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Chapter 14. Sore Throat
Using throat culture to confirm negative RADT is reserved
for patients who are at higher risk for severe infection or
complications, patients in close contact with individuals at
high risk for complications, patients living in college dormitories or other settings, and patients living in an area where
acute rheumatic fever is endemic [1].
283
Treatment
Group A strep pharyngitis is self-limited and resolves without
treatment; however, treatment (Figs.14.3 and 14.4) is to prevent complications which include suppurative (bacteremia,
cervical lymphadenitis, endocarditis, mastoiditis, meningitis,
otitis media, peritonsillar/retropharyngeal abscess, and pneumonia) and nonsuppurative (poststreptococcal glomerulonephritis and rheumatic fever).
Sulfonamides, fluoroquinolones, and tetracyclines have a
high rate of resistance and failure to eradicate the organisms
from the pharynx.
Patients with GAS generally improve within 3–4days and
are no longer contagious after 24h of antibiotics.
284
Patient with sore throat
Risk of
GAS
phar
1 to 2.5%
No antibiotics indicated Treat with antibiotics
c
L. Ciuffo
Apply streptococcal score
Score < 0
yngitis
No further
testing or
antibiotics
indicated
Criteria
Absence of cough
Swollen and tender anterior
cervical nodes
Temperature > 100.4˚F (38˚C)
Tonsillar exudates or swelling
Age
3 to 14 years
15 to 44 years
45 years and older
Cumulative score:
Score = 1 Score = 2 Score = 3 Score > 4
Risk of
GAS
pharyngitis
5 to 10%
Perform throat culture or RADT
Risk of
GAS
pharyngitis
11 to 17%
Option
Points
1
1
1
1
1
0
–1
Risk of
GAS
pharyngitis
28 to 35%
Risk of
GAS
pharyngitis
51 to 53%
Consider empiri
treatment with
antibiotics
Negative
F . Modified Centor score and management options using
clinical decision rule. Other factors should be considered (e.g., a
Positive
score of 1, but recent family contact with documented streptococcal
infection). GAS group A beta-hemolytic streptococcus, RADT rapid
antigen detection testing [7, 12]
Antibiotic Options for Group A Strep pharyngitis (#1, #4, #8, #13# 14)
Drug Class of Antimicrobial Route of Administration Dosage Duration
Penicillin
Penicillin G benzathine
Amoxicillin
Cephalexin
Clindamycin
Clarithromycin
Azithromycin
e500 mg x day 1 followed by 250
mg xdays 2-5
Chapter 14. Sore Throat
Penicillin PO 500 mg bid 10 days
Penicillin IM 1,200,000 Units
Broad Spectrum Penicillin PO 500 mg bid 10 days
Cephalosporin PO
Lincomycin 300 mg tid 10 Days
Macrolide 250 mg bid 10 Days
Macrolid
PO
PO
PO
500 mg bid 10 days
285
x 1 dose
F . Antibiotic options for group A strep pharyngitis [1, 4,
9–11]
Symptomatic Treatment
Systemic oral therapy is effective at reducing the pain of
acute pharyngitis. Acetaminophen and nonsteroidal antiinflammatory drugs (NSAIDs) remain the two most studied. NSAIDs appear to be more effective than acetaminophen.
Topical therapies are an alternative for patients who are at
higher risk for side effects from it. The use of glucocorticoids for the treatment of sore throat pain is generally not
suggested due to the potential for serious side effects compared with the slight reduction in the duration of sore throat
pain [12].
Clinical Pearls
• Use the modified Centor Score to guide testing.
• Rapid antigen detection tests should be reserved for con-
cern about starting antibiotics [6].
• Throat culture remains the standard for bacterial pharyn-
gitis [6].
• Empirical antibiotic use should be limited to patients who
are severely ill and no improvement within 5 days of
presentation.
286
L. Ciuffo
• Red flags include rigors, inability to swallow, stridor, muf-
fled voice, respiratory distress, and tripod position.
Don’t Miss This
• Evaluate for serious complications in patients presenting
with drooling, dysphonia, muffled voice, and neck
swelling.
References
1. McIntosh K, etal. Covid–19: clinical features. Up to Date. 2 Apr
2021.
2. Sykes Edward A, etal. Pharyngitis. Approach to diagnosis and
treatment. Can Fam Physician. 2020;66(4):251–7.
3. Chow AW, Doron S. Evaluation of acute pharyngitis in adults.
Up to Date. 21 Sept 2020.
4. Lovato A, Giacomo R, Cosimo d F. Sore throat in covid–19.
Comment on “Clinical characteristics of hospitalized patients
with SARS-CoV-2 infection”. J Med Virol. 2020;92(7):714–5.
5. Shulman ST, Bisno AL, etal. Clinical practice guidelines for the
diagnosis and management of Group A Streptococcal pharyngitis. 2012 update by the Infection Disease Society of America.
Clin Infect Dis. 2012;55(10):e86–102.
6. Stewart EH, etal. Rapid antigen group a streptococcus test to
diagnose pharyngitis: a systematic review and meta-analysis.
PLoS One. 2014;9(11):e111727.
7. Stead W, etal. Symptomatic treatment of acute pharyngitis in
adults. Up to Date. 22 Mar 2021.
8. Glezen WP, Clyde WA Jr, Senior RJ, etal. Group A streptococci,
mycoplasmas and viruses associated with acute pharyngitis.
JAMA. 1967;202:455–60.
9. Huovinen P, Lahtonen R, Ziegler T, etal. Pharyngitis in adults
the presence of coexistence of viruses and bacterial organisms.
Ann Intern Med. 1989;110:612.
10. Vincent Miriam T, et al. Pharyngitis. Am Fam Physician.
2004;69(6):1465–70.
Chapter 14. Sore Throat
11. Snow V, Mottur-Pilson C, Cooper RJ, etal. Principals of appropriate antibiotic use for acute pharyngitis in adults. Ann Intern
Med. 2001;134:506.
12. McIsaac WJ, White D, Tannenbaum D, Low DE.A clinical score
to reduce unnecessary antibiotic use in patients with a sore
throat. CMAJ. 1998;158(1):79.
287
Chapter 15
Sleep Apnea
JhansiNalamati andDushyantDamania
Introduction
Sleep disorders are very common in the primary care setting.
Sleep deficiency/deprivation is a common health problem in
the United States. Prevalence of obstructive sleep apnea
(OSA) is estimated to be around 3% among women and 10%
among men 30–49years of age; and 9% among women and
17% among men 50–70years of age, with approximately ~24
million undiagnosed [1–3]. Based on the International
Classification of Sleep Disorders (ICSD-3), insomnia is the
most common sleep disorder in the general population followed by sleep-disordered breathing, including obstructive
sleep apnea/hypopnea syndrome and central sleep apnea [4].
J. Nalamati (*) · D. Damania
Department of Medicine, NYP Hudson Valley Hospital, Cortlandt
Manor, NY, USA
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2022
E. Sydney et al. (eds.), Handbook of Outpatient Medicine,
https://doi.org/10.1007/978-3-031-15353-2_15
289
290
J. Nalamati and D. Damania
ICSD3 Classifies Sleep Disorders into Seven Major Categories [4]
1. Insomnia
2. Sleep-disordered breathing disorders
3. Central disorders of hypersomnolence
4. Circadian rhythm sleep-wake disorder
5. Parasomnias
6. Sleep-related movement disorder
7. Other sleep disorders
Sleep apnea is classified as obstructive sleep apnea/hypop-
nea syndrome (OSAHS) and central sleep apnea (CSA).
Prevalence
Obstructive sleep apnea prevalence varies widely, with 9–38%
having OSA (AHI 5 events/h). It is also seen more in men
and in the elderly. Moderate to severe forms of OSA with an
apnea-hypopnea index (AHI of 15 events/h) in the general
population ranged from 6 to 17% and as high as 49% with
advanced age [5].
Sleep History
In addition to general medical, surgical, family, caffeine
intake, and medication history (specifically herbal remedies
or over-the-counter medications), the focused sleep history
should include a general question about excessive daytime
sleepiness (EDS) or fatigue (including history of sleepiness
while driving and accidents), difficulty falling asleep at night
or maintaining sleep, sleep latency, snoring, nocturnal awakenings, witnessed apneas, sleeping position (lateral, supine, or
prone), resuscitative snorts, restless legs, limb movements
(noted by the partner), bedtime, wake time, daytime naps,
sleep paralysis, and cataplexy.
Chapter 15. Sleep Apnea
291
Screening Questionnaires toAssess theRisk
ofOSA
Commonly used questionnaires to assess the risk of OSA are
the Epworth sleepiness score with STOP-Bang questionnaire
[6, 7].
STOP-Bang Questionnaire
S Snoring
T Tired or sleepy
O Observed apneas
P Pressure (hypertension)
B BMI >35
A Age>50years
N Neck circumference>16in. in men and
15in. in women
G Gender: Male
0–2, low risk of OSA; 3–4, moderate risk of OSA; and 5–8, high risk
of OSA
Adapted from Chung F, Subramanyam R, Liao P, Sasaki E, Shapiro
C, Sun Y. High STOP-Bang score indicates a high probability of
obstructive sleep apnoea. Br J Anaesth. 2012 May;108(5):768–75.
https://doi.org/10.1093/bja/aes022. Epub 2012 Mar 8. www.stop-
bang.ca
Epworth sleepiness score (ESS) is the most widely used in
clinical practice to evaluate the severity of sleepiness.
Developed by Murray Johns at Epworth Hospital in
Melbourne, Australia, this validated an eight-item questionnaire about the person’s chance of dozing in differing circumstances. Dozing probability is designated as none (0), slight
[1], moderate [2], or high [3] for eight situations [8], which are
sitting and reading, watching TV, sitting inactive in a public
place, being a passenger in a car for an hour, lying down in the
292
J. Nalamati and D. Damania
afternoon, sitting and talking to someone, sitting quietly after
lunch with no alcohol, and stopping for few minutes in traffic
while driving.
Understanding ESS Score
0–10 Normal range in healthy adults
11–14 Mild sleepiness
15–17 Moderate sleepiness
18 or higher Severe sleepiness
Focused Physical Exam
Attention should be paid to the pharyngeal examination.
Increased BMI is a risk factor for OSA, especially when associated with short neck or increased neck circumference.
Overall, narrowed pharyngeal space, in addition to enlarged
tonsils and adenoids, increases the risk of OSA.Craniofacial
abnormalities also increase the risk of obstructive sleep
apnea/hypopnea syndrome (OSAHS), as do abnormalities
associated with reduced pharyngeal space [9].
OSA/SDB (Obstructive Sleep Apnea/SleepDisordered Breathing)
Definition
OSA is defined by repetitive complete obstruction (apnea) or
partial obstruction (hypopnea) of the collapsible part of the
upper airway during sleep [10]. Apnea or hypopnea is cessation of breathing or decreased breathing for 10s, associated
with oxygen desaturation of at least 3% and followed by an
arousal (Fig. 15.1). Hypopnea is defined by the decrease in
airflow by 30–50%, associated with at least 3% oxygen desaturation, followed by an arousal. AHI is the sum of apneas and
Chapter 15. Sleep Apnea
F . Five-minute epoch of supine stage II sleep in a subject
with severe OSA.Cessation (apnea) in breathing (a) result in arterial oxygen desaturation (b) and EEG arousal from sleep (c). Chest
wall motion continues during the apneas indication that the events
are due to upper airway obstruction [11]
293
hypopneas per hour of sleep. Respiratory disturbance index
(RDI) is also used interchangeably with AHI.
Primary snoring is defined by normal AHI with snoring.
Ninety-four percent of patients with OSA have snoring.
Classically, the three clinical features of OSA are loud snoring, witnessed apneas, and excessive daytime sleepiness. Sleep
apnea is classified as mild (AHI 5–15 per hour of sleep),
moderate (AHI 15–30 per hour of sleep), and severe (AHI
>30 per hour of sleep).
Risk Factors
Risk factors include male sex, obesity, large neck circumference, narrowed pharynx or airway, certain craniofacial abnormalities, family history, postmenopausal women, smoking,
chronic gastroesophageal reflux disease (GERD), and other
chronic medical conditions including CHF, ESRD, chronic