Accident and Emergency Nursing (2005) 13, 15–17

Accident and
Emergency
Nursing

www.elsevierhealth.com/journals/aaen

Sore throats
Anthony Summers Dip H E Nursing, Dip Critical Care Nursing
(inc ENB 199), Emergency Nurse Practitioner, BSc (Hons) Nursing

45 Higham Road, Wainscott, Kent ME3 8BE, UK

Received 1 March 2004; accepted 1 October 2004

KEYWORDS Summary This work looks at how a nurse practitioner can assess, diagnose and
Sore throat; treat a patient that presents to the Accident and Emergency (A&E) department with
McIsaac scoring; a sore throat. A brief look is taken at the common causes of sore throat. The reader
Nurse Practitioners is then introduced to a simple scoring system (McIsaac scoring) to determine
whether a patient requires antibiotics to treat their sore throat. A list is then given
of alternative diagnoses and how they should be treated.
c 2004 Elsevier Ltd. All rights reserved.

Sore throat those patients with sore throats whose treatment

Sore throat is a symptom associated with many dis-
eases, of which the most common are pharyngitis,
laryngitis and tonsillitis (Cross and Rimmer, 2002).
The management of all of these conditions is similar.
Patients with sore throats do not generally pre-
sent to Accident and Emergency (A&E) departments
except at times when their GP surgery is closed or if
they cannot get an early appointment. The diagnosis
and management of these conditions is, however,
usually straight forward and well within the compe-
tence and scope of the Nurse Practitioner (NPR).
This paper examines the causes of the sore
throat, and how the McIsaac score can be used as
a guide to its treatment. The paper also identifies
E-mail address: theuknurse@yahoo.co.uk.
lies outside the scope of NPR’s and what actions
should be taken to manage them.
Causes of sore throat
Viral agents cause about 50% of sore throats;
around 20% are caused by bacterial infection. No
clear cause can be found in the remaining 30%
(Cross and Rimmer, 2002). Most are viral agents
associated with upper respiratory tract infections
such as the common cold (Stephenson, 2000).
The commonest bacterial agent causing sore
throats is the group A b-haemolytic streptococcus
(GABHS) and it is those who present with this type
of infection that are most likely to respond to anti-
biotics (Cooper et al., 2001).


0965-2302/$ - see front matter c 2004 Elsevier Ltd. All rights reserved.
doi:10.1016/j.aaen.2004.10.008
16
Causes of non-infective sore throats include:
allergies, mouth breathing, gastrointestinal reflux,
post nasal drip, allergic rhinitis and other environ-
mental agents (Cross and Rimmer, 2002).
Where patients present with a chronic sore
throat, the irritant effects of excessive alcohol in-
take, smoking and malignancy should be ruled out.
In immuno-compromised patients, infection with
less common agents such as Candidia (thrush),
cytomegalovirus and herpes simplex can be the
cause of a sore throat. These conditions require
specialist treatment (Cross and Rimmer, 2002).
McIsaac scoring
McIsaac et al. (1998) proposed a scoring system for
determining which patients with sore throats would
benefit from antibiotics and to reduce the over pre-
scription of antibiotics to those in which there would
be no benefit. McIsaac’s initial study in 1998 in-
cluded 521 patients from a medical centre in Toron-
to with an age range of 3–76 years. Results showed
that there was a significant reduction in the amount
of unnecessary antibiotics prescribed when the scor-
ing system was used. From this study four clinical
signs were identified as being significant:
(1) Temperature >38 °C.
(2) Absence of a cough.
(3) Tonsillar swelling or exudate.
(4) Tender anterior cervical lymph nodes.
For each of these clinical signs that a patient
exhibited a score of one was given. Since throat
infection is more prevalent in the young, the scores
are adjusted for age. For patients of 15 years and
under +1 was added to the score. The scores of pa-
tients aged 15–44 years did not alter, and for those
of over 45 years 1 was deducted from their score.
Thus, according to the score it was decided
whether or not the patient should receive antibiot-
ics. Those with a score of <3 would not receive
antibiotics and were prescribed symptomatic treat-
ment. Those with a score of 3 or greater would re-
ceive a course of antibiotics.
Using this scoring system McIsaac et al. (1998)
found that bacterial infections could be accurately
identified. By using this score, prescriptions for
antibiotics could be reduced by 48%. Since there
is constant concern about the over-prescription of
antibiotics and the development of antibiotic
resistant bacteria, the consequent reduction in
unnecessary antibiotic prescriptions is important.
McIsaac et al. (2000) validated the scoring sys-
tem using both children and adults. In this study a
A. Summers
total of 621 children and adults from 49 Ontario
communities were assessed by family doctors and
their decisions as to whether to prescribe antibiot-
ics or not recorded. The results again showed that
the use of a scoring system was an accurate and
reliable method of determining the appropriate
management for patients presenting with sore
throats.
Treatment of sore throats
Patients who attend with simple pharyngitis, laryn-
gitis or tonsillitis, should have a McIsaac score of
<3. The treatment for these patients is reassurance
and advice about symptomatic relief. This advice
would include the drinking of plenty of fluids, and
the use of Paracetamol as an antipyretic and an-
algesic. The patient should see their GP if the pro-
blem persists.
The treatment for those patients with a McIsaac
score of 3 or greater is a course of antibiotics. The
current policy in the trust where the author works
is to prescribe Penicillin V 500 mg qds or Erythro-
mycin 250 mg qds for 10 days if allergic to penicillin
(Directorate of Pharmacy, 2001).
Exclusions for nurse practitioners
There are several types of sore throats that nurse
practitioners may not treat. These conditions are
listed below:
(1) Children of 5 years or under: This is because
children with sore throats often have diverse
symptoms that make them difficult to
diagnose.
(2) Quinsy: An abscess in the tissues of the poste-
rior pharynx. NPRs should refer all these cases
to the ENT SHO.
(3) Epiglottitis: Children that present with this
condition need to be kept calm and any exam-
ination in A&E kept to a minimum. Refer
patients to paediatrics urgently (Dolan and
Holt, 2000).
(4) Dysphgia: Painful swallowing – refer to A&E
doctor for assessment.
(5) Hoarseness of >2 week: Refer to A&E doctor
for assessment
(6) Recurrent throat infections: Consider referral
to A&E doctor or GP.
(7) Ulceration: Refer to A&E doctor for
assessment.
Sore throats
Diagnosis
A diagnosis needs to be made and recorded in all
patients presenting with sore throats. If only the
oropharynx is inflamed the diagnosis is pharyngitis.
If the main symptom is hoarseness, with discomfort
low in the throat and few signs of infection the
diagnosis is laryngitis. When the tonsils are in-
flamed the diagnosis is tonsillitis.
If one of these diagnoses cannot be made when
someone presents with a sore throat the patient
needs to be referred to an A&E doctor.
Conclusion
This report has reviewed the causes of sore throat
and highlights the fact that only 20% require antibi-
otics. The report confirms that by using a straight-
forward scoring system, patients who would
benefit from antibiotics can be identified.
By targeting those that need antibiotics, the
build up of antibiotic resistant bacteria in the com-
munity can be slowed.
17
The report looks at the exclusions included in
the protocol that would stop patients being seen
by the NPR. Finally, the three most likely diagnoses
that the NPR would be able to treat are given each
with a definition.
References
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