61. Upper respiratory tract infections Flashcards
Common bacterial causes of pharyngitis
Group a strep
Non-Group A strep
Fuso bacterium
Mixed a robes and and robes
What is the Waldeyer ring?
Lymphoid tissue in the franks, consisting of the palatine tonsils/tonsils, frenal tonsils (adenoid), two will tonsils surrounding the eustachian tubes and lingual tonsils at the base of the tongue
What general factors are important to consider in pharyngitis
Symptom chronicity
Associated completes.
Patient comorbidity.
Patient risk factors
What common symptoms may indicate that a virus is responsible for pharyngitis
Rhea
Cough.
Conjunctivitis
Congestion.
Headache.
Usually proceeded by a sore throat inflammation and hypertrophy of the tissue in the waldeyer are common without exudate
What triad does mono usually present with?
Fever
Tonsillar pharyngitis. with exit date and hypertrophy, intermittently on the junction of the hard and soft palette
Posterior cervical lymphadenopathy
Mono: what virus causes this and what organ tends to enlarge?
EBV.
Splenomegaly
What disease gets a itchy,, morbilliform rash when given beta-lactam?
Mono
Influenza as a non-exudative cause of pharyngitis and sore throat – other symptoms?
Fever
Chills
Myalgia
Headache
What other symptoms of pharyngitis may occur when HIV is the cause cause?
Fever.
Sore throat
Nontender lymphadenopathy.
Diffuse maculopapular rash
Arthralgia
Mucocutaneous ulceration.
Diarrhea
When pharyngitis is caused by HSV what other symptoms might be present?
Pallet hyperaemia with sore throat
Odynophagia
Stomatitis
Tender, cervical adenopathy
List eight infectious causes specifically bacterial of pharyngitis
Group a haemolytic strep
Group, C and B haemolytic strep
Fusobacterium
Neiseria
Corynebacterium diptheria
Chlamydia
Mycoplasma
Arcano bacterium haemolyticum
Name nine causes of viral infectious pharyngitis
Rhinovirus
Coronavirus
ParaInfluenza
Influenza
Adenovirus
HIV.
Ebv
Herpes
CMB
Name, one fungal cause of pharyngitis
Candida
Name for serious adjacent infections to infectious causes of pharyngitis
Retro pharyngeal abscess.
Parapharyngeal abscess
Epiglottitis
Ludwig angina
Name 10 non-infectious ideologies of pharyngitis
Tumor.
Autoimmune disease
Neurogenic pain
Foreign body
Trauma
Medication induced
Steven Johnson syndrome.
Allergic reaction.
Oesophageal reflux
Environmental exposure
Normally, how much faster do group a strep pharyngitis resolve than untreated?
16 hours and contagious. Decreases to 24 hours after the start of antibiotics rather than up to one week in untreated patients.
Group A strep: pharyngitis symptoms that are characteristic
Rapid onset of sore throat
Odynophagia
Cervical adenopathy.
Fever
Chills.
Next stiffness
GAS pharyngitis: common signs
erythema and edema of pharynx
grey white tonsillar exudates
palatal petechiae
tender cerivcal adenoapthy
Suppurtative complications of GAS pharyngitis
AOM
mastoiditis
meningits
peritonsilar or retropharyngeal abscess
nec fasc/hem spread
rheumatic fever
What is Lemierre syndrome
septic jugular vein thrombophlebitis casued by commonly fusobacterium
arcanobacterium haemolyticum typically involved in what kind of pharyngitis infections?
RPA
can get a urticarial, maculopapular rash sparing face, palm, handsFranc
What zoonotic gram neg bacillus may cause false pos monospot test and atupical lymphocytes on peripheral smear after drinking contaminated food or water
Francisella tularenis
Tx for pharyngitis: options oral - nonpen allergic
Penicillin V
Child: 250mg BID or TID daily x10d vs adult 500mg bid 10d
amox 50mg/kg up to 1g daily or 25mg/kg up to 500 bid x10d
Single dose cs dex 0.6mg/kg up to 10mg po
Tx for pharyngitis: options oral - penicillin allergi
cephalexin 20mg/kg/dose max 500mg/dose bid x10d
clinda 7mg/kg/dose max 300/dose tid x10d
azithromycin 12/mg/kg max 500 per dose x5d
metronidazole 500mg IV q8h or kids 10-15m/kg max 500
AND
ceftr adult 2g IV q24h, child 50m/kg
or
pip-tazo 3.375g IV q6h, child 100mg/kg of pip q6-8h
Centor criteria for GAS pharyngitis
swollen tonsils exudates
tender anterior cervical adenopathy
absent cough
fever
Monospot sn and sp (high vs low)
high sp
vvariable sn as false neg early
First line dx test gas pharyngitis?
rapid antigen test
high sn and sp when performed correct - bilat tonsils and posterior pharynx
Testing for pharyngitis bugs: how to test for:
arcanobacterium haemolyticum
human blood agar
Testing for pharyngitis bugs: how to test for: diphterhia
Loeffler medium
Testing for pharyngitis bugs: how to test for:
candida
pseudohyphae on gram stain or + KOH stain
Testing for pharyngitis bugs: how to test for:chlamydia or gonorrhea
throat swab with naat
Management of mono
supportive
Tx of influenza on who?
within 2d presentation:
possible on documented or suspected influenza cases in hospitalized patients, children less than 2 years old, adults 65 years and older, preg- nant women and within 2 weeks postpartum, patients with immunosup- pression, and patients with chronic cardiac, pulmonary, hepatic, renal or hematologic disorders.
Diphtheria tx
diphtheria antitoxin and penicillin or eryththromycin
Candidal pharyngitis tx
topical clotrimazole or nystatin swish and swallow
Laryngitis: ac vs chronic
<3 vs >3 weeks
Laryngitis: chr causes
gerd
overuse of voice
trauma
thermal/chem burn
irritant
allergic reaction
Laryngitis: chr sensation?
globus sens or excess throat clearing
Laryngitis: - when do majority resolve?
2 weeks
Laryngitis: tx peds?
dex 0.6mg/kg up to 10
Epiglottitis: why is it rarer now?
h influ big cause, now vaccinated
Epiglottitis: increased risk?
dm
immunocompromised
substance abuse
Causes of Epiglottitis:
h influ
strep pneumo
staph
vs
burns, trauma, inhalational injury
Epiglottitis: signficiant geatures
sit forward in sitting position
cannot anage secretions
hoarse
Epiglottitis: ddx
rpa
anaphylaxis
angioedema
tumor
thyroiditis
chemical/thermal injury
FB
Epiglottitis: diagnostic test?
flex laryngoscopy (call ent)
Epiglottitis: management
abc keep them calm
call ent/anesthesia
iv abx
cs dex 0.6mg/kg to 10
nebulized epi 2.25% racemic epi diluated in ns given q3-4 hours
Peritonsillar cellulitis: vs abscess
abscess is collection of pus between palatine tonsil capusle and superior constrictor m of palatopharyngeus m
vs
cellulitis no collection
Peritonsillar abscess: RF
recent strep tonsillitis
mono
obstruction or infection of weber glands
smoking
dental or peridontal disease
antiinlamm meds
Peritonsillar abscess: mc bug?
strep pyogenes
recurrent can have fusobacterium
Peritonsillar abscess: complication
rupture into airway
spread into adj peritonsillar space
Peritonsillar abscess: features
unilateral sore throat
odynophagia
dysphagia
fever
malaise
drooling
muffled voice
trismus
ipsilateral otalgia
once abscess formed = uvula deviation towards contralateral tonsil
Epiglottis top 5 bugs in a normal host
h influ
strep pneumo
gas
staph
neisseria
Epiglottis top 5 bugs in a normal host - can tx with what abx?
amp sulbactam or ceftr and vanco or clinda/ cefepime or puptazo
and
vanco
Epiglottis additional 2 bugs immunocompromised to consider
pasteurella
aspergillis
RPA/PTA/peritonsilar abscess/Ludwig angina common 5 community bugs
gas
staph
strep milleri
aracnobacterium hemolyticum
mixed oral flora
RPA/PTA/peritonsilar abscess/Ludwig angina common 5 community bugs - tx
vanco
amp sulbactam
OR
clinda and levo
RPA/PTA/peritonsilar abscess/Ludwig angina if immunocompromised tx with?
cefepime and metronidazole
OR pip tazo and vanco
RPA/PTA/peritonsilar abscess/Ludwig angina - if MRSA risk add what 2 abx options?
vanco
linezolid
DDX of suppurative pharyngeal infection
retroph cellulits or abscess
parapharyngeal abscess
peritonsilar abscess
retropharyngeal tumor
tendinits of longus colli m
meningitis
hematoma secondary to trauma
carotid a aneurysm
Dx testing for RPA/PTA/peritonsilar abscess/Ludwig angina
CT contrast enhanced
RPA/PTA/peritonsilar abscess/Ludwig angina -larger abscess management?
drainage via needle aspiration via u/s guided to watch for carotid a
spray with topical lido/benzocaine
RPA/PTA/peritonsilar abscess/Ludwig angina - when to consider admission?
toxic appearing
require iv hydration and analgesia
signs of parapharyngeal ext on ct
immunocompromised with mult comorbidities
Ludwig angina: what is this?
rapidly progressive, bilatreal, gangrenuous cellulitis of submandibular spaces
Ludwig angina: why is this a bilateral process?
communication among open posterior aspect of submandibular spaces
Ludwig angina: mc causes?
mandibuldar molars dental origin
- these end up right under mylohyoid m of mandible and have a thin osseous structure
other: mandibular #, oral trauma, secondary infection from oral malignancy, suppurative parotitis, adj head nad neck infection
Ludwig angina: RF
immunocomprised and diabetic
Ludwig angina: clinical features key
recent dental infection or procedure with dysphagia, odynophagia, drooling, swelling of fx of mouth, neck stiffness, muffled voice, tongue displacement or protrustion
trismus
tense brawny neck edema
Ludwig angina: ddx
rpa
pta
parotid/submandibular gland abscess
oropharyngeal tumor
sublingual hematoma
glossal or posterior oropharyngeal angioedema
laryngeal diphtheria
Ludwig angina: management
airway!!!! - ent or anesthesia for flexible bronch vs surgical airway if no time
abx once airway secured
RPA - what is this?
infection of deep neck behind hypoharynx and esophagus in midline of neck, anterior to danger and prevertebral spaces extending to diaphragm and coccyx
RPA -mc what age?
<5 male as LN present here that drain nasal cavity, paranasal sinu, oropharynx, hypopharynx space, middle ear, eustachian tube
RPA - when do these go away
puberty
RPA - adult causes more likely from?
penetrating trauma
fb
iatrogenic instrumentation
adj infection
hematologic spread of infection or spine infection
RPA - RF
immunosuppressiion
chronic steroid
dm
HIV
RPA - complications
abscess rupture and aspiration
airway compromise
involvement of carotid sheath - aneusym, arterial erosion, Lemierre syndrome, palsy of CN 9-12, mediastinitis
RPA - PE
tender cervical LN
new swelling
torticollis
fever
RPA - preferred diagnostic test
ct contrast enhanced
RPA - ct findings
fluid collection with central hypodensity and complete ring enh with scalloping
fat stranding and edema characterized by low density thickening without peripheral enhancement may be early
RPA - lateral neck radiograph + ?
rpa space from anteroinf aspect of second vertebral body to posterior pharyngeal wall >7mm or retrotracheal space at 6th vb >14mm child vs 22mm adult - abnormal!!
RPA - management
airway stabilization
abx
dex
Parapharyngeal abscess: what is in close proximity?
airway
carotid sheath
mediastinum
either side of neck and extends from skull base to stulogloggus m at angle of mandible
Parapharyngeal abscess: usually come from what prior infection?
dental
Parapharyngeal abscess: possible complications
airwau obstuction from edema
neck or mediastinal spread
vascular involvement
nerve compromise
abscess rupture can lead to pneumonia, lung abscess or empyema
ipsilateral Horner syndrome and neuropathies of CN 9-12
rupture of carotid aneyrm or erosion of close
Lemierre syndrome
Cavernous sinus thrombosis - what is this?
Cavernous sinus thrombosis: when to expect this?
proptosis, impaired EOM, pupillary changes - spread of infection through opthalmic venous system
Parapharyngeal abscess: pain with ? can be characteristic
mastication
Parapharyngeal abscess: preferred diagnostic test?
contrast enh ct
Parapharyngeal abscess: management
airway
dex
abx
ent
Rhinosinusitis: what is this?
inflamm of upper airways and paranasal sinuses assoc with nasal discharge, facial pain or pressure, nasal blockade and sense of fullness
Acute rhinosinusitis classification < than _ weeks
4
Acute rhinosinusitis viral vs bacterial typical couse
Viral etiologies tend to have symptoms that peak and resolve in a few days, whereas bacterial etiol- ogies tend to last longer than 10 days with persistent symptoms or will worsen after a period of improving symptom
What structural abnormalities predispose someone to rhinosinusistis?
nasal septal deviation
infraorbital ethmoid air cells > 3mm
acessory ostia
conchae bullosa
oroantral fistula
maxillary dental disease
Chronic rhinosinusitis > _ weeks
12
Complications of rhinosinusitis:
cellulitis
meningitis
orbital or intracranial abscess
Symptoms of rhinosinusitis:
purulent nasal discharge
facial pain or pressure
posterior nasal drip
decreased sn of smell
all with headache/fatigue/malaise, fever
DDX rhinosinusitis
allergic rhinitis
dental infection
headache syndromes
tumor
IC abscess
Diagnostic criteria of rhinosinusitis: clinical 3
- at least 10d of ongoing sx no improvement
- 3-4d severe sx including fever >39 with nasal discharge or facial pain without improvement
- onset progressive sx with worsening sx after initially improved
Management rhinosinusitis: acute
self resolving
management on sx and pt education
acetaminophen
ibuprofen
nasal irrig saline 1-2 spray ea nostril q4h
IN CS 2 sprays ea nostril once daily
Only use abx if meet rhinosinusitis defn:
abx to use?
amox 500mg PO TID or amox clav BID x5d
Rhinosinusitis: Amox clav when to use - RF
pt smokes
diabetes
recent abx
older >65
HC worker
Rhinosinusitis: if allergic to pen use?
doxy
levo and moxi but reserved for pt without other options
Rhinosinusitis: if treating bacterial sinusitis, how long to tx for?
5-14d (initially try 5d)
child 10d
Rhinosinusitis: when to refer to ent?
more than 4 episodes per year of distinct ea episodes
A previously well 18-year-old male presents with throat pain and fever to 39 °C for the past 2 days. He denies vomiting, diarrhea, cough, or rhinorrhea. He is not sexually active. Physical exam is notable for tender anterior cervical lymphadenopathy and symmet- rically swollen and erythematous palatine tonsils with a gray-white tonsillar exudate. The remainder of his neck and physical exam is benign. What is the most appropriate next step?
a. Empirically prescribe amoxicillin for 10 days
b. Obtain a complete blood count with differential
c. Obtain an intraoral tonsillar ultrasound
d. Perform a rapid strep antigen test and prescribe antibiotics only
if there is a positive result
d
A 34-year-old male presents with complaints of high fever, left- sided face pain, and purulent nasal discharge for 10 days. He has been attempting symptom management with nasal saline irrigation and intranasal corticosteroids, but after initial improvement reports worsening symptoms. What is the next step in treatment?
a. CT scan of his face to evaluate for complications of rhinosinus- itis
b. Obtain bacterial culture via sinus puncture
c. Prescribe a 5-day course of amoxicillin
d. Supportive care with antiinflammatory medications, rest, and
continued nasal saline irrigation
c
- A 19-year-old female patient presents to the emergency department
with vision changes and headaches. She reports a sore throat 10 days ago started to improve, but never completely resolved. For the past 3 days she noted increasing left-sided neck pain and fevers. On exam she appears uncomfortable with a fever and mild tachycardia. She is warm and diaphoretic with a dry forehead on the left. Her left eyelid is slightly lower than the right and her left pupil is 3 mm smaller than the right. Her extraocular movements are intact, and her intraoral exam shows symmetric tonsils with mild erythema and a midline uvula. She has mild trismus. What is most likely caus- ing her symptoms?
a. Parapharyngeal abscess with invasion of the carotid sheath
b. Peritonsillar abscess with compression of the carotid sheath
c. Spread of infection into the cavernous sinus causing thrombosis
and intracranial abscess
d. Submandibular space infection and spread into retropharynx
A
- Patients presenting with symptoms concerning for a retropharyn-
geal abscess are best evaluated using what modality? a. Contrast-enhancedCT
b. Intraoral ultrasound
c. Lateralneckx-ray
d. Visualization with a fiberoptic scope
A
- This bacterium is frequently implicated in non-GAS pharyngi- tis and is also most commonly implicated in suppurative jugular thrombophlebitis:
a. Arcanobacteriumhaemolyticum
b. Fusobacterium necrophorum
c. Haemophilus influenzae type B
d. Methicillin-resistant Staphylococcus aureus
B
When to consider diptheria?
unimm pt with travel to endemic area
Diptheria syndromes
looks like strep - pharyngeal/tonsillar - grey white spots –> worry systemic tox
nasal diptheria also plausible - crusting/upper lip infection –> worry systemic tox
laryngeal diphtheria: looks like bronchiolitis/laryngitis ish - hoarse voice, cough
cutaenous dipheria: chronic ulcer somewhere - less systemic toxic than systemi
Systemic toxin complications of diptheria
myocarditis
neuritis (CN palate, eyes; systemic- paralysis)
renal failure
Treatment of diptheria:
droplet precautions
abx: pen, macrolides
antixtoxin if severe- ID on call
Reporting for probable case and call PH
Liverpool PTA score: 5 variables
unilateral sore throat
trismus
male
pharyngeal voice change
uvular deviation
when to drain an abscess - what general size?
1cm
