Painful Throat Flashcards by Amanda Sim

Anatomy of throat

Throat refers to pharynx
Extends from base of skull to lower border of cricoid cartilage
- Nasopharynx
- Oropharynx: Posterior 1/3 of tongue and behind you
- Hypopharynx: Posterior to larynx where pyriform sinus is at
- Palatine tonsil lies between palatopharyngeus and palatoglossus

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Where do sore throats arise from?

Oropharynx and hypopharynx

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Pain from throat is sensed by?

Pain is sensed by CN IX and X (via pharyngeal plexus) which also supply middle and external ear -> referred otalgia

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Causes of painful throat

Acute
Infection:
1. Pharyngitis
- Viral
- Bacterial
- Fungal: Candida albicans
2. Tonsillitis
3. Deep neck space infection
- Retropharyngeal abscess
- Parapharyngeal abscess
- Peritonsillar abscess
4. Acute epiglottitis/supraglottitis

Foreign body throat
Caustic ingestion

Chronic
1. Tumour
2. Post-nasal drip (AR, chronic sinusitis)
3. Irritants (smoking/alcohol/chemicals)
4. Laryngopharyngeal reflux

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Infective cause: Clinical features acute pharyngitis

Sore throat (<1week)
Rhinitis (Rhinorrhea, blocked nose)
Laryngitis (Hoarseness of voice) symptoms
Throat pain
Pain on swallowing

Systemic symptoms:
- Malaise
- Myalgia
- Fever

Mx: symptomatic tx
Resolves within 3-5 days

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Physical findings in acute pharyngitis

Red, swollen tonsils
White pus
Palpable lymph nodes (submandibular)
Lymphoid tissues at back of throat might be hypertrophied with exudates

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Causative organisms of acute pharyngitis

Viral: Influenca/Adenovirus
Bacterial: Group A streptococcus (Strep pyogenes)

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How to determine between bacterial vs viral cause of acute pharyngitis?

CENTOR score
- Age: 3-14yo
- Exudate/swelling of tonsils
- Tender/swelling cervical lymph nodes
- Temperature > 38 degrees
- Absence of cough

2-3 points: Perform rapid antigen test or culture
4 points or more: Start empiric abx

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Causative organisms of acute tonsillitis

Bacterial: Group A beta-haemolytic strep (strep pyogenes)
Viral: EBV (infectious mononucleosis)

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What constitutes recurrent tonsillitis?

> 1x/year

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What criteria to use for indication of tonsillectomy?

Paradise criteria
- >7x/year
or
- >5x/year for 2 consecutive years
or
- >3x/year for 3 consecutive years

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Clinical features of acute tonsillitis

Commoner in young
- Severe (Worse than URTI) sore throat
- Fever, C&R
- Poor oral intake due to odynophagia
- Dysphagia
- Hoarse voice
- Halitosis (Bad breath)

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Physical findings in acute tonsillitis

Bilateral erythematous enlarged tonsils with purulent exudates (In lacey-white pattern) in tonsillar crypts
Tender jugulodigastric LN (Along SCM; rest of neck is okay)

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Management of acute tonsillitis

Supportive:
- Adequate hydration
- Analgesia
- Antipyretics
- Anesthetic gargle
- Abx
1st line: Penicillin (GABHS) for 10 days

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Complications of acute tonsillitis

Septic:
- Quinsy (Peritonsillar abscess)
- Lemierre’s syndrome (Anaerobic bacteria in Quinsy flourishes, abscess wall ruptures and spreads to IJV –> IJV thrombophlebitis –> Sepsis, lung abscess)
- Deep neck abscess and necrotizing fasciitis
-> Parapharyngeal or retropharyngeal abscesses

Immunological:
- Acute rheumatic fever
- Glomerulonephritis

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Causative organism of infectious mononucleosis

Epstein-Barr virus, transmitted by saliva

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Clinical features of infectious mononucleosis

High fever, marked fatigue
Sore throat of longer duration than bacterial tonsillitis
Tender, symmetric posterior cervical lymphadenopathy
Hepatosplenomegaly and atypical lymphocytosis
Rash after amoxicillin/ampicillin abx

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What can be observed in infectious mononucleosis if given penicillin abx?

Rash

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Physical findings in infectious mononucleosis

Bilateral exudative tonsillitis
Palatal petechiae
Uvular edema
Multiple bilateral enlarged tender posterior cervical LNs (Not just jugulodigastric!)
Hepatosplenomegaly

What advice to give patients with infectious mononucleosis?

Avoid contact sports for 6 weeks -> splenic rupture

Peak incidence of epiglottitis/supraglottitis

4 years old

Most common causative organism of epiglottitis in Paeds

Haemophilus Influenza Type B

*other organisms:
Streptococcus pneumonia
B-hemolytic streptococcus
Staphylococcus aureus

Risk factors of epiglottitis

Unvaccinated against Hib
Immunocompromised
DM

Symptoms of epiglottitis in Paeds

Fever
Stridor
Sore throat
Drooling
Respiratory distress
Sitting in tripod position
Sniffing posture
Dysphagia
Muffled voice
Anxiety, restlessness

Lateral neck x-ray findings in epiglottitis

- Thumbprint/ Thumb sign - Loss of cervical lordosis (due to pre-vertebral muscle spasm) - Overdistended/ Dilated hypopharynx

Management of epiglottitis

- Avoid triggering patient - Maintenance of airway/ Secure airway (ETT/ Surgical cricothyroidotomy/ tracheostomy)/ Bag-Valve-Mask while waiting - Humidified oxygen - Blood culture and epiglottic culture, followed by IV 3rd generation cephalosporin (Ceftriaxone/ Cefotaxime) with cover for MRSA via vancomycin - IV Steroids (Dexamethasone 8mg STAT) to reduce airway edema

Clinical features of peritonsillar abscess aka Quinsy

!Medical emergency! - Worsening unilateral sore throat that's not better despite Abx (pus shld be drained) - Fever - Trismus (Irritation and spasm of pterygoid muscles which help to open mouth --> Lockjaw (Normal mouth opening is 3 fingerbreadths) - Hot potato voice (Muffled due to obstruction in oropharynx)

Physical findings in Quinsy

- Unilateral tonsillar erythema and enlargement (Medialisation of tonsil) - Soft palate swelling - Uvula deviation to contralateral side

Definitive management for peritonsillar abscess aka Quinsy

Incision and drainage under LA - instant relief - tonsillectomy for recurrent quinsy (>1x/year)

Specific physical finding for patients with retropharyngeal abscess

Neck stiffness

Difference between retropharyngeal and parapharyngeal abscess

Retropharyngeal abscess - Presents with odynophagia - Child < 4 yo - Behind pharynx - Bulge in posterior pharyngeal wall - Widened prevertebral soft tissue Parapharyngeal abscess - Presents with neck swelling - Immunocompromised adult - Lateral to pharynx - Tender neck swelling

Common sites of foreign body lodgement

Tonsil Vallecula Tongue base Pyriform sinus Upper esophageal sphincter (Cricopharyngeus)

Eagle syndrome

Elongated styloid process impinging on glossopharyngeal nerve --> Glossopharyngeal neuralgia - Throat and neck pain

Management of Infectious mononucleosis

Symptomatic tx

Investigations for infectious mononucleosis

Monospot test Positive EBV viral capsid antigen IgM Atypical lymphocytosis LFT transaminitis

Most common FB in throat

Fish bone

Clinical features of FB throat

Immediate throat pain Odynophagia Dysphagia Haemoptysis Retrosternal discomfort

Removal of FB from throat

FB in oropharynx and hypopharynx: remove in clinic using forceps/nasoendoscopy FB in cricopharynx and oesophagus: rigid esophagoscopy

Laryngopharyngeal reflux

Laryngeal manifestation of GERD - Globus feeling - Hoarseness - Chronic cough - Chronic sore throat

Superficial cervical fascia

Lies between dermis and deep cervical fascia Contains: - facial muscles of expression - platysma muscle

Deep cervical fascia is divided into

Investing layer Pretracheal layer Prevertebral layer Carotid sheaths

Investing layer of deep cervical fascia

- Most superficial - Trapezius, SCM, submandibular and parotid glands

Pretracheal layer of deep cervical fascia

- Middle layer - Split into 2 parts 1. Muscular - strap muscles 2. Visceral - thyroid gland, pharynx, larynx, trachea and oesophagus

Prevertebral layer of deep cervical fascia

- Surrounds vertebral column and muscles of the back - Brachial plexus and subclavian artery

Carotid sheaths

- Runs from BOS to thoracic mediastinum - Contents: 1. Common carotid artery 2. Internal jugular vein 3. Vagus nerve

Most common cause of deep neck infections

Dental infections and dental caries

What is Ludwig's angina?

Cellulitis of submental, sublingual and submandibular spaces