Assessment Basics for the School Nurse: Sore Throats

Sore throats: everyone seems to have them at the same time. What’s causing them, what are we looking for and what can we do about it?

Sore throats can be benign much of the time – from post nasal drip, too much talking, allergies, environmental irritation, or random unnamed viruses. But at times they can be worse than a run of the mill cold – strep throat, tonsillitis, mono, Coxsackie/hand-foot-mouth, flu, Covid, or even chickenpox or epiglottitis.

Equipment needed

1. Tongue blades
2. Flashlight/pen light
3. Table salt/water/cup

Throat assessment

1. Asses external appearance: do they have any injuries, swollen glands, drooling/difficulty managing their own saliva, swelling of the mouth or face?
2. How does their voice sound? scratchy, hoarse, whispering, muffled “hot potato” voice?
3. Assess for fever.
4. Using light and tongue blade, have the student open their mouth and stick their tongue out. Gently push down on the tongue to visualize the back of the throat and tonsils. It helps if the student can say “ahhhh” as this causes the tongue to lower giving better visibility to the back of the throat.

Things you may see on exam

1. Enlarged tonsils: tonsils appear swollen. In some cases they are so swollen they are touching.
2. Tonsillar exudate/white patches/pus: With certain tonsillar ailments the tonsils can have white patches, white spots, pus, and have a “raw hamburger” appearance (sorry for the visual).
3. Post nasal drip: I have never been good at spotting post nasal drip but doctors seem to see it all the time. Post nasal drip can cause a sore throat, especially in the morning when you first wake up and the mucus has been sitting there all night.
4. Deviated uvula: The uvula is not hanging in the middle like it is supposed to. This can be an indicator of a peritonsillar abscess which is an emergency. In a peritonsillar abscess the uvula will deviate away from the side where the abscess is. Deviated uvula can also be an indicator of cranial nerve damage which is also potentially an emergency.
5. Erythematous tissue: Redness in the throat and tonsils. This is an indicator of an inflammatory process like tonsillitis, irritation from increased coughing, or a viral process.
6. Red spots to throat and/or roof of mouth: Petechiae in the mouth can be an indicator of a blood disorder or mono; red spots can also be an indicator of strep, hand foot and mouth, or oral thrush.
7. Ulcers or canker sores: These look like a whitish concave area inside the mouth or around the throat. can be caused by minor injury (like getting poked with a pointy chip), eating too much salt or sugar, hand foot and mouth disease, or even a herpes simplex outbreak.
8. Dental: The student may have some dental caries or fractured teeth that is referring the pain backward to the throat or causing general mouth pain.

Images of throat exams

Scroll by fast if these might gross you out!

In the health room

1. While there isn’t a whole lot we can do about sore throats at school, there are a few things you can try like gargling with warm salt water, popsicles or freezies, sucking on ice.
2. In some schools/districts Halls or throat lozenges are permitted to be given by the nurse. Check your district guidelines before dispensing throat lozenges or allowing self carry of throat lozenges.
3. If sore throat is accompanied by fever then the student should be sent home.
4. If exam shows any of the above issues, or any other concerns, call parent to report.
5. Symptoms of strep throat can include not only a sore throat with swollen tonsils and exudate but also stomachache, headache, nausea, vomiting, fever, and a red “sandy” rash on the trunk. The student should be evaluated as soon as possible.

Tips and tricks

1. gargling with salt water is often very helpful. Try adding 1/4 teaspoon or so of table salt to some warm water, mix it up and have the student gargle a little bit with it.
2. Cold liquids, popsicles or freezies are great for temporary sore throat relief.
3. Tea and honey can relieve a sore throat. Honey has antiviral and antibacterial properties and can help fight illness. Remember to never give honey to anyone under 12 months old due to the potential for infant botulism.
4. Allergy medicine or decongestants: If the sore throat is caused by post nasal drip or a cold then trying something that will dry up excess mucus might help. This wouldn’t be given at school but the parent can consider this for home.
5. Motrin or Tylenol: I prefer to use these sparingly and try other things first but they can certainly help with a sore throat. Ibuprofen is better than Acetaminophen for inflammation.

When is it an emergency?

1. When there is difficulty breathing: If the student has a sore throat and difficulty breathing this could be a sign of anaphylaxis. Check a pulseox, auscultate lungs for wheezing, assess for swelling in the mouth, assess for known allergies. If anaphylaxis is suspected use your anaphylaxis action plan and give Epi and call 911.
2. When there is real difficulty swallowing or managing saliva: Tonsils are so swollen that the student can not swallow their saliva. This can be an indicator of mono, peritonsillar abscess, strep throat and causes the risk of aspiration and compromised airway.
3. Deviated uvula: The uvula is not hanging in the middle like it is supposed to. This can be an indicator of a peritonsillar abscess which is an emergency. In a peritonsillar abscess the uvula will deviate away from the side where the abscess is. Deviated uvula can also be an indicator of cranial nerve damage which is also potentially an emergency.

At the end of the day, we of course can’t diagnose anything but we must know when to refer out for further assessment and treatment.

Please feel free to follow for more assessment tips and comment if you have anything to add!

References

https://my.clevelandclinic.org/health/body/22674-uvula#:~:text=A%20deviated%20uvula%20is%20one,away%20from%20the%20infected%20tonsil.

https://www.medicalnewstoday.com/articles/324876#prevention

https://www.mayoclinic.org/diseases-conditions/sore-throat/symptoms-causes/syc-20351635#:~:text=The%20most%20common%20cause%20of,with%20antibiotics%20to%20prevent%20complications.

https://www.entandallergy.com/blog-posts/details/16-best-sore-throat-remedies-to-make-you-feel-better-fast-according-to-doctors