Infections of Throat - Lecture 8 Flashcards
tonsillitis define
inflammation of plantains tonsil glands
pharyngitis define
inflammation of any structure of the pharynx including adenoids and lingual tonsils
what is the main focus of diagnosis and treatment for tonsillitis and pharyngitis?
identify GABHS (Strep progenies) -Prevent complications of rheumatic fever, post-streptococcal glomerulonephritis
what is the most common cause of viral tonsillitis and pharyngitis?
-rhinovirus
what is the most common cause of bacterial tonsillitis and pharyngitis?
Group A beta hemolytic strep
-strep progenies or Group A strep (GAS)
common symptoms for BOTH bacterial and viral tonsillitis and pharyngitis?
- SORE THROAT
- LYMPHADENOPATHY
- dysphagia
- odynophagia
- fever
- exudate
bacterial tonsillitis and pharyngitis symptoms?
- NO coryza, cough or other URI sx
- anterior LAD*
- sudden onset sore throat
- fever
- petecchaie of soft palate
scarlet fever (GABHS) symptoms?
- strawberry tongue
- sandpaper rash that is on trunk and back
- more common in children
viral tonsillitis and pharyngitis symptoms?
- Coryza, cough
- Malaise
- Fatigue
- Hoarseness
Mononucleosis symptoms
viral symptoms PLUS
- posterior LAD*
- “kissing tonsils”
- hepatosplenomegaly - spleen starts to sequester the virus
diphtheria signs
adherent dense grey pseudomembrane covering the tonsils
scarlet fever (GABHS pharyngitis)
- Fever
- Strawberry tongue
- Sandpaper-like rash to trunk and armpits
pharyngitis & tonsillitis dx of GABHS criteria (Symptoms)
- fever
- anterior cervical lymphadenopathy
- tonsillar exudate
- absence of cough
if have score of 4 in the pharyngitis & tonsillitis dx criteria, what do you NOT have to do?
don’t need to swab throat
-just treat for strep pharyngitis
score of 0-1 on pharyngitis & tonsillitis dx of GABHS?
likelihood low, no further testing
score of 2-3 on pharyngitis & tonsillitis dx of GABHS?
confirm via RAPDT
if Rapid strep test is positive, what do you do?
stop there and treat b/c 90-99% sensitive
throat culture for tonsillitis or pharyngitis?
- Most reliable
- 24-48 hour turn around
- Often ordered w/RAPDT and if negative lab will do a reflex culture
is there dx for viral tonsillitis or pharyngitis?
no dx available or indicated
test for influenza?
rapid influenza
EBV (mono) tests to order?
- Monospot (Heterophile agglutination test)
- Anti-EBV titer
- CBC with diff (atypical lymphs) – typically have 35% of atypical lymphs
- Elevated LFTs
viral pharyngitis & tonsillitis treatment
- Gargle with warm water
- Antipyretics
- Analgesia
- Rest
- +/- single dose decadron (dexamethasone)
- +/- IVF if dehydrated
can people with mono play contact sports?
NO b/c may have hepatosplenomegaly and it can rupture if get hit
if patient with mono receives amoxicillin for presumptive strep pharyngitis, what can they develop?
a rash (NOT A DRUG ALLERGY)
influenza treatment
tamiflu
treatment for adult bacterial GABHS
Pen VK PO x 10 days
treatment for homeless IV drug users with bacterial GABHS
Pen G IM
treatment for children with bacterial GABHS
PenVK x 10 days (Gross taste)
Amoxicillin x 10 days (tastes like bubblegum)
treatment for pts with PCN allergies and have bacterial GABHS
cephalosporin or macrolide
complication of pharyngitis & tonsillitis
peritonsillar abscess (PTA)
peritonsillar abscess is what?
Collection of pus located b/w the capsule of palatine tonsil and pharyngeal muscle
where is peritonsillar abscess commonly located?
superior pole of the tonsil
pathogenesis of peritonsillar abscess
Typically preceded by tonsillitis and pharyngitis -> cellulitis -> phlegmon (in b/w cellulitis and abscess) abscess
is peritonsillar abscess unilateral or bilateral?
unilateral
what is the most common deep space infection of head and neck?
peritonsillar abscess
most common cause of peritonsillar abscess?
GABHS most common
symptoms of peritonsillar abscess
- UNILATERAL SEVERE SORE THROAT
- IPSILATERAL EAR PAIN
- fatigue
- fever
- decreased PO intake
- TRISMUS (can’t open mouth fully)
- neck pain with movement
Classic sign of peritonsillar abscess
MUFFLED/”HOT POTATO VOICE”
other signs of peritonsillar abscess
- Unilateral swollen and fluctuant tonsil with contralateral deviation of uvula
- Pooling of saliva/drooling
- Trismus
- Neck swelling
- Fever
- Rancid or fetor breath
- Erythema or exudate of the tonsil
diff dx of peritonsillar abscess
- Retro pharyngeal abscess
- Recent tonsil surgery (possible complication)
- Oral cavity malignancy
- Strep throat
- Mono
- Epiglottitis
- Ludwig’s angina (abscess that occurs under the tongue d/t dental cavity)
- Dental infection
- Peritonsillitis
what is the #1 diagnostic for peritonsillar abscess
clinically
diagnostics for peritonsillar abscess
CLINICALLY
- CT neck w/IV contrast
- intra-oral ultrasonography
- lateral soft tissue
what is the BEST imaging option for peritonsillar abscess
CT neck w/IV contrast
treatment of peritonsillar abscess
- secure airway
- drainage (needle aspiration)
- empiric
empiric txt for peritonsillar abscess
- Unsayn IV or Clindamycin IV
- Augmentin x14D
Untreated peritonsillar abscess complications
- Airway obstruction (d/t large size of peritonsillar abscess)
- Internal jugular seeding of infection
- Pseudo aneurysm of carotid artery
- Septicemia
rheumatic fever
delayed, non-suppurative sequelae of GABHS pharyngitis involving lesions of joints, heart, subcutaneous tissue and central nervous system
*Cardiac may be permanent
average age for rheumatic fever?
5-15 y.o
what is the leading cause of heart disease in developing countries?
rheumatic fever
carditis/valvulitis rheumatic fever - what is most affected?
mitral valve
carditis/valvulitis rheumatic feverself-limiting or long-term effects?
both
carditis/valvulitis rheumatic fever, who is affected more, children or adults?
children > adults
migratory arthritis rheumatic fever, clinical manifestations?
asymmetric pattern, large joints
- knees, elbows wrists
- in older teen/adults
rheumatic fever dx
- evidence of recent strep infection PLUS
- 2major OR
- 1 major and 2 minor OR
- 3 minor (recurrent AF only)
major symptoms for rheumatic fever
migratory arthritis
- carditis/valvulitis
- sydenham chorea
- erythema marginatum
- subcutaneous nodeuls
minor symptoms for rheumatic fever
- arthralgia
- fever
- elevated ESR or CRP
- prolonged PR interval
what must all patients with confirmed or suspected ARF undergo?
echocardiography to evaluate for carditis
labs for rheumatic fever
- Rapid strep
- Throat culture
- Anti-streptococcal titers
- Antistreptolysin O or anti-DNAse B
- C-reactive protein (CRP) or erythrocyte sedimentation rate (ESR) – may be elevated
imaging and other procedures for rheumatic fever
- EKG – prolonged PR interval
- Chest x-ray – cardiomegaly or CHF
- Echocardiogram – for valvulitis or carditis
rheumatic fever acute management
- PenVK (Adults and children)
- salicylates (aspirin - not <13y.o)
- +/- corticosteroids
- bed rest
secondary ppx for rheumatic fever
- recurrence is possible
- PCN benzathine G IM every 4 weeks
Post-streptococcal glomerulonephritis
due to skin cellulitis or strep throat
Post-streptococcal glomerulonephritis s/sx
- occur 1-3 weeks after the strep throat
- EDEMA, HEMATURIA
- htn, proteinuria, oliguria
Post-streptococcal glomerulonephritis dx
- urine dip and microscopy
- streptozyme test
- rapid strep.strep throat culture
- renal function
- hemolytic component (C3 decreased)
- +/- renal biopsy
Post-streptococcal glomerulonephritis txt
- treat underlying condition (cellulitis or strep if not treated)
- mostly symptomatic/supportive therapy
Post-streptococcal glomerulonephritis symptomatic/supportive therapy
- Restrict salt and water intake
- +/- diuretics (edema)
- HTN control (diuretics, CCB, ACE)
- Limited activity
- +/- dialysis if needed
laryngitis
inflammation of larynx and vocal fold mucosa
-vocal cord edematous
function of larynx
prevent aspiration of food into lungs, voice
acute laryngitis cause?
VIRAL (bacterial, GERD, environmental, vocal trauma)
acute laryngitis resolves when?
7-10 days
chronic laryngitis lasts?
> 3 weeks
laryngitis s/sx
- preceding URI sx (cough, rhinos)
- HOARSENESS (dysphonia)
- odynophonia
- odynophagia
laryngitis dx
- clinical dx based on hx and symptoms
- rarely need to visualize larynx
laryngitis txt
voice rest and inhaled humidifier
what are the 3 major salivary glands?
parotid, submandibular, sublingual
function of salivary glands?
lubrication to aid in swallowing and digestive enzymes to break down food
sialadenitis etiology
viral, bacterial, inflammatory & autoimmune (sjogre’s syndrome), stone, etc.
parotitis is secondary to what?
mumps
parotitis
acute-onset parotid swelling that lasts 2 days
- exposed 2-3 weeks before onset of symptoms
- paramyxoviral disease spread by respiratory route
who is most affected by parotitis?
children (historical), now college students
sialadenitis viral is what?
mumps!
mumps is the most common what?
non-suppurative sialadenitis
what type of virus is mumps?
paramyoxyvirus
symptoms of mumps
bilateral parotid glands (parotitis) & edema
- prodrome 48 hours before
- a few days later (unilateral testicular swelling & tenderness)
complications of mumps
deafness, orchitis, meningitis, fetal congenital abnormalities
treatment of mumps
(supportive) bed rest, hydration, sialogogues (medication that promotes secretion of saliva)
HIV sialadenitis
- Parotid most common
- Bilateral
- Tender, erythematous
HIV sialadenitis txt
antiviral & supportive therapy
Sialadenitis work-up
-Physical exam
-Mumps titer – RT-PCR or serology (IGM elevated) – if indicated
-HIV RNA – if indicated
-If unclear or unimproved:
Ultrasound
CT face/neck
Sialadenoscopy
sialadenitis bacterial etiology
stone -> submandibular
elderly, malnourish or post-op -> parotid
sialadenitis bacterial s/sx
- Sudden onset pain
- Unilateral
- Firm and tender
- Expression of pus
organism causing bacterial sialadenitis
staph aureus
txt for bacterial sialdenitis
- Antibiotics parenteral or oral (Nafcillin, dicloxacillin, Augmentin)
- Massage of duct
- Warm compresses
- Sialogogues
- Surgical drainage if abscess develops
mumps txt
- Symptom/supportive
- Analgesia
- Warm or cold compresses on parotid
- Testicular pain treated with scrotal sling
mumps prevention
VACCINATION
- 2 doses of MMR (measles, mumps, rubella)
- 12 months of age and 4-6 years of age
