What is the workup for throat pain (odynophagia)?

From the Guidelines

The workup for throat pain should begin with a thorough history and physical examination, focusing on symptom duration, severity, associated symptoms, and risk factors. For acute throat pain, a rapid strep test should be performed if streptococcal pharyngitis is suspected, especially with fever, tonsillar exudates, tender cervical lymphadenopathy, and absence of cough. If positive, treat with penicillin V 500 mg twice daily for 10 days or amoxicillin 500 mg twice daily for 10 days, as suggested by 1. For penicillin-allergic patients, use azithromycin 500 mg on day 1, then 250 mg daily for 4 more days. Symptomatic relief can be achieved with acetaminophen 650 mg every 6 hours or ibuprofen 400-600 mg every 6-8 hours, along with warm salt water gargles and throat lozenges, as recommended by 1 and 1. Some key points to consider in the workup and management of throat pain include:

• The typical course of a sore throat is less than 1 week and antibiotics are usually not needed because they do little to alleviate symptoms and may have adverse effects, as noted in 1 and 1.
• For persistent throat pain (>2 weeks), consider referral to an otolaryngologist for laryngoscopy to evaluate for other causes such as laryngopharyngeal reflux, which may require proton pump inhibitors like omeprazole 20 mg daily for 8 weeks.
• If there are concerning features like unilateral symptoms, voice changes, dysphagia, weight loss, or neck mass, expedite referral to rule out malignancy.
• For smokers with persistent throat pain, counseling on smoking cessation is essential as it's a major contributor to chronic pharyngitis and increases risk of head and neck cancers.

From the FDA Drug Label

Pharyngitis/Tonsillitis In three double-blind controlled studies, conducted in the United States, azithromycin (12 mg/kg once a day for 5 days) was compared to penicillin V (250 mg three times a day for 10 days) in the treatment of pharyngitis due to documented Group A β-hemolytic streptococci (GABHS or S. pyogenes)

Three U. S. Streptococcal Pharyngitis Studies Azithromycin vs. Penicillin V EFFICACY RESULTS Day 14Day 30 Bacteriologic Eradication: Azithromycin323/340 (95%)255/330 (77%) Penicillin V242/332 (73%)206/325 (63%) Clinical Success (Cure plus improvement): Azithromycin336/343 (98%)310/330 (94%) Penicillin V284/338 (84%)241/325 (74%)

The workup for throat pain may include antibiotic treatment with azithromycin for pharyngitis/tonsillitis caused by Group A β-hemolytic streptococci (GABHS or S. pyogenes).

• Clinical success rates for azithromycin were 98% at Day 14 and 94% at Day 30.
• Bacteriologic eradication rates for azithromycin were 95% at Day 14 and 77% at Day 30. 2

From the Research

Throat Pain Workup

• The workup for throat pain typically involves a physical examination and patient history to diagnose Group A beta-hemolytic streptococcal (GABHS) pharyngitis 3, 4.
• Diagnostic methods for GABHS pharyngitis include:
  • Clinical scoring systems
  • Rapid antigen detection tests
  • Throat culture
  • Nucleic acid amplification tests
  • Machine learning and artificial intelligence 4
• The modified Centor or FeverPAIN score can be used to determine the need for a rapid antigen detection test, with a score of 2 or 3 indicating a higher likelihood of GABHS pharyngitis 3.
• If a rapid antigen test is negative, a throat culture may be recommended, especially in children and adolescents 5.

Treatment of GABHS Pharyngitis

• First-line treatment for GABHS pharyngitis typically includes a 10-day course of penicillin or amoxicillin 3, 5.
• Alternative treatments for patients allergic to penicillin include:
  • First-generation cephalosporins
  • Clindamycin
  • Macrolide antibiotics 3, 6
• Nonsteroidal anti-inflammatory drugs and medicated throat lozenges may be effective in treating fever and pain associated with GABHS pharyngitis 3.
• Corticosteroids are not recommended for routine use in treating GABHS pharyngitis, as they provide only a small reduction in symptom duration 3, 5.

Antibiotic Treatment Comparison

• The effectiveness of different antibiotics in treating GABHS pharyngitis is uncertain, with low-certainty evidence suggesting that cephalosporins and macrolides may be comparable to penicillin in terms of symptom resolution 6.
• Carbacephem may be more effective than penicillin in adults and children, but the evidence is limited 6.
• Azithromycin may be effective in a single dose, but the evidence is very low-certainty and limited to one unpublished trial in children 6.