Symptoms in the Pharmacy :Respiratory Problems (10)

Symptoms for direct referral
 

Hoarseness

Hoarseness is caused when there is inflammation of the vocal cords in
the larynx (laryngitis). Laryngitis is typically caused by a self-limiting
viral infection. It is usually associated with a sore throat and a hoarse,

diminished voice. Antibiotics are of no value and symptomatic advice

which includes resting the voice, should be given. The infection usually settles within                     a few days and referral is not necessary.

When this infection occurs in babies, infants or small children, it
can cause croup (acute laryngotracheitis) and present difficulty in
breathing and stridor . In this situation referral is essential.
When hoarseness persists for more than 3 weeks, especially when
it is not associated with an acute infection, referral is necessary. There
are many causes of persistent hoarseness, some of which are serious.
For example, laryngeal cancer can present in this way and hoarseness
may be the only early symptom. A doctor will normally refer
the patient to a ear, nose and throat (ENT) specialist for accurate
diagnosis.

Dysphagia

Difficulty in swallowing can occur in severe throat infection. It can
happen when an abscess develops in the region of the tonsils (quinsy)
as a complication of tonsillitis. This will usually result in a hospital
admission where an operation to drain the abscess may be necessary
and high-dose parenteral antibiotics may be given.
Glandular fever (infectious mononucleosis) is one viral cause of sore
throat that often produces marked discomfort and may cause dysphagia.
If this is suspected, referral is necessary for an accurate diagnosis.
Most bad sore throats will cause discomfort on swallowing but not
true difficulty and do not necessarily need referral unless there are
other reasons for concern. Dysphagia, when not associated with a sore
throat, always needs referral .

Appearance of throat

It is commonly thought that the presence of white spots, exudates
or pus on the tonsils is an indication for referral or a means of
differentiating between viral and bacterial infection, but this is not
always so. Unfortunately the appearance can be the same in both types
of infection and sometimes the throat can appear almost normal
without exudates in a streptococcal (bacterial) infection.

Thrush

An exception not to be forgotten is candidal (thrush) infection that
produces white plaques. However, these are rarely confined to the
throat alone and are most commonly seen in babies or the very elderly.
It is an unusual infection in young adults and may be associated with
more serious disorders that interfere with the body’s immune system,
e.g. leukaemia, HIV and acquired immune deficiency syndrome
(AIDS), or with immunosuppressive therapy (e.g. steroids). The
plaques may be seen in the throat and on the gums and tongue.
When they are scraped off, the surface is raw and inflamed. Referral
is advised if thrush is suspected and the throat is sore and painful. 

Glandular fever

Glandular fever is a viral throat infection caused by the Epstein–Barr
virus (EBV). It is well known because of its tendency to leave its victims
debilitated for some months afterwards and its association with the
controversial condition myalgic encephalomyelitis (ME). The infection
typically occurs in teenagers and young adults, with peak incidence
between the ages of 14 and 21. It is known as the ‘kissing disease’!

A severe sore throat may follow 1 or 2 weeks of general malaise. The
throat may become very inflamed with creamy exudates present. There
may be difficulty in swallowing because of the painful throat. Glands
(lymph nodes) in the neck and axillae (armpits) may be enlarged and
tender. The diagnosis can be confirmed with a blood test, although this
may not become positive until 1 week after the onset of the illness.
Antibiotics are of no value; in fact if ampicillin is given during the
infection, a measles-type rash is likely to develop in 80% of those with
glandular fever. Treatment is aimed at symptomatic relief.

When to refer

• Sore throat lasting 1 week or more
• Recurrent bouts of infection
• Hoarseness of more than 3 weeks’ duration
• Difficulty in swallowing (dysphagia)
• Failed medication