Oropharynx and Larynx Flashcards
Often the _____ is a component
of a Upper Respiratory Infection (URI)
syndrome
pharyngitis
VIRAL PHARYNGITIS Etiology/Pathophysiology
○ Many different common viruses are known etiologic agents.
■ Rhinovirus (>100 different subtypes) - About 20% of cases
■ Adenovirus - Probably nearly as common as Rhinovirus
■ Epstein-Barr Virus - causal agent of Infectious Mononucleosis
● Will be discussed separately later
VIRAL PHARYNGITIS Clinical presentation
○ Throat pain/soreness
○ Nasal congestion
○ Fever, generally low-grade
○ Nonproductive cough is
common with URI syndrome
○ Hoarse voice is possible
Viral Pharyngitis Physical Exam
○ Edema and erythema of the
oropharynx
○ Scant exudate is possible
○ May see shallow vesicles
○ In URI, nasal mucosa
■ Erythematous
■ Rhinorrhea
○ Conjunctivitis sometimes
VIRAL PHARYNGITIS Diagnostic Evaluation
Generally, considered a clinical diagnosis based on H&P
■ Lab tests should be reserved for select cases based on suspicion.
○ Rapid testing available for some viruses
■ RSV, influenza
○ If H&P suggest it could be strep throat…
■ Strep testing could be considered
VIRAL PHARYNGITIS Management
○ Rest, time, reassurance, return precautions.
○ Hydration is very important!
○ Ibuprofen > Acetaminophen
■ Aspirin is not first choice
○ Topical anesthetics (gargles, lozenges)
VIRAL PHARYNGITIS Management IF Herpes simplex is the pathogen
■ Acyclovir or Valacyclovir can help
VIRAL PHARYNGITIS Management IF Influenza is the pathogen
■ Oseltamivir (Tamiflu) can help shorten duration of illness
If the patient has significant URI-associated nasal congestion, eustachian
tube dysfunction can result in _____
subsequent sinusitis and/or otitis media
Some patients with influenza may later develop secondary _____, which may then require antibiotic treatment
bacterial pneumonia
A common type of viral pharyngitis known as ____ is caused by the Epstein-Barr Virus (EBV)
Infectious Mononucleosis
(“mono”)
EBV is transmitted via intimate contact with ____
bodily secretions, primarily
oropharyngeal secretions (“kissing disease”)
Infection of B lymphocytes results in a humoral and cellular response with
EBV
EBV PHARYNGITIS History
○ Interestingly, most are actually
asymptomatic
○ Incubation period is 1-2 months
○ Fatigue.
○ Prolonged malaise.
○ Sore throat
EBV PHARYNGITIS Physical Exam
○ Early signs
■ Fever
■ Lymphadenopathy
● Commonly b/l Post Cervical
■ Pharyngitis
○ Later signs may include…
■ Hepatomegaly
■ Splenomegaly
■ Palatal petechiae
■ Jaundice (30% of elderly patients)
_____ is the most common confirmatory test in the presence of signs/symptoms of EBV pharyngitis
A rapid heterophile agglutination test (known commonly a Monospot test)
EBV PHARYNGITIS Management
○ Antibiotic treatment is not indicated.
○ Treatment approach is mostly the same as other viral pharyngitis.
■ Rest, hydration, NSAIDs, topical anesthetics
○ Patient education that symptoms of fatigue and malaise can persist for weeks or even months
○ Patients with extreme tonsillar
enlargement may be at risk of airway
obstructions. In this case, a short course of
steroids would be appropriate.
■ Ex: Prednisone PO for 5 days
Patients with extreme tonsillar
enlargement due to EBV may be at risk of airway obstructions. In this case, a short course of _____ would be appropriate
steroids
acute bacterial pharyngitis caused
by Group A Beta-Hemolytic Streptococci (GABHS)
STREPTOCOCCAL PHARYNGITIS
STREPTOCOCCAL PHARYNGITIS History
○ Rather sudden onset of sore throat
○ Fever, often high
○ Pain and difficulty with swallowing
○ “Swollen glands” in the neck
○ Usually no cough or rhinorrhea
STREPTOCOCCAL PHARYNGITIS Physical Exam
○ Oropharyngeal erythema and edema
○ Tonsillar exudate and swelling
■ Grayish white patchy exudate
○ Tender, enlarged anterior cervical lymph
nodes
○ Febrile
____ commonly accompanies strep throat
Scarlet fever
Scarlet Fever on H&P
Scarlet fever commonly accompanies strep throat.
■ Results from pyrogenic exotoxin released by GABHS
■ Scarlatiniform rash that blanches with pressure
■ Appears on the 2nd day of illness and fades within a week
■ Followed by extensive desquamation that lasts for several weeks
First line medication class for Strep is ____
Penicillin
● Penicillin VK or Amoxicillin for 10 days
● IM Bicillin (Penicillin G benzathine) x 1 is
also effective
Tx for strep if allergic to penicillins
■ Macrolides (azithromycin, clarithromycin)
■ Cephalosporins (cefdinir)
■ Clindamycin
When is a tonsillectomy warranted?
○ Surgical removal of the tonsils is a fairly common surgical procedure in
children and teens- Performed by ENT surgeon.
○ Generally reserved for those with recurrent cases.
■ 7 episodes of throat infection in 1 year OR
■ 5 episodes each year for 2 years OR
■ 3 episodes annually for 3 years
DIPHTHERIA Epidemiology
A form of bacterial pharyngitis cause by Corynebacterium diphtheria
● Uncommon the developed nations due to widespread immunization practices;
usually seen in those who are not fully vaccinated (TDaP and Td vaccines).
Pathophysiology of Diptheria
○ Spread mostly by respiratory secretions/droplets.
○ Incubation period is 2-5 days and can stay communicable for 2-6 weeks if not
treated with antibiotics.
○ Upper respiratory bacterial colonies secrete an exotoxin and produce a thick,
tenacious gray membrane in the oropharynx
DIPHTHERIA History
○ Sore throat.
○ Low-grade fever (rarely >103°F)
○ Malaise, weakness
○ Headache
○ Cervical lymphadenopathy
DIPHTHERIA Physical Exam
○ Pharyngeal erythema and edema
○ Thick, gray, leathery pseudomembrane
forms in the pharynx
■ Attempts at scraping away should not
occur, but would reveal ulcerations
with bleeding (don’t do it)
○ Extensive anterior and submandibular
cervical lymphadenopathy is common
■ “Bull’s neck” appearance
What will a DIPHTHERIA throat culture show?
■ Gram stain of sample will show clusters of bacilli
■ Culture should be obtained all close contacts too
DIPHTHERIA Clinical Management
○ Patient should be transport to the nearest hospital.
○ Secure airway for patients with impending respiratory compromise.
○ Treatment should be initiated before confirmatory tests are completed
due to the high potential for mortality and morbidity.
○ Isolate all cases promptly and use universal and droplet precautions.
○ An antitoxin is given to anyone suspected to have diphtheria and can be
administered without confirmation from cultures
Diptheria Patients with active disease, as well as all close contacts with suspected
exposure, should be treated with ____
Antibiotics
■ Erythromycin or Penicillin for 14 days
LUDWIG ANGINA
Considered a deep neck infection, Ludwig
Angina is a potentially life-threating deep
cellulitis of the floor of the mouth
the most commonly encountered deep neck infection
Ludwig Angina
____ are responsible in 80% of cases of ludwig angina
Dental infections
LUDWIG ANGINA History
○ Rapidly progressing symptoms
○ Bilateral lower facial edema around
the mandible and upper neck
■ Can be asymmetric
○ Pain
LUDWIG ANGINA Physical Exam
○ Tender, indurated, warm swelling of the submental area
○ Swelling of the floor of the mouth
○ Severe trismus can occur
○ Drooling or pooling of secretions
○ Tongue is edematous and displaced
posteriorly and superiorly
LUDWIG ANGINA Diagnostic evaluation
○ Should be see in Emergency
Department right away (not clinic).
○ CT of the neck with contrast STAT.
■ Ensure airway is patent before
sending for scan
LUDWIG ANGINA Clinical management
○ Patient should be admitted for continued management
Broad-spectrum IV antibiotics for several days
○ If CT shows an abscess, ENT surgical
consultation is indicated
PERITONSILLAR ABSCESS
● Generally result from dental infections, tonsillitis (such as strep throat),
parotitis, or complicated sinus infections.
○ Most common is progression from acute tonsillitis to cellulitis to abscess
formation in the peritonsillar soft tissue
PERITONSILLAR ABSCESS History
○ Symptoms commonly began about
3-5 days prior as sore throat
○ Throat pain markedly more severe
on the affected side
○ Fever is common
PERITONSILLAR ABSCESS Physical Exam
○ Pharyngeal erythema with asymmetric
tonsillar hypertrophy
■ Uvula pointed away from abscess
■ Tonsillar displacement
○ Hot potato/muffled voice
PERITONSILLAR ABSCESS diagnostic imaging
○ CT of face with contrast is indicated.
■ This will show abscess
■ Delineates size, extension
PERITONSILLAR ABSCESS Management
○ Monitor and assess the patient’s airway closely
○ Fluid resuscitation is often required.
○ Pain medications
○ Oral steroids
○ Empiric antibiotics should be administered for 14 days
● Clinical Management (continued)-
○ Drainage can be performed in the ED; consulting with ENT is best
○ Drainage is commonly done by needle aspiration.
○ If large and requiring I&D, patient should go to the OR with ENT
PERITONSILLAR ABSCESS
Drainage techniques
○ Anesthetic Technique
then
○ Needle aspiration technique or
○ Scalpel technique (should be done by ENT provider):
RETROPHARYNGEAL ABSCESS
A deep neck infection resulting in an abscess located in the deep tissues of the
throat, behind the posterior pharyngeal wall (retropharyngeal space).
● Retropharyngeal Abscess (RPA) occurs less commonly today than in the past,
likely because of widespread use of antibiotics for suppurative URIs.
○ Incidence has recently started to increase, however (unknown reasons).
RETROPHARYNGEAL ABSCESS Mortality
● Mortality rate is generally low at 1-2%.
○ However, once mediastinitis occurs, mortality approaches 50%, even with
antibiotic therapy.
● Considered a medical emergency that usually requires surgical intervention
RETROPHARYNGEAL ABSCESS History
○ Sore throat, can be severe
○ Fever
○ Dysphagia
○ Odynophagia
○ Neck pain
○ Neck stiffness
○ Neck swelling (in infants)
○ Poor oral intake
RETROPHARYNGEAL ABSCESS Diagnostic Evaluation
○ Lateral neck XR imaging could be
obtained.
○ CT scan of the neck with contrast is the most sensitive.
■ Will reveal the abscess and show extent of involvement
○ Chest x-ray is indicated to evaluate for aspiration pneumonia or other Dx.
RETROPHARYNGEAL ABSCESS Clinical Management
○ Initial focus is on protecting and monitoring the airway.
○ Once blood cultures have been taken, IV antibiotics should be started.
○ IV fluid resuscitation may be needed, especially if dehydrated.
○ Once the diagnosis has been established, ENT surgeon should be consulted right away
EPIGLOTTITIS
Acute inflammation in the supraglottic region of the pharynx with inflammation of
the epiglottis, vallecula, arytenoids, and aryepiglottic folds
EPIGLOTTITIS Physical Exam
○ Tripod position - Sitting up on hands,
with the tongue out and the head
forward.
○ Drooling/inability to handle secretions
○ Severe pain on gentle palpation over the
larynx or hyoid bone
○ Stridor: A late finding indicating advanced
airway obstruction
○ Cervical adenopathy is common
○ Respiratory distress
EPIGLOTTITIS Diagnostic eval
○ A clinical diagnosis based on H&P.
○ DO NOT attempt direct visualization of the epiglottis!
○ Lateral neck soft-tissue radiographs are historically used.
■ Reveal classic “thumbprint” sign (seen in about 79% of cases)
○ Direct visualization of the epiglottis using nasopharyngoscopy/ laryngoscopy is
preferred and is replacing radiographic evaluation for suspected epiglottitis
(cherry red epiglottis)
EPIGLOTTITIS Management
○ Avoid agitation and manipulation.
○ Airway management is the most urgent consideration.
○ Intubation may be required with little warning
○ After airway management, IV 3rd-generation cephalosporin and vancomycin.
ACUTE LARYNGITIS
Simply, inflammation of the larynx
● Onset is usually rather abrupt and is usually self-limited, less than 3 weeks.
○ Commonly attributed to viruses (uncommonly bacterial)
Can manifest in chronic forms too, where a patient may deal with a hoarse
voice for years or the rest of their life with____
ACUTE LARYNGITIS
ACUTE LARYNGITIS History
○ Patients report vocal hoarseness or “lost my voice.”
○ Commonly associated with rather mild URI symptoms
○ Visualization of the larynx is usually not imperative or commonly performed.
■ Indirect examination of the airway with a mirror or direct examination with
a flexible nasolaryngoscope reveals erythema and edema of the vocal
folds, secretions, and irregularities of the surface contour of the vocal fold
LARYNGOTRACHEOBRONCHITIS AKA
Croup
LARYNGOTRACHEOBRONCHITIS
Also known as Acute Viral Laryngotracheitis and Croup, this is the most
common form of airway obstruction in young children
Parainfluenza Virus is the most common pathogen, causing an estimated
75% of cases of ____
LARYNGOTRACHEOBRONCHITIS (CROUP)
LARYNGOTRACHEOBRONCHITIS (CROUP) History
○ The illness generally starts with 1-3 days of low-grade fever and URI symptoms
○ “barking cough” (seal-like), hoarse voice,
inspiratory stridor, and possibly some
respiratory distress for the patient
○ Symptoms are usually worse at night
and usually increase with patient
agitation (crying or running)
LARYNGOTRACHEOBRONCHITIS (CROUP) Diagnostic evaluation
○ Essentially a clinical diagnosis based on
H&P
○ Anteroposterior (AP) radiograph of the soft tissues of the neck could be obtained.
■ “Steeple sign”
LARYNGOTRACHEOBRONCHITIS (CROUP)
Management
○ Mild disease does not usually require significant medical treatment.
■ Supportive measures (saline drops, acetaminophen, etc.)
■ Cool-mist humidifiers
■ Steamy bathrooms
■ Cool night air (can be especially helpful)
○ For more significant cases, which is common…
■ Can prescribe a single dose of oral dexamethasone (0.6 mg/kg to a
max of 20 mg).
Hospitalization and nebulized epinephrine is needed in only the severe cases of
LARYNGOTRACHEOBRONCHITIS (CROUP)
Bronchoscopy is generally warranted for
Airway foreign body
Acute laryngitis is the most
common cause of ____
Hoarseness
Besides viral laryngitis, some other causes of Hoarseness include
○ Voice Misuse
○ Benign vocal cord lesions
○ Vocal hemorrhage
○ Laryngopharyngeal reflux (LPR)
