What Is the Best Way to Treat Pharyngitis?

Sara Hunt, MSN, RN, PHN, FNP-C, is a licensed and board-certified family nurse practitioner, a public health nurse, an adjunct assistant professor of health policy, and a doctor of nursing practice student at the University of California, San Francisco. She was the spring 2015 health policy fellow at the American Association of Nurse Practitioners’ Government Affairs Office in Washington, DC.

Pharyngitis is one of the 10 most commonly reported chief complaints in primary care¹and retail health.²

There are many different causes of throat discomfort, but patients commonly associate a sore throat with an infection and may think that they need antibiotics. This unfortunately leads to unnecessary antibiotic prescribing when clinicians do not apply evidence-based practice. The vast majority of these patients, both adult and pediatric, will have a viral and not bacterial infection. Somewhere between 5% and 17% of tonsillopharyngitis in adults and 15% to 30% in children are caused by bacteria, most commonly group A β-haemolytic streptococcus (GABHS).³

Unfortunately, some providers may think that group GABHS can be diagnosed by appearance alone, but this is not true. Diagnostic tools such as the Center Score can help providers decide if a rapid strep test, culture, and/or antibiotics are warranted, but only a rapid strep test and culture can confirm an actual GABHS diagnosis. A recent metanalysis of 8 studies found that the presentation of group A strep (GAS) and non-GAS pharyngitis are similar.⁴Additionally, not all sore throats are infectious. Although pharyngitis can most certainly be caused by bacteria, fungi, or viruses, there are numerous other environmental and occupational causes.

It is estimated that up to 40% of these viral infections are caused by adenovirus and rhinovirus.⁵The others are coronavirus, coxsackievirus, cytomegalovirus, Epstein-Barr virus, herpes simplex virus, human immunodeficiency virus, influenza virus, and the parainfluenza virus.⁶

Although GABHS is the most common bacterial pharyngitis, it can also be caused byArcanobacterium haemolyticum, Chlamydophila psittaci,Corynebacterium diphtheriae, Francisella tularensis, Fusobacterium necrophorum,group C and G streptococci, mixed anaerobes,Mycoplasma pneumoniae, Neisseria gonorrhoeae, Treponema pallidum, Yersinia enterocolitica, and Yersinia pestis.⁶

Other causes of sore throats include:⁵

• Cold temperature and low humidity
• Exposure to occupational irritants, such as boron acid, dust, and oxide; chemical odors; crude oil spills; fluorinated hydrocarbons; machining coolants for those who work in the metal working industry; newspaper printing, such as filler materials, inks and organic solvents; nitrogen trichloride from indoor swimming pools; and organic screen-printing solvents
• Health conditions such as allergies, certain types of cancer, gastroesophageal disease, Kawasaki disease, postnasal drip, and thyroid disease⁷
• Medications, such as angiotensin-converting-enzyme inhibitors, chemotherapy agents, and inhaled corticosteroids
• Recent surgery, such as general anesthesia and laryngeal mask airway ortracheal intubation
• Shouting in those who work in certain occupations, such as aerobics instructors and school teachers
• Smoking
• Snoring and sleeping with the mouth open

Treatment

The main treatment for sore throats is comfort measures and treating the underlying cause.

Comfort measures include:

• Herbal supplements.Ingredients, such as licorice root, marshmallow root, and slippery elm root, might help soothe a sore throat.⁸These can be found in teas such as Traditional Medicinals Organic Throat Coat and Yogi Throat Comfort. One controlled double-blind randomized trial found that a mixture of coffee and honey can be highly effective at treating persistent post-infectious coughs, which in turn may help soothe a sore throat from coughing.⁹
• Humification.Dry air can make a sore throat worse, so using a humidifier or standing in a steamy shower can help alleviate throat pain.
• Hydration.Staying hydrated can keep mucus and mucus membranes moist; recover lost fluids from diarrhea, fever, sweating, and vomiting; and regulate body temperature. Fluids also can provide direct comfort for a sore throat. Cold and warm beverages, such as popsicles, tea, and water, can be soothing.
• Rest.It is important to rest the body to allow it to fight off infection and the throat to decrease irritation.
• Sore throat lozenges.There are many different types of lozenges available to soothe sore throats. Many contain numbing ingredients, such as benzocaine and menthol and may also contain pectin or sugar to act as demeculants.⁹Even plain hard candies can act as effective demeculants.¹⁰
• Warm salt water gargle. Adding a quarter to a half teaspoon (1.25 to 2.50 milliliters) of table salt to 4 to 8 ounces (120 to 240 milliliters) of warm water can help comfort a sore throat.⁸Children who are old enough to know how to gargle and spit, usually about 6 and older, and adults⁸can try this age-old solution.

References

1. Finley CR, Chan DS, Garrison S, et al. What are the most common conditions in primary care? Systematic review.Can Fam Physician. 2018;64(11):832—840.
2. Mehrotra A, Wang MC, Lave JR, Adams JL, McGlynn EA. Retail clinics, primary care physicians, and emergency departments: a comparison of patients' visits.Health Aff (Millwood). 2008;27(5):1272—1282. doi:10.1377/hlthaff.27.5.1272
3. Patel C, Green BD, Batt JM. Antibiotic prescribing for tonsillopharyngitis in a general practice setting: can the use of Modified Centor Criteria reduce antibiotic prescribing?Aust J Gen Pract. 2019;48(6):395-401.
4. Thai TN, Dale AP, Ebell MH. Signs and symptoms of Group A versus Non-Group A strep throat: A meta-analysis.Fam Pract. 2017;35(3):231-238. doi:10.1093/fampra/cmx072.
5. Renner B, Mueller CA, Shephard A. Environmental and non-infectious factors in the aetiology of pharyngitis (sore throat).Inflamm Res. 2012;61(10):1041—1052. doi:10.1007/s00011-012-0540-9
6. Anjos LM, Marcondes MB, Lima MF, Mondelli AL, Okoshi MP. Streptococcal acute pharyngitis.Rev Soc Bras Med Trop. 2014;47(4):409-413.
7. Shephard EA, Parkinson MA, Hamilton WT. Recognising laryngeal cancer in primary care: a large case—control study using electronic records.Br J Gen Pract. 2019;69(679):e127-e133. doi:10.3399/bjgp19x700997.
8. Mayo Clinic. Sore throat. mayoclinic.org/diseases-conditions/sore-throat/diagnosis-treatment/drc-20351640. Accessed August 8, 2019.
9. Raeessi MA, Aslani J, Raeessi N, Gharaie H, Zarchi AA, Raeessi F. Honey plus coffee versus systemic steroid in the treatment of persistent post-infectious cough: a randomised controlled trial.Prim Care Resp J. 2013;22(3):325-330. doi:10.4104/pcrj.2013.00072.
10. Fookes C. Sore throat remedies and treatments.Drugs.com.Updated July 9, 2019. drugs.com/slideshow/sore-throat-1105. Accessed August 8, 2019.