Sore throat (목앓이, 인후통)

The Root of Ambulatory Care
- 저 자 : 이진우
- 출 판 : 군자출판사
- 페이지수: 543면
이진우 선생님, 군자출판사와 제휴를 통해 책 내용 및 그림을 제공합니다.
무단 복제/배포 금지.
KEYWORDS:
..More common in childhood, adolescence and young adulthood.
Infectious (common)
i. Viral : most common-all ages, all seasons but more prevalent during winter
ii. Bacterial : most important-group A β-hemolytic streptococci (most common
from ages 5 to 15years)
iii. Fungal : candida
Environmental (common)
Smoking, Smog, Dust allergens
Drainage from above/below
i. Postnasal drip
ii. GERD
Rare causes
i. Hypothyroidism/hyperthyroidism
ii. Thyroiditis
iii. Foreign body
iv. Leukemia, agranulocytosis
v. Diphtheria
vi. Gonorrhea in 10% of patient with anogenital gonorrhea
Sore throat with pharyngeal ulcers
i. Ganker sores (aphthous stomatitis)
ii. Herpangina
iii. Herpes simplex
iv. Fusospirochetal infection
Sore throat
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The Root of ambulatory care
v. Candidiasis
vi. Herpes zoster
vii. Chicken pox
viii. Primary or secodndary syphilitic ulcerations (usually not painful)
1. Inspection : pharyngeal erythema, enlargement of tonsils, asymmetry, position of
uvula, exudates, pseudomembrane, enanthema, postnasal drip,
posterior or lateral swelling, ulcers
2. Palpation :
..Enlarged and tender anterior cervical nodes → bacterial infection
..Enlarged and tender posterior cervical nodes → viral infection
..Throat inspection normal → check thyroid gland
3. Rapid strep test/CBC/ Throat culture → if high risk for complications (DM,
rheumatic fever history, outbreak of a nephrogenic strain)
Lat neck radiography → if drooling exists (epiglottitis?)
CT/MRI → if retropharyngeal or peritonsillar abscess
In patients whose clinical picture is consistent with influenza, common cold, or irritants,
no further laboratory tests are needed.
..Cough, rhinorrhea, conjunctivitis, diarrhea등의 증상이 동반된다면 Streptococcal
infection의 가능성보단 Irritants, Allergies, viral infection의 가능성이 높다.
..Pharyngeal exudates is not diagnostic for strep tonsillitis ; only 50% of patients
with strep throat have exudates, and, of all patients with exudate, only 50% have
strep throat.
Key tests
Sore throat
MCISAAC Modification of the Center Strep Score
1. Add points for patient
Symptom or sign Points
History of fever or measured temperature > 38℃ (100.4℉) 1
Absence of cough 1
Tender anterior cervical adenopathy 1
Tonsillar swelling or exudates 1
Age < 15 years 1
Age ≥ 45 years -1
2.Find risk of strep
Points LR % with Strep(patients with strep/total)
-1 or 0 0.05 1 (2/179)
1 0.52 10 (13/134)
2 0.95 17 (18/109)
3 2.5 35 (28/81)
4 or 5 4.9 51 (39/77)
Fig 1. Bacterial/Viral tonsillitis
Nonbacterial / Viral
Monitor at home,
gargle with salt water
Red
swollen
tonsils
Throat
redness
Throat
redness
Gray
furry
tongue
Red swollen
tonsils
Whitish
spots
Swollen uvula
Bacterial
Come to the
Health Center
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The Root of ambulatory care
None or one present
Symptomatic Treatment ;
consider other causes
Perform rapid antigen
detection test
Treat symptoms and
send throat specimen
for culture
Two or three present All four present
Treat with antibiotics
No penicillin allergy Penicillin allergy
First line therapy ;
penicillin or amoxicillin
First line therapy ;
erythromycin
Clinical failure
Questions about
compliance
Penicillin G benzathine
Second line therapy:
amoxicillin-clavulanate
potassium, azithromycin,
cephalosporin
Number of signs and symptoms present :
1)Lack of cough
2)History of fever
3)Tonsillar exudate
4)Swollen, tender anterior lymph nodes
Negative test
Negative test Positive test
or
Fig 2. Suggested algorithm for the diagnosis and treatment of sore throat
Key treatments
Sore throat
1. Viral : Symptomatic therapy (aspirin/acetaminophen in children, lozenges, salt
water gargling, plenty of fluids)
2. Bacterial : Antibiotics therapy
..Amoxicillin.. 500mg 1C, 1C tid
..Amocla.. 250/125mg 1T, 1~2T tid
..NSAIDs/Acetaminophen
..Gargle/Troche
..Antihistamine agents if needed
3. Candidiasis : see oral thrush
Retropharyngeal or peritonsillar abscess may require surgery and IV Clindamycin
or Nafcillin.
..Amocla.. - amoxicillin/clavulanate
..Bacterial origin인 경우 고열, 전신권태, 인후통 등의 증상 소실 후에도 3일간
추가 투여가 요구된다.
Peritonsillar abscess
- Streptococcal infection시 suppurative complication (e.g., peritonsillar abscess)와 immune
complications (e.g., glomerulonephritis)의 발생빈도는 항생제 사용여부와 상관없이 낮은
편이다.
- 주로 20~40대에 많이 생기며, S. pyogens, S. aureus, H. influenzae, Anaerobes 등이
주 원인균이다.
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The Root of ambulatory care
- Physical examination : muffled“ hot potato”voice, trismus (difficulty opening the mouth),
erythematous, swollen tonsil pushing the uvula to the opposite side.
- Diagnosis : needle aspiration of pus from abscess
- Treatment : Clindamycin or 2nd/3rd generation cephalosporin
참고 문헌
Cynthia S. Hayes, M.D., M.H.A., Harold Williamson, JR., M.D., M.S.P.H. : Management of Group A Beta-
Hemolytic Streptococcal pharyngitis. A journal of the American Academy of Family Physicains 2001
;63 : 1557-1564, 1565
L. Peter Schwiebert, M.D. : Sore throat, in A Lange clinical manual Family Medicine Ambulatory Care
& Prevention, 4th ed, Mark B. Mengel, M.D., L. Peter Schwiebert M.D. (ed). United States of
America, The McGrwa-Hill Companies, Inc., 2005, P 353-359
Frank C. Burwick : Sore throat, in Saunders Manual of Medical Practice, 2nd ed, Robert E. Rakel(ed).
Philadelphia, Saunders, 2000, P 150-152
심경원 : 목의 통증, in 가정의학 임상편. 서울, 계측문화사, 2002, P 724-727
안회영 : 최신임상이비인후과학. 서울, 군자출판사, 2005, P 149