Head and Neck Infections

Question 1

What are the signs and symptoms of bacterial pharyngitis?

Answer 1

chief complaint of a “sore throat” and fever with acute onset, tender anterior cervical lymphadenopathy, tonsilar exudate => denial of cough, hoarseness, nasal congestion (i.e., only one mucus membrane)

Question 2

What are the characteristics of viral pharyngitis?

Answer 2

sore throat and symptoms that affect > 1 mucus membrane (e.g., cough, hoarseness, congestion)

Question 3

What are the S and S of peritonsillar abscess?

Answer 3

“hot potato voice,” uvula deviated to unaffected side, unable to swallow, trismus (unable to open mouth), drooling

Question 4

What are the S and S of infectious mononucleosis?

Answer 4

myalgia and fatigue develop before sore throat (Epstein-Barr virus - infects and replicates in B lymphocytes), posterior lymphadenopathy (cannot clear - sits in lymphocytes/can cause Hodgkin’s lymphoma), abdominal pain (due to hepatomegaly and splenomegaly)

Question 5

What is the worse case scenario complication with EBV infection?

Answer 5

splenomegaly leading to splenic rupture - need to sit out of sports for > 4 weeks

Question 6

How is bacterial pharyngitis diagnosed?

Answer 6

with rapid antigen detection test - perform only for patients who meet > 1 Center Criteria => throat culture okay for kids but unnecessary for adults

Question 7

What are the 5 Center Criteria?

Answer 7

Tonsilar exudate +1
Tender anterior cervical adenopathy +1 
Fever +1 
Absence of cough +1
Age: 
< 15 years years  +1
> 45 years - 1

Question 8

When is blood work necessary with a sore throat?

Answer 8

when the diagnosis is infectious mononucleosis => criteria that support the diagnosis: (1) number of lymphocytes is elevated, (2) atypical lymphocytes present, and (3) liver function tests are elevated

Question 9

What is the treatment for IM?

Answer 9

supportive (viral infection) - use of corticosteroids is controversial

Question 10

What is the initial treatment for peritonsilar abscess?

Answer 10

clindamycin or amoxicillin

Question 11

What are the S and S of bacterial rhinosinusitis?

Answer 11

high fever, unilateral discharge from one nostril, nasal congestion, facial pain (worse when bending over), diffuse nasal mucosal edema and erythema, lungs clear

Question 12

What are the S and S of viral rhinitis?

Answer 12

> 1 mucus membrane ,low fever, nasal congestion, facial pain (worse when bending over)

Question 13

What are the S and S of allergic rhinitis?

Answer 13

watery eyes, itchiness (hallmark of allergies), bilateral nasal congestion, > 1 mucus membrane, clear discharge, history of asthma/seasonal allergies, bilateral conjunctivitis, sneezing, lack of fever, allergic shiners, pale nasal mucosa

Question 14

How is bacterial rhinosinusitis diagnosed?

Answer 14

clinically - sinus x-ray and CT scan are generally unnecessary (cannot distinguish between viral and bacterial infections)

Question 15

When is CT scan recommended for patients with possible bacterial rhinosinusitis?

Answer 15

recurrent (>= 3/year) infections (will ID obstructive lesion – polyp or carcinoma)

Question 16

What is the “gold standard” for diagnosing bacterial rhinosinusitis?

Answer 16

culture from sinus aspirate (NOT nasal swab) – needle aspiration of discharge => only use if PT doesn’t respond to adequate therapy

Question 17

What is the best initial therapy for bacterial rhinosinusitis?

Answer 17

watchful waiting (supportive)

Question 18

When should antibiotics be initiated in patient with bacterial rhinosinusitis?

Answer 18

only if the patient meets one of the following three criteria: (1) severe symptoms (fever > 102 or facial pain) >= 3 consecutive days, (2) any symptoms (severe or not) >= 10 days, or (3) double sickening/improvement followed by worsening

Question 19

What is the best initial Tx for patients with bacterial rhinosinusitis who require Abx?

Answer 19

Augmentin – gives both Gram+ and Gram- coverage => alternative Tx: respiratory FQ (levofloxacin or moxifloxacin) – if PT has penicillin allergy

Question 20

What are the S and S of acute otitis media?

Answer 20

acute onset, unilateral ear pain, fever, hearing loss on affected side, lack of tragal tenderness, no adenopathy, TM opaque/bulging/immobile

Question 21

What is otitis media with effusion?

Answer 21

PT will have fluid behind TM but no infection (TM more likely to be retracted due to negative pressure in the eustachian tubes – bones will be more prominently seen) => no fever or pain, will have hearing loss

Question 22

What is acute otitis externa?

Answer 22

cellulitis – more common in swimmers, painful to touch

Question 23

What is malignant otitis externa (osteomyelitis)?

Answer 23

cellulitis that spreads to bone => common in people with uncontrolled diabetes and those who are immunocompromised (S and S include severe otalgia that extends to TMJ, pain with chewing, nocturnal pain, edema, erythema of ear canal extending to pinna and mandibular area, cranial nerve/facial palsies)

Question 24

What is the initial diagnostic test for acute otitis media?

Answer 24

no diagnostic tests are needed - clinical Dx (start Tx if PT has TM effusion [bulging and/or immobility] and inflammation [pain and/or fever])

Question 25

When might you perform CT scan, culture, or tympanocentesis (aspiration of the middle ear fluid) in a patient with otalgia?

Answer 25

recurrent infection or infection non-responsive to Tx

Question 26

What is the best initial Abx Tx for PT with acute otitis media?

Answer 26

Augmentin

Question 27

What is the Tx for allergic rhinitis?

Answer 27

supportive: Sudafed for decongestion, nasal corticosteroids, and anticholinergic for discharge

Question 28

What is conductive hearing loss?

Answer 28

hearing loss due to blockage of ear canal or disorder of TM

Question 29

What is sensorineural hearing loss?

Answer 29

hearing loss only due to inner ear

Question 30

When do you perform a Weber test?

Answer 30

only in a patient with hearing loss (e.g., identified through Whisper Test) - it is NOT a screening test => helps distinguish conductive from sensorineural hearing loss

Question 31

What are the possible interpretations of the Weber test?

Answer 31

normal hearing => sound heard bilaterally (from air and skull); conductive hearing loss => sound heard better on affected side; sensorineural hearing loss => sound heard louder on unaffected side

Question 32

When do you perform a Rinne test?

Answer 32

only after a Weber test suggests conductive hearing loss - confirms the finding

Question 33

What are the possible interpretations of the Rinne test

Answer 33

normal hearing = air conduction (AC) time 2X bone conduction (BC) time; conductive hearing loss = bone conduction is heard longer than the air conduction (BC > AC); sensorineural hearing loss = AC > BC, but may not be twice as long

Question 34

What is the best initial test for infectious mononeucleosis?

Answer 34

Monospot - detects heterophil antibodies (positive in 80%) => if Monospot negative but IM still suspected, test for IgM antibodies (confirms diagnosis)

Question 35

What is the best initial treatment for Strep pharyngitis?

Answer 35

PCN VK - clarithromycin for PTs with severe penicillin allergy (hypotension and difficulty breathing) and if pregnant