Oropharynx and Larynx Flashcards
1
Q
One of the most common complaints in primary care
A
sore throat
Acute Pharyngitis
2
Q
Acute Pharyngitis is mainly caused by what type of pathogen
A
60 - 90% viral
5 - 30% bacterial
3
Q
Acute Pharyngitis is highest prevalent during what season
A
winter
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
5
Q
clinical findings of influenza
A
Sore throat - More severe
Fever
Myalgia, headache, cough
6
Q
clinical findings of adenovirus
A
Sore throat
Fever
Post-auricular adenopathy
Myalgias
conjunctivitis
7
Q
clinical findings of HSV infection
A
Pharyngeal inflammation and exudate
Vesicles and shallow ulcers on hard palate and tongue
8
Q
clinical findings of Coxsackievirus - Herpangina
A
“Mouth blisters”
Small vesicles on soft palate and uvula that rupture to form shallow white ulcers
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
10
Q
Diagnosis/Screening of Viral Pharyngitis
A
- Rapid antigen detection test
- Anytime a chief complaint of sore throat
- Rapid strep screen
— If negative, can confirm with throat culture - 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 - Serum EBV specific antibodies
- Usually not necessary if patients with manifestations consistent with IM are monospot positive - NP swab
11
Q
MONO LAB VALUES
A
Lymphocytosis
Atypical lymphocytosis
Total WBC 12000-18000
Elevated Liver Function Tests
12
Q
tx for viral pharyngitis
A
- Supportive care for all viruses
- Fever reducers/pain relievers, magic mouthwash, cold food - Influenza
- Tamiflu - <48 hrs of sx onset - HSV
- Acyclovir / Valacyclovir (Valtrex) - 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
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
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”
15
Q
associated severe sx of Streptococcal Pharyngitis / Tonsillitis (GABHS)
A
Scarlatiniform Rash
Palatal Petechiae
Strawberry tongue: enlarged red papillae
16
Q
Diagnostic Testing for Streptococcal Pharyngitis / Tonsillitis (GABHS)
A
- Patients with a clinical syndrome compatible with GAS pharyngitis who lack symptoms of a respiratory viral syndrome
- Rapid Antigen Detection Strep test first line testing
- Specifically for GABHS
- 90-99% accurate
- Can have false negatives - Throat culture
- Most sensitive but takes up to 2 - 3 days to get results
- 90-95% accurate
17
Q
first line tx for Group A Streptococcus / Strep throat
A
- Pen VK
- Pen G benzathine (Bicillin) IM as a single dose
- Amoxicillin
- Cephalexin (Keflex)/ Cefdinir
- Cephalosporins
- PCN allergic reaction of rash - Azithromycin / Clindamycin
- Anaphylaxis reaction
18
Q
Second line / Treatment Failure
of Group A Streptococcus / Strep throat
A
Augmentin
Erythromycin
Clindamycin
Azithromycin (Zithromax)
19
Q
education for pt with strep throat
A
- Have pt change toothbrush after 24 hours
- Not contagious any longer after 24 hours of treatment
- Strep will “go away” on it’s own without antibiotics
- However, a patient will remain contagious for 2-3 weeks after symptoms abate
20
Q
Complications of Streptococcal Pharyngitis / Tonsillitis (GABHS)
A
- OM in children
- Secondary antibody formation because of cross-reactivity = rheumatic fever and valvular heart disease
- Antigen-antibody complexes = acute poststreptococcal glomerulonephritis
21
Q
Rheumatic fever and glomerulonephritis typically appear when after streptococcal illness
A
2 - 3 weeks
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
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
24
Q
what is a quinsy
A
abscess
25
Most common deep neck infection in children and adolescents
Peritonsillar Abscess
26
pathogen causing Peritonsillar Abscess
1. Often polymicrobial
2. Streptococcus pyogenes (group A strep)
3. Staph aureus
4. Respiratory anaerobes
27
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
Peritonsillar Abscess
28
Extremely swollen and fluctuant tonsil
Deviation of the uvula to the opposite side
what are you suspecting
Peritonsillar Abscess
29
labs for Peritonsillar Abscess
Not necessary to make diagnosis, but can illustrate level of illness
CBC with differential
Serum electrolytes
Blood culture
Throat culture
30
what can Help to differentiate from other deep neck space infections and to look for complications for peritonsillar abscesses
Imaging
**CT with IV contrast**
31
what can help Exclude epiglottitis or retropharyngeal abscess from peritonsillar abscess?
Lateral neck radiographs
32
how to confirm diagnose peritonsillar abscess
aspiration of pus from abscess.
33
management of Peritonsillar Abscess
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)
34
ddx of Peritonsillar Abscess
Epiglottitis
Retropharyngeal abscess or cellulitis
Abscess of the parapharyngeal space
Severe tonsillopharyngitis
35
complications of Peritonsillar Abscess
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
36
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
Retropharyngeal Abscess
37
Retropharyngeal Abscess typically results after what conditions?
URI, trauma / foreign body, or can be idiopathic
38
Retropharyngeal Abscess MC in who?
children due to more frequent URIs
39
Deep neck space infections are typically caused by what pathogen
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
40
Neck swelling / mass / lymphadenopathy
Spiking fever
Neck pain, stiff neck
Odynophagia
Dysphagia
these clinical findings are from what condition?
Retropharyngeal Abscess
Other associated sx
Anorexia
Malaise
Irritability
41
diagnostic testing of Retropharyngeal Abscess
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
management of Retropharyngeal Abscess
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
Inflammation of the larynx
Leads to edema of the vocal cords
Acute Laryngitis
44
MC cause of hoarseness
Acute Laryngitis
45
acute laryngitis can be caused by ___ or ____
infectious or noninfectious
Non infectious causes:
Vocal strain / cysts
Vocal cord polyps
Reflux
46
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
Acute Laryngitis
***Assess airway first
47
etiology of acute laryngitis
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
tx for acute laryngitis
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
tx for actors/singers with acute laryngitis
oral steroids or erythromycin
50
when would you require ENT or otolaryngology referral for laryngitis
Laryngitis lasting > 2 wks in the absence of URI symptoms or specifically in a pt who uses tobacco or drinks alcohol
51
Age specific viral syndrome characterized by acute laryngeal and subglottic swelling
Laryngotracheobronchitis - Croup
52
Resulting in hoarseness, barky, seal-type cough, respiratory distress, and inspiratory stridor
Laryngotracheobronchitis - Croup
53
Laryngotracheobronchitis - Croup is a relatively common infection in who? at what age? when does it most likely going to occur?
children
Peak age incidence - 3 months to 3 years
Occurs more frequently in late fall (September - December), to a lesser extent spring
54
Pathogenesis of Laryngotracheobronchitis - Croup
Infection of the upper airways - larynx, trachea, and upper levels of bronchial tree
Edema of the airways
55
pathogen causing Laryngotracheobronchitis - Croup
1. virus
- **Parainfluenza - 75%, specifically 1a d 3**
- Adenovirus
- RSV
2. Mycoplasma pneumoniae - 3 - 4%
56
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?
Laryngotracheobronchitis - Croup
57
Stridor in croup results from what
obstruction to airflow during both inspiration and expiration
Most marked on inspiration
58
a child's distress from croup is most evident during when?
inspiration
59
signs of distress and inspiratory stridor from croup
retractions of the accessory muscles of the chest wall
Respiratory rate increased
Prolonged inspiration, wheezes, rhonchi
60
signs of distress and inspiratory stridor from croup
retractions of the accessory muscles of the chest wall
Respiratory rate increased
Prolonged inspiration, wheezes, rhonchi
61
imaging findings for croup
1. generally not needed
2. CXR - Normal
3. Soft tissue x-ray of the neck
- Subglottic narrowing
- **“Steeple sign”**
62
tx for mild croup
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
what can aggravate narrowing of the airway in children
Crying and anxiety make children take short, rapid breaths
Minimal handling of child, make sure they are comfortable
64
tx for moderate-severe croup
evaluated in ER
65
No stridor at rest
Barky cough
Hoarse cry
No /mild chest wall retractions
what is the severity of croup
mild
66
Stridor at rest
Mild to moderate retractions
what is the severity of croup
moderate
67
Stridor at rest
Marked retractions with agitations
Lethargy, cyanosis
what is the severity of croup
severe
68
ALL pts with croup will receive what?
1. Dexamethasone
2. Nebulized Epinephrine
3. Supportive care including humidified air or oxygen, antipyretics, fluid intake, nebulized saline
69
croup pt is discharging to home, what are the next steps
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
ddx of croup
Other respiratory illnesses
Bacterial tracheitis
Epiglottitis
Peritonsillar abscess
Bronchiolitis
Pneumonia
Asthma
71
complications with croup
Hypoxemia
Bacterial tracheitis
72
Cellulitis of the supraglottis and surrounding structures
Results from bacteremia and or direct invasion of the epithelial layer by the pathogenic organism
Epiglottitis
Airway emergency in children
73
what is the primary source of pathogens in epiglottitis
posterior nasopharynx
74
MC causative pathogen of epiglottitis
H. flu type B
Vaccinate!!!
Also caused by caustic ingestion, foreign body, thermal injury
75
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
Epiglottitis
76
mainstay tx for epiglottitis
maintenance of airway
77
diagnostic to confirm epiglottitis
visualization of an erythematous, edematous, epiglottis during laryngoscopy when securing the airway
Typical findings are cherry-red and swollen epiglottis
78
“Thumbprint sign” is seen in imaging, what is this indicative of?
epiglottitis
Imaging - Only needed if pt is stable and want to differentiate from croup
Lateral neck radiograph
79
work up/tx of epiglottitis
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
3. + / - steroids
80
Most Common Neck space infection
Ludwig’s Angina
81
Bilateral Cellulitis of the sublingual, submandibular, and submental spaces
Arises from infected or recently extracted tooth ⅔ of the time
Ludwig’s Angina
- Lower 2nd and 3rd molars
- Polymicrobial infection from flora of oral cavity
82
MC causative pathogen of Ludwig's Angina
treptococci Viridans
83
4 main descriptive characteristics of Ludwig's Angina
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
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
Ludwig’s Angina
Deep neck abscesses = emergencies
- can rapidly compromise the airway
85
workup/tx for ludwig's angina
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
- Benign
- Vocal abuse
what is this tumor of larynx
Vocal cord nodules
Tx: Voice habit modification, +/- surgical
87
- Vocal abuse
- Smoking
- Chemical irritants
what is this tumor larynx
tx?
Vocal cord polyps
Tx: Lifestyle change, Inhaled steroid spray, removal
88
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?
Squamous cell carcinoma
Surgery
Radiation and / or chemotherapy
89
Lesion or damage to the recurrent laryngeal or vagus nerve
Breathy dysphonia and effortful voicing
Vocal Cord Paralysis
90
Causes of unilateral recurrent laryngeal nerve involvement that causes Vocal Cord Paralysis
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
voice hoarse and breathy
Airway not obstructed
what type of vocal cord paralysis
unilateral
92
Inspiratory stridor
Voice limited intensity, but good quality
DOE (dyspnea on exertion)
what type of vocal cord paralysis
bilateral
Causes
Thyroid surgery
Esophageal cancer
Ventricular shunt malformation
93
Causes of unilateral or bilateral Vocal Cord Paralysis
Advanced rheumatoid arthritis
Intubation injuries
Glottic and subglottic stenosis
Laryngeal cancer
tumor MC
94
work up/tx for vocal cord paralysis
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
what can cause hypertrophic tonsil obstruction
Oropharyngeal airway
Oropharyngeal swallowing pathway
96
what can cause hypertrophic tonsil infections
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
Recommendations for tonsil removal
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
what is the grading for tonsils
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
are soft aggregates of bacterial and cellular debris that form in the tonsillar crypts (crevices)
Tonsilloliths
AKA tonsil stones
100
tx for tonsilloliths
Low pressure irrigator, cotton swab, mouth rinse, salt water rinse
