EENT #8 (Nose/Sinus) Flashcards
Strep Pharyngitis (Strep Throat) has the highest incidence of ______ if untreated in children 5-15 years of age
Rheumatic fever
Cause of Strep Pharyngitis
Group A Strep (Strep Pyogenes)
Symptoms of Strep Pharyngitis
- Dysphagia (pain with swallowing)
- Fever
- No symptoms of viral infections: cough, hoarseness, coryza, diarrhea
What is usually seen on exam of a patient with Strep Pharyngitis?
- Fever
- Absent Cough
- Anterior Cervical LAD
- Tonsillar Exudate/Petechiae
CENTOR CRITERIA
Best initial test for strep pharyngitis
-Rapid antigen detection test (if negative, throat cultures should be obtained especially in children 5-15 years old)
Definitive diagnostic for Strep Pharyngitis
Throat culture
First-line treatment for Strep Pharyngitis
-Penicillin (Pen G or VK, Amoxicillin)
If the patient has a penicillin allergy, what medications should be given for Strep Pharyngitis?
Macrolides (Erythromycin, Azithromycin)
Clindamycin
Cephalosporins
What are some complications of Strep Pharyngitis?
Rheumatic Fever
Acute glomerulonephritis
Peritonsillar Abscess
MC etiology of laryngitis
Viral upper respiratory tract infection: Adenovirus, Rhinovirus, Influenza, RSV, Parainfluenza
What are other causes of laryngitis?
Vocal strain
Irritants (GERD, acid)
Polyps
Laryngeal cancer
Symptoms of laryngitis
- Hoarseness (hallmark)
- Aphonia (inability to speak)
- Dry or scratchy throat
- May have viral URI symptoms
Treatment for laryngitis
-Supportive care mainstay: hydration, humidification, vocal rest, warm saline gargles, lozenges
A peritonsillar abscess (Quinsy) is a complication of tonsillitis or pharyngitis. This condition is often polymicrobial, but often the predominant species is
Group A Strep (Strep Pyogenes)
Symptoms of a peritonsillar abscess
- Dysphagia
- Severe unilateral pharyngitis
- High fever
- Muffled “hot potato voice”
- Difficulty handling oral secretions (drooling)
- Trismus (lockjaw)
What is on physical exam in a peritonsillar abscess?
Swollen or fluctuant tonsil causing uvula deviation to contralateral side
Bulging of soft palate
Anterior Cervical LAD
What is the imaging study of choice for peritonsillar abscess
CT scan
Management for peritonsillar abscess
- Drainage (aspiration or I&D) + ABX
- -Oral (Clindamycin or Amoxicillin-Clavulanic Acid)
- -Parenteral (Ampicillin-Sulbactam, Clindamycin)
When should a tonsillectomy be considered for a peritonsillar abscess?
Patients who fail to respond to drainage
Abscess with complications
Prior episodes of abscess
Recurrent severe pharyngitis
How can you prevent Peritonsillar Abscess
Prompt Treatment of Streptococcal infections
A retropharyngeal abscess, although common in children ages 2-4, can occur in adults as a result of
Penetrating trauma (chicken bones, instrumentation, dental procedures)
Etiologies of Retropharyngeal Abscess
-Often polymicrobial (Group A Strep is MC)
Symptoms of Retropharyngeal abscess
- Torticollis (unwilling to move neck due to pain)
- Neck stiffness with extension
- Fever, drooling, dysphagia, chest pain, trismus, hot potato voice
- Midline or unilateral posterior pharyngeal wall edema (MC)
- Anterior cervical LAD
- Lateral neck mass and swelling
If suspicion is high, what is the preferred imaging method for retropharyngeal abscess
CT scan of neck with contrast
However, if a lateral neck radiograph is performed, what is seen with a retropharyngeal abscess?
increased prevertbral space > 50% of width of adjacent vertebral body
Treatment for retropharyngeal abscess
- Surgical incision and drainage for large abscesses
- If abscess < 2.5 cm, may be observed for 24-48 hours with ABX
- ABX: IV Ampicillin-Sulbactam or Clindamycin
Oral Lichen Planus has increased incidence with
Hepatitis C infection
Symptoms of oral lichen planus
- Reticular: lacy reticular leukoplakia of oral mucosa (Wickham striae). Painless
- Erythematous: red patches that may be painful
- Erosive: erosions or ulcers. Painful.
What is the MC type of oral lichen planus?
Reticular
Although oral lichen planus is often a clinical diagnosis, what should be done in the erythematous and erosive types to rule out malignancy?
Biopsy
Initial treatment of choice for oral lichen planus
Local glucocorticoids (Clobetasol, Betamethasone)
However, second line treatment for oral lichen planus is
Topical (Tacrolimus, Cyclosporine), intralesional corticosteroid injections
-Systemic glucocorticoids if no response to topical therapy
What is Ludwig’s Angina?
Rapidly spreading cellulitis of the floor of the mouth
Risk factors for Ludwig’s Angina?
- MC due to dental infections (second or third mandibular molars)
- Diabetes
- HIV
Symptoms of Ludwig’s Angina
- Fever, chills, malaise, stridor
- Tender, symmetric swelling
- Woody induration and erythema of upper neck and chin
- Pus on floor of mouth
- Swelling of the tongue can lead to airway compromise
Initial diagnostic for Ludwig’s Angina
-CT scan
Management of Ludwig’s Angina (normal person)
- IV ABX: Ampicillin-Sulbactam OR Ceftriaxone + Metronidazole OR Clindamycin + Levofloxacin
- Add Vancomycin if MRSA is suspected
However, if the patient is immunocompromised and has Ludwig’s Angina, what is the treatment?
-IV ABX: Cefepime + Metronidazole
OR Imipinem
OR Meropenem
OR Piperacillin-Tazobactam
-Add Vancomycin if MRSA suspected
Risk factors for oropharyngeal candidiasis
- Immunocompromised states (HIV, chemotherapy, diabetes)
- Use of inhaled corticosteroids without a spacer
- Antibiotic use
- Xerostomia (salivary glands don’t make enough saliva to keep mouth wet)
- Denture use
Symptoms and Exam findings of oral candidiasis (thrush)
- Loss of taste or cotton in mouth
- Throat or mouth pain with eating and swallowing
- White curd-like plaques on buccal mucosa that are easily scraped off (may leave behind erythema and friable mucosa if scraped)
What is the diagnostic that is done for oral thrush?
-Potassium Hydroxide: budding yeast and pseudohyphae (smear performed on scrapings)
Management of Thrush
-Topical (first line): Nystatin liquid swish and swallow, Clotrimazole troches or Miconazole buccal tablets
______ is usually reserved for refractory cases of Thrush
Oral Fluconazole
Aphthous Ulcers (Ulcerative Stomatitis) are recurrently seen in patients with what conditions?
IBD HIV Celiac disease SLE Methotrexate use Neutropenia
Symptoms of an aphthous ulcer
-Small, painful, shallow round or oval shallow ulcer (yellow, white or grey central exudate) with erythematous halo
Treatment for aphthous ulcer
- First line: Topical oral glucocorticoids: Clobetasol, Dexamethasone, Triamcinolone
- Topical analgesics: 2% viscous lidocaine, aluminum hydroxide + magnesium hydroxide +simethicone
What is oral leukoplakia characterized by?
Painless white patchy lesions that cannot be scraped off
What diagnostic should be done for oral leukoplakia?
Biopsy to rule out squamous cell carcinoma
Risk factors for oral leukoplakia
- Chronic irritation due to tobacco
- Alcohol
- Dentures
- HPV infections
How do you manage oral leukoplakia?
Avoidance of irritants
-Cryotherapy, laser ablation, surgical excision if malignant
