Sore throat (목앓이, 인후통) - KMLE 의학 서적: The Root of Ambulatory Care(외래 진료 지침서), 이진우

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 391 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 393 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. 395 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