Sore Throat Flashcards
1
Q
acute vs chronic pharyngitis
A
acute: less than 2 weeks duration
chronic: more than 2 weeks duration
2
Q
categories of the causes of pharyngitis
A
infectious vs non-infectious causes
infectious can be viral or bacterial
3
Q
what is the most common cause of sore throat?
A
infection - viral is more common than bacterial
4
Q
when do we consider fungal causes of pharyngitis? is it common?
A
it is rare
consider in patients who are immunocompromised, with chronic steriod or antibiotic use
5
Q
____ and ____ (types of viruses) account for __% of viral pharyngitis cases
A
rhinoviruses and coronaviruses account for 25% of viral pharyngitis cases
(common cold included in rhinoviruses and coronaviruses)
6
Q
what viruses can cause viral pharyngitis (10)
A
rhinovirus
coronavirus
adenovirus
herpes simplex virus (HSV)
influenza A and B
parainfluenza virus
Epstein-Barr virus
cytomegalovirus
human herpesvirus (HHV) 6
HIV
7
Q
in the adult population, what % of sore throats are caused by viruses?
in the children’s (ages 5-16 and ages <5) population, what % of sore throats are caused by viruses?
A
adults: 85-85%
children ages 5-16: 70%
children ages <5: 95%
8
Q
what is the most common cause of bacterial pharyngitis? what % of sore throats does it cause in adults? in children?
A
Group A beta-hemolytic streprococci (GABHS)
adults: up to 15%
children: about 30%
9
Q
what bacteria can cause bacterial pharyngitis (7)
A
GABHS - group A beta-hemolytic streptococci
fusobacterium necrophorum
group C beta-hemolytic streptococci
Neisseria gonorrhoeae
Cornybacterium diptheriae
Mycoplasma pneomoniae
Chlamydophilia pneumoniae
- apart from GABHS, the other causes are quite rare and seen mostly in chronic steroid or antibiotic use
10
Q
non-infectious causes of sore throat (7)
A
persistent cough
upper airway cough syndrome (postnasal drip)
GERD
acute thyroiditis
neoplasm
allergies
smoking
11
Q
when do we consider non-infectious pharyngitis?
A
- patients with chronic sore throat (>2 weeks)
- patients without signs of infection
- patients who do not respond to treatment
12
Q
what are some clinical signs of infection (re: pharyngitis)
A
swollen lymph nodes
fever
- redness is not necessarily a sign of infection, more a sign of irritation
13
Q
what is the general approach to acute pharyngitis:
A
- rule out serious diagnoses and red flags that call for urgent/emergent management
- most cases are due to infectious cause - determine if bacterial or viral cause
- identify acute sore throat caused by GABHS, antibiotic Tx may be indicated where viral resolves on its own and we provide supportive therapy
14
Q
urgent vs emergent situation
A
emergent is more serious than urgent
15
Q
red flag definition
what do they prompt us to do?
A
- definition: signs and symptoms found in the patient history and clinical examination that may indicate possible serious underlying pathology
- they prompt further investigation and/or referral
16
Q
trismus definition
what does it suggest
A
lock jaw
inability to open mouth fully
suggests peritonsillar swelling
17
Q
pls take this opportunity to review the table of red flag findings with acute pharyngitis and what diagnoses they may indicate
A
pls
18
Q
suppurative definition
A
pus-forming
related to infection
19
Q
what happens in acute epiglottitis
how common is it, how serious is it
what causes it
what population does it mostly affect - has this changed? why?
does it occur more often in a certain time period?
A
rare but potentially fatal
inflammation of the epiglottis and adjacent tissues
bacterial infectious primarily caused by Haemophilius influenziae
most commonly seen in children ages 2-6 but HiB vaccination in infants has decreased the incidence in children and we see it in adults a little more
most common in winter and spring
a medical emergency -> refer!
20
Q
diagnostic criteria for acute epiglotitis
A
positive thumb sign on lateral radiograph of the neck
21
Q
clinical presentation of acute epiglottitis
A
- acute onset fever, severe sore throat, toxic appearance
- 4 Ds: dysphagia, drooling, dysphonia, distress (respiratory stridor, tripod position, severe dyspnea, irritability, restless)
22
Q
tripod position definition
A
- indicates difficulty breathing
- patients will lean forward so the trunk of their body is one of the limbs of the tripod and their arms are pointed forward so gravity helps them get air into their lungs easier
23
Q
what should you NOT do when examining someone with suspected acute epiglottitis?
A
do not use a tongue depressor when examining the oropharynx as it can cause spasm of the tissues in the neck and throat to cause airway obstruction/compromise the airway
24
Q
what is the medical condition also called Quinsy
A
peritonsillar abscess
25
what happens in peritonsillar abscess
what population is most affected?
are there conditions that tend to occur with it or progress to it?
what organism is responsible for causing peritonsillar abscess?
how is it diagnosed?
is the most common deep infection of the head and neck
most common in young adults (20-40 yo) and immunocompromised, and diabetics
usually begins as acute tonsillitis -> cellulitis -> abscess formation
a polymicrobial infection (bacterial)
diagnosis is made clinically without labwork/imaging in patients with the typical presentation - culture from abscess drainage confirms diagnosis
26
what common organisms can cause peritonsillar abscess?
group A streptococci
staphylococcus aureus
haemophilus influenzae
fosobacterium
peptostreptococcus
pigmented prevatella species
veillonella
27
clinical presentation of peritonsillar abscess
severe unilateral sore throat, causing dysphagia and odynophagia
fever and malaise
dysphonia - muffled hot potato voice
rancid or fetor breath
otalgia
trismus
oropharyngeal exam shows erythematous enlarged tonsil and bulging soft palate on affected side, uvular deviation to contralateral side
may have severely tender cervical lymphadenopathy
28
what is typical treatment for peritonsillar abscess?
drainage, antibiotic therapy, supportive care
29
what happens in a retropharyngeal abscess
what population is most affected
are there conditions that occur before it and lead to retropharyngeal abscess?
what is the course of action?
retropharyngeal edema due to cellulitis and suppurative adenitis of lymph nodes in retropharyngeal space
preceded by upper respiratory infection, pharyngitis, otitis media, wound infection following penetrating injury to posterior pharynx
peak incidence in 3-5 yo (these lymph nodes disappear after age 5 or 6)
treat as impending airway emergency - requires antibiotic therapy, possible surgical consult for needle aspiration or incision and drainage
30
clinical presentation of retropharyngeal abscess
sore throat and dysphagia
fever
drooling
dysphonia
neck stiffness! limited ROM - especially hyperextension
stridor
may see bulging of posterior wall of oropharynx on clinical exam
31
what associated symptoms are more likely to present with viral illness (re: pharyngitis)
cough
nasal congestion
conjunctivitis
hoarseness
diarrhea
oropharyngeal lesions (ulcers or vesicles)
32
what viruses are most likely to cause pharyngitis in children? what are the most common viruses (%)
common cold (50%) - rhinovirus, coronavirus
influenza (5%) - influenza type A and B
mononucleosis (5%) - Epstein-Barr virus
33
in what cases would viral pharyngitis require antibiotic therapy
only if there is a secondary bacterial infection
34
streptococcal pharyngitis
what is involved?
what age group is most commonly affected?
risk factors?
infection of pharynx - caused by GABHS bacteria
most common in children ages 5-15
risk factors: exposure to sick contact with GABHS, winter or early spring
35
typical presentation of streptococcal pharyngitis
acute onset of fever and sore throat
headaches, nausea and vomiting, malaise, dysphagia, abdominal pain
cough and rhinorrhea usually absent! (if present suggests more viral cause)
edema and erythema of tonsils and pharynx
non-adherent tonsillar and/or pharyngeal exudate
enlarged and tender anterior cervical lymph nodes
1 in 10 cases may evolve into scarlet fever
may have palatine petechiae
36
what is scarlet fever
a scarletiniform rash with a texture like sandpaper; tends to be concentrated in axillary region
strawberry tongue may appear - taste buds become enlarged, tongue is swollen and red
exotoxins cause redness, rashes are small papules, raised red lesions
there is fever associated with this rash - the exotoxins are erythrogenic and leave xanthan (the red rash the develops after the infection)
37
suppurative complications of streptococcal pharyngitis
peritonsillar abscess
retropharyngeal abscess
otitis media
sinusitis
mastoiditis
cervical lymphadenitis
meningitis
bacteremia
38
non-suppurative complications of streptococcal pharyngitis
acute rheumatic fever
poststreptococcal glomerulonephritis
PANDAS (pediatric autoimmune neuropsychiatric disorder associated with group A streptococcal) infection
39
what populations have higher risk of developing suppurative complications?
immunocompromised patients: diabetes, chemotherapy, immunosuppressive drugs
40
what evidence for strep throat is the best evidence statistically
- fever is NOT a strong source of evidence
- exudate present - tonsillar or pharyngeal exudate
- tender anterior cervical lymph nodes
- strep exposure in the past 2 weeks
- the absence of pharyngeal exudate helps rule out
41
what does the Modified Centor score do?
helps predict probability of streptococcal pharyngitis and guide clinical decision making
42
what does the mnemonic for M-CENTOR stand for? how do you score it?
Must be older than 3 years old
Cough - no cough (+1)
Exudates or swelling - present (+1)
Nodes - anterior cervical lymphadenopathy (+1)
Temperature - history of fever or temp >38 (+1)
Only Young - patients <15 yo (+1)
Rarely Elder - patients >45 yo (-1)
43
what are the pros of using a rapid strep test for streptococcal pharyngitis?
can be done in office with rapid turnover time
useful for ruling in streptococcal pharyngitis - highly specific
44
what are the cons of using a rapid strep test for streptococcal pharyngitis?
lower sensitivity - if negative, there are chances that it could be a false negative
unable to distinguish between carriers of GABHS and active infection
45
what is the gold standard for diagnosing strep throat?
why?
throat culture
it has a 10% or less false negative rate
46
what are the benefits/disadvantages of using antibiotic therapy for GABHS pharyngitis
- decreases transmission of GABHS and shortens duration of the illness by 1-2 days but does not make a difference in time off school or work
- prevents suppurative complications (acute otitis media, acute sinusitis, peritonsillar abscess)
- prevents acute rheumatic fever
- most cases are self-limiting in 7-10 days without antibiotics
47
do carriers of GABHS require treatment?
no, they have GABHS as part of their normal flora and it does not make them sick, thus they are "carriers"
48
what happens in infectious mononucleosis?
what age group is most affected?
an infection caused by Epstein-Barr virus in more than 90% of cases
most common in ages 5-25 years
49
typical presentation of infectious mononucelosis
gradual onset, low grade fever, sore throat
malaise, fatigue
tonsillar exudates
palatine petechaie
lymphadenopathy - especially posterior cervical lymph nodes
splenomegaly in 50% of cases but splenic rupture is an uncommon complication (highest risk in first 3 weeks of illness)
50
what symptoms are the most clinically significant in diagnosing infectious mononucleosis?
axillary lymphadenopathy
posterior cervical lymphadenoapthy
palatine patechiae
inguinal lymphadenopathy
tonsillar or pharyngeal exudate
splenomegaly
atypical lymphocytosis (a lot of WBCs being produced)
the absence of any lymphadenopathy decreases likelihood of infectious mononucleosis
51
what is the Monospot test?
a rapid screening test that detects heterophil antibody agglutination
best initial test for EBV infection
fast, inexpensive and has high specificity (helps rule in the diagnosis of mono)
can be conducted in office
52
what does a productive cough suggest compared to a dry or unproductive cough?
productive cough suggests a more infectious type of cough but not all types of infectious cough are productive
also suggests conditions like congestive heart failure where fluid can build up in the lungs due to non-infectious cause
53
pls take this time to review the table about red flags associated with cough
pls pls - you will be glad you did
54
hemoptysis definition
coughing up blood
55
how to differentiate between serious or benign cause of hemoptysis?
a higher level of pain in the lungs when coughing up blood would be concerning
copious amounts of blood more concerning than just blood tinged sputum
chronic cough can irritate the lung tissue and result in benign coughing up of some blood
56
does acute respiratory disease more often travel from upper to lower respiratory tract or lower to upper respiratory tract?
most often spreads from upper respiratory tract to lower respiratory tract
57
is common cold more limited to upper respiratory tract or lower respiratory tract? which structures does it often affect?
upper respiratory tract
pharynx, sinuses, nose
58
what happens in common cold
when does incidence peak?
when are symptoms usually worst? is it self limiting?
viral infection of upper respiratory tract with inflammation
peaks in winter months
worst symptoms 2-3 days, resolves in 7-10 days
cough may last 2-3 weeks
59
what organisms are responsible for causing common cold
many viruses can cause it
rhinoviruses are the most common cause - grows at optimal temp that is inside the human nose
other viruses: coronavirus, adenovirus, parainfluenza virus, respiratory syncytial virus
60
risk factors for developing common cold
immunocompromised people
children
students
people working in healthcare setting
elderly
psychological stress or excessive fatigue
smoking
anyone with anatomical nasopharyngeal disorders
61
clinical presentation of common cold
nasal congestion, rhinorrhea, sneezing
sore throat, cough
slight body aches that are NOT debilitating
mild headache
afebrile or low grade fever
malaise
may have conjunctivitis or sinus symptoms
chest exam is normal - no signs of LRTI
62
complications of common cold
asthma or COPD exacerbation
secondary infection: acute otitis media, acute sinusitis, other infections (pneumonia, streptococcal pharyngitis, croup, broncholitis, bronchitis
63
what is croup
a viral infection typically caused by parainfluenza virus that leads to swelling of the larynx and a barking cough
64
what is the common treatment for common cold
it is self limiting - no antibiotics unless there is a secondary bacterial infection
antipyretics, analgesics
ensure hydration
steam inhalation
warm fluids
lozenges
saline nasal rinse
65
___ medications should not be given to children <___ years old for common cold
cough and cold pharmacy meds should not be given to children under 6 years old because of the risks of adverse effects
66
what happens in influenza
when does incidence peak?
how long after exposure to virus do symptoms appear
when is the contagious period
infection by influenza A or B virus
peaks in winter months
symptoms appear after 1-4 days following exposure
contagious period 1 day before symptoms to 5 days after symptom onset
67
clinical presentation of influenza
acute onset
fever that is much higher than common cold and lasts longer (2-5 days)
cough
myalgia
weakness and fatigue that can persist for several weeks
other common symptoms: headache, chills, featigue, loss of appetite, sore throat, nasal congestion, rhinorrhea, diarrhea, nausea, vomiting
68
how might influenza clinically present in preverbal children
not drinking or eating -> lost appetitie
not playing or talking to others -> malaise
69
which populations are more likely to have complications from the flu
young children
older adults >65 years
living in long term care homes
persons with chronic illnesses
pregnant women
diabetics
heart or lung conditions
70
what symptom, if present, is the best evidence of influenza infection?
rigors
71
how are rigors different from chills?
rigors are suddenly feeling cold, plus shivering, plus fever, often with sweating
chills are rapid muscle contraction that occurs when the body feels cold
72
what 4 variables are considered in the influenza clinical decision rule?
fever plus cough
myalgias
duration <48 hours
chills or sweats
73
what is the most common complication of flu
what signs should you watch for
pneumonia
watch for signs of lower respiratory infection - tachypnea or tachycardia along with fever, signs of consolidation on chest exam
74
conductive hearing loss vs sensorineural hearing loss
conductive - hearing loss due to dysfunction in parts of the auditory pathway from the external ear to middle ear
sensorineural - hearing loss due to dysfunction in parts of the auditory pathway from the inner ear to the auditory cortex
75
Weber test findings in:
normal patient
conductive hearing loss
sensorineural hearing loss
normal patient: heard at midline/no lateralization
conductive hearing loss: lateralization to affected ear
sensorineural hearing loss: lateralization to unaffected ear
76
Rinne test findings in:
normal patient
conductive hearing loss
sensorineural hearing loss
normal patient: AC > BC
conductive hearing loss: BC > AC
sensorineural hearing loss: AC > BC
77
what happens in otitis externa?
what is the layperson term for this
what population is most commonly affected
inflammation or infection of external ear canal
aka. swimmer's ear
most common in adolescents
78
what organism is responsible for causing otitis externa
most commonly a bacterial infection of Pseudomonas species or Staphylococcus aureus
can be a fungal infection <10% of the time due to Candida albicans or Aspergillus niger
79
risk factors for otitis externa
swimming or repeated water immersion
mechanical trauma
narrow ear canals
cerumen obstruction (leads to moisture retention)
skin conditions like eczema and psoriasis
immunocompromised
80
typical presentation of otitis externa
otalgia, pruritis, ear fullness
possible otorrhea
hearing impairment findings consistent with conductive hearing loss
periauricular lymphadenopathy
pain on movement of the auricle or tragus
erythematous, edematous, inflamed external auditory canal
81
what happens in acute otitis media
what population is it most prevalent in? peak incidence at what age group? why?
acute inflammation secondary to infection
most common in children
peak incidence at 6-24 months of age
more susceptible due to developing immune system and shorter, more horizontal eustachian tube that accumulates fluid more easily
82
which organisms are responsible for causing acute otitis media?
streptococcus pneumonaie
Haemophilus influenzae
Moraxella catarrhalis
83
risk factors for acute otitis media
shorter and more horizontal eustachian tubes
age <5yo
family history of ear infections
low birth weight
male > female
premature birth
recent URTI
prior ear infections
white ethnicity
exposure to tobacco smoke or air pollution
GERD
lack of breastfeeding
pacifier use after 6 months of age
84
typical presentation of otitis media
otalgia
fever, irritability
possible otorrhea
anorexia (loss of appetite)
may have vomiting or lethargy
hearing impairment - consistent with conductive hearing loss
bulging, inflamed, cloudy/erythematous, immobile tympanic membrane with obscured landmarks
85
what signs of otitis media, if present, provide the best evidence for it
cloudy TM
bulging TM
distinctly impaired mobility of TM
86
is a red tympanic membrane a good indicator of acute otitis media?
no. there are other factors that can cause the TM to be red such as crying
87
typical management of acute otitis media - do we need antibiotics?
do antibiotics help with pain? do they decrease the time to recovery?
in 80% of children, acute otitis media resolves without antibiotics
management involves symptom management of fever and ear pain
follow with watchful waiting or delayed antibiotic prescription
do not result in early resolution, but decrease the pain by day 2-3
88
when are antibiotics indicated in acute otitis media?
age < 6 months
bilateral ear infections
otorrhea in children > 6 months
ear findings with severe otalgia, otalgia lasting at least 2 days or a temperature of > 39C
89
complications of acute otitis media
perforated tympanic membrane
suppurative complications: acute mastoiditis, meningitis, brain abscess
90
acute mastoiditis:
what is it
clinical findings
typical treatment
tenderness behind the ear on mastoid process
will be swollen and red, can protrude and push ear outward
abnormal tympanic membrane
otalgia
WBCs elevated, CT scan confirms diagnosis
treatment with IV antibiotics and possibly drainage
