What are the treatment options for a 78-year-old female with congestion and sore throat?

Treatment of Congestion and Sore Throat in a 78-Year-Old Female

For this 78-year-old woman with congestion and sore throat, start with ibuprofen or acetaminophen for symptom relief and do NOT prescribe antibiotics unless she has 3-4 Centor criteria (fever, tonsillar exudates, tender anterior cervical lymphadenopathy, absence of cough) AND a positive rapid strep test. 1

Initial Symptomatic Management

The primary treatment approach focuses on symptom relief since most cases are viral and self-limited:

• Analgesics are the cornerstone of therapy: Either ibuprofen or acetaminophen (paracetamol) should be offered to all patients with sore throat for pain relief 2, 1
• Nasal saline irrigation provides symptomatic relief for congestion with minimal risk of adverse effects 2
• Oral decongestants may provide relief of nasal congestion, though use caution in elderly patients with hypertension or anxiety 2
• Topical decongestants can be used but limit to 3-5 days maximum to avoid rebound congestion 2

Determining Need for Antibiotics

Most sore throats (>65%) are viral and resolve within one week without antibiotics 1, 3. The decision to use antibiotics depends on clinical scoring:

Low Probability (0-2 Centor Criteria)

• Do NOT prescribe antibiotics for patients with 0-2 Centor criteria 2, 1, 3
• Reassure the patient that typical sore throat duration is less than one week 1, 3
• Continue analgesic therapy only 1

Higher Probability (3-4 Centor Criteria)

• Consider rapid antigen testing (RAT) in patients with 3-4 Centor criteria 2, 1
• If RAT is positive for group A Streptococcus, discuss with the patient that antibiotics provide only modest benefit (shortening symptoms by 1-2 days) 1, 3
• Throat culture is NOT necessary after a negative RAT 2, 1
• If antibiotics are prescribed, penicillin V for 10 days is first-line 1

Additional Symptomatic Options

• Topical intranasal steroids may provide modest relief of nasal congestion and facial discomfort, though the benefit is small (73% improvement vs 66% with placebo at 14-21 days) 2
• Avoid antihistamines, systemic steroids, and guaifenesin as evidence for efficacy is lacking or inconsistent 2
• Do NOT use zinc gluconate for sore throat 2, 1
• Herbal treatments and acupuncture have inconsistent evidence and are not recommended 2, 1

Critical Red Flags in Elderly Patients

Given her age, maintain high suspicion for serious complications if symptoms are severe or refractory:

• Peritonsillar abscess: Look for unilateral tonsillar swelling, uvular deviation, trismus, "hot potato voice," and difficulty swallowing 4, 5
• Retropharyngeal abscess: Assess for neck stiffness, neck tenderness or swelling, drooling, and difficulty swallowing 4, 5
• Epiglottitis: Evaluate for drooling, stridor, sitting forward position, and respiratory distress—airway management is paramount 4, 5
• Lemierre syndrome: Though more common in adolescents and young adults, consider in severe pharyngitis with septic appearance 4, 6

Important Caveats

• Discolored nasal discharge does NOT indicate bacterial infection—it reflects inflammation with neutrophils, not bacteria 2
• Antibiotics do NOT prevent rheumatic fever or glomerulonephritis in low-risk patients without previous rheumatic fever history 2, 3
• Most patients (>80%) achieve complete symptom resolution within one week regardless of antibiotic use 3
• In elderly patients, be particularly cautious with oral decongestants if hypertension or cardiac disease is present 2