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Medicine for the Outdoors

Dr. Paul Auerbach is the world's leading outdoor health expert. His blog offers tips on outdoor safety and advice on how to handle wilderness emergencies.

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Sore Throat

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Sore throat is a common problem at home and outdoors. Sore throat (pharyngitis) is a common complication of viral infections (the common cold, infectious mononucleosis), breathing dry air (“altitude throat”), or primary bacterial throat infection (“strep throat”). Symptoms of an infection include pain with swallowing, fever, swollen lymph nodes (“swollen glands”) in the anterior neck, red throat, swollen tonsils, pus over the tonsils and throat, headache, fever, abdominal pain, and nausea and vomiting.

Because the symptoms of a viral throat and tonsil infection and a bacterial strep (group A beta-hemolytic streptococcus [GABHS]) throat are frequently identical, it is hard to make the differentiation without a throat-swab “rapid strep test” or bacterial culture. Below the age of 3 years, a child rarely has a strep throat; in young adults, the presence of strep throat in the presence of classic symptoms (fever, pus, and swollen tonsils and lymph glands in the neck) is roughly 50%. However, because the potential complications (kidney or heart disease) of an untreated strep throat in a young person outweigh the complications of antibiotic use, it is advisable to treat a person who is outdoors and without a definitive diagnosis (e.g., on a camping trip) with penicillin (or amoxicillin), cefadroxil, or erythromycin for a full 10-day course, or with azithromycin or clarithromycin for 5 days. If none of these drugs is available, clindamycin or cephalexin can be used. Even if the victim improves after 2 to 3 days, the antibiotic should be taken for the full course.

Adjuncts to care include saltwater gargles (1/2 tsp, or 2.5 ml, of table salt in 1 cup, or 237 ml, of warm water), throat lozenges, warm fluids (to moisten and soothe the throat), and aspirin or acetaminophen to control fever. To avoid Reye syndrome (postviral encephalopathy and liver failure), do not use aspirin to control fever in a child under the age of 17.

If a person develops an acute sore throat that rapidly becomes extremely uncomfortable (severe pain, difficulty swallowing), a single dose of dexamethasone or its equivalent may be given along with an antibiotic, assuming the victim can swallow the medications. This may help decrease inflammation, but should not be given routinely for a “nontoxic,” or run-of-the-mill, sore throat (see below). If someone with a sore throat has a high fever associated with difficult or noisy breathing, altered (e.g. hoarse) or muffled voice (“like talking with a potato in his mouth”), drooling, stiff neck, or any visible swelling (bulging) in the back of the throat, he should be made as comfortable as possible and transported immediately to a hospital. Such a condition may indicate an abscess in the back of the throat or next to a tonsil, infection and inflammation of the epiglottis (epiglottitis), or massively swollen tonsils. Any of these may rapidly obstruct the airway.

If a person develops tender swelling under the tongue and/or under the chin, particularly associated with swollen lymph glands in the neck, fever, difficulty swallowing, and foul breath, this may indicate an infection in the floor of the mouth. Treat the victim with an antibiotic as for a strep throat and seek immediate physician consultation.

A sore throat can be caused by overgrown of the fungus Candida albicans, which leads to a condition known as “thrush.” This occurs most commonly in persons who are immunosuppressed, have recently taken broad-spectrum antibiotics, use inhaled or oral steroids, wear dentures or orthodontic appliances, have diabetes, or are elders. Symptoms include burning in the mouth and throat, white patches on the palate and in the mouth and throat, painful swallowing, heartburn, drooling, and loss of appetite. If thrush is suspected, it can be treated with nystatin (Mycostatin) oral suspension, swished and swallowed four times a day for 2 weeks, or with nystatin oral lozenges 4 to 5 times daily for two weeks.

In a paper entitled "Clinical efficacy of dexamethasone for acute exudative pharyngitis," A. Taser and colleagues from the Department of Emergency Medicine at Nazilli General Hospital in Nazilli, Aydin, Turkey reported their investigation about whether treatment with single-dose dexamethasone could provide relief of symptoms in acute pharyngitis. A prospective, randomized, double-blinded, placebo-controlled clinical trial was undertaken over a 3-month period, and included all consecutive patients between 18 and 65 years of age presenting with acute exudative (inflammation, redness, and pus) pharyngitis, sore throat, pain on swallowing, or a combination. Each patient was treated with azithromycin and acetaminophen for 3 days. The effects of placebo and a single dose (8 mg) intramuscular injection of dexamethasone were compared. The patients were asked to report the exact time to onset of pain relief and time to complete relief of pain. After completion of the treatment, telephone follow-up regarding the relief of pain was conducted. After certain patients were excluded, 42 patients were assigned to the placebo group and 31 were assigned to the intramuscular dexamethasone group. Time to perceived onset of pain relief was 8.06 +/- 4.86 hours in steroid-treated patients, as opposed to 19.90 +/- 9.39 hours in the control group (p = 0.000). The interval required to become pain-free was 28.97 +/- 12.00 hours in the dexamethasone group, vs. 53.74 +/- 16.23 hours in the placebo group (p = 0.000). No side effects and no new complaints attributable to the dexamethasone and azithromycin were observed. The conclusion was that sore throat and pain on swallowing in patients with acute exudative pharyngitis may respond better to treatment with an 8-mg single dose of intramuscular dexamethasone accompanied by an antibiotic regimen than to antibiotics alone. In an outdoor setting, where dexamethasone for intramuscular injection would likely not be available, an oral dose of dexamethasone or another equivalent steroid could be used. The precise dose of dexamethasone for oral administration for this indication has not been determined, but a low one-time therapeutic dose would be 0.6 milligrams per kilogram (2.2 pounds) of body weight, up to a maximum dose of 10 mg.

Recently, the American Heart Association (AHA) rewrote its recommendations for diagnosing and treating acute streptococcal pharyngitis, which is its first update since 1995. The statement, released online in the journal Circulation, notes that prevention of rheumatic fever depends on control of streptococcal infection.

Here are some of the AHA's recommendations:

A throat swab-and-culture is the standard method of diagnosing strep throat. Antigen ("rapid strep") tests have low sensitivity, and culture backup is likely necessary in children and adolescents to confirm negative results.

Oral penicillin V, amoxicillin, and injected benzathine penicillin G are the recommended treatments. Alternatives for patients allergic to penicillin include a narrow-spectrum oral cephalosporin, oral clindamycin, an oral macrolide antibiotic, or azithromycin.

Join me from January 24 to February 2, 2010 for an exciting dive and wilderness medicine CME adventure aboard the Nautilus Explorer to Socorro Island, Mexico to benefit the Wilderness Medical Society.

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About the Author

Dr. Paul S. Auerbach is the world’s leading authority on wilderness medicine.

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