Oropharynx and Larynx - Exam 4 Flashcards
What are the 6 components of the oropharynx?
The middle part of the throat behind the mouth.
The back 1/3 of the tongue.
The soft palate & uvula.
The side and back walls of the throat.
The tonsils.
What are the 6 components of the larynx?
_____ is one of the MC complaints in primary care. _____ is viral. Highest in _____ months
sore throat (acute pharyngitis)
50% are viral
highest in winter months
_____ is the MC bacterial pathogen cause of acute pharyngitis
Group A strep
Sore throat - Not severe
Coryzal symptoms
Fever - rare
PE - little to no findings
No adenopathy or pharyngeal exudates
What am I?
viral pharyngitis: respiratory viruses
Sore throat - More severe
Fever
Myalgia, headache, cough
What am I?
viral pharyngitis: influenza
Sore throat
Fever
Post-auricular adenopathy
Myalgias
conjunctivitis
What am I?
Viral pharyngitis: Adenovirus
If conjunctivitis is present, it is almost always _____
adenovirus
**Pharyngeal inflammation and exudate
Vesicles and shallow ulcers on hard palate and tongue
What am I?
What is the tx?
HSV Infection
Acyclovir / Valacyclovir (Valtrex)
“Mouth blisters”
Small vesicles on soft palate and uvula that rupture to form shallow white ulcers
What am I?
**Mouth ulcers are almost always _____
Coxsackievirus - Herpangina (Hand, foot and mouth dz)
Viral!!!
Pharyngitis
Pharyngeal exudate: White - purple
Fever
Fatigue: persistent and severe
Generalized lymphadenopathy: posterior cervical
splenomegaly
HA
Maculopapular, urticarial, or petechial rash
What am I?
What does the rise commonly arise after?
What is the pt education?
Epstein-Barr Virus (mononucleosis)
Can arise with ampicillin/amoxicilin
Avoid contact sports for 4 weeks
Risk of splenic rupture
Can use oral Prednisone taper if tonsillar swelling is significant
Antivirals and Steroids not recommended in regular treatment; does not reduce duration
What are some diagnostic/screening tools that you can order for viral pharyngitis?
Rapid antigen detection test (rapid strep screen)
monospot
serum EBV specific antibodies
NP swab
What is important to remember about the monospot test?
Can have false negatives in early course
Not reactive on young children less than 4 years of age - high false negative
What are the mono lab values? **What is the value that sets it apart?
Lymphocytosis
**Atypical lymphocytosis
Total WBC 12000-18000
Elevated Liver Function Tests
**What organism is strep throat caused by?
strep pyogenes
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
What am I?
What is the MC organism?
What is the highlighted s/s?
GABHS- strep throat
Strep pyogenes
Hoarseness, cough, coryza not suggestive of this illness
Which dz presents with a sandpaper rash that blanches and resembles a sunburn. What are an additional 2 important symptoms to note?
Strep throat
palatal petechiae
strawberry tongue
Rapid Antigen Detection Strep test first line testing is first line for ______. How accurate is it?
Strep throat- GABHS
90-99% accurate
Can have false negatives
What is the Centor criteria? What dz is it associated with? What do the result indicate? **If _____ is present need to think viral
Tonsillar exudates
Tender anterior cervical lymphadenopathy
Fever
Absence of cough
strep throat
greater than or equal to 3 need to strep test the patient, less than 3 do not need to strep test
cough present think viral!!!
What is the first line tx for strep throat? What is second line?
Pen VK
Pen G benzathine (Bicillin) IM as a single dose
Amoxicillin
second:
Augmentin
Erythromycin
Clindamycin
Azithromycin (Zithromax)
What is the first line tx for strep throat for a pt with a mild PCN allergy? What about for a severe PCN allergy?
Cephalexin (Keflex)/ Cefdinir / Cephalosporins
Penicillin allergic reaction of rash
Azithromycin / Clindamycin
Anaphylaxis reaction
What are the pt education points for strep throat?
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
_____ is a common strep throat complication in children
Otitis media
Strep throat secondary antibody formation because of cross-reactivity may result in _____ and ______
rheumatic fever
valvular heart disease
strep throat antigen-antibody complexes may lead to acute _______
poststreptococcal glomerulonephritis
When do Rheumatic fever and glomerulonephritis typically appear? _____ will be elevated after recent strep infection
2 - 3 weeks after streptococcal illness
Antistreptolysin O (ASO) titer
What is the correct throat swab procedure?
rub swab over posterior pharynx and bilateral tonsillar pillars
AVOID: tongue, teeth and gums
What are some differences between strep throat and viral pharyngitis?
What is a peritonsillar abscess? Complication of _____. Also called ______.
Forms between one of your tonsils and the wall of your throat
tonsillitis
quinsy
What organisms are MC for a peritonsillar abscess?
Often polymicrobial
**Streptococcus pyogenes (group A strep)
**Staph aureus
Respiratory anaerobes
Severe sore throat (usually unilateral)
Fever
Muffled voice - “hot potato” voice
Drooling
Odynophagia
Trismus
muscle spasms
Neck swelling and pain
Referred ear pain
Fatigue, irritability, decreased oral intake
deviation of the uvula to the opposite side
What am I?
What are the highlighted s/s?
peritonsillar abscess
Hot potato voice
Deviation of the uvula to the opposite side
**How do you confirm the dx of a peritonsilar abscess? What is the imaging of choice?
Diagnosis confirmed by aspiration of pus from abscess.
CT with IV contrast but not necessary to make dx
What is the management for a peritonsillar abscess?
airway is the first priority!!
consult ENT
Needle aspiration or I&D
IV Ampicillin-sulbactam (Unasyn) or Clindamycin
Add Vancomycin if patient doesn’t respond promptly
can switch to oral once improvement is noted. Augmentin or clinda
What structures does a retropharyngeal abscess come between? What is a typical patient?
Occurs between the prevertebral fascia and the constrictor muscles
more common in children after a upper respiratory infection
The deep cervical fascial spaces are normally bound together by ______ and intercommunicate to varied degrees
Deep neck space infections are typically ______ and represent the normal resident flora of the contiguous mucosal surfaces from which the infection originated. _____, ____ and _____ may share common organisms.
loose connective tissue
polymicrobial
oral cavity, upper respiratory tract, and certain parts of the ears
Neck swelling / mass / lymphadenopathy
Spiking fever
Neck pain, stiff neck
Odynophagia
Dysphagia
Anorexia
Malaise
Irritability
What am I?
What is the dx tool of choice?
Retropharyngeal Abscess
CT neck with IV contrast (imaging of choice)
What is the tx for retropharyngeal abscess? When should you see improvement?
maintain airway
IV antibiotics
Ampicillin / Sulbactam (Unasyn) or
Ceftriaxone plus Metronidazole or
Clindamycin plus Levofloxacin
Surgical drainage of abscess with ultrasound guided needle aspiration or open drainage
24 - 48 hours: Consider new antibiotics and / or surgery if not
______ is the MC cause of hoarseness. And is inflammation of the larynx. Name 3 non-infectious causes
Acute Laryngitis
Vocal strain / cysts
Vocal cord polyps
Reflux
Hoarseness
Typically preceded by viral URI
Exudative tonsillopharyngitis with fever and anterior cervical lymphadenopathy
What am I?
What are 3 common organisms?
Acute Laryngitis
Group A Streptococcus or C. diphtheriae
M. catarrhalis
What is the tx for viral acute laryngitis? bacterial?
viral: voice rest and hydration
bacterial: PCN or erythromycin
What should you give actors/singers for acute laryngitis?
Can be given oral steroids or erythromycin to help speed up recovery for performances
**What should you do if laryngitis (hoarseness) lasting > 2 weeks in the absence of URI symptoms?
specifically in a pt who uses tobacco or drinks alcohol requires ENT or otolaryngology referral
Resulting in hoarseness, barky, seal-type cough, respiratory distress, and inspiratory stridor. Relatively common in what age children?
Laryngotracheobronchitis - Croup
common infection in children peak age is 3 months to 3 years
What is the infection of the upper airways - larynx, trachea, and upper levels of bronchial tree and edema of the airways? What is the MC viruses?
Laryngotracheobronchitis - Croup
**Parainfluenza - 75%, specifically 1 and 3
Adenovirus
RSV
_____ is the source of 3-4% of Laryngotracheobronchitis - Croup?
Mycoplasma pneumoniae
Prodromal URI symptoms for 1-2 days
Barking, “Seal-Like” cough
Inspiratory Stridor
fever possible
symptoms worse at night
respiratory distress
Then followed by the characteristic cough, which indicates progression
in distress: accessory muscles of the chest wall
What am I?
What should you tell the parents?
croup
have the kid go outside the cold air helps to constrict
Stridor results from obstruction to airflow during both _____ and ______
Most marked on _____
inspiration and expiration
inspiration
What is “steeple sign” associated with? what is it actually?
Soft tissue x-ray of the neck
Subglottic narrowing
imaging and labs are generally NOT needed
The tx of croup depends on ______. What is considered mild? What is the tx?
depends on severity!
mild:
No stridor at rest
Barky cough
Hoarse cry
No /mild chest wall retractions
tx:
supportive care and exposure to cold air
also instruct parents to watch for difficulty breathing, stridor at rest, worsening course, prolonged symptoms >7 day
What is considered mild croup but brought into the office? What is the tx?
Mild (managed outpatient)
If brought into outpatient setting, can do dexamethasone (decadron) single dose (.15 to .6 mg/kg)
Or oral Prednisolone 1mg/kg single dose
*Minimal handling of child, make sure they are comfortable
**Crying and anxiety make children take short, rapid breaths, which aggravate narrowing of the airway
What is considered moderate croup? severe? What is the tx?
Moderate:
Stridor at rest
Mild to moderate retractions
severe:
Stridor at rest
Marked retractions with agitations
Lethargy, cyanosis
both should be evaluated at the ER!!!!
Dexamethasone
Nebulized Epinephrine
Supportive care including humidified air or oxygen, antipyretics, fluid intake, nebulized saline
need to observe for 3-4 hours after rx intervention and additional epi should be given if s/s persist
_____ is cellulitis of the supraglottis and surrounding structures. Is it an emergency? **What organism is it caused by? How do you prevent it?
Epiglottitis
YES!! airway emergency in children
**Haemophilus influenzae type B
Vaccinate!!!!
Acutely with dysphagia, drooling, and distress
Classic “tripod” position
Sudden onset of High fever
Anxious, restless, irritable
Stridor
Can present with Toxic appearance
Rapidly sore throat
Odynophagia out of proportion to oropharyngeal findings
What am I?
How do you confirm dx?
What are the typical findings?
What is the first priority?
Epiglottitis
laryngoscopy that confirms cherry red and swollen epiglottis
Maintenance of airway is mainstay of treatment!!!!! Need to maintain airway before anything else!!!
When do you need to order an xray on a pt with epiglottitis? **What will you commonly find?
Radiographs are NOT necessary to make the diagnosis, only order if the pt is stable and want to differentiate from croup
thumbprint sign on lateral neck radiograph
What is the tx for epiglottitis? When should you start tx?
tx: Ceftriaxone plus Vancomycin first line OR
Ceftriaxone plus Clindamycin also accepted as first line
start tx with empiric IV antibiotic treatment should begin AFTER blood and epiglottic cultures are obtained
______ is the MC neck space infection. Describe it. What does it typically arise from? What is important to note?
Ludwig’s angina
Bilateral Cellulitis of the sublingual, submandibular, and submental spaces
Arises from infected or recently extracted tooth ⅔ of the time
Aggressive and spreads rapidly can potentially cause airway obstruction
What is the tx for epiglottitis if the pt has a severe PCN allergy?
can use Vancomycin plus fluoroquinolone
What are the 4 main descriptive characteristics of Ludwig’s Angina?
- Begins in floor of mouth with a “woody” or brawny cellulitis (skin has a hard, firm texture or feel)
- Rapidly spreading without involvement of lymph nodes
- Sublingual and submaxillary spaces are involved
- Bilateral
Dysphagia, odynophagia
Edema and erythema of the sublingual region
Tongue displaced up and back
Marked neck pain and swelling
Fever, chills, malaise
Dysarthria
Disturbance of speech
Drooling, stiff neck
tender , symmetric, and “woody” induration (known as “bull neck”)
What am I?
Why is this an emergency?
Ludwig’s Angina
Deep neck abscesses are emergencies b/c they can rapidly compromise the airway
Why is the tongue displacement in Ludwig’s angina potentially fatal? _____ is the MC cause of death
tongue displacement up and back. Potential airway obstruction
Asphyxiation - most common cause of death
What is the tx for Ludgwig’s Angina?
______ are usually benign and occur from vocal abuse. What is the tx?
Vocal cord nodules
Voice habit modification
+/- surgical excision
_____ are caused by vocal abuse, smoking and chemical irritants. What is the tx?
Vocal cord polyps
Tx:
Lifestyle change
Inhaled steroid spray
Removal
_____ is the MC tumor of the larynx. What are 2 risk factors? What is the s/s? What is the tx?
Squamous cell carcinoma
smokers and alcohol use
hoarseness!!
tx:
Surgery
Radiation and / or chemotherapy
vocal cords are _____ when someone is speaking and _____ when not speaking
closed when speaking
open when NOT speaking
Lesion or damage to the _____ or _____ nerve leads to vocal cord paralysis
recurrent laryngeal nerve
vagus nerve
_______ is the MC cause of unilateral vocal cord paralysis. What is second MC? What is the dx TOC?
Iatrogenic
idiopathic
CT or MRI
voice hoarse and breathy equal _____ vocal cord paralysis
Inspiratory stridor
Voice limited intensity, but good quality
dyspnea on exertion equal _____ vocal cord paralysis
unilateral
bilateral
What are some causes of bilateral vocal cord paralysis?
Thyroid surgery
Esophageal cancer
Ventricular shunt malformation
How do you dx vocal cord paralysis?
Laryngoscopy, bronchoscopy, esophagoscopy
CT of head, neck and chest
need to determine the cause!!!
_______ vocal cord paralysis may resolve spontaneously. How long could it take?
Unilateral
may take up to a year
How do you grade hypertrophic tonsils? What is the range?
based on where the tonsils are compared to the pillars
Grade 0-4
When is a tonsillectomy recommended?
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
Oral temp ≥ 101℉ (38.3℃)
Enlarged (> 2 cm) or tender anterior cervical lymph nodes
Tonsillar exudate
Positive culture for group A beta-hemolytic Streptococcus
or obstructive sleep apnea
_____ are soft aggregates of bacterial and cellular debris that form in the tonsillar crypts (crevices). What can they indicate?
Tonsilloliths: AKA tonsil stones
can indicate need to get sx
Which of the following s/s are not generally seen in strep throat?
Nausea /vomiting
Fever
Cough/congestion
cough
A 12 y/o patient presents to the office with a sore throat. Mom states pt has had a fever of 101F as well but is not coughing or congested. You notice tender cervical lymph nodes that are enlarged, as well as tonsillar exudate. What is your next step?
Rapid strep screen and culture
Immediately treat
Do nothing and say it’s viral
rapid strep screen and culture
What is the imaging modality of choice for a retropharyngeal abscess?
CT with contract
What is the most common pathogen associated with croup?
Parainfluenza virus 1 and 3
A 1 year old child presents to the clinic with a barking cough. The mom stated it started in the middle of the night. The mom describes the cough as “seal like.”
Mom states she also has a low grade fever and mild runny nose. She denies any trouble breathing. She brings him to the office for evaluation and the patient coughs, which sounds like a seal bark. What is you treatment for this patient?
steroids IM
A 3 year old male presents to the clinic with a severely sore throat. Mom states he has to sit in a specific way in order to not have trouble breathing. On PE, you notice the patient is drooling and looks to be in pain. You later learn in the encounter the patient is on a delayed vaccine schedule. What is your diagnosis?
epiglottitis
Which nerves are damaged in vocal cord paralysis?
CN X and recurrent laryngeal nerve
What is the most common type of cancer that causes malignant tumors of the larynx?
squamous cell
Are vocal cord polyps concerning for malignancy? What is their MC cause?
polyps are benign
overuse
