Sore throats Flashcards
What is acute tonsillitis?
Acute tonsillitis is an inflammation of the tonsils
What is pharyngitis?
inflammation of the pharynx (Sore throat)
What is the most common cause of acute tonsillitis and pharyngitis?
Viral infection
What are some viral causes of acute tonsillitis and pharyngitis?
EBV
RhinovirusI
Influenza
Parainfluenza
Enterovirus
Adenovirus
What are some bacterial causes of acute tonsillitis and pharyngitis?
Strep. pyogenes (Most common)
H. influenza
Staph. aureus
Strep. pneumoniae
What are some non-infectious causes of pharyngitis?
Physical irritation from GORD or chronic irritation from cigarette smoke
What is shown?
Acute tonsillitis
What is shown?
Acute pharyngitis
What are some symptoms of viral tonsillitis?
- Malaise
- Sore throat, mild analgesia requirement
- Temperature
- Able to undertake near normal activity
- Possible lymphadenopathy
What are some symptoms of bacterial tonsillitis?
- Systemic upset
- Fever
- Odynophagia
- Halitosis
- Unable to work/school
- Lymphadenopathy
How long will viral tonsillitis usually last?
3-4 days
How long will bacterial tonsillitis usually last?
Around 1 week
What are some pieces of self-care advice that should be given in acute tonsillitis and pharyngitis?
- Eat and drink, rest
- Regular analgesia (paracetamol/ibuprofen)
- Medicated lozenges
What scoring system is used to determine whether tonsillitis requires antibiotics?
FeverPAIN
What does FeverPAIN stand for?
Fever
P - Purulence (Pus on tonsils)
A - Attended rapidly within 3 days
I - Inflamed tonsils
N - No cough or coryza (Inflammation of mucus membranes in the nose)
What does a FeverPAIN score of 0-1 suggest?
Low association of isolating streptococcus
No need for antibiotics
What does a FeverPAIN score of 2-3 suggest?
Moderate association with streptotoccus Consider delayed presentation for antibiotics
What does a FeverPAIN score of 4-5 suggest?
Highest association (62-65% likelihood of streptococcus)
Treat with antibiotic
What is the first line antibiotic used in treatment of Strep. pyogenes in acute tonsillitis?
Penicillin (Clarithromycin if allergic)
When should a patient with tonsillitis be admitted or referred?
- Stridor
- Breathing difficulty
- Clinical dehydration
- Systemically unwell
- Persistent sore throat lasting 3-4 weeks (± Neck mass)
- Red or white patches lasting over 3 weeks
How is acute tonsillitis managed in hospital?
IV fluids, antibiotics and steroids
How is infection control achieved in acute Strep. pyogenes (GAS) infection in hospital?
- Isolation for the first 48 hours of treatment
- Standard infection control precautions
- Contact precautions
- Risk assess need for droplet precautions
When is surgery indicated in tonsillitis?
Recommended for recurrent severe sore throat due to acute tonsillitis in adults
‘Watchful waiting’ more appropriate than tonsillectomy for children with mild sore throats
What are some complications of acute tonsillitis?
- Otitis media (most common)
- Peritonsillar abscess (quincy)
- Parapharyngeal abscess
- Lemierre symdrome (suppurative thrombophlebitis of jugular vein)
What are some late complications of Strep. pyogenes infection?
- Rheumatic fever - fever, arthritis and pancarditis 3 weeks post sore throat
- Glomerulonepthritis - haematuria, albuminuria and oedema 1-3 weeks post sore throat
What causes quinsy (Peritonsillar abscess)?
Bacteria between the muscle and the tonsil produce pus
How does quinsy present?
- Unilateral throat pain and odynophagia
- Trismus (Pain opening mouth)
- 3-7 days of preceding acute tonsillitis
- Medial displacement of tonsil and uvula
- Concavity of palate lost
What is shown?
Quinsy (Peritonsillar abscess)
How is quinsy managed?
Aspiration and antibiotics
What is chronic tonsillitis?
Persistent infection of the tonsils - symptoms that persist beyond two weeks
What are some bacterial causes of chronic tonsillitis?
S. pyogenes (GAS), H. influenza, S. aureus, S. pneumoniae
How is chronic tonsillitis managed?
- Surgery rarely offered
- Manage with simple dental mouthwash, will settle by itself but may take some time
What are some causes of neutropenia?
DMARDs
Carbimazole
Chemotherapy
Leukaemia
Asplenia
Anaplastic anaemia
HIV with low CD4+
What should be done in patient who is on a DMARD presents with rash, oral ulceration, nausea/vomiting, diarrhoea, dry cough, or new onset/increasing dyspnea?
DMARD should be stopped and specialised advice taken
What should be done in a patient who is on a DMARD in the event of a severe sore throat or abnormal bruising?
Treatment should be withheld, an urgent FBC taken and any blood test abnormalities discussed with specialist team
- Provide symptomatic relief
- Consider prescribing an antibiotic, taking into account potential interactions with DMARDs
What is diphtheria?
Potentially fatal contagious bacterial infection that mainly affects the nose and throat
What bacteria causes diphtheria?
Corynebacterium diphtheria
Why is diphtheria potentially fatal?
The organism produces a potent exotoxin which is cardiotoxic and neurotoxic
How does diphtheria present?
Severe sore throat with a grey-white membrane across the pharynx (pseudomembrane)
What is shown?
Diphtheria
What is shown?
Diphtheria - Pseudomembrane in the posterior pharynx
How is diphtheria managed?
- Antibiotic (penicillin/erythromycin)
- Antibiotic and diptheria antitoxin for severe cases
How is diphtheria prevented?
Toxoid vaccine - made from a cell-free purified toxin extracted from a strain of C. dipththeriae
What is infectious mononucleosis (Glandular fever)?
A disease of young adults caused by the Ebstein-Barr virus
How does EBV cause infectious mononucleosis?
EBV is a virus of the Herpes family which establishes a persistent infection in epithelial cells, notably in the pharynx
In who does infectious mononucleosis more commonly occur?
- Primary infection in early childhood rarely results in infectious mononeucleosis
- Primary infection in those >10 years often causes infectious mononucleosis
How does glandular fever present?
Triad:
- Fever
- Pharyngitis
- Lymphadenopathy
Also:
- Malaise and lethargy
What are some clinical signs of infectious mononucleosis?
- Gross tonsillar enlargement with membranous exudates
- Marked cervical lymphadenopathy
- Generalised lymphadenopathy
- Palatal petchial haemorrahages
- Hepatosplenomegaly, jaundice, hepatitis
- Rash
What is shown?
Glandular fever
What is shown?
Glandular fever
What are some investigations required in glandular fever?
- Blood count and film - atypical lymphocytes/lymphocytosis in peripheral blood
- EVB serology is the most accurate test, antibody tests (monospot or Paul-Bunnel test) are sometimes used
- Low CRP
- Deranged liver function tests
How is glandular fever managed?
Self-limiting illness so symptomatic treatment:
- Bed rest
- Paracetamol
- Avoid sport for 6 weeks to avoid splenic rupture
What is the role of antibiotics in management of infectious mononucleosis?
Prevention of secondary infection
What antibiotics should never be given in tonsillitis and glandular fever?
Ampicillin / Amoxicillin
What will occur is amoxicillin is given in glandular fever?
Diagnostic generalised macular rash will result
What is given is severe, unrelenting glandular fever?
Systemic steroids
What are some complications of glandular fever?
- Anaemia, thrombocytopenia
- Splenic rupture
- Upper airway obstruction
- Increased risk of lymphoma, especially in immunosuppressed
What are laryngeal nodes and polyps?
Non-inflammatory response to laryngeal injury usually caused by vocal cord abuse and irritation
What are some causes of laryngeal nodes and polyps?
Vocal abuse
Infection
Smoking can all damage the mucosa of the larynx leading to the formation of polyps
Hypothyroidism (Rare)
Where do laryngeal nodules form?
Young women
Located bilaterally on middle 1/3 to posterior 1/3 on the vocal cord
Where do laryngeal polyps form?
Unilateral and pedunculated
How do laryngeal nodes and polyps present?
- Voice changes - hoarseness, raspy voice
- Pain
- Frequent coughing/throat clearing
How will laryngeal nodes and polyps show on biopsy?
- Stratified squamous epithelium
- Stroma oedematous/fibrous/myxoid
How are laryngeal nodes and polyps managed?
- Voice therapy
- Some cases require surgery to remove the growths
What is a contact ulcer of the throat?
Raw sores on the mucous membrane covering the cartilage to which the vocal cords are attached
What causes a laryngeal contact ulcer?
Benign response to injury to the posterior vocal cord:
- Chronic throat clearing
- Voice abuse
- GORD
- Intubation
How will a laryngeal contact ulcer present?
- Mild pain while speaking or swallowing
- Varying degrees of hoarseness
How is a laryngeal contact ulcer managed?
- Rest
- Voice therapy
What is epiglottis?
Inflammation of the epiglottis
What are some bacterial causes of epiglottis?
Streptococcus pneumoniae
Streptococcus pyogenes
Staphylococcus aureus
Historically H. influenza but vaccines have diminished cases
What are some symptoms of epiglottis?
- Severe sore throat
- Drooling saliva
- Pyrexia
What are some clinical signs of epiglottis?
- Examination of oral cavity is normal - no inflammation of tonsils
- May have stridor
How is a diagnosis of epiglottis made?
- Clinical diagnosis
- Only attempt examination if prepared for intubation
How is mild epiglottis managed?
- Supportive
- Antibiotics
- Nebulisers (adrenaline/saline)
- Corticosteroids
How is severe epiglottis managed?
- Antibiotics
- Intubation and ventilation
- Tracheostomy
What is Reinke’s oedema?
Swelling of the vocal cords due to fluid collected within the Reinke’s space
What is the most common cause of Reinke’s oedema?
Smoking is the most common cause
How will Reinke’s oedema present?
- Hoarse voice
- Dysphonia
- Throat discomfort
What is shown?
Reinke’s oedema
How is Reinke’s oedema managed?
- Management of risk factors e.g. smoking cessation
- Voice therapy
- If the elimination of risk factors is not sufficient to improve the patient’s symptoms, surgery may be required
What is subglottic stenosis?
Narrowing of the airway below the vocal cords (subglottis) and above the trachea
What causes subglottic stenosis?
- Idiopathic
- Vasculitis
How will subglottic stenosis managed?
Progressive breathing difficulty, often exacerbated by exertion
How is subglottic stenosis managed?
- Division of the stenosis
- If recurrent - resection and reconstruction
