What is the best treatment for a patient with a sore throat and husky voice, considering potential underlying conditions like allergies or asthma?

Treatment of Sore Throat with Husky Voice

For a patient presenting with sore throat and husky voice (hoarseness), start with ibuprofen or paracetamol for symptomatic relief and avoid routine antibiotics or corticosteroids unless specific criteria are met. 1

Initial Symptomatic Management

• Ibuprofen or paracetamol are the recommended first-line treatments for acute sore throat symptoms, providing effective pain relief without the risks associated with antibiotics or steroids. 1
• These analgesics should be used regularly rather than as needed to maintain consistent symptom control. 1

When to Avoid Antibiotics

Antibiotics should NOT be routinely prescribed for either the sore throat or the hoarseness component of this presentation. 1

• For sore throat: Antibiotics are not indicated in patients with 0-2 Centor criteria (which include fever, tonsillar exudates, tender anterior cervical lymphadenopathy, and absence of cough). 1
• For hoarseness: There is no evidence supporting antibiotic use for dysphonia, and routine prescription represents ineffective therapy with documented adverse events. 1
• The prevention of complications like quinsy, otitis media, or sinusitis is NOT an indication for antibiotic therapy in sore throat. 1

When to Avoid Corticosteroids

Do not routinely prescribe oral or inhaled corticosteroids for hoarseness prior to visualizing the larynx. 1

• Despite common practice, there are no studies supporting empiric steroid use for hoarseness except in very specific circumstances (professional voice users with allergic laryngitis). 1
• Corticosteroids carry significant risks including short- and long-term side effects, and paradoxically, inhaled steroids themselves can cause hoarseness. 1
• For sore throat with 3-4 Centor criteria, corticosteroids combined with antibiotics can be considered in adults with severe presentations, but this is not routine practice. 1

When Antibiotics May Be Considered for Sore Throat

If the patient has 3-4 Centor criteria (high likelihood of Group A streptococcal pharyngitis):

• Discuss the modest benefits versus risks with the patient, as antibiotics provide only moderate symptom relief even in streptococcal-positive cases. 1
• If antibiotics are indicated, penicillin V twice or three times daily for 10 days is the first-choice agent. 1
• Rapid antigen testing (RAT) can help target antibiotic use in patients with 3-4 Centor criteria, though throat culture after negative RAT is not necessary. 1

Critical Red Flags Requiring Urgent Evaluation

Visualize the larynx urgently or refer immediately if any of these features are present with hoarseness: 1

• History of tobacco or alcohol use (increased cancer risk). 1
• Recent head, neck, or chest surgery or endotracheal intubation (vocal fold injury). 1
• Concomitant neck mass, hemoptysis, dysphagia, odynophagia, or otalgia. 1
• Respiratory distress or stridor (airway compromise). 1
• Unexplained weight loss or neurologic symptoms. 1

Timing of Laryngoscopy for Persistent Hoarseness

• Laryngoscopy should be performed if hoarseness fails to resolve within 4 weeks, regardless of sore throat resolution. 1
• Earlier laryngoscopy (at any time) is appropriate if serious underlying causes are suspected based on red flags above. 1
• The 2018 guideline shortened the observation period from 3 months to 4 weeks, reflecting updated evidence on earlier diagnosis. 1

Addressing Potential Underlying Conditions

If Allergies or Asthma Are Present:

• Intranasal corticosteroids are recommended for allergic rhinitis symptoms affecting quality of life, and may improve coexisting asthma control. 1
• Second-generation oral antihistamines are recommended for sneezing and itching associated with allergic rhinitis. 1
• Treatment of allergic rhinitis can reduce bronchial hyperresponsiveness and improve asthma symptoms. 1
• However, these treatments address nasal/respiratory allergy symptoms, not the acute sore throat or hoarseness directly. 1

If Inhaled Corticosteroids for Asthma:

• Consider that inhaled corticosteroids themselves may cause hoarseness through direct irritation or fungal laryngitis. 1
• This requires laryngoscopy to diagnose, not empiric antifungal therapy. 1

Common Pitfalls to Avoid

• Do not prescribe antireflux medications (PPIs) for isolated hoarseness based on symptoms alone without laryngoscopy, despite the temptation to treat presumed laryngopharyngeal reflux. 1
• Do not obtain CT or MRI for voice complaints prior to visualizing the larynx. 1
• Do not use biomarkers (C-reactive protein, procalcitonin) routinely in assessing acute sore throat. 1
• Avoid zinc gluconate as it is not recommended for sore throat treatment. 1

Natural History and Patient Counseling

• Acute sore throat typically improves within 7-10 days with supportive care alone. 1, 2
• Most cases are viral and self-limiting, making symptomatic treatment the cornerstone of management. 1, 2
• Encourage self-management with analgesics while monitoring for red flag symptoms requiring urgent evaluation. 2