Buttercups Training - Healthcare Assistant Course
At The Medicine Counter
9
Coughs and Colds
Introduction to Coughs and Colds ......................................................................... 2 Colds ........................................................................................................... 5 Coughs ........................................................................................................ 10 Sinusitis ....................................................................................................... 14 Sore Throats ................................................................................................. 15 Chronic Sore Throat ........................................................................................ 17 Laryngitis ..................................................................................................... 18 Key Points to Remember ................................................................................... 19 Objectives
On completion of this module you will be able to:
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Identify the three main classes of micro-organism and suggest an infection that each
type can cause
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Understand the cause of the common cold and identify its symptoms
Know when to refer cold symptoms to the pharmacist
List the side effects and restrictions on the use of decongestant medicines
Provide appropriate advice and medicinal treatment for colds
Identify the causes and types of cough and know when to refer a cough to the pharmacist
Provide appropriate advice and medicinal treatment for a cough
Understand the legal restrictions on the sale of cough and cold remedies in children
Identify the causes of a sore throat and know when to refer to the pharmacist
Use extended questioning techniques to obtain a fuller picture of a customer’s condition
Provide appropriate advice and medicinal treatment for a sore throat
Identify the symptoms of laryngitis and know when to refer to the pharmacist
At The Medicine Counter : Coughs and Colds
Contents
Buttercups Training - Healthcare Assistant Course
At The Medicine Counter
Coughs and Colds
Introduction to Coughs and Colds
At this point in the course it will be useful to take a brief look at the underlying causes of a diverse range
of conditions we call “infections”. All infections are caused by one or other type of micro-organism. Let’s
look at what we mean by the terms ‘micro-organism’ or ‘microbe’, of which there are four main classes;
bacteria, fungi, protozoa and viruses. Although you will no doubt have learnt something about these
organisms previously, it will do no harm to refresh our memories.
Microbiology
Microbiology is the study of extremely small living organisms – called micro-organisms - so small that
they cannot be seen without a microscope. Even though we cannot see them, micro-organisms are all
around us; they have been found in every possible environment from the frozen arctic to hot springs
at the bottom of the ocean and everywhere in between. We have even found a meteorite that was
once part of Mars which is claimed to contain fossilised microbes, although this is, of course, still
controversial.
There are an estimated one billion E.coli bacteria living inside our intestines and every external part
of our bodies is teeming with a huge range of different microbes.
Most micro-organisms are either harmless to us or are even beneficial; the E.coli in our intestines help
us to digest food; bacteria are now used to produce human insulin and other hormones; both bread
and beer are made using yeast – perhaps making it a micro-organism we couldn’t live without?
Despite this, we are probably most aware of micro-organisms when they cause us
problems, like causing food to go off or when a wound becomes infected. Let’s look at the
four main classes:
Bacteria
Simple Bacterial Cell Structure
Cell Wall
Nuclear Material
Coughs
And Colds
Cytoplasm
Cell Membrane
Bacteria are very simple, single-celled organisms which
consist of a strong cell wall surrounding the cytoplasm (cell
fluid) in which floats a ring of DNA. Although they can be a
variety of shapes and sizes, they all have the same basic
features (shown left).
The most common shapes are spheres and cylinders (rod
shaped), but some have more exotic twists and spirals.
Visit the website http://microscopy.fsu.edu and explore
some of the beautiful images of bacteria (and viruses).
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Bacterial cells reproduce in the same way as our own cells do, by copying their DNA and then splitting the
cell in two, with each half getting its own copy of the DNA. Sometimes the copy isn’t a perfect one and
potentially a new, possibly improved type of bacterium is ‘born’. This fact has led to strains of bacteria
which are capable of fighting back against the antibiotics we use to kill them, a sobering thought
considering the mortality rate prior to the discovery of penicillin.
One of these ‘strains’ that you will no doubt have heard of is called MRSA, Methicillin Resistant
Staphylococcus aureus. This bacterium has become resistant to a wide range of antibiotics allowing it to
cause serious and life-threatening infections – an elegant example of evolution in action.
Although often harmless, if conditions are right, bacteria can multiply very
rapidly reaching massive numbers in just a few bacterial generations. If
they are allowed to multiply unopposed by the immune system, they can
give rise to a wide range of infections, from septicaemia and meningitis
to leprosy and tuberculosis.
Fungi
Fungi are a very varied group of organisms, not all of them are microscopic; they
include simple, single-celled organisms like yeasts as well as multi-cellular (many
cells) organisms like moulds and mushrooms. Yeasts are essentially similar in
structure to bacteria, with the addition of a separate nucleus surrounded by a
nuclear membrane (their DNA is not free-floating but is protected by a
membrane).
Hyphae
Most fungi have a more complex structure than bacteria and yeasts. They grow
as long threads called hyphae (shown right) and are made up of many cells in an
organised pattern.
Fungi tend to colonise (grow on) the skin, hair and nails and they
are responsible for many of the common, minor skin
infections such as athlete’s foot or ringworm.
Protozoa
Protozoa are also single-celled organisms. They live in a water environment such as in ponds, ditches, soil
and sea. Like fungal cells they also have a nuclear membrane surrounding their genetic material. They
include some of the largest single-celled organisms known to science, with some very large protozoa
achieving 2mm in length.
Most protozoa are harmless to man, but a few do cause disease. Malaria is caused by a
protozoan, so is amoebic dysentery, a diarrhoeal disease that kills people by the thousands
in developing countries.
Visit the following website to see some videos of protozoa:
http://microscopy.fsu.edu/moviegallery/pondscum/protozoa/amoeba/index.html
Coughs
And Colds
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Viruses
Viruses are the smallest of the true micro-organisms, so small that even bacteria can be infected by them.
They can only be seen using an electron microscope which magnifies in excess of 25,000 times. Viruses are
made up of a core of genetic material (DNA or RNA) inside a coat of protein. The protein coat protects the
genetic material from the outside world.
Viruses are very different from the other types of micro-organisms because they are entirely parasitic; they
can only reproduce when inside other living cells (a host cell). They cannot grow in any sort of nutrient
medium. To grow and reproduce they must take over the energy and protein producing systems of the host
cell; in effect they hijack the cell for their own use. The appearance and shape of viruses is very variable,
some are shown below.
Herpes Simplex
Tobacco Mosaic
Virus
Mumps Virus
Staphylococcal Phage
(infects bacteria)
Pox Virus
Viruses cause many diseases such as measles, mumps, polio, colds and influenza ('flu'). Human viruses are
often specific to a particular type of human cell. The influenza virus only reproduces in the cells of the
respiratory tract. Many viral infections in man are mild and may not produce any symptoms. A few, like
rabies are extremely serious. Some human viruses can cause disease in other animals. Likewise, we can
catch some viruses from animals.
Throughout the remainder of this course we will encounter a variety of infections caused
by a wide range of micro-organisms. You may find it useful to refer back to this section
when learning about a particular infection and its causes.
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And Colds
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Colds
The common cold is an infection caused by a virus; there are over 200 different
viruses which can cause the symptoms of a cold. The cold virus can survive on door
handles, telephones, keyboards and other objects. If an infected object is touched
and then you touch your eyes or nose, the virus can find its way into the body
where it can multiply and cause infection. We touch our eyes or nose at least
every 2-3 hours, so there is ample chance for the virus to enter our body.
Since you can also catch a cold by inhaling droplets of mucus infected
with a cold virus, it is also very important to cover the mouth and nose
when sneezing and coughing.
The lining of the nasal passages (and other bodily orifices) consists of a layer of mucus producing cells
supplied by blood vessels (a mucous membrane). Mucus is a thick, sticky substance produced by the
cells of the mucous membrane and functions as a cleaner or lubricator.
In this case mucus has two functions:
1. It keeps the inside of the nose moist and supple
2. It traps dust, dirt and harmful particles, as well as micro-organisms, preventing them from being
inhaled into your lungs
It is an unpleasant fact that in a 24 hour period we produce around 1 litre of mucus; this passes down
the back of the throat, into the stomach, hopefully destroying any microbes it may contain.
During a cold this volume of mucus can increase dramatically in an attempt to cleanse the airways.
When the cold virus enters the body and attacks
the cells of the mucous membrane, they swell and
produce even more mucus; the blood capillaries
also swell. This leads to fluid accumulation and
encourages even more mucus to be produced.
The enlarged blood vessels reduce airflow through
the nose making it difficult to breathe. So the nose
runs with mucus and, combined with the swollen
blood vessels, this creates a blocked, or congested,
sensation. If the extra mucus is allowed to remain
for too long then bacteria may colonise (grow) in
it, leading to a further infection.
Symptoms begin 2-3 days after infection
with the cold virus and will include:
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Runny nose
Sore throat
Sneezing
Cough
Fever (high temperature)
Blocked nose (congestion)
Watery eyes
Headache
Tiredness/muscular aches and pains
These symptoms can last from 2-14 days, but most people recover after a week.
Coughs
And Colds
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Referral Criteria
In general, anyone suffering from a cold and showing one or more of the following symptoms or
complications should be referred to your pharmacist:
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Wheezing
Sore throat which doesn’t improve after 3 days
Pain on breathing or coughing
Earache
Blood stained or coloured mucus
Shortness of breath
A cough that is dry at night and productive in the morning
If the symptoms have lasted longer than 14 days
A cough that is worsened by exercise
If there is a rash
If neck stiffness is present (risk of meningitis)
Headaches in children (risk of meningitis)
The standard referral criteria apply as always.
Treatment Options
The principle aim of treatment for a cold is to relieve the symptoms so as to make the patient comfortable
whilst the body’s immune system deals with the infection.
There have been some attempts to shorten the duration of a cold by the use of medicine, with little
supporting evidence, however as yet, there is no cure. Due to the huge range of viruses that can be
responsible, a vaccine is unlikely to be developed; although anyone who does discover a cure or
prophylactic medicine (preventer) for the cold is likely to become very rich!
There is a huge range of cold remedies designed to relieve the various symptoms and you should
try and familiarise yourself with these products. Explore the products on your shelves and look
for the symptoms they treat and the medicines they contain. Remember, though, that the more
medicines a product contains, the greater the risk of suffering from side effects or even
overdose.
It is often better to recommend multiple products each containing only one drug to try and
minimise the risks. There is also the possibility that ingredients included in a combination
product
can have opposing effects which may cancel each other out.
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And Colds
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Decongestants
Decongestants belong to a class of drugs called sympathomimetics which stimulate a certain part of the
nervous system.
One effect of this stimulation is to narrow the blood vessels; this reduces the inflammation in the nasal
membrane and hence reduces the nasal congestion. If applied topically directly to the nasal lining by nasal
drops or sprays, they can work within minutes. If taken by mouth these drugs take longer to work but will
also last for longer.
Pseudoephedrine and phenylephrine are taken orally as tablets, capsules or liquids to reduce
congestion. Because of their general action on the nervous system, they can have undesirable side
effects including increased blood sugar levels, increased heart rate, and muscle tremor.
Due to these side effects, oral decongestants must be avoided by people with:
 Heart problems
 High blood pressure
 Overactive thyroid gland
 Diabetes
 Other medication, as there are many drug interactions
The following phrase may help you remember the groups of people
who must not take decongestants:
Monkeys
Medicines – many interactions
Don’t
Diabetes
Truly
Thyroid problems
BeHave
Properly
Blood pressure: Heart disease
Pregnant
Oxymetazoline and xylometazoline are applied topically via drops and sprays. If used in excess, or
for too long, topical decongestants, can cause what is known as ‘rebound congestion’.
This means that the congestion improves whilst using the product but then appears to get worse and
the medicine no longer works to relieve it. You don’t need to understand why this happens but it does
mean that...
Products containing these medicines must not be used for longer than seven days
continuously.
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And Colds
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In addition to the problems of side effects and rebound congestion, there are a number of other issues
concerning the use of decongestants. Decongestants have a stimulant effect on the body, increasing the
rate of the heart and the activity of the nervous system (think of how you feel when you are scared or
excited and adrenaline is coursing through your body, the effect is the same). At the very least, this can
cause some people to have difficulty getting to sleep and so decongestants shouldn’t be taken in the
evening or at night.
Because of this stimulant effect however, decongestants show a serious potential for abuse. Some people
have used decongestants alone, or mixed with illegal drugs to get a “buzz”. But more worryingly, they can
be used as an ingredient to actually make illegal drugs.
Legal Matters
In 2007 the sale and supply of pseudoephedrine hit the headlines due to its
potential for illicit conversion to methylamphetamine, commonly known as
crystal meth, an addictive class A drug. The Medicines Health Regulatory
Authority (MHRA) proposed restrictions on the amount that could be sold OTC,
and that the transaction must be carried out by a pharmacist. The Royal
Pharmaceutical Society of Great Britain (RPSGB) issued its own guidance as
follows:
 Pharmacy staff should continue to be alert for frequent requests, or
requests for large amounts
 Pack sizes are restricted to 720mg (12 tablets) of pseudoephedrine or
180mg of ephedrine, with sales limited to one pack per customer and to be
carried out by a pharmacist.
Pharmacy
as a profession responded well to enforcing these stricter controls
and as a result made a big impact on reducing the misuse and abuse of
pseudoephedrine and, consequently, on crystal meth. It was hailed as a
success for pharmacy and highlighted its ability to manage drug misuse. Of
course, the controls are still in place and we must all remain vigilant.
Antihistamines
Antihistamines are used to treat a variety of conditions; they are covered in detail in another module
(Summer and Travel Medicine).
In this particular case, they are used to dry up nasal secretions and reduce sneezing, although they will not
have much of an effect on congestion. Some antihistamines commonly encountered in cold remedies include
diphenhydramine, chlorphenamine, promethazine and triprolidine. These are known as the ‘traditional’
or ‘older’ antihistamines and they will cause drowsiness. They are often included in night-time cold
remedies for that very reason, allowing the patient to sleep despite their cold symptoms.
Coughs
And Colds
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Operators of machinery and drivers should be warned of this effect. In daytime cold remedies, antihistamines are often used in combination with
decongestants; this should counteract their drowsy effect so that there is no
overall change in the patient’s state of alertness.
Analgesics
Pain-killers, such as paracetamol, ibuprofen and aspirin, are often used in
cold remedies in combination with other ingredients to relieve muscular
aches and pains and headache. They also have the advantage of being
antipyretic (they reduce fever).
As discussed above, it is better to recommend products containing individual drugs rather than a
combination product to give the customer more flexibility in dosing, and to reduce the possibility of
overdosing (particularly on paracetamol). However, if you do sell combination remedies make sure that you
alert the customer to the inclusion of an analgesic within the medicine. Ibuprofen suspension and
paracetamol suspension are available for children, and you should ensure that the customer reads the
directions for dosage.
Aspirin and ibuprofen belong to a class of drugs called NSAIDs (Non Steroidal Anti Inflammatory
Drugs). You should be able to remember the following facts:
 Aspirin and ibuprofen may not be given to someone with a history of asthma unless the customer
knows that they are not sensitive to them
 Customers with stomach problems such as ulcers should not take ibuprofen or aspirin
 Ibuprofen suspension can be given to children over 3 months (check product licence)
 Aspirin cannot be given to children under 16 years of age
 Aspirin should not be used in pregnancy
Other
treatments
Aromatic Inhalations
Aromatic inhalations containing volatile substances such as eucalyptus oil or menthol may be useful
to soothe
coughs (see below) and improve nasal congestion.
Applying it as a chest rub or to pillows can be of benefit but is not recommended for infants under 3
months old and asthmatic patients may find volatile oils too irritant. Be aware that inhalants may be
liable to abuse as they can be used to enhance the effects of other drugs which are said to create a
“buzz.”
Coughs
And Colds
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Echinacea
Echinacea is a herbal remedy that increases the number of white blood cells (needed for the immune
system to work) and is claimed to have anti-viral properties. It is not suitable for use in pregnancy,
breast feeding women, people with HIV, asthma, multiple sclerosis or diabetes. There is little
sound evidence for its effectiveness as a preventer of colds but there are some studies that show
that extracts of the plant can reduce the duration of and lessen the symptoms of a coldi.
Vitamin C
Vitamin C is often included in cough and cold remedies for its beneficial effects on the immune
system. When a person has an infection their vitamin C levels are rapidly depleted so it is a natural
assumption that replacing it will help recovery. Again, there is some evidence to show that vitamin C
can reduce and shorten the symptoms of a cold. It may ‘strengthen’ an individual’s immune system
making them slightly less likely to contract a cold, although the evidence is not conclusiveii.
Coughs
Very often a cough goes hand-in-hand with a cold. Coughing is a natural part of the body’s defence system
and serves an important purpose. A cough can be an indicator of infection, inflammation or irritation of the
body’s airways. We all cough once or twice every hour to clear the airways of any mucus or debris. The
coughing will become more frequent and more intense when there is an infection present
There are two types of cough your customers may present you with:
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Dry (non-productive)
Chesty (productive)
A chesty (productive) cough
A dry (non productive) cough
This is where the person feels that they are
coughing something up – referred to as
mucus, phlegm or sputum. This is usually
clear or pale green, however if it is yellow,
brown or dark green it could indicate a
bacterial infection and the patient should be
referred.
This is where the cells of the mucous
membrane have become swollen and are
raw, sore and inflamed. It is often felt as a
tickle in the back of the throat which
triggers the coughing and there is little
mucus production. In this case, coughing is
harmful because it removes the protective,
soothing mucus that is present. This makes
the cells even more uncomfortable, leading
to more coughing in a vicious cycle that
needs to be stopped.
The lungs are like sponges – they are made up of
millions of tiny air sacs. Around each sac is a
network of blood vessels that take oxygen from the
air inside the sac.
Coughs
And Colds
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If those little sacs get full of mucus then it is more difficult to get the oxygen across the membrane and
into the blood. The lungs send messages to the brain to say “expel the mucus” and the brain initiates what
is known as the cough reflex. It is very important that we do not interfere with this natural process.
What do you think might happen if you stop the cough reflex from occurring? The mucus and debris cannot
be removed from the lungs and so there is more chance of causing a chest infection. The two different
types of cough therefore require different treatment.
So how can you be sure which type of cough a customer has? Asking the customer whether
they have a chesty or dry cough is rarely successful; how do they know? Ask them how
they feel, how their chest feels and whether they are coughing anything up.
Referral Criteria
A note on chronic (long-lasting) coughs: There are many reasons why a cough may persist for weeks
or even months; the majority of which can be serious conditions and so a chronic cough must be
referred to your pharmacist. Causes of chronic cough include: asthma, pneumonia, bronchitis, COPD
(a lung disease associated with smoking), tuberculosis and lung cancer. In addition, a certain class of
blood pressure medicines can cause a chronic dry cough which stops soon after the drug is stopped.
This is one of the reasons why patients on other medication must always be referred.
The following symptoms must be referred to your pharmacist:
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A cough lasting longer than two weeks
A regularly recurring cough
Shortness of breath/wheezing
Chest pain or pain when breathing
Coloured sputum (especially yellow or brown)
Blood in the sputum
Treatment of a Cough
Expectorants
Expectorants are commonly recommended for (chesty) productive coughs. An expectorant causes
cells to produce thinner mucus so that it is easier to clear by coughing. It is important to tell your
customers that they will still cough after having an expectorant – expectorants do not stop the cough,
they make it easier to remove the mucus making the cough less painful and reducing its duration.
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And Colds
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Expectorants Continued
Guaifenesin is the most commonly used expectorant and is found in a variety of products. It is not
known to interact with any other drugs so, if used alone, can be a safe option for those on other
medication (although you should still refer to the pharmacist). It can cause side effects of nausea,
diarrhoea and headache although these occur rarely unless the stated dose is exceeded.
Ipecacuanha and ammonium chloride are often found in older, traditional remedies but there is
little conclusive evidence of their effectiveness. Productive coughs are helped by an adequate intake
of fluid and anything soothing, such as a syrup, which makes the cough less uncomfortable without
suppressing it.
Suppressants
Suppressants (antitussives) are recommended for (dry) non-productive coughs. Suppressants are
actually opioid drugs related to morphine, with one of their side effects being to suppress the
cough reflex in the brain. Methadone is a powerful opioid used mainly as a heroin substitute, but
it is also prescribed by doctors to treat a dry cough in terminally ill patients. Of course, we can’t
recommend methadone to our customers but the theory is the same and other, much weaker,
opioids can be used.
Codeine is a powerful suppressant but will also cause drowsiness and constipation. Its use is now
limited because of its addictive nature and it should not be recommended to patients. In any
case, the CHM has advised that liquid codeine-containing products for coughs must not be sold for
use in children under 18 years old or breast-feeding mothers.
Pholcodine and dextromethorphan are weak opioids recommended for troublesome dry coughs.
Although these two medicines can theoretically cause drowsiness and constipation, it rarely
occurs at the dosages given in OTC cough medicines.
A cough suppressant must never be used for a chesty, productive cough as it will stop the
cough reflex and prevent excess mucus being expelled.
Diphenhydramine
Diphenhydramine is an antihistamine which can reduce a cough in two ways. It causes drowsiness and
the sedative effect may help to suppress a cough; this is often used in night-time cough remedies but
may cause problems during the day. The second way it can help is when nasal secretions drip down the
back of the throat causing an irritating cough (known as post-nasal drip); an antihistamine can dry up
these secretions and thus improve the cough.
Antihistamines should not be used in patients with prostate or thyroid problems, glaucoma, or certain
gastrointestinal and heart problems.
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And Colds
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Often cough syrups act merely as soothers to try and comfort the sufferer and soothe any soreness whilst
the lungs get on with the business of clearing the trouble. They may also be used when the cough is just a
tickle as a result of a virus or too dry an atmosphere.
Soothers and demulcents like glycerin, honey, treacle and simple linctus which are soft, gentle and sticky
can be used in this way (but are not good for your teeth, unless sugar-free!).
Legal Matters
Treatment of Coughs and Colds in Children Under 12 Years of AgeError! Bookmark
not defined.
Following a review of children’s cough and cold preparations by the
Commission on Human Medicines (CHM), new guidance was issued in March 2008
on treating children with coughs and colds. Due to a lack of evidence
regarding their effectiveness coupled with concerns over the dangers of
overdose, a range of measures were introduced to ensure the safe use of
these products in children under 12 years of age.
The main changes are:
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Cough and cold remedies containing certain ingredients* must no longer
be used in children under 6 years of age
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Products for children from 6-12 years old will continue to be available
in pharmacies where advice can be given, although some combinations
which are illogical (such as cough suppressants and expectorants) are
being phased out

All liquid products will be in a child resistant container (CRC)
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And Colds
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All OTC cough and cold medicines containing the following active ingredients are affected by
the previous CHM Guidance:
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Antitussives (suppressants) : dextromethorphan and pholcodine
Expectorants: guaifenesin and ipecacuanha
Nasal decongestants: ephedrine, oxymetazoline, phenylephrine, pseudoephedrine and
xylometazoline
Antihistamines: brompheniramine, chlorphenamine, diphenhydramine, doxylamine,
promethazine and triprolidine
Instead of selling these treatments, simple advice should now be given to parents of young children
with coughs and colds:
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Coughs and colds are self limiting conditions and will usually get better by themselves in 5-7
days
Trying simple measures such as ensuring your child has plenty to drink and gets enough rest will
help
Paracetamol or ibuprofen can be used to reduce your child’s temperature and any aches and
pains
For young babies particularly those who are having difficulty feeding, normal saline drops are
available to help thin and clear nasal secretions
If your child is over the age of 1, a warm drink of lemon and honey may help to ease a cough
(babies under 1 year should not be given honey due to a risk of a bacterial infection)
Encourage all the family to wash their hands to prevent the spread of colds from infected
secretions
Tissues should be used to catch cough or sneeze droplets and then disposed of in a bin
Sinusitis
Sinusitis is a condition that often accompanies a cold and, as it is a cause of pain. The pain, which is felt
under the eyes and in the head, particularly when bending down, is associated with congestion and catarrh.
Symptoms
Symptoms of sinusitis include:
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Pain behind the eyes
Sore eyes and tenderness
Nasal congestion
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And Colds
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Referral Criteria
Refer to the pharmacist if the pain is severe, prolonged or the customer is unwell.
Treatment Options
Treatment consists of a suitable analgesic and a decongestant.
Sore Throats
Background
Infection often causes inflammation in the respiratory tract and when it affects the throat (pharynx), this is
known as pharyngitis. If the inflammation affects the tonsils it is known as tonsillitis. In either case, we
know it as a sore throat. The cause of the infection may either be viral, bacterial or fungal.
60-90% of all throat infections are caused by a virus and therefore will not respond to antibiotics such as
penicillin. These cases can therefore be safely treated in the pharmacy by giving appropriate advice and
medicines to relieve the symptoms.
Throat Infections
Bacterial infections will normally require treatment from the doctor so you should refer all
suspected cases to your pharmacist. They can be distinguished from viral infections by the following
signs and symptoms:
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Sudden onset of discomfort
Worsens over a few days
Lymphoid tissue (glands in the neck) often swells
Sufferer feels generally unwell
Pustules may be present on the tonsils
Rarely, fungal infections can also occur, particularly in asthmatic patients who use corticosteroid
inhalers and fail to rinse their mouth out after use.
Remember you learnt about the 2WHAM questions earlier in the course? Sometimes these do not
obtain enough information from the customer to be able to decide on the cause of their condition.
Here are three more questions that can also help to gather information:
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Throat Infections Continued
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Progress – is it getting better, worse or spreading?
History – have you suffered with it before?
Illness – are there any other symptoms – do you feel well otherwise?
We refer to these questions as 2WHAMPHI. Finding out whether the sore throat is worsening, whether
there has been a history of sore throat or tonsillitis, and particularly whether or not the customer
feels ill are all very important questions.
A customer suffering from tonsillitis will almost certainly recognise the symptoms and will be
able to recite a long history of throat problems. These customers should be referred to the
pharmacist as should anyone whose sore throat has not improved after three days or is
unresponsive to treatment.
Treatment Options
There are a wide variety of products available to relieve sore throats, most commonly in the form of
lozenges or sprays. A lozenge is a bit like a hard, boiled sweet except that it also contains a medicine.
Pastilles are also available which are like lozenges but soft and chewy. There are many different active
ingredients found in these products, most of which are either antiseptic, anaesthetic or both. You should
familiarise yourself with the various products and ensure you are aware of their instructions for use.
Much of the benefit of using a lozenge comes from stimulating the salivary
glands to lubricate the throat. The sucking action increases the production
of saliva and lozenges often have fruity flavours which also stimulates
saliva. Drugs can then be added to the lozenge in order to increase their
effectiveness.
Throat sprays and mouthwashes/gargles have the advantage that they can be targeted directly at the
affected area for immediate relief of pain.
Antiseptics
Tyrothricin is an antibiotic that is useful for reducing the severity and duration of a throat infection.
If used early enough it can prevent the infection from progressing and it can be used in children as
young as three.
Many preparations contain antifungal or antiseptic ingredients such as benzalkonium chloride,
dequalinium chloride, cetylpyridinium chloride and hexylresorcinol. Evidence for their
effectiveness is not conclusive but their inclusion in sore throat remedies is logical.
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Anaesthetics
Anaesthetic agents such as benzocaine and lidocaine will numb the throat, thereby relieving pain.
They do sometimes cause sensitisation (an allergy develops) so their use should be limited to a
maximum of 5 days. The loss of sensation caused by an anaesthetic can make swallowing difficult in
children and the elderly. Care should also be taken when consuming hot food and drinks so as not to
burn the anaesthetized mouth.
Flurbiprofen
Flurbiprofen is an NSAID targeted specifically at treating sore throats. It is found OTC only in lozenge
form and will reduce the inflammation and pain of a sore throat. The usual restrictions to the sale of
NSAIDs apply, it is not suitable for children under 12 and must not be used for longer than three days.
Benzydamine
Benzydamine is another NSAID found in some sprays and a mouthwash which can be used as a gargle to
relieve pain and inflammation.
Hexetidine
Hexetidine is also found in some mouthwashes and has both anaesthetic and antiseptic activity.
Chronic Sore Throat
The word ’chronic’ indicates a habitual or continual condition, not necessarily a severe or dreadful one. In
this case it is caused by continuing irritation.
Certain activities might cause a chronic
sore throat:
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Chronic sinus infection
Chronic mouth breathing
Singing
Speaking or shouting
Alcohol abuse
Coughing and vomiting
Smoking
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A Word of Warning!
Pus can accumulate between the tonsil and
its bed although only the affected tonsil is
visible. This is called “quinsy” and it starts
off as tonsillitis. Swallowing will become
increasingly difficult and is a potentially
serious situation as choking can occur if
both tonsils swell. You should always refer
difficulty in swallowing, which can also be
associated with glandular fever,
oesophagitis and other serious conditions.
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Always refer a chronic sore throat to your pharmacist.
Laryngitis
Background
Laryngitis is the term given to inflammation of the larynx, or voice box, it is sometimes called ‘hoarseness’.
Inflammation of the vocal cords in the larynx causes a gruff, husky voice or even complete (temporary) loss
of voice. This is usually caused by a virus which will get better of its own accord. Resting the voice for a
couple of days should improve the problem.
In young children laryngitis can cause “croup” which produces tightening of the airways and difficulty in
breathing.
There are also some other causes of hoarseness:
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Arthritis
Cancer
Vocal cord abuse (shouting?)
Psychological issues
Thyroid problems
Solvent abuse
Inhalation of smoke
As you can see, chronic laryngitis may be a sign of something very serious so you should
refer hoarseness to the pharmacist after 3 days.
Treatment Options
Treatment includes drinking plenty of fluids to lubricate the throat, with the use of lozenges to stimulate
saliva and aid lubrication. Analgesics can be used if there is any pain, however the best treatment is just to
‘rest’ the voice, i.e. try to talk as little as possible and certainly no raising of the voice or singing!
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Key Points to Remember
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Pack sizes are restricted to 720mg (12 tablets) of pseudoephedrine or 180mg of ephedrine, with sales
limited to one pack per customer and to be carried out by a pharmacist
Refer children under 12 with coughs or colds to the pharmacist
Most coughs and colds are viral and will go away of their own accord but sensible choice of OTC
medicines relieves symptoms.
You may now complete the Formulary and Multiple Choice Questions for this module before
continuing onto module 10.
Remember to complete the summary of achievements section once you have completed these
tasks.
References
i
Linde, K. Barrett, B. Bauer, R. Melchart, D. and Woelkart, K. ‘Echinacea for preventing and treating the common cold’.
Cochrane Database of Systematic Reviews 2006, Issue 1. Art. No.: CD000530. DOI:10.1002/14651858.CD000530.pub2:
Downloaded from www2.cochrane.org/reviews/en/ab000530.html as at September 2010
ii
Hemilä, H. Chalker E. and Douglas, B. ‘Vitamin C for preventing and treating the common cold’. Cochrane Database of
Systematic Reviews 2007, Issue 3. Art. No.: CD000980. DOI: 10.1002/14651858.CD000980.pub3: Downloaded at
www2.cochrane.org/reviews/en/ab000980.html as at September 2010
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