 (34%) had a definite association with the intake of fried foods especially chips. These factors could possibly be acting by altering the bacterial microflora or lowering host immunity by altering local factors. Another significant etiological factor appears to be the fairly strong association of these sore throat episodes with smoking, be it passive or active (in the case of some of the adults). 44% of the patients gave a positive history of passive smoking. Ice creams and sweets seemed to predisposing in only 22% and 26% cases respectively, thus this did not show a strong association with the presenting complaint as the others. There would thus appear either to be some basis in the age old concept of avoidance of cold and fried things during an episode of a sore throat, or this maybe reflective of a biased history provided by the patients and the attendants. No comparisons were possible with other similar studies since these predisposing factors have not apparently been delved into very deeply in the literature reviewed by us. Paradise et al only considered demographic profile details in the history and they found no statistically significant association of any of the factors considered. So, what then would be the appropriate treatment protocol for cases of sore throat and tonsillitis? A schematic representation of the guideline is given in Figure 1. CONCLUSION Although sore throat continues to be one of the commonest complaints encountered by otolaryngologists on a regular basis, its definition, diagnosis and management continues to be somewhat hazy. All cases of sore throat do not require antibiotic therapy, nor do all ultimately need surgeries in the form of tonsillectomies. However, it would be fair to say that frequent attacks associated with clinical features of lymphadenopathy, fever, tonsillar hypertrophy and exudates and a positive throat culture (especially for GABHS), would require more aggressive treatment - first in the form of antibiotic therapy, failing which a tonsillectomy would have to be performed.

7 Cold drinks and fried stuffs along with passive smoking would appear to have an etiological/predisposing role to play in this condition. A rational and systematic approach to this condition would ensure that antimicrobial abuse and unwarranted tonsillectomies do not take place. Throat swab culture and fine needle aspirate cultures are useful adjuncts in planning treatment protocols of this condition. REFERENCES 1. Wiatrak B.J., Woolley A.L. in Cumming's Otolaryngology & head & Neck Surgery, Vol.5, Paed. Otolaryngol, chapter 12, Hayes C.S., Williamson H. Jr. (2001): Management of Group A beta hemolytic streptococcal pahryngitis, Am Fam. Physician. 3. Shapiro NL, Cunningham MJ (1995): Streptococcal pharyngitis in children, Curr Opin Otolaryngol Head Neck Surg, 3: Paradise J.L., Bluestone CD. et al (1978): History of recurrent sore throat as an indication for tonsillectomy. The New Engl. J. of Med. Vol. 298, 8, Cooper RJ, Hoffman RT (2001) : Principles of Appropriate Antibiotic Use for Acute Pharyngitis in Adults: Background, Ann Intern Med. 134: Woolford T.J., Ahmed A., Willat D J. et al (2000): Spontaneous resolution of tonsillitis of tonsillitis in children on the waiting list for tonsillectomy, clin. Otolaryngol. 25, Capper R., Canter RJ. (2001) : Is there agreement among general practitioners, paediatricians and otolaryngologists about the management of children with recurrent tonsillitis, Clin. Otolaryngol, 26, The cause of tonsillitis, Everett M.T. (1979) : The practitioner, Vol.223, Toner J.G., Stewart T.J., Campbell J.B. et al (1986): Tonsil flora in the very young tonsillectomy patient. Clin. Otolaryngol. 11, Address for Correspondence : Dr Kadambari Batra J-37, Sector 25, Noida