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Symptomatic Treatment for Acute Pharyngitis

Roberts, James R. MD

InFocus: Part VI in a Series

For those loyal readers who have waded through months of discussions on the etiology, diagnosis, and treatment of acute pharyngitis, your patience is about to be rewarded with a practical rather than theoretical discourse on a subject near and dear to every patient's heart: the relief of pain.

Dr. Roberts is the chairman of the department of emergency medicine and the director of the division of toxicology at Mercy Health Systems and a professor of emergency medicine and toxicology at Drexel University School of Medicine/The Medical College of PA/Hahnemann University in Philadelphia.

Almost every pain study comes up with the same disappointing conclusion: Physicians do a poor job at relieving pain, and strep throat is no exception

A compendium of Dr. James Roberts' InFocus columns is available in book form. The 302-page volume, InFocus: Roberts' Practical Guide to Common Medical Emergencies, is available from Lippincott Williams & Wilkins for $49.95 by calling (800)638–3030.

Emergency physicians are often frustrated by their inability to make pinpoint diagnoses for a number of complaints, and often our years of experience and clinical acumen are used merely to point the patient in the right direction or begin therapy for the most likely pathology. One thing we can do, however, is relieve pain, and we should be better at pain relief than any other physician on the hospital staff. Patients generally couldn't care less about the nuances of the microbiology of their sore throats, but they certainly care a great deal about how they feel once they leave the department. Therefore, the sagacious clinician will spend a significant amount of time and effort to make patients feel better faster.

Almost every pain study, even those done recently, that looks at the way physicians approach pain relief comes up with the same disappointing conclusion: Physicians do a poor job at relieving pain. We underuse analgesics, even when the diagnosis is crystal clear, by doling out minuscule amounts of narcotics, under-utilizing nerve blocks and local anesthetics, and by giving pain control a brief once-over just prior to discharge or admission. “Symptomatic care” is probably the vaguest and certainly the shortest chapter in any medical textbook, but this topic should head the list of “things that make the doctor look good.”

This month's column will focus on the specific issue of how to relieve pain in the patient with acute pharyngitis. Most textbooks indicate that pharyngitis should be treated symptomatically, and that annoys me no end. When left as such, the author assumes that everyone knows how to do it adequately or that it is almost an afterthought in the overall scheme. Ask any resident to explain symptomatic care by giving specifics, and that will be a brief discourse indeed. I was quite disappointed when I reviewed the literature on the topic of pain relief for pharyngitis because I could find very little that specifically addressed the issue. Lots of stuff on throat cultures, little or none on pain relief. Most of what I will discuss has been gleaned through personal experience, and is flavored with my own particular biases. I would urge readers to send in any tricks of the trade or caveats they have discovered that are not included in the following discussion.

Dexamethasone as Adjuvant Therapy for Severe Acute Pharyngitis, O'Brien J, et al, Ann Emerg Med, 1993:222:215

The authors of this paper attempted to determine the efficacy of a single 10 mg IM dose of dexamethasone (Decadron) as adjuvant therapy to pain relief for severe, acute exudative pharyngitis. It was a prospective randomized, double-blinded, placebo-controlled trial that was conducted in a large, urban community hospital emergency department. Eligible subjects were between 12 and 65, all had visible pus on the tonsils, and all complained of severe odynophagia. Patients with cancer, diabetes, AIDS, previous steroid use, suspected peritonsillar abscess, or ulcerated pharyngitis were excluded. The treatment variable consisted of a 10 mg IM dose of dexamethasone or saline placebo. All subjects were treated with antibiotics, either penicillin or erythromycin. Interestingly, no throat cultures were performed, and no diagnostic studies were done to differentiate pathogens.

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At the beginning of this study, patients graded their pain on visual analog scales, and follow-up was obtained via questionnaire, telephone call, return visit, or mail-in questionnaire. Upon entry into the study, the groups were similar in their initial pain scores. Follow-up was obtained on 51 patients, and all subjects exhibited a significant improvement in their pain score within 24 hours, regardless of study intervention. Those receiving steroids demonstrated greater pain relief than those receiving placebo, demonstrated by a statistically significant reduction in pain score. Those receiving steroids reported onset of pain relief to be faster than placebo (6.3 hours vs. 12.4 hours for controls). Likewise the steroid-treated patients were free of pain sooner than the placebo group (15 vs. 35 hours respectively). There were no side effects from the dexamethasone and rescue analgesic use was similar in type, strength, and number of doses in the two groups.

The authors note that because antibiotics fail to provide prompt symptomatic relief in patients with acute exudative pharyngitis, a method to provide rapid and potent pain relief would be highly desirable. They believe that the type and dose of steroid administered in this study provided such benefit. Overall, patients treated with dexamethasone felt better faster, and they were totally pain-free more rapidly. The single dose of dexamethasone was chosen because of a half-life of 40 to 70 hours and a high anti-inflammatory profile. The authors believe that the pharmacokinetics of dexamethasone provide a physiological taper over five to seven days following a single dose. Patients in this study were considered to have severe symptoms, and the study was not designed to demonstrate a benefit in the less painful cases. Interestingly, cultures were not done and the benefit was similar regardless of etiology, be it bacterial or viral.

Physicians underuse analgesics, even when the diagnosis is clear, by doling out minuscule amounts of narcotics, under-utilizing nerve blocks and local anesthetics, and by giving pain control a brief once-over prior to discharge

Comment: The authors note that corticosteroids have been shown to reduce the severity of croup and bronchospasm, two conditions where inflammation has been recognized as an important etiology of symptoms. This article seems to be the first scientific approach that evaluates steroid therapy for acute pharyngitis, although anecdotal recommendations for such treatment have existed for a number of years.

This study was quite small, with only about 25 patients per group, and although the results were statistically significant, the differences were actually quite modest, and all patients improved quickly. On a 15 cm visual pain scale at 24 hours, the reduction in pain was only 1.8 cm in the dexamethasone group compared with 1.2 in the placebo group. I am somewhat confused by this statistic because it appears that although the pain score still demonstrated the existence of some pain at 24 hours, the mean time to complete lack of pain averaged 15 hours in the treatment group. That barely reaches statistical significance. However, the conclusion was that Decadron appeared to be helpful, and there was no suggestion that it was harmful.

Our otolaryngology colleagues have kept secret their routine use of steroids for acute ENT pain, but emergency physicians are now on to them. Many of my colleagues have adopted this therapeutic tactic, and routinely administer this protocol to patients with severe symptoms. A single IM injection appears to be the way to go, and I see no compelling reason to provide follow-up steroids or choose an oral preparation. I would give it IV if you are already infusing fluids. I see no downside to steroids used in this manner, although I'm not at all convinced that it is a miraculous cure. However, every little bit helps, and I see no reason why the intervention should not be routinely considered for those in agony. The reader is reminded of the remarkable curative properties initially attributed to corticosteroids in many diseases from head trauma to septic shock, but many of these claims have had their initial shine tarnished with larger scientific studies. However, steroids for a bad sore throat have been touted as beneficial by other authors, and many physicians have now incorporated this drug into their practice. While not for every minor sore throat, there is analgesic benefit (albeit modest) from steroids with no downsides.

Steroids for a bad sore throat have been touted as beneficial, and while not for every minor sore throat, there is a modest benefit from steroids with no downsides

Marvez-Valls et al (Acad Emerg Med 1998;5:567) also demonstrated a minimal beneficial effect of the steroid betamethasone over placebo on the course of pain in acute exudative pharyngitis. In their study, a single 2 ml IM injection of Celestone was used in conjunction with antibiotics. Patients felt better at 24 and 48 hours with the steroid treatment, and the effect seemed to be more pronounced in those with a positive culture for strep. Again, there is no magic bullet for the misery of a strep throat, but parenteral steroids do appear to be somewhat helpful.

Studies have demonstrated that antibiotics do, in fact, hasten the relief of pain in a strep throat. The archaic practice of doing a culture and then waiting for 24 to 48 hours to begin antibiotics because “the course is similar with or without treatment” has been proven to be erroneous. Antibiotics do help relieve pain, even if it is only by a few hours.

So-called “symptomatic treatment” of acute pharyngitis requires further comment. In my mind, the number one strategy — bar none — for the relief of acute pain is the judicious use of narcotic analgesics. For some reason, many emergency physicians are reluctant to use narcotics for anything except myocardial infarction or fractured bones, and those few brave souls who are extremely courageous and generous often drop the ball when it comes to proper dosing. If one feels compelled to give 25–50 mg of IM Demerol or 2–4 mg of IM morphine, they best give it to the intern, ward clerk, or medical student because such a minuscule dose does little for someone in severe pain except make them a bit euphoric (or nauseated).

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If one is serious about relieving the pain of acute pharyngitis, real analgesics in adequate doses should be dispensed. Probably the best way to convince a physician that acute pharyngitis deserves narcotics is for the doctor to be infected himself. Then watch how quickly he reaches for Percodan or Vicodin. Everyone has his own favorite narcotic analgesic so I will not attempt to dissuade anyone from a preferred regimen. The bottom line is that serious pain relief begins in the ED (by giving the actual medication, not by merely giving a prescription).

NSAIDs and non-narcotic OTC analgesics are fine after the first day or two, but serious drugs (AKA narcotics) should be used by physicians who want to relieve serious pain. I usually prefer an initial IM/IV narcotic with a few oxycodone/hydrocodone tablets to go. This negates the need for an already miserable patient to have to stop at a drug store, the problems of prescription altering, call backs from the drug store for illegible handwriting, forgetting the DEA number, and so on. If one opts for this approach, coupled with my favorite antibiotic regimen, IM benzathine penicillin, the patient goes right from the ED to their bedroom in a slightly narcotized state, bypassing an hour wait in an crowded drug store and fighting with the clerk about their ever-dwindling prescription plan while infecting the entire store.

Because many patients are unable to swallow liquids, they are frequently mildly dehydrated if they have been putting up with their acute pharyngitis for a few days. I have never seen it studied, but I'm convinced that a liter or two of saline over a few hours — a very safe regimen in young healthy patients — does wonders for symptomatic relief. IVs also have a tremendous placebo effect. Likewise, one always feels better when the temperature is 99°F vs. 103°F, and therefore antipyretics should be given in the ED with specific instructions about timing and subsequent dosing for effective fever control at home.

Topical anesthetic sprays are frequently used, and although patients seem to love the brightly colored flavored OTC concoctions for a scratchy throat from a viral URI, I question their value in strep throat. They are benign but consist mainly of a flavored syrup, spray, or lozenge mixed with menthol (Cepacol) or phenol (Chloraseptic). Some clinicians try for more potent topical pain relief, but in my experience a totally numb throat produces a very distressing feeling to many individuals; they feel they can't swallow their saliva and sense that they are gagging on their own secretions.

Remember that oral viscous lidocaine when swallowed or when applied topically for even short periods of time to an inflamed area is absorbed systemically. Viscous lidocaine is supplied in a 2% gel — 20 mg/ml — so a teaspoon contains 100 mg of absorbable lidocaine. Because the analgesic effect is very transient, it doesn't take long for a patient to become lidocaine toxic if he is given a prescription or bottle of this preparation to take as needed. If the patient is not properly instructed and swallows the topical, the average adult gulp — 15 mls — results in an ingestion of 300 mg of lidocaine. I would similarly caution about the use of Cetacaine, a preparation containing mostly benzocaine (20%). If you use it enough, you will run across a case of methemoglobinemia simply from spraying the throat a few times. Lidocaine spray comes in a 10% metered dose spray bottle that dispenses only 10 mg of lidocaine per puff. This is a good choice for one-time acute relief in the ED, but prolonged prescription topical anesthetics for a sore throat should be avoided.

There are a number of anecdotal interventions or home remedies that have been advocated over the years. I could find no scientific evaluations for most of them. Gargling with warm salt water seems to be an omnipresent recommendation, and some swear by it. When I tried it for my post-operative sore throat, it worked wonders, and I carried around my bottle of warm Evian water with a tablespoon of salt, and used it every 15–20 minutes. Gargling with aspirin is another home remedy that has been advocated, but there is no great benefit of applying this anti-inflammatory topically. It's probably a good drug to swallow for mild analgesia and temperature control, but gargling with aspirin should probably be forgotten. Patients also seem to like lozenges or other forms of soothing topicals, but I believe that they have more of a placebo effect than a real benefit. Some colleagues have used Tessalon Perles, round beads containing a topical anesthetic similar to tetracaine. The beads are bitten, and the liquid is held in the back of the throat and then swallowed. My wife thinks tea with honey and lemon is a cure-all. It may temporarily soothe the raw throat, especially if you add a generous shot of bourbon.

I could find no good article on the universally recommended “symptomatic treatment.” This is disappointing, and I'm particularly annoyed when textbooks recommend “symptomatic” treatment, and leave it at that. This often is interpreted as “nothing works.”

As with most other painful conditions, physicians tend to under use pain medications because of the misconception that toxicity is common and drug addiction even more common. Those doctors who refuse to prescribe reasonable doses of narcotics for the patient with a severe strep throat quickly rethink their dogma when they develop a similar infection.

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