Mouth and Throat Disorder Flashcards
A 19-year-old man comes to your office with a complaint of a sore throat. His illness began 3 days ago with a sore throat, followed by persistent fevers of 102 0F.
What are the common diagnostic considerations for patients with acute sore throat?
What questions are helpful in determining the cause of sore throat? OLDCART
How do you assess for the presence of potentially serious causes of sore throat? (DDx)
-diff dx- strep, mono, pharyngitis, post nasal drip,
most common cause of sore throat
viral
-common for young children
acute tonsillitis and pharyngitis
-Acute viral or bacterial infection
-Viral most common -> ibuprofen, aspirin, decongestant (caution for young children)
-Tonsillitis and pharyngitis typically occur simultaneously -> pharyngitis precedes tonsilitis usually*
-Peak incidence in winter and early spring
-Repeat attacks
-schools, cramped living, traveling, or working conditions, Military camps commonly affected
-M=F
-All ages are affected (MC 5-15 yoa)
-Tonsillitis under 3 years -> rare and usually viral
acute tonsillitis and pharyngitis etiology
-Common causes- Influenza A and B viruses, H1N1 influenza, Respiratory syncytial virus (RSV), Adenovirus
-Rare causes- Herpes simplex, Neisseria gonorrhoeae
-serious causes:
-Streptococcus group A* and G, group A beta-hemolytic streptococci
-Fusobacterium necrophorum*
-Epstein-Barr virus
-Staphylococcus aureus
-Neisseria gonorrhoeae*
-Chlamydia pneumoniae
-Mycoplasma pneumoniae
-Chlamydial trachomatis*
-other causes: GERD, Postnasal drainage from chronic allergies, Neoplasm, Corynebacterium diphtheriae
pharyngitis signs and symptoms
-Fever, Sore throat, Halitosis, Dysphagia, Odynophagia, Cervical lymph nodes, Headache, Otalgia, Lethargy/ malaise, Vomiting,
-Difficulty breathing-> Mouth breathing, snoring, nocturnal breathing pauses, or sleep apnea
-Swollen hyperemic red tonsils / pharynx
-Often coated with a yellow or thin white non-confluent membrane
-Peels away without bleeding* (different from diphtheria)*
-Throat may be edematous, blistered, or have painful ulcers
-CHRONIC tonsillitis- White particulate matter in tonsillar crypts (pockets) **
-Cervical lymph nodes may be swollen, enlarged, or tender
-Dry mucous membranes- mouth breathers
GABHS pharyngitis(group A beta hemolytic streptococcus)
-Often associated with:
-Headache
-Pharyngeal exudate
-Painful cervical adenopathy
-GI symptoms
-Chills
-High fever
-Hoarseness, coryza and cough NOT associated**
Viral pharyngitis
-usually associated with:
-sneezing
-rhinorrhea
-cough!
GABHS pharyngitis predisposing factors
-GABHS epidemics
-Recent family history - may be passed between family members ; ‘ping-pong’ effect
-Close quarters (military barracks, dormitories)
-Immunosuppression
-Recent illness
-Also ask about previous treatments, treatment failures, and medication allergies
-consider antibiotics to prevent spread (even if pt is fine)
GABHS differential diagnosis
-Mononucleosis
-Peritonsillar abscess
-Parapharyngeal abscess- can comprise airway
-Scarlet fever- sandpaper rash
-Diphtheria –gray pseudomembrane -> cannot come off -> bleed, antitoxin -> cause heart valve problems
-Epiglottitis
-Vincent’s Angina (Trench mouth)- can cause lugwigs angina (deep cellulitis of neck)
-Squamous cell carcinoma of the tonsils
Rule out or Rule in Group A streptococcal pharyngitis
-Suspected on the basis of clinical signs and symptoms
-Confirmed with laboratory testing – d/o how likely it is to be GABS
-Positive rapid antigen test or a positive throat culture (days for results)
-A negative rapid antigen test does NOT rule out streptococcal pharyngitis and should be confirmed with a throat culture **
-White blood count (WBC) with differential
-Monospot - if multiple cervical lymph nodes swollen
-Lateral neck radiograph - to rule out epiglottitis
-Computed tomography (CT) scan - to rule out pharyngeal abscess
centor criteria
-Group A beta-hemolytic streptococcal infections –
risk of Rheumatic fever and Glomerulonephritis
-The following may indicate streptococcal infections in the absence of throat culture results
-1. Fever >100°F (38°C)
-2. Pharyngotonsillar exudates
-3. Tender anterior cervical adenopathy
-4. Lack of a cough
GABHS treatment
-supportive care
-relieve fever, sore throat, tonsillar swelling
-gargle with warm salt water
-drink warm fluids
-start antibiotics?
-pts with zero or one centor criteria -> very low risk -> do not need throat cultures or RADT of throat swab and should not receive antibiotics
-2. pts with 2-3 centor criteria -> need throat cultures AND RADT of throat swabs since + result would warrant antibiotic treatment -> ALWAYS SEND CULTURE
-3. pts who have all 4 centor criteria are likely to have GABHS -> receive empiric therapy without throat culture or RADT
- + COUGH- NOT STREP
GABHS antibiotics
-Antibiotics recommended when GABHS confirmed with rapid antigen-detection test or throat swab culture
-RF can be prevented if treatment given up to 9 days of presentation
-Ensure follow-up for recurrent infections lasting over 3 weeks
-Prevent future attacks
-Prevent spread -> ask pt not to go to work for up to 3 days
-PCN treatment of choice in both children and adults
-adults:
-1st choice- Pen VK 250mg BID or 500mg TID x 10 days
-amoxicillin 500mg Q 12h x 10 days also reasonable
-single dose IM benzathine/procaine penicillin- can be given as single dose, drug is expensive, frequently unavailable, causes injection site pain
-secondary options:
-azithromycin, clarithromycin, erythromycin base, cephalexin (cefadroxil, clindamycin)
rheumatic fever
-immune complex
-complexes placed on the valves
-endocarditis
-prophylaxis penicillin for up to 5 years daily OR single dose IM benzathine/procane penicillin 1x month (painful, expensive) -> for pts that are not compliant
rheumatic fever jones criteria
-major criteria: carditis, arthritis, chorea, erythema marginatum, subcutaneous nodules
-minor criteria- high fever, joint pain (without inflammation) -> arthalgia, ESR, CRP, prolonged PR interval in ECG
-fleeting arthritis- one joint gets better and the next becomes inflamed
-2 major and 1 minor to dx
-throat swab culture or rapid strep
-elevated/increasing strep antibody titer
tonsillectomy or adenotonsillectomy treatment
-pts with recurrent tonsillitis or pts which all other treatments have failed
-Risk vs. benefit
-Absolute indications -> Upper airway obstruction, severe dysphagia, sleep disorders, or cardiopulmonary complications; Peri-tonsillar abscess OR Tonsillitis resulting in febrile convulsions
-Relative indications:
-3 or more tonsil infections per year
-Streptococcal carrier not responding to treatment
-CI: Bleeding diathesis; Poor anesthetic risk or comorbidities
other strep considerations
-What is the ‘Strep carrier state’?
-Some pts carry GABHSB but do not manifest illness-> never treated
-unknowingly infect family members, sometimes repeatedly
-If multiple family members show repeated illness -> worthwhile to perform throat cultures on the asymptomatic family members
-pregnancy- GABHS vaginal infection associated with increased risk of preterm delivery
-Eradication of beta-hemolytic streptococcus from nasopharynx is advised if infection occurs during pregnancy
non-suppurative complications of GAS
-NO PUS
-Rheumatic fever
-Rheumatic heart disease
-Acute Glomerulonephritis- hematuria, high BP, edema
other ways strep can present
-scarlet fever- sandpaper like rash
-impetigo - blisters around mouth
suppurative complications of GAS
-PUS +
-Peri-tonsillar abscess (quinsy)
-Impetigo
-Otitis media
-Mastoiditis
-Sinusitis
-Bacteremia
-Pneumonia
-Meningitis
-Osteomyelitis (OM)
-Necrotizing fasciitis
-Cellulitis
peritonsillar abscess dx
-History and clinical findings
-CBC with diff
-Blood cultures
-Monospot test
-Tonsillar swab
peritonsillar abscess symptoms and signs
-Unilateral ±, severe throat pain
-Dysphagia
-Odynophagia
-Trismus (difficulty opening the -mouth wide)
-Neck pain
-Referred ear pain
-Drooling -> also seen in epiglottitis
-Muffled (‘hot potato’) voice- muffled mumbling
-Fever
-Severe dehydration
-Possibly extreme distress
-Tonsillar hypertrophy
-Palatal edema
-CONTRALATERAL deflection of the swollen uvula -> spreads laterally*
-trouble breathing
-Inferior and MEDIAL displacement of the infected tonsil
-Fluctuant peritonsillar fullness
-Tender cervical adenopathy
-Edema in the neck due to infective lymphadenopathy
-Inflamed oropharyngeal mucosa
-Drooling
-Rancid breath
-Brawny pitting of the ipsilateral neck in advanced infection
-Signs and symptoms may not always be dramatic
peritonsillar abscess
-collection of fluid in peritonsillar space -> pushes tonsil medially, -> obscure definition of anterior tonsillar pillar
-Beware of examining oropharynx in children-> use of tongue depressor in airway obstruction may provoke respiratory arrest
-Maintain a high index of suspicion
-Treatment of peritonsillar cellulitis - either resolves over several days or evolves into peritonsillar abscess
-AKA Quinsy
-One or both tonsils affected -> form pus pockets
-Onset of symptoms to abscess formation approx. 2-8 days
-may form without preceding hx of tonsillitis
retropharyngeal abscess
-Presentation depends on stage of illness
-Early in disease- indistinguishable from uncomplicated pharyngitis
-With disease progression- symptoms related to inflammation and obstruction of the upper aerodigestive tract develop
-SERIOUS
retropharyngeal abscess signs and symptoms
-Dysphagia
-Odynophagia
-Drooling with decreased oral intake
-Neck stiffness
-Muffled, or with a “hot potato” quality
-Respiratory distress (stridor, tachypnea, or both)
-Neck swelling, mass, or lymphadenopathy
-Trismus
-Chest pain (in patients with mediastinal extension)- can spread
