Sore Throat And/Or Rhinorrhea

Introduction

Sore throat and rhinorrhea are common presenting symptoms in primary care settings across Canada. As a future Canadian physician preparing for the MCCQE1, it's crucial to understand the etiology, diagnosis, and management of these conditions within the Canadian healthcare context.

Epidemiology in Canada

• Sore throat accounts for 1-2% of all ambulatory care visits in Canada
• Upper respiratory tract infections (URTIs) are the most common reason for acute care visits in Canadian primary care settings
• Seasonal variations: Peak incidence during winter months (December to February)

Etiology

Clinical Presentation

Sore Throat

• Pain or discomfort in the throat, often worse when swallowing
• Erythema of the pharynx and tonsils
• Cervical lymphadenopathy
• Fever (more common in bacterial infections)

Rhinorrhea

• Clear or colored nasal discharge
• Nasal congestion
• Postnasal drip
• Associated symptoms: headache, cough, facial pain

Diagnosis

Canadian Guidelines for Management

Sore Throat

1. Viral Pharyngitis

   • Symptomatic treatment: analgesics, throat lozenges, warm salt water gargles
   • Avoid antibiotics

2. Bacterial Pharyngitis (Group A Streptococcus)

   • Antibiotics if confirmed by RADT or culture
   • First-line: Penicillin V 300 mg PO QID for 10 days
   • Alternatives for penicillin allergy: Cephalexin, Clindamycin, or Macrolides

Rhinorrhea

1. Viral Rhinosinusitis

   • Symptomatic treatment: nasal saline irrigation, decongestants (short-term use)
   • Avoid antibiotics unless bacterial superinfection suspected

2. Allergic Rhinitis

   • Intranasal corticosteroids (e.g., Fluticasone)
   • Oral antihistamines (e.g., Cetirizine)
   • Allergen avoidance strategies

Key Points to Remember for MCCQE1

1. Most cases of sore throat and rhinorrhea are viral and self-limiting
2. Use Centor criteria to assess the likelihood of Group A Streptococcal pharyngitis
3. RADT is recommended for suspected bacterial pharyngitis before antibiotic prescription
4. Antibiotics should be prescribed judiciously, following Canadian antibiotic stewardship principles
5. Consider environmental factors specific to Canadian regions (e.g., seasonal allergies, cold dry air)
6. Familiarize yourself with Canadian guidelines for upper respiratory tract infections management

CanMEDS Roles Application

• Medical Expert: Accurately diagnose and manage sore throat and rhinorrhea
• Communicator: Explain the viral nature of most cases to patients, justifying the decision not to prescribe antibiotics
• Collaborator: Work with pharmacists and nurse practitioners in managing these common conditions
• Leader: Implement antibiotic stewardship practices in your future clinical settings
• Health Advocate: Educate patients on prevention strategies and appropriate use of over-the-counter medications
• Scholar: Stay updated on the latest Canadian guidelines for upper respiratory tract infections
• Professional: Practice ethical decision-making in antibiotic prescription

Sample Question

A 28-year-old woman presents to your family practice in Toronto with a 3-day history of sore throat, rhinorrhea, and low-grade fever. She denies cough or shortness of breath. On examination, her temperature is 38.1°C, and her oropharynx shows erythema with tonsillar exudates. Tender anterior cervical lymphadenopathy is present. Which one of the following is the most appropriate next step in management?

• A. Prescribe amoxicillin 500 mg PO TID for 7 days
• B. Perform a rapid antigen detection test for Group A Streptococcus
• C. Order a throat culture and wait for results before treating
• D. Prescribe symptomatic treatment and reassure the patient
• E. Refer the patient to an ENT specialist

Explanation

The correct answer is:

• B. Perform a rapid antigen detection test for Group A Streptococcus

This patient presents with symptoms suggestive of acute pharyngitis, which could be viral or bacterial. Given the presence of fever, tonsillar exudates, and cervical lymphadenopathy, there's a possibility of Group A Streptococcal (GAS) pharyngitis. In line with Canadian guidelines, the most appropriate next step is to perform a rapid antigen detection test (RADT) for GAS.

• A is incorrect because antibiotics should not be prescribed empirically without confirming bacterial etiology, especially in the context of antibiotic stewardship.
• C is not the best option as RADT provides quicker results and is recommended as the first-line test in Canadian practice.
• D is premature without ruling out GAS pharyngitis, which would require antibiotic treatment if confirmed.
• E is unnecessary at this stage, as pharyngitis can typically be managed in primary care settings.

This question tests your knowledge of the appropriate diagnostic approach to sore throat in the Canadian healthcare context, aligning with MCCQE1 objectives and the CanMEDS Medical Expert role.

References

1. Allen UD, et al. The use of antibiotics for viral upper respiratory tract infections: Canadian Paediatric Society. Paediatr Child Health. 2018;23(8):517-518.
2. Choosing Wisely Canada. "Otolaryngology: Ten Things Physicians and Patients Should Question." https://choosingwiselycanada.org/recommendation/otolaryngology/ (opens in a new tab)
3. Public Health Agency of Canada. "Canadian Antimicrobial Resistance Surveillance System Report 2020." https://www.canada.ca/en/public-health/services/publications/drugs-health-products/canadian-antimicrobial-resistance-surveillance-system-2020-report-summary.html (opens in a new tab)
4. Respiratory Health Strategic Clinical Network. "Primary Care Management of Acute Rhinosinusitis." Alberta Health Services, 2019.
5. The College of Family Physicians of Canada. "Antibiotics for Acute Upper Respiratory Tract Infections." Choosing Wisely Canada, 2021.