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EENT > Oropharynx and Larynx > Flashcards

Oropharynx and Larynx Flashcards

1
Q

One of the most common complaints in primary care

A

sore throat
Acute Pharyngitis

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2
Q

Acute Pharyngitis is mainly caused by what type of pathogen

A

60 - 90% viral
5 - 30% bacterial

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3
Q

Acute Pharyngitis is highest prevalent during what season

A

winter

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4
Q

clinical findings of rsp Viral Pharyngitis

A

Sore throat - Not severe
Coryzal symptoms
Fever - rare
PE - little to no findings
No adenopathy or pharyngeal exudates

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5
Q

clinical findings of influenza

A

Sore throat - More severe
Fever
Myalgia, headache, cough

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6
Q

clinical findings of adenovirus

A

Sore throat
Fever
Post-auricular adenopathy
Myalgias
conjunctivitis

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7
Q

clinical findings of HSV infection

A

Pharyngeal inflammation and exudate
Vesicles and shallow ulcers on hard palate and tongue

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8
Q

clinical findings of Coxsackievirus - Herpangina

A

“Mouth blisters”
Small vesicles on soft palate and uvula that rupture to form shallow white ulcers

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9
Q

clinical findings of EBV

A

Pharyngitis
Pharyngeal exudate
White - purple
Fever
Fatigue - May be persistent and severe
Generalized lymphadenopathy - posterior cervical
Splenomegaly
Headache
Maculopapular, urticarial, or petechial rash
Can arise with ampicillin/amoxicilin

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10
Q

Diagnosis/Screening of Viral Pharyngitis

A
  1. Rapid antigen detection test
    - Anytime a chief complaint of sore throat
    - Rapid strep screen
    — If negative, can confirm with throat culture
  2. Monospot
    - Looks for heterophile antibodies
    - Can have false negatives in early course
    - Not reactive on young children less than 4 years of age - high false negative
  3. Serum EBV specific antibodies
    - Usually not necessary if patients with manifestations consistent with IM are monospot positive
  4. NP swab
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11
Q

MONO LAB VALUES

A

Lymphocytosis
Atypical lymphocytosis
Total WBC 12000-18000
Elevated Liver Function Tests

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12
Q

tx for viral pharyngitis

A
  1. Supportive care for all viruses
    - Fever reducers/pain relievers, magic mouthwash, cold food
  2. Influenza
    - Tamiflu - <48 hrs of sx onset
  3. HSV
    - Acyclovir / Valacyclovir (Valtrex)
  4. EBV / mono
    - Avoid contact sports for 4 weeks
    - Can use oral Prednisone taper if tonsillar swelling is significant
    - Antivirals and Steroids not recommended in regular treatment; does not reduce duration
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13
Q

clinical findings of GABHS

A

Fever over 38C (100.4F)
Sore Throat
odynophagia
Malaise
Nausea, Vomiting
Tender anterior cervical lymphadenopathy
Pharynx, soft palate, tonsils erythematous and edematous
Tonsillar exudate
Palatal petechiae
Hoarseness, cough, coryza not suggestive of this illness
History of exposure

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14
Q

diffusely erythematous and resembles a sunburn
Superimposed fine red papules give the skin a sandpaper consistency
Most intense in groin and axilla and blanches on pressure
Fades in 2-5 days
commonly from GABHS
what is this condition

A

Scarlatiniform Rash
“scarlet fever”

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15
Q

associated severe sx of Streptococcal Pharyngitis / Tonsillitis (GABHS)

A

Scarlatiniform Rash
Palatal Petechiae
Strawberry tongue: enlarged red papillae

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16
Q

Diagnostic Testing for Streptococcal Pharyngitis / Tonsillitis (GABHS)

A
  1. Patients with a clinical syndrome compatible with GAS pharyngitis who lack symptoms of a respiratory viral syndrome
  2. Rapid Antigen Detection Strep test first line testing
    - Specifically for GABHS
    - 90-99% accurate
    - Can have false negatives
  3. Throat culture
    - Most sensitive but takes up to 2 - 3 days to get results
    - 90-95% accurate
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17
Q

first line tx for Group A Streptococcus / Strep throat

A
  1. Pen VK
  2. Pen G benzathine (Bicillin) IM as a single dose
  3. Amoxicillin
  4. Cephalexin (Keflex)/ Cefdinir
  5. Cephalosporins
    - PCN allergic reaction of rash
  6. Azithromycin / Clindamycin
    - Anaphylaxis reaction
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18
Q

Second line / Treatment Failure
of Group A Streptococcus / Strep throat

A

Augmentin
Erythromycin
Clindamycin
Azithromycin (Zithromax)

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19
Q

education for pt with strep throat

A
  1. Have pt change toothbrush after 24 hours
  2. Not contagious any longer after 24 hours of treatment
  3. Strep will “go away” on it’s own without antibiotics
    - However, a patient will remain contagious for 2-3 weeks after symptoms abate
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20
Q

Complications of Streptococcal Pharyngitis / Tonsillitis (GABHS)

A
  1. OM in children
  2. Secondary antibody formation because of cross-reactivity = rheumatic fever and valvular heart disease
  3. Antigen-antibody complexes = acute poststreptococcal glomerulonephritis
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21
Q

Rheumatic fever and glomerulonephritis typically appear when after streptococcal illness

A

2 - 3 weeks

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22
Q

what are you ordering with a pt with rheumatic fever and glomerulonephritis after having strep?

A

Antistreptolysin O (ASO) titer
will be elevated after recent strep infection

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23
Q

when infection penetrates the tonsillar capsule and involves the surrounding tissues
Forms between one of your tonsils and the wall of your throat
what can this cause?

A

Cellulitis and abscess

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24
Q

what is a quinsy

A

abscess

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25
Q

Most common deep neck infection in children and adolescents

A

Peritonsillar Abscess

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26
Q

pathogen causing Peritonsillar Abscess

A
  1. Often polymicrobial
  2. Streptococcus pyogenes (group A strep)
  3. Staph aureus
  4. Respiratory anaerobes
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27
Q

Severe sore throat (usually unilateral)
Fever
Muffled voice - “hot potato” voice
Drooling
Odynophagia
Trismus - Painful: restricts normal mandibular movement and function d/t masticatory muscle spasms
Neck swelling and pain
Referred ear pain
Fatigue, irritability, decreased oral intake

A

Peritonsillar Abscess

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28
Q

Extremely swollen and fluctuant tonsil
Deviation of the uvula to the opposite side
what are you suspecting

A

Peritonsillar Abscess

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29
Q

labs for Peritonsillar Abscess

A

Not necessary to make diagnosis, but can illustrate level of illness
CBC with differential
Serum electrolytes
Blood culture
Throat culture

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30
Q

what can Help to differentiate from other deep neck space infections and to look for complications for peritonsillar abscesses

A

Imaging
CT with IV contrast

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31
Q

what can help Exclude epiglottitis or retropharyngeal abscess from peritonsillar abscess?

A

Lateral neck radiographs

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32
Q

how to confirm diagnose peritonsillar abscess

A

aspiration of pus from abscess.

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33
Q

management of Peritonsillar Abscess

A
  1. Airway
  2. Consult ENT
  3. Needle aspiration or I&D
  4. abx
    - Initially IV - until improved
    – Ampicillin-sulbactam or clinda
    – Add Vancomycin if pt doesn’t respond promptly
    - Switch to oral - for 14 total
    — Augmentin or clinda
    — MRSA - clinda or Linezolid (Zyvox)
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34
Q

ddx of Peritonsillar Abscess

A

Epiglottitis
Retropharyngeal abscess or cellulitis
Abscess of the parapharyngeal space
Severe tonsillopharyngitis

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35
Q

complications of Peritonsillar Abscess

A
  1. compromise the upper airway or spread to the surrounding structure
    - Airway obstruction, Aspiration, Pneumonia, Bacteremia, Internal jugular vein thrombosis, Carotid artery rupture, Necrotizing fasciitis
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36
Q

Abscess of the deep neck structures
Posterior wall of esophagus and anterior cervical fascia
Occurs between the prevertebral fascia and the constrictor muscles
what is this condition

A

Retropharyngeal Abscess

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37
Q

Retropharyngeal Abscess typically results after what conditions?

A

URI, trauma / foreign body, or can be idiopathic

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38
Q

Retropharyngeal Abscess MC in who?

A

children due to more frequent URIs

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39
Q

Deep neck space infections are typically caused by what pathogen

A
  1. polymicrobial and represent the normal resident flora of the continguous mucosal surfaces from which the infection originated
    - Due to the close anatomic relationships, the resident flora of the oral cavity, upper resiratory tract, and certain parts of the ears share many common organisms
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40
Q

Neck swelling / mass / lymphadenopathy
Spiking fever
Neck pain, stiff neck
Odynophagia
Dysphagia
these clinical findings are from what condition?

A

Retropharyngeal Abscess
Other associated sx
Anorexia
Malaise
Irritability

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41
Q

diagnostic testing of Retropharyngeal Abscess

A
  1. CT neck with IV contrast (imaging of choice)
    - Ring enhancing lesion in the retropharyngeal space
    - Loss of definition between the anatomic spaces in the neck
  2. X-ray of the neck
    - Increased swelling in prevertebral space
  3. Labs
    - CBC, Blood cx, Purulent material cx
42
Q

management of Retropharyngeal Abscess

A
  1. Airway first
  2. Empiric IV abx
    - Ampicillin / Sulbactam (Unasyn) or
    - Ceftriaxone + Metronidazole or
    - clina + Levofloxacin
  3. Surgical drainage of abscess with ultrasound guided needle aspiration or open drainage
  4. Clinical improvement seen 24 - 48 hr
    - Consider new abx/surgery if not
    - Otolaryngologist consult
  5. Continue IV tx until afebrile and able to tolerate oral abx
    - Metronidazole or Levofloxacin
    - Total of 2-3 weeks
43
Q

Inflammation of the larynx
Leads to edema of the vocal cords

A

Acute Laryngitis

44
Q

MC cause of hoarseness

A

Acute Laryngitis

45
Q

acute laryngitis can be caused by ___ or ____

A

infectious or noninfectious
Non infectious causes:
Vocal strain / cysts
Vocal cord polyps
Reflux

46
Q
  1. Hoarseness
  2. Typically preceded by viral URI
    - May last 1-2 weeks after symptoms of URI clear
  3. Exudative tonsillopharyngitis with fever and anterior cervical lymphadenopathy = highly suggestive of bacterial origin
  4. Significant edema can cause airway distress
    clinical findings are for what condition
A

Acute Laryngitis
***Assess airway first

47
Q

etiology of acute laryngitis

A
  1. Viruses
    - Rhinovirus, Influenza, Parainfluenza, Adenovirus, Coxsackievirus, Coronavirus, RSV
  2. Bacterial
    - Group A Streptococcus or C. diphtheriae
    - M. catarrhalis
  3. Candidiasis
    - Immunosuppressed patients
    - Inhaled steroids
  4. GERD
    - Chronic reflux
48
Q

tx for acute laryngitis

A
  1. Viral
    - Voice rest
    - Hydration
  2. Bacterial
    - Antibiotics - PCN, erythromycin
    - Supportive care
  3. Vocal strain
    - Vocal therapy
    - Vocal hygiene
  4. Vocal polyps
    - Surgical removal
  5. GERD
    - PPI
    - ENT referral - pH monitoring
49
Q

tx for actors/singers with acute laryngitis

A

oral steroids or erythromycin

50
Q

when would you require ENT or otolaryngology referral for laryngitis

A

Laryngitis lasting > 2 wks in the absence of URI symptoms or specifically in a pt who uses tobacco or drinks alcohol

51
Q

Age specific viral syndrome characterized by acute laryngeal and subglottic swelling

A

Laryngotracheobronchitis - Croup

52
Q

Resulting in hoarseness, barky, seal-type cough, respiratory distress, and inspiratory stridor

A

Laryngotracheobronchitis - Croup

53
Q

Laryngotracheobronchitis - Croup is a relatively common infection in who? at what age? when does it most likely going to occur?

A

children
Peak age incidence - 3 months to 3 years
Occurs more frequently in late fall (September - December), to a lesser extent spring

54
Q

Pathogenesis of Laryngotracheobronchitis - Croup

A

Infection of the upper airways - larynx, trachea, and upper levels of bronchial tree
Edema of the airways

55
Q

pathogen causing Laryngotracheobronchitis - Croup

A
  1. virus
    - Parainfluenza - 75%, specifically 1a d 3
    - Adenovirus
    - RSV
  2. Mycoplasma pneumoniae - 3 - 4%
56
Q
  1. Prodromal URI symptoms for 1-2 days
  2. Then followed by the characteristic cough
    - Cough may be spasmodic, with a deep, brassy cough (nonproductive, high-pitched), harsh quality
    - Barking, “Seal-Like” cough
  3. Inspiratory Stridor
  4. Fever possible
  5. sx worse at night
  6. Respiratory distress

what is this condition?

A

Laryngotracheobronchitis - Croup

57
Q

Stridor in croup results from what

A

obstruction to airflow during both inspiration and expiration
Most marked on inspiration

58
Q

a child’s distress from croup is most evident during when?

A

inspiration

59
Q

signs of distress and inspiratory stridor from croup

A

retractions of the accessory muscles of the chest wall
Respiratory rate increased
Prolonged inspiration, wheezes, rhonchi

60
Q

signs of distress and inspiratory stridor from croup

A

retractions of the accessory muscles of the chest wall
Respiratory rate increased
Prolonged inspiration, wheezes, rhonchi

61
Q

imaging findings for croup

A
  1. generally not needed
  2. CXR - Normal
  3. Soft tissue x-ray of the neck
    - Subglottic narrowing
    - “Steeple sign”
62
Q

tx for mild croup

A
  1. managed at home
    - supportive tx - mist, antipyretics, fluid intake, exposure to cold air
    - watch for difficulty breathing, stridor at rest, worsening course, prolonged sx >7 day
  2. managed outpatient
    - dexamethasone (decadron)
    - oral Prednisolone
63
Q

what can aggravate narrowing of the airway in children

A

Crying and anxiety make children take short, rapid breaths
Minimal handling of child, make sure they are comfortable

64
Q

tx for moderate-severe croup

A

evaluated in ER

65
Q

No stridor at rest
Barky cough
Hoarse cry
No /mild chest wall retractions
what is the severity of croup

66
Q

Stridor at rest
Mild to moderate retractions
what is the severity of croup

67
Q

Stridor at rest
Marked retractions with agitations
Lethargy, cyanosis
what is the severity of croup

68
Q

ALL pts with croup will receive what?

A
  1. Dexamethasone
  2. Nebulized Epinephrine
  3. Supportive care including humidified air or oxygen, antipyretics, fluid intake, nebulized saline
69
Q

croup pt is discharging to home, what are the next steps

A
  1. Observe for 3-4 hrs after meds
    - sx improve within 30 min of administration of nebulized EPI
    - Additional EPI given if children have recurrence/worsening of sx during observation period, including admittance to hospital
  2. After 3-4 hrs, children can be discharge if they meet following criteria:
    - No stridor at rest
    - Normal pulse ox
    - Good air exchange
    - Normal color and level of consciousness
    - Ability to tolerate fluids
    - Caregiver understanding of indications to return when needed
70
Q

ddx of croup

A

Other respiratory illnesses
Bacterial tracheitis
Epiglottitis
Peritonsillar abscess
Bronchiolitis
Pneumonia
Asthma

71
Q

complications with croup

A

Hypoxemia
Bacterial tracheitis

72
Q

Cellulitis of the supraglottis and surrounding structures
Results from bacteremia and or direct invasion of the epithelial layer by the pathogenic organism

A

Epiglottitis
Airway emergency in children

73
Q

what is the primary source of pathogens in epiglottitis

A

posterior nasopharynx

74
Q

MC causative pathogen of epiglottitis

A

H. flu type B
Vaccinate!!!
Also caused by caustic ingestion, foreign body, thermal injury

75
Q
  1. Acutely with dysphagia, drooling, and distress
  2. Classic “tripod” position
  3. Sudden onset of High fever
  4. Anxious, restless, irritable
  5. Stridor
  6. Toxic appearance
  7. Rapidly sore throat
  8. Odynophagia out of proportion to oropharyngeal findings
A

Epiglottitis

76
Q

mainstay tx for epiglottitis

A

maintenance of airway

77
Q

diagnostic to confirm epiglottitis

A

visualization of an erythematous, edematous, epiglottis during laryngoscopy when securing the airway
Typical findings are cherry-red and swollen epiglottis

78
Q

“Thumbprint sign” is seen in imaging, what is this indicative of?

A

epiglottitis
Imaging - Only needed if pt is stable and want to differentiate from croup
Lateral neck radiograph

79
Q

work up/tx of epiglottitis

A
  1. Empiric IV abx begin after blood and epiglottic cx are obtained
    - 3rd gen Cephalo (Ceftriaxone) + Vanc first line
    - 3rd Gen Cephalo (Ceftriaxone) + Clinda also accepted as first line
    - If anaphylaxis occurs with PCN - Vanc + fluoroquinolone
    - Most will treat for 7-10 days
  2. Antipyretics
    • / - steroids
80
Q

Most Common Neck space infection

A

Ludwig’s Angina

81
Q

Bilateral Cellulitis of the sublingual, submandibular, and submental spaces
Arises from infected or recently extracted tooth ⅔ of the time

A

Ludwig’s Angina
- Lower 2nd and 3rd molars
- Polymicrobial infection from flora of oral cavity

82
Q

MC causative pathogen of Ludwig’s Angina

A

treptococci Viridans

83
Q

4 main descriptive characteristics of Ludwig’s Angina

A
  1. Begins in floor of mouth with a “woody” or brawny cellulitis (skin has a hard, firm texture or feel)
  2. Rapidly spreading without involvement of LN
  3. Sublingual and submaxillary spaces are involved
  4. Bilateral
84
Q
  1. Dysphagia, odynophagia
  2. Edema and erythema of the sublingual region
  3. Tongue displaced up and back
    - Potential airway obstruction
    - Asphyxiation - most common cause of death
  4. Marked neck pain and swelling
  5. Fever, chills, malaise
  6. Dysarthria - Disturbance of speech
  7. Drooling, stiff neck, tender, symmetric, and “woody” induration (known as “bull neck”)
    what is this conditon
A

Ludwig’s Angina
Deep neck abscesses = emergencies
- can rapidly compromise the airway

85
Q

workup/tx for ludwig’s angina

A
  1. Admit to hospital
  2. CT with IV contrast imaging of choice
  3. Close monitoring of airway and possible intubation
  4. Empiric IV antibiotic
    - Ampicillin-sulbactam (Unasyn) alone
    - Ceftriaxone + metronidazole
    - PCN allergic: Clindamycin + levofloxacin
  5. Obtain culture via needle aspiration if possible
  6. May need surgical drainage
    - However, this is not a typical abscess, so there is usually nothing to drain initially
86
Q
  • Benign
  • Vocal abuse
    what is this tumor of larynx
A

Vocal cord nodules
Tx: Voice habit modification, +/- surgical

87
Q
  • Vocal abuse
  • Smoking
  • Chemical irritants
    what is this tumor larynx
    tx?
A

Vocal cord polyps
Tx: Lifestyle change, Inhaled steroid spray, removal

88
Q

Most common tumor in larynx
Risk Factors: Smokers, Alcohol
s/sx: Hoarseness
Advanced Disease: Odynophagia, hemoptysis, weight loss, otalgia, vocal cord immobility, cervical adenopathy
what is this tumor larynx?
tx?

A

Squamous cell carcinoma
Surgery
Radiation and / or chemotherapy

89
Q

Lesion or damage to the recurrent laryngeal or vagus nerve
Breathy dysphonia and effortful voicing

A

Vocal Cord Paralysis

90
Q

Causes of unilateral recurrent laryngeal nerve involvement that causes Vocal Cord Paralysis

A

Thyroid surgery
Other neck surgery
Mediastinal or apical involvement by lung cancer
Skull base tumors - vagus nerve
Iatrogenic - MC cause of unilateral vocal cord paralysis
Idiopathic - second most common
may need CT or MRI

91
Q

voice hoarse and breathy
Airway not obstructed
what type of vocal cord paralysis

A

unilateral

92
Q

Inspiratory stridor
Voice limited intensity, but good quality
DOE (dyspnea on exertion)
what type of vocal cord paralysis

A

bilateral
Causes
Thyroid surgery
Esophageal cancer
Ventricular shunt malformation

93
Q

Causes of unilateral or bilateral Vocal Cord Paralysis

A

Advanced rheumatoid arthritis
Intubation injuries
Glottic and subglottic stenosis
Laryngeal cancer
tumor MC

94
Q

work up/tx for vocal cord paralysis

A
  1. Determine cause
    - Laryngoscopy, bronchoscopy, esophagoscopy
    - Neurologic examination
    - Enhanced CT of head, neck and chest
    - Thyroid gland scan
    - Upper GI series
  2. Maintain airway
  3. Unilateral is occasionally temporary, may resolve spontaneously
    - May take at least a year
    - Surgery may be needed
95
Q

what can cause hypertrophic tonsil obstruction

A

Oropharyngeal airway
Oropharyngeal swallowing pathway

96
Q

what can cause hypertrophic tonsil infections

A

recurrent or chronic infection may involve
Middle ear space
Mastoid air cells
Nose
Nasopharynx
Adenoids
Paranasal sinuses
Oropharynx
Tonsils
Peritonsillar tissues
Cervical lymph nodes

97
Q

Recommendations for tonsil removal

A
  1. Obstructive sleep apnea
  2. Recurrent throat infection
    - ≥ 3 episodes in each of 3 years, ≥ 5 episodes in each of 2 years, or ≥ 7 episodes in 1 year
    — Each episode characterized by at least ONE of the following:
    1) Oral temp ≥ 101℉ (38.3℃)
    2) Enlarged (> 2 cm) or tender anterior cervical lymph nodes
    3) Tonsillar exudate
    4) Positive culture for group A beta-hemolytic Streptococcus
98
Q

what is the grading for tonsils

A

0 - surgically removed tonsils
1 - tonsils hidden within tonsil pillars
2 - tonsils extending to the pillars
3 - visible beyond pillars
4 - enlarged to midline

99
Q

are soft aggregates of bacterial and cellular debris that form in the tonsillar crypts (crevices)

A

Tonsilloliths
AKA tonsil stones

100
Q

tx for tonsilloliths

A

Low pressure irrigator, cotton swab, mouth rinse, salt water rinse

EENT (11 decks)

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