What is the Best Antibiotic for Strep Throat?

The traditional answer for the best antibiotic to treat strep throat is penicillin. This antibiotic works astoundingly well... until it doesn't. Why is that?

Although in the lab, penicillin is probably the most effective antibiotic against Group A beta-hemolytic streptococci (GABHS) or "strep throat" infection, when it comes to human beings, it doesn't always work. A recent paper out of Georgetown elucidates the reasons why that might be the case and also explains why if you took a survey of ENT doctors, clindamycin and augmentin are perhaps the two most popular antibiotics used in our patient population (patients seen in an ENT practice suffering from recurrent and/or severe infections of the head and neck region).

Penicillin may fail to work because:

• presence of beta-lactamase producing bacteria that "protect" strep from penicillins
• absence of bacteria that interfere with the growth of strep
• co-aggregation between strep and Moraxella catarrhalis
• poor penetration of penicillin into the tonsillar tissue cells which allows intra-cellular strep and Staphylococcus aureus to survive

Indeed, in the treatment of recurrent and chronic strep throat, clindamycin or amoxicillin-clavulanic acid (augmentin) can eradicate both aerobic and anaerobic beta-lactamase producing bacteria as well as strep itself. Cephalosporins and clindamycin have superior intracellular penetration which enhances their efficacy as well.

Of course, if a patient has suffered from such severe and recurrent strep infections, it just might be time to remove and tonsils and adenoids surgically.

Reference:
Penicillin failure in the treatment of group A streptococcal pharyngo-tonsillitis: Causes and solutions. Journal of Pediatric Infectious Diseases. Volume 8, Number 2 / 2013 Pages 59-69

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Vocal Cord Tear Silences R&B Singer Frank Ocean

Image by Fred von Lohmann from Wikipedia

On July 25, 2013, R&B singer Frank Ocean was forced to cancel his entire Australian concert tour due to a small vocal cord tear.

After singing his opening night with a sore throat during which he reportedly sounded "noticeably off-key," he seeked medical attention and was informed of the unfortunate condition of his vocal cord. Listening to his voice on this YouTube video recorded during this fateful concert, his voice actually does not sound as bad as I would expect with a vocal cord tear. However, at time point 1:20, there was an obvious pitch break.

If a vocal cord tear was truly present, it must have been extremely small and not along the free edge because even with a small vocal cord tear located along the vibrating margin, the vocal quality would have been noticeably degraded throughout the vocal range. Why?


In order for the vocal cords to produce a clear voice, the vocal cords must come together and vibrate evenly. This vibration occurs on the vocal cord mucosa. ANYTHING that disrupts this mucosal vibration would result in a raspy voice including small bumps like a nodule or polyp, but also a vocal cord tear. Watch video of normal vocal cords in motion.

Small bumps typically cause problems in the voice only in the high range at quiet volumes because often the bump can vibrate along with the mucosa (just like a buoy on the ocean). As long as the vibration is unaffected, the voice comes out. As a bump gets bigger, a greater portion of the vocal range becomes affected.

A tear, however, depending on where it is located could affect the entire vocal range due to vibratory disruption as it moves to and around the tear (the tear acts like an anchored pillar in the ocean).

The only way to correct a tear is MANDATORY strict voice rest for several weeks. Further using the voice when injured like this may only "rip" the tear larger potentially causing a greater risk of scar formation and a permanent hoarse voice.

Strict voice rest means absolutely no talking and whispering. Such activities cause the vocal cords to come together and "bang" against the vocal cord tear preventing proper healing. I would even instruct patients to avoid even mouthing words as it causes the brain to "think" you are talking even if you are not. Essentially, the lips should always remain closed except when eating/drinking. The analogy would be if you have surgery done on the heel of your foot, you should not walk or put any weight on the heel, otherwise risk improper healing.

Here's an example picture of a vocal cord tear on both vocal cords in a patient suffering from viral laryngitis who did not quit using her voice for a prolonged period of time.

WHY would a vocal cord tear appear in the first place? Usually from excessively traumatic vocal abuse (ie, strong cough, scream, yell, etc).

Source:
Frank Ocean Suffers Tear to Vocal Cord, Scraps Australian Mini-Tour. Billboard Biz 7/26/13

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Nasal Hair Removal and Nasal Sores

It is not unusual that I encounter a patient who develops crusting and sores around the entrance to the nose where coincidentally nasal hair is found... in both men and women.

Other complaints/symptoms beyond crusting and sores include:

• Skin Splitting
• Pimple/Acne Formation
• Scabbing
• Ulcers

People often try applying lotion, neosporin, or cortisone cream... which does help, but not completely with recurrent flareups.

The most common triggers I find that lead to such recurrent sores are nose-picking and nasal hair removal.

The best thing is to avoid doing either... but... if one must...

Nose picking is pretty self-explanatory, but nasal hair removal does require some clarification.

People often use tweezers or even their fingers to pull the offending long nasal hair out for either cosmetic or annoyance reasons.

Yanking nasal hair out is not a good idea beyond the watery eyes it may bring. It causes micro-trauma to the surrounding skin and hair follicle that may lead to infection. Furthermore, just like any other place on the body where hair is removed, ingrown hair growth can also occur.

Aha! one might say... Use an electric nasal hair cutter! That's a good idea, but make sure it does not cut down to the skin for the same reasons as stated above. Also, ensure the blades are kept sharp to prevent hair pulling.

There are good nasal hair cutters and there are bad ones...

From personal testing of a variety of nasal hair cutters, I like the Groom Mate Platinum XL.

I'm sure there are other good ones, but it may also come down to personal preference.

Now, if there's an active recurrent nasal sore that's not healing, the best way to treat it is with prescription cortisporin ointment.

However, best to have a doctor to check it out as there are other more malicious reasons for a nasal sore including skin cancer.

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Natural Remedies for a Sore Throat, Cough, and Viral Infections

Homeopathy and alternative medicine often get a bum rap, but they have come up with some treatments for sore throats and upper respiratory viral illnesses that actually have been proven to work.

Here's a few...

1) Honey

Sore throats (and coughing) can be soothed by swallowing honey straight-up or slightly diluted with warm water with honey to make it easier to swallow. The best time to do this is at bedtime given it will stick around for awhile (eating/drinking will wash away the coating). The purpose of honey is to create a throat barrier to ease the discomfort.

Think of it like chapstick to coat irritated lips, but meant for the throat.

Use of honey is also recommended by the World Health Organization which has also published a monogram on viral colds and the various treatments explained. Pay particular close attention to Annex 3 (Page 11) which gives various recipes to treat pediatric cough including the use of honey.

Reference:
Effect of Honey, Dextromethorphan, and No Treatment on Nocturnal Cough and Sleep Quality for Coughing Children and Their Parents. Arch Pediatr Adolesc Med. 2007;161(12):1140-1146.

2) Humidification

Dry cool air increases risk of viral infections as well as giving it to others. As such, add room humidification to a bedroom and keep the door closed (small room humidifiers can't humidify an entire house... so keep door closed!).

Why does this help? Increased humidification inactivates viruses!

Humidification also helps minimize a persistent dry cough worse at night often due to reactive airway disease triggered by breathing in dry air.

However, keep in mind that if you actively have a viral illness, it is too late for humidity to help. It is best used as a preventative measure.

Reference:
Dynamics of airborne influenza A viruses indoors and dependence on humidity. PLoS One. 2011;6(6):e21481. Epub 2011 Jun 24. Influenza virus transmission is dependent on relative humidity and temperature. PLoS Pathog. 2007;3:e151.

Heated, humidified air for the common cold. Cochrane Database Syst Rev. 2011 May 11;(5):CD001728.

3) Gargling and Saline Flushes

Gargle with saline water... or even just tap-water on a daily basis. Why does this help prevent viral infections? It washes away the viral particles before it gets a chance to cause problems.

It's also probably why drinking lots of fluids also helps since the viruses get deactivated in the stomach from the acidic digestion.

Unfortunately, gargling only helps with the throat... saline flushes are required to help with sino-nasal problems.

Reference:
Can we prevent influenza-like illnesses by gargling? Intern Med. 2007;46(18):1623-4. Epub 2007 Sep 14.

4) Xylitol

This naturally-occurring sugar substitute apparently has all sorts of anti-bacterial as well as anti-fungal properties and has been known to doctors and scientists but hardly marketed or promoted in any fashion.

However, the importance of this compound is that it DOES appear to significantly decrease the incidence of ear infections and sinus infections when used regularly. It comes in nasal spray form as well as gum.

Reference:

Xylitol as a prophylaxis for acute otitis media: systematic review. Int J Audiol. 2010 Oct;49(10):754-61.

A novel use of xylitol sugar in preventing acute otitis media. Pediatrics. 1998 Oct;102(4 Pt 1):879-84.

Xylitol chewing gum in prevention of acute otitis media: double blind randomised trial. BMJ. 1996 Nov 9;313(7066):1180-4.

Failure of xylitol given three times a day for preventing acute otitis media. Pediatr Infect Dis J. 2007 May;26(5):423-7.

Xylitol administered only during respiratory infections failed to prevent acute otitis media. Pediatrics. 2002 Feb;109(2):E19.

Conclusion

Sometimes the BEST medicine are things you can do at home without need for a physician visit... and is based on fact rather than anecdotal evidence.

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Cold Sores Due to a Single Gene

Specifically, individuals who suffer from cold sores triggered by Herpes Virus Simplex - 1 (HSV-1) several times a year may have a single nucleotide polymorphism in their gene C21orf91 – dubbed rs1062202. Researchers have suggested it be called by the more "easy-to-remember" name Cold Sore Susceptibility Gene 1 (CSSG1).

Having this genetic change of swapping a thymine to a cytosine nucleotide was significantly associated (p=0.0047) with more frequent cold sores. Analysis has also found collections of 5 variants that are transmitted together with the C21orf91 gene of which two seemed to be neutral in terms of cold sore frequency, one was protective, and two were associated with increased susceptibility.

What does this all mean for an individual? It means if your parents get them a lot, than you may too.

Such individuals may benefit from regular use of anti-viral antibiotics to prevent such frequent recurrences.

Reference:
C21orf91 genotypes correlate with herpes simplex labialis (cold sore) frequency: Description of a cold sore susceptibility gene. J Inf Dis 2011; DOI: 10.1093/infdis/jir633.

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