Lecture 5 Sinusitis/Pharyngitis Flashcards
What is pharyngitis
Infection of the Pharynx
Most common causes are viral
Main bacterial causes: Group A beta-hemolytic streptococcus ( S.pyogenes)
- pharyngitis due to GABHS -> AKA strep throat
What are the high risk groups for pharyngitis, how is it spread?
Children 5-15 years old
Parents of school age children
Adults who wok with children
Greatest in winter/early spring
Spread via direct contact (usually from hands) with droplets of saliva or nasal secretion
Clinical representation of pharyngitis
Sore throat is most common symptoms
Other signs and symptoms include: Fever, Odynophagia, tender/enlarged cervvical lymph nodes, scarlatiniform rash
Scarlet fever -> characteristic rash with diffuse erythematous eruption, usually in setting of pharyngitis
Strongly indicative of viral etiology: Rhinorrhea, cough, hoarseness, conjunctivitis, diarrhea, oropharyngeal vesicles
Complication of pharyngitis
Are rare
Include acute rheumatic fever, peritonsillar abscess, retropharyngeal abscess, otitis media, rhinosinusituis, reactive arthritis
Acute rheumatic fever - autoimmune complication
- characterized by inflammatory response affecting heart, joints, brain, skin and soft tissue
Diagnosis of pharyngitis
Cannot Diagnose with symptoms alone and cannot diagnose with lab testing alone.
Only those with positive microbiologic testing for GABHS require antibacterial treatment
Positive test does not necessarily indicate disease - patient may be carrier and not actively infected
What is the modified centor score and explain the points
Identify patients who would benefit from diagnostic testing for streptococcal pharyngitis
- 1 point for each 4 criteria present ( fever, tonsillar or pharyngeal exudate, tender anterior crevical lymph nodes, absence of cough
+1 point if <15 yrs old, -1 point if >45 yrs old
0-1 points - very low risk of strep
3-4 points - increased risk for strep
What is the gold standard diagnosis for pharyngitis
Throat swab for culture but requires 24-48 hrs for results
Throat swab for rapid antigen detection test (RADT) is more practical and results within minutes, less expensive, point of care
Why is delaying therapy while waiting for throat culture results reasonable
Does not affect risk complication
GAS pharyngitis is often self limiting disease (8-10days)
Delay may reduce reinfection rates
Unnecessary antibacterial use can be avoided in up to 50% of patients
How does antibacterial therapy help patients with pharyngitis
Lowers severity of symptoms and duration of symptoms by 1 day
Lowers risk of transmission
Lowers risk of suppurative complications and rheumatic fever
Antibacterial therapy drug of choice for pharyngitis
Penicillin VK x 10 days
Paediatrics :
- <27kg : 300mg po BID-TID
- > 27kg : 600mg po BID-TID
Adults : 600mg po BID or 300mg po TID
No in vitro resistance
If suspension required amoxicillin 50mg/kg po divided once-twice daily
Patient is allergic to penicillin, what is therapy for pharyngitis, pediatric and adults
Pediatrics (Non severe) :
-cephalexin 40mg/kg/d po div BID x 10 days Paediatrics
Pediatrics (Severe) :
-clindamycin 20mg/kg/d po div TID x 10 days
- azithromycin 20mg/kg po daily for 3 day
- clairthromycin 15mg/kg/d po div BID x 10 day
Adults:
Cefuroxime 500mg po BID x 10day
Alternative for adults:
-clindamycin 300mg po TID x 10 day
-Azithromycin 500mg po daily x 3 days
- clarithromycin 250mg po BID x 10 day
Symptomatic relief for pharyngitis
Lozenges
Acetaminophen
Ibuprofen
Hydration
Follow up for pharyngitis
Follow up culture not routinely recommended, except if:
History of rheumatic fever
Persistent symptoms
Recurrent symptoms
Symptoms may last 2-7 days
Paranasal sinuses (4 pairs)
Sinuses are hollow air spaces in the body
Frontal sinuses: over the eyes in the brow area
Maxillary sinuses: inside each cheekbone
Ethmoid sinuses: just behind the bridge of the nose and between the eyes
Sphenoid : in the upper region of the nose and behind the eyes
Paranasal sinuses, when are they present?
Maxillary and ethmoid sinuses are present in infancy
Sphenoid sinuses are present by the third year and develop up to 12 years of age
Frontal sinuses appear by the 5th year and develop into adolescence
Facts about each sinus
Has an opening to the nose
Joined with the nasal passage by a continuous mucous membrane lining
Allowed free change of air and mucous
Produces a thin mucous that “washes” over the sinuses via cilia
Approximately 1 cup of mucous is produced each day and swallowed unnoticably
Most common predisposing factor for acute rhinosisnustits is a ______ ________ _____
Viral upper respiratory tract infection
Children have approximately how many upper respiratory tract infections a year
6-10
Predisposing factors of sinusitis
Medical condition
Irritants
Anatomic
Medications
Trauma
Medical conditions: URTICARIA, allergic rhinitis, cystic fibrosis, immunodeficiency, wegeners sundrome
Irritants: tobacco smoke, pollution, chlorine
Anatomic: deviated nasal septum, enlarged adenoids, immobile cilia, polyps, tumours, foreign bodies
Medications; overuse of untranslated decongestants, cocaine abuse
Traumas: dental procedures, diving
Prevention of sinusitis
Limit spread of viral infections by handwashing
Avoid environmental tobacco smoke
Avoid allergen exposure
Regular influenza and other vaccines
Symptoms of sinusitis
Fever
Nasal congestion
Maxillary toothache
Facial pain
Facial swelling
Headache
Cough plays a more significant role in children
Colour of nasal discharged is related to the presence of neutrophils and should not be used to diagnose sinusitis
Diagnosis of acute sinusitis
Requirements **
Gold standard
Diagnosis requires at least 2 major symptoms
P- facial pain
O- nasal obstruction
D- postnatal discharge
S- hyposmia/ losing smell
At least one symptoms has to be O or D
Gold standard - puncture aspirate of sinus fluid, not usually done
Acute bacterial sinusitis - pathogens and percentages
S. Pneumoniae (50%)
H. Influenza (50%)
M.catarrrhalis (20%)
Mixed anaerobes (10%)
Bacterial sinusitis- clinical presentation and diagnosis
1.Persistent symptoms or signs compatible with acute rhinosinusitis lasting > 10days without any evidence of clinical improvement
- Severe symptoms or signs of high fever and purulent discharge or facial pain lasting for at least 3-4 days at the beginning of illness
- Worsening symptoms or signs characterized by the new onset of fever, headache or increase in nasal discharge following a typical viral upper respiratory infection that lasted 5-6 days and was initially improving
Managment of Acute sinusitis
Analgesics
Irrigation with normal saline
Inhalation of steam
Short duration (<5 days) intranasal decongestants
First gen antihistamine not recommended
Second gen antihistamines may be recommended if allergic component
Nasal corticosteroids - may benefit
Selective antibacterial therapy
Acute sinusitis - adult initial therapy (No beta lactame allergy)
Amoxi 500mg-1g TID x 5-7 days
Severe/immunocompromised : fever > 39 and purulent nasal discharge or facial pain 3-4 days, amoxi 1g BID plus amoxicillin/clav 875mg bid 5-7days
** Higher dose if recent antibacterial is in last 3 months
Acute sinusitis- adults initials therapy (Beta lactam Allergic)
Doxycycline 200mg once, then 100 mg bid x 5-7days
Severe/ Immune compromised:
(Non severe allergy) - ceftriaxone 1-2, IV daily x 5-7 days
Severe allergy/ anaphylaxis- levofloxacin 750 mg po daily x 5 days
Acute sinusitis- adults, failure of 1st line ( No beta lactam allergy)
Amoxi/clav 875mg po bid x 5-10days +/- amoxicillin 1gm po bid x 5-10days
Acute sinusitis- adults failure of 1st line (beta lactam allergy)
Levofloxacin 750mg po daily x 5-10days
Acute sinusitis - pediatric ( No beta lactam allergy)
< 2 yrs, recent antibacterial ( within 3 months) and or in day care
YES: Amoxi 90mg/kg/day div bid-tid for 10 days
NO : amoxi 40mg/kg/day div tid x 10 days
IF severe or immunocompromised: amoxi 45mg/kg/day plus amox/clav 7:1 45mf/kg/day each div bid-tid x 10days
Acute sinusitis- pediatric ( penicillin allergic)
Non severe- clindamycin 20-30mg/kg/day div tid + cefixime 8mg/kg/day div bid x 10 days
Or
Cefuroxime 30mg/kg/day po div bid x 10days
IF severe or immunocompromised:
Non severe allergy- ceftriaxone 100mg/kg/day IV daily
Severe allergy (doxycycline 4mg/kg/day div bid) (>8rs old)
Levofloxacin 10-20mg/kg IV/PO div q12-24hr
Acute sinusitis - Pediatric failure of first line treatment ( non beta lactam allergy)
Amox/clav 7:1 45mg/kg/day +/- amoxi 45mg/kg/day
Each div bid-tid x 10days
Acute sinusitis- pediatric failure of first line treatment (Penicillin allergic)
Non severe - clindamycin 20-30mg/kg/day div tid + cefixime 8mg/kg/day div bid x 10 days
If severe or immunocompromised
Non severe allergy: ceftriaxone 100mg/kg/day IV daily
Severe : levofloxacin 10-20 mg/kg div q12-24
