What is the best treatment approach for a patient with throat pain and mild congestion, likely due to a viral upper respiratory tract infection?

Treatment of Throat Pain with Mild Congestion

For throat pain with mild congestion from a likely viral upper respiratory infection, treat symptomatically with analgesics (acetaminophen or ibuprofen), nasal saline irrigation, and oral decongestants if needed—antibiotics should not be prescribed as they are ineffective for viral illness and cause more harm than benefit. 1

Immediate Symptomatic Relief

Analgesics are the cornerstone of treatment since pain relief is often the primary reason patients seek care 2:

• Acetaminophen or ibuprofen for throat pain and any associated fever 1, 2
• Throat lozenges containing phenol can provide additional topical relief for sore throat 1, 3
• Salt water gargles may help, though evidence is limited 1

Nasal Congestion Management

Nasal saline irrigation should be recommended as first-line therapy for congestion 4, 2:

• Use 2-3 times daily with buffered hypertonic (3%-5%) saline for superior anti-inflammatory effect 1, 4
• Provides safe, low-risk symptom improvement and facilitates clearance of secretions 2

Oral decongestants (pseudoephedrine or phenylephrine) may be added for additional congestion relief 1, 2:

• Use with caution in patients with hypertension or anxiety 4, 2

Topical nasal decongestants can be used but only for 3-5 days maximum to prevent rebound congestion (rhinitis medicamentosa) 1, 4, 2

Optional Adjunctive Therapies

First-generation antihistamine/decongestant combinations (brompheniramine plus pseudoephedrine) provide more rapid improvement in post-nasal drip and throat clearing compared to newer antihistamines 1, 2:

• Newer non-sedating antihistamines are relatively ineffective for viral URI symptoms 1, 2
• Work through anticholinergic drying effect rather than histamine blockade 1

Intranasal corticosteroids may provide modest additional symptom relief 4, 2

What NOT to Do

Never prescribe antibiotics for viral upper respiratory infections 1, 2:

• Antibiotics are completely ineffective for viral illness 2
• The number needed to harm (8) exceeds the number needed to treat (18) even when bacterial infection is present 1
• Increases antimicrobial resistance and puts patients at risk for adverse effects 1, 4

Do not use antihistamines alone in non-allergic patients, as they may worsen congestion by drying nasal mucosa 1

When to Consider Bacterial Infection

Reserve antibiotics only if the patient develops signs of bacterial superinfection 1, 2:

• Symptoms persist beyond 10 days without improvement 1, 2
• Severe symptoms with fever >39°C (102.2°F) plus purulent discharge for ≥3 consecutive days 1
• "Double sickening"—initial improvement followed by worsening after 5-7 days 1, 2

For streptococcal pharyngitis specifically, test with rapid antigen detection or culture before prescribing antibiotics 1

Patient Education

Counsel patients that 2:

• Viral URI typically peaks within 3 days and resolves within 10-14 days 4, 2
• Symptoms may persist up to 2 weeks without indicating bacterial infection 1
• Purulent or discolored nasal discharge does NOT indicate bacterial infection—it simply reflects inflammation 4, 2

Provide return precautions for fever persisting beyond expected course, severe facial pain, respiratory distress, or symptoms worsening after initial improvement 2

Common Pitfalls to Avoid

• Do not mistake purulent discharge for bacterial infection—colored mucus is normal in viral URI and does not warrant antibiotics 4, 2
• Do not prescribe antibiotics for patient satisfaction—this increases resistance without providing benefit 2
• Avoid prolonged topical decongestant use beyond 3-5 days due to rebound congestion risk 1, 4, 2
• Do not use β-agonists (albuterol) unless the patient has underlying asthma or COPD 2