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61. Upper respiratory tract infections Flashcards

1
Q

Common bacterial causes of pharyngitis

A

Group a strep
Non-Group A strep
Fuso bacterium
Mixed a robes and and robes

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2
Q

What is the Waldeyer ring?

A

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

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3
Q

What general factors are important to consider in pharyngitis

A

Symptom chronicity
Associated completes.
Patient comorbidity.
Patient risk factors

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4
Q

What common symptoms may indicate that a virus is responsible for pharyngitis

A

Rhea
Cough.
Conjunctivitis
Congestion.
Headache.
Usually proceeded by a sore throat inflammation and hypertrophy of the tissue in the waldeyer are common without exudate

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5
Q

What triad does mono usually present with?

A

Fever
Tonsillar pharyngitis. with exit date and hypertrophy, intermittently on the junction of the hard and soft palette
Posterior cervical lymphadenopathy

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6
Q

Mono: what virus causes this and what organ tends to enlarge?

A

EBV.
Splenomegaly

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7
Q

What disease gets a itchy,, morbilliform rash when given beta-lactam?

A

Mono

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8
Q

Influenza as a non-exudative cause of pharyngitis and sore throat – other symptoms?

A

Fever
Chills
Myalgia
Headache

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9
Q

What other symptoms of pharyngitis may occur when HIV is the cause cause?

A

Fever.
Sore throat
Nontender lymphadenopathy.
Diffuse maculopapular rash
Arthralgia
Mucocutaneous ulceration.
Diarrhea

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10
Q

When pharyngitis is caused by HSV what other symptoms might be present?

A

Pallet hyperaemia with sore throat
Odynophagia
Stomatitis
Tender, cervical adenopathy

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11
Q

List eight infectious causes specifically bacterial of pharyngitis

A

Group a haemolytic strep
Group, C and B haemolytic strep
Fusobacterium
Neiseria
Corynebacterium diptheria
Chlamydia
Mycoplasma
Arcano bacterium haemolyticum

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12
Q

Name nine causes of viral infectious pharyngitis

A

Rhinovirus
Coronavirus

ParaInfluenza
Influenza
Adenovirus

HIV.
Ebv
Herpes
CMB

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13
Q

Name, one fungal cause of pharyngitis

A

Candida

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14
Q

Name for serious adjacent infections to infectious causes of pharyngitis

A

Retro pharyngeal abscess.
Parapharyngeal abscess
Epiglottitis
Ludwig angina

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15
Q

Name 10 non-infectious ideologies of pharyngitis

A

Tumor.
Autoimmune disease
Neurogenic pain
Foreign body
Trauma
Medication induced
Steven Johnson syndrome.
Allergic reaction.
Oesophageal reflux
Environmental exposure

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16
Q

Normally, how much faster do group a strep pharyngitis resolve than untreated?

A

16 hours and contagious. Decreases to 24 hours after the start of antibiotics rather than up to one week in untreated patients.

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17
Q

Group A strep: pharyngitis symptoms that are characteristic

A

Rapid onset of sore throat
Odynophagia
Cervical adenopathy.
Fever
Chills.
Next stiffness

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18
Q

GAS pharyngitis: common signs

A

erythema and edema of pharynx
grey white tonsillar exudates
palatal petechiae
tender cerivcal adenoapthy

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19
Q

Suppurtative complications of GAS pharyngitis

A

AOM
mastoiditis
meningits
peritonsilar or retropharyngeal abscess
nec fasc/hem spread
rheumatic fever

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20
Q

What is Lemierre syndrome

A

septic jugular vein thrombophlebitis casued by commonly fusobacterium

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21
Q

arcanobacterium haemolyticum typically involved in what kind of pharyngitis infections?

A

RPA

can get a urticarial, maculopapular rash sparing face, palm, handsFranc

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22
Q

What zoonotic gram neg bacillus may cause false pos monospot test and atupical lymphocytes on peripheral smear after drinking contaminated food or water

A

Francisella tularenis

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23
Q

Tx for pharyngitis: options oral - nonpen allergic

A

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

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24
Q

Tx for pharyngitis: options oral - penicillin allergi

A

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

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25
Centor criteria for GAS pharyngitis
swollen tonsils exudates tender anterior cervical adenopathy absent cough fever
26
Monospot sn and sp (high vs low)
high sp vvariable sn as false neg early
27
First line dx test gas pharyngitis?
rapid antigen test high sn and sp when performed correct - bilat tonsils and posterior pharynx
28
Testing for pharyngitis bugs: how to test for: arcanobacterium haemolyticum
human blood agar
29
Testing for pharyngitis bugs: how to test for: diphterhia
Loeffler medium
30
Testing for pharyngitis bugs: how to test for: candida
pseudohyphae on gram stain or + KOH stain
31
Testing for pharyngitis bugs: how to test for:chlamydia or gonorrhea
throat swab with naat
32
Management of mono
supportive
33
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.
34
Diphtheria tx
diphtheria antitoxin and penicillin or eryththromycin
35
Candidal pharyngitis tx
topical clotrimazole or nystatin swish and swallow
36
Laryngitis: ac vs chronic
<3 vs >3 weeks
37
Laryngitis: chr causes
gerd overuse of voice trauma thermal/chem burn irritant allergic reaction
38
Laryngitis: chr sensation?
globus sens or excess throat clearing
39
Laryngitis: - when do majority resolve?
2 weeks
40
Laryngitis: tx peds?
dex 0.6mg/kg up to 10
41
Epiglottitis: why is it rarer now?
h influ big cause, now vaccinated
42
Epiglottitis: increased risk?
dm immunocompromised substance abuse
43
Causes of Epiglottitis:
h influ strep pneumo staph vs burns, trauma, inhalational injury
44
Epiglottitis: signficiant geatures
sit forward in sitting position cannot anage secretions hoarse
45
Epiglottitis: ddx
rpa anaphylaxis angioedema tumor thyroiditis chemical/thermal injury FB
46
Epiglottitis: diagnostic test?
flex laryngoscopy (call ent)
47
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
48
Peritonsillar cellulitis: vs abscess
abscess is collection of pus between palatine tonsil capusle and superior constrictor m of palatopharyngeus m vs cellulitis no collection
49
Peritonsillar abscess: RF
recent strep tonsillitis mono obstruction or infection of weber glands smoking dental or peridontal disease antiinlamm meds
50
Peritonsillar abscess: mc bug?
strep pyogenes recurrent can have fusobacterium
51
Peritonsillar abscess: complication
rupture into airway spread into adj peritonsillar space
52
Peritonsillar abscess: features
unilateral sore throat odynophagia dysphagia fever malaise drooling muffled voice trismus ipsilateral otalgia once abscess formed = uvula deviation towards contralateral tonsil
53
Epiglottis top 5 bugs in a normal host
h influ strep pneumo gas staph neisseria
54
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
55
Epiglottis additional 2 bugs immunocompromised to consider
pasteurella aspergillis
56
RPA/PTA/peritonsilar abscess/Ludwig angina common 5 community bugs
gas staph strep milleri aracnobacterium hemolyticum mixed oral flora
57
RPA/PTA/peritonsilar abscess/Ludwig angina common 5 community bugs - tx
vanco amp sulbactam OR clinda and levo
58
RPA/PTA/peritonsilar abscess/Ludwig angina if immunocompromised tx with?
cefepime and metronidazole OR pip tazo and vanco
59
RPA/PTA/peritonsilar abscess/Ludwig angina - if MRSA risk add what 2 abx options?
vanco linezolid
60
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
61
Dx testing for RPA/PTA/peritonsilar abscess/Ludwig angina
CT contrast enhanced
62
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
63
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
64
Ludwig angina: what is this?
rapidly progressive, bilatreal, gangrenuous cellulitis of submandibular spaces
65
Ludwig angina: why is this a bilateral process?
communication among open posterior aspect of submandibular spaces
66
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
67
Ludwig angina: RF
immunocomprised and diabetic
68
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
69
Ludwig angina: ddx
rpa pta parotid/submandibular gland abscess oropharyngeal tumor sublingual hematoma glossal or posterior oropharyngeal angioedema laryngeal diphtheria
70
Ludwig angina: management
airway!!!! - ent or anesthesia for flexible bronch vs surgical airway if no time abx once airway secured
71
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
72
RPA -mc what age?
<5 male as LN present here that drain nasal cavity, paranasal sinu, oropharynx, hypopharynx space, middle ear, eustachian tube
73
RPA - when do these go away
puberty
74
RPA - adult causes more likely from?
penetrating trauma fb iatrogenic instrumentation adj infection hematologic spread of infection or spine infection
75
RPA - RF
immunosuppressiion chronic steroid dm HIV
76
RPA - complications
abscess rupture and aspiration airway compromise involvement of carotid sheath - aneusym, arterial erosion, Lemierre syndrome, palsy of CN 9-12, mediastinitis
77
RPA - PE
tender cervical LN new swelling torticollis fever
78
RPA - preferred diagnostic test
ct contrast enhanced
79
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
80
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!!
81
RPA - management
airway stabilization abx dex
82
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
83
Parapharyngeal abscess: usually come from what prior infection?
dental
84
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?
85
Cavernous sinus thrombosis: when to expect this?
proptosis, impaired EOM, pupillary changes - spread of infection through opthalmic venous system
86
Parapharyngeal abscess: pain with ? can be characteristic
mastication
87
Parapharyngeal abscess: preferred diagnostic test?
contrast enh ct
88
Parapharyngeal abscess: management
airway dex abx ent
89
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
90
Acute rhinosinusitis classification < than _ weeks
4
91
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
92
What structural abnormalities predispose someone to rhinosinusistis?
nasal septal deviation infraorbital ethmoid air cells > 3mm acessory ostia conchae bullosa oroantral fistula maxillary dental disease
93
Chronic rhinosinusitis > _ weeks
12
94
Complications of rhinosinusitis:
cellulitis meningitis orbital or intracranial abscess
95
Symptoms of rhinosinusitis:
purulent nasal discharge facial pain or pressure posterior nasal drip decreased sn of smell all with headache/fatigue/malaise, fever
96
DDX rhinosinusitis
allergic rhinitis dental infection headache syndromes tumor IC abscess
97
Diagnostic criteria of rhinosinusitis: clinical 3
1. at least 10d of ongoing sx no improvement 2. 3-4d severe sx including fever >39 with nasal discharge or facial pain without improvement 3. onset progressive sx with worsening sx after initially improved
98
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
99
Only use abx if meet rhinosinusitis defn: abx to use?
amox 500mg PO TID or amox clav BID x5d
100
Rhinosinusitis: Amox clav when to use - RF
pt smokes diabetes recent abx older >65 HC worker
101
Rhinosinusitis: if allergic to pen use?
doxy levo and moxi but reserved for pt without other options
102
Rhinosinusitis: if treating bacterial sinusitis, how long to tx for?
5-14d (initially try 5d) child 10d
103
Rhinosinusitis: when to refer to ent?
more than 4 episodes per year of distinct ea episodes
104
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
104
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
105
2. 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
106
4. 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
107
5. 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
108
When to consider diptheria?
unimm pt with travel to endemic area
109
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
110
Systemic toxin complications of diptheria
myocarditis neuritis (CN palate, eyes; systemic- paralysis) renal failure
111
Treatment of diptheria:
droplet precautions abx: pen, macrolides antixtoxin if severe- ID on call Reporting for probable case and call PH
112
Liverpool PTA score: 5 variables
unilateral sore throat trismus male pharyngeal voice change uvular deviation
113
when to drain an abscess - what general size?
1cm

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