What is the treatment for a sore throat and hoarseness?

Treatment of Sore Throat and Hoarseness

Start with ibuprofen or paracetamol for symptomatic relief of sore throat, and avoid empiric antibiotics or anti-reflux medications for hoarseness unless specific criteria are met. 1

Sore Throat Management

First-Line Symptomatic Treatment

• Ibuprofen or paracetamol are the recommended first-line treatments for acute sore throat pain relief 1, 2
• Ibuprofen demonstrates slightly superior efficacy compared to paracetamol, particularly at 2 hours post-administration 2, 3
• Both medications carry low risk of adverse effects when used short-term according to directions 2

Antibiotic Decision Algorithm

The decision to use antibiotics should be based on Centor criteria scoring:

For patients with 0-2 Centor criteria (low severity):

• Do NOT prescribe antibiotics for symptom relief 1
• Continue symptomatic treatment with ibuprofen or paracetamol 1, 2
• Approximately 82% of patients will be symptom-free by one week without antibiotics 4

For patients with 3-4 Centor criteria (high severity):

• Consider discussing modest antibiotic benefits with the patient, weighing against side effects, antimicrobial resistance, and costs 1
• If antibiotics are indicated, prescribe penicillin V twice or three times daily for 10 days 1, 2
• Antibiotics reduce sore throat symptoms at day 3 (number needed to treat = 6) but have minimal additional benefit by one week (number needed to treat = 18) 4

Corticosteroid Considerations

• Corticosteroids are NOT routinely recommended for sore throat treatment 1, 2
• May be considered in adult patients with severe presentations (3-4 Centor criteria) in conjunction with antibiotic therapy 1, 2, 5
• Single dose of oral dexamethasone (maximum 10 mg) is the recommended approach if used 5

What NOT to Use for Sore Throat

• Zinc gluconate is not recommended due to conflicting efficacy and increased adverse effects 1, 2
• Herbal treatments and acupuncture have inconsistent evidence and should not be recommended 1, 2
• Topical (local) antibiotics or antiseptics lack efficacy data and should be avoided 2, 6

Hoarseness Management

Initial Approach

• Do NOT prescribe anti-reflux medications empirically for hoarseness without GERD symptoms or laryngoscopic evidence of laryngitis 1
• Proton pump inhibitors (PPIs) carry risks including hip fractures in older adults, vitamin B12 deficiency, iron deficiency anemia, and increased pancreatitis risk 1

When to Consider Anti-Reflux Therapy

Anti-reflux medications may be prescribed ONLY when:

• Laryngoscopy demonstrates chronic laryngitis (erythema, edema, redundant tissue, or surface irregularities of the interarytenoid mucosa, arytenoid mucosa, posterior laryngeal mucosa, and/or vocal folds) 1
• Even with laryngoscopic findings, evidence for benefit remains limited 1

Conservative Management for Hoarseness

• Voice rest (especially avoiding whispering) 7
• Proper vocal hygiene for vocal abuse-related causes 7
• Voice therapy is effective for improving voice quality if conservative measures fail 7, 8

When to Refer for Laryngoscopy

Immediate evaluation (within 2 weeks) if:

• Risk factors present: tobacco use, heavy alcohol use, or hemoptysis 7

Evaluation within 3 months if:

• No clear etiology identified 7
• Conservative management ineffective 7
• Symptoms persist despite treatment changes 9

Medication-Induced Hoarseness

• ACE inhibitors (e.g., ramipril) cause chronic hoarseness and cough in up to 16% of patients, often beginning after several months of treatment 9
• Switch to an AT1 blocker (e.g., candesartan) as first choice, as these do not cause cough 9
• Monitor symptoms for at least 4 weeks after medication change 9

Critical Pitfalls to Avoid

• Do not use antibiotics to prevent rheumatic fever or glomerulonephritis in low-risk patients (those without previous history of rheumatic fever) 1
• Do not use antibiotics to prevent suppurative complications such as quinsy, acute otitis media, or sinusitis in most cases 1
• Do not prescribe empiric corticosteroids, antibiotics, or PPIs for hoarseness without proper evaluation 1, 7
• Avoid biomarkers (C-reactive protein, procalcitonin) for routine assessment of acute sore throat 1