3- Throat (common conditions) Flashcards
tonsilitis background
- Inflammation of the palatine tonsils
- Most commonly viral
Bacterial causes (up to 40% of cases)
- Streptococcus pyogenes (Group A )
- Strep pneumoniae
- Others: H.influenzae, Moraxella catarrhalis, staph aureus
Presentation of tonsilitis
- Fever
- Sore throat
- Pain/difficulty swallowing
- Examination
o Cervical lymph nodes
o Bad breath
o Exudate on tonsils
Criteria to determine if viral or bacterial
- Centor criteria
- FeverPAIN
Criteria to determine if viral or bacterial
- Centor criteria
- FeverPAIN
management of tonsilitis if likely viral
- Safety net
- Simple analgesia with paracetamol and ibuprofen
- Advise patient to return if pain has not settled after 3 days or fever >38.3
management of tonsilitis if likely bacterial
Centor >3, FeverPAIN >4
- Penicillin V for 10 days
- Clarithromycin if penicillin allergic
lower threshold for antibiotics for tonsilitis if
o Immunocompromised
o Young infants
o Co-morbidities
Complications of tonsilitis
- Peritonsillar abscess
- Otitis media
- Scarlet fever
- Rheumatic fever
- Post strep glomerulonephritis or arthritis
Peritonsillar abscess ‘quinsy’
Background
- Arises when there is a bacterial infection with trapped pus, forming an abscess in the region of the tonsils
- Complication of untreated tonsillitis -> can arise without tonsillitis
- Affects adults and children more equally than tonsilitis
Causes of quinzy
- Streptococcus pyogenus (step A)
- Or Staph aureus,
- H.influenzae
Presentation of quinsy
- Sore throat
- Painful swallowing
- Fever
- Neck pain
- Referred ear pain
- Swollen tender lymph nodes
- If its unilateral (quinsy) -> will deviate the uvula towards the swelling
Additional symptoms that can indicate a peritonsillar abscess include:
- Trismus, which refers to when the patient is unable to open their mouth
- Change in voice due to the pharyngeal swelling, described in textbooks as a “hot potato voice”
- Swelling and erythema in the area beside the tonsils
symptoms of quinsy
Symptoms
- Severe throat pain
- Fever
- Bad breath
- Drooling
- Difficulty opening mouth
- Can follow on from untreated or partially treated tonsilitis
- Can arise on its own
o Aerobic and anaerobic bacteria
management of quinsy
Management
- Needle aspiration or surgical incision and drainage to remove pus from abscess
- Antibiotics
- Some ENT surgeons also give dexamethasone to settle inflammation
Tonsillectomy
Tonsillectomy is the name for the surgical removal of the tonsils. Removing the tonsils prevents further episodes of tonsillitis, although patients can still get a sore throat from other causes (e.g., pharyngitis). The procedure is performed under a general anaesthetic as a day case. Patients can usually go home the same day after a period of observation.
indication for tonsillectomy
The number of episodes of acute sore throat they specify for a tonsillectomy are:
- 7 or more in 1 year
- 5 per year for 2 years
- 3 per year for 3 years
Other indications are:
- Recurrent tonsillar abscesses (2 episodes)
- Enlarged tonsils causing difficulty breathing, swallowing or snoring
complications of tonsillectomy
- Sore throat where the tonsillar tissue has been removed (this can last 2 weeks)
- Damage to teeth
- Infection
- Post-tonsillectomy bleeding
- Anaesthetic risks
which is the most important complication of tonsillecvtomy
post-tonsillectomy bleeding
post-tonsillectomy bleeding management
Immediate management
- call ENT registrar and get invovled early
- Get IV access and send bloods: FBC, clotting, group and save and crossmatch
- Keep patient calm and give adequate analgesia
- sit them up and encoruage to spit out blood rather than swallowing
- Make the patient Nill by mouth in case an anaesthetic and operation is required
- IV fluid for maintence and resuscitation
Conservative approach for less severe bleeds
- hydrogen peroxide gargle
- Adrenalin soaked swab applied topically
Definitive/ severe bleeding
- surgery
**If severe bleeding or airway compromise **->
intubate
Croup
Background
- Acute infective respiratory disease affecting young children
o 6 months – 2 years - URTI causes oedema in the larynx
croup cause
Cause: Parainfluenza virus
- Influenzas
- Adenovirus
- Respiratory syncytial virus
FYI: croup used to be caused by
diphtheria
- Croup caused by diphtheria would lead to epiglottitis and has a high mortality
- Vaccination against diphtheria therefore rare
Presentation of croup
- Increased work of breathing
- Barking cough
- Hoarse voice
- Stridor low grade fever
Presentation of epiglottitis
- Patient presenting with a sore throat and stridor
- Drooling
- Tripod position, sat forward with a hand on each knee
- High fever
- Difficulty or painful swallowing
- Muffled voice
- Scared and quiet child
- Septic and unwell appearance
epiglottiis investigations
Investigations
- If child acutely unwell -> no investigations -> DO NOT DISTRESS PATIENT
- Lateral X-ray will show ‘thumbs sign’
o This is soft tissue shadow that looks like a thumb pressed into the trachea
o Can also exclude foreign body
where are most stones located
submandibular glands
investigations for salivary stones
- History
- US
- X-ray
- Sialogram- contrast dye injected into gland
Enlarged pharyngeal tonsils
Background
Enlarged adenoidss can block eustachian tube
Presentation
- Recurrent/persistent middle ear infection
- Snoring/sleep apnoea
- Sleeping with mouth open
- Chronic sinusitis
- Sore throat
- Nasal tone to voice
false diverticulum pathophysiology
- Caused by a posteromedial (false diverticulum) arises in weakness between the 2 parts of the inferior constrictor (Killians dehiscence)
- Probably due to
o Failure of UOS to relax
o Abnormal timing of swallowing
o Essentially there is a higher pressure in laryngopharynx
o Weakness in inferior constrictor muscle produces outpouching
presentation if pathology associated with glossopharyngeal or vagus nerve
Obvious things
- Absent gag
- Uvula deviated away from lesion (Lower Motor Neurone lesion)
More subtle
- Dysphagia
- Taste impairment (posterior tongue IX)
- Loss of sensation oropharynx
presentation if pathology associated with hypoglossal nerve
- Wasted tongue
- Stick tongue out- tongue may deviated
o Damage to nerve itself (LMN)- points to side of the lesion (tongue never lies)
o Muscle wasting
o Fasciculations
Pre-malignant conditions
- Leucoplakia (white patches)
- Erythroplakia (red patches)
- Erythroleukoplakia (red and white patches)
- Oral lichen planus
- Actinic cheilitis
