Throat and Mouth Flashcards
Viral causes of tonsillitis/pharyngitis?
- Common cold – rhinovirus, coronavirus, parainfluenza = 25% of sore throats
- Influenza A/B (4%)
- Adenovirus (4%)
- HSV (2%)
- EBV (glandular fever – 1%)
Bacterial cause of tonsillitis?
Group A β-haemolytic streptococcus (GABHS) – 15-30% of sore throats in children, 10% in adults
General symptoms of tonsillitis?
Sore throat, dysphagia, otalgia, malaise, headache
Complications of tonsillitis?
- Otitis media/Sinusitis
-
Peritonsillar abscess (quinsy)
- Sore throat, dysphagia, peritonsillar bulge, uvular deviation, trismus, muffled voice.
-
Parapharyngeal abscess
- Diffuse swelling in neck. Rare but serious.
-
Lemierre syndrome
- Acute septicaemia and jugular vein thrombosis secondary to infection with Fusobacterium species + septic emboli. Rare.
Centor criteria?
- Presence of tonsillar exudate
- Presence of tender anterior cervical lymphadenoapthy
- History of fever
- Absence of cough
3/4 = infection due to strep (+ve PV = 50%)
all 4 absent = strep unlikely (-ve PV = 80%)
Differentials for sore throat?
Infectious Mono
Scarlet Fever
Diptheria
What is scarlet fever? How does it present?
Endotoxins from Strep Pyogenes
- Rash on chest, axillae, behind ears 12-48h after initial sore throat.
- Pin prick blanching rash, facial flushing with circumoral pallor, strawberry tongue
Management of tonsillitis/pharyngitis?
Symptomatic
- Regular PCM/ibuprofen to relieve pain and fever
- Consider mouthwashes or spray (benzydamine)
Antibiotics
- Not routine
- If centor +ve
- Penicillin V (10 days)
- Clarithromycin or erythromycin (5 days)
- Avoid amoxicillin –> EBV causes rash
- If immunosuppressed seek advice
- If DMARDs or carbimazole - check FBC urgently
Surgery
- Tonsillectomy
Criteria for tonsillectomy?
- Recurrent sore throat due to tonsillitis (definitely)
- Episodes of sore throat are disabling and prevent normal functioning
- >7 well documented, clinically significant adequately treated sore throats in the preceding year
- >5 episodes in each of the last 2 years
- >3 in the last 3 years
Complications = primary/secondary bleeding
Causes of laryngitis?
Infective
- Viral – most common. Rhinovirus, adenovirus, influenza, parainfluenza.
- Bacterial – HiB, strep pneumonia, Staph Aureus, Moraxella catarrhalis
- Fungal – (10%) recent abx or ICS = risk factors.
Trauma
- Excessive voice use or misuse during phonation (yelling, screaming, forceful singing)
Symptoms of laryngitis?
-
Dysphonia
- Breathlessness, harshness, limited pitch range, reduced vocal projection or loudness
-
Dysphagia
- Globus, choking sensations, pain on swallowing, regurgitation, feeling of food getting stuck
- Fever and systemic symptoms
Management of laryngitis?
Self-limiting, usually resolved in 2 weeks.
-
Vocal Hygeine
- Voice rest and hydration
- Humidifcation (inhalation of steam, use humidifier and avoid air con and dry heat)
- Limit caffeine intake
- Stop predisposing factors (smoking, alcohol)
-
Abx
- Not routine
- Consider if persistent fever, purulent sputum, associated distant disease etc.
Causes of croup?
Viral (95%)
- Parainfluenza
- RSV, adenovirus, influenza
Bacterial Tracheitis
- Pseudomembranous croup
- Similar to viral croup but child has high fever, appears toxic and has rapidly progressive airways obstruction.
- Caused by Staph Aureus –> IV Abx
Presentation of croup?
Children aged 6 months - 6 years
- Prodrome: coryza
- Barking cough (seal cough)
- Harsh stridor
- Hoarseness of voice
Score for assessing croup severity?
Westley Croup Score
- Stridor
- Subcostal recession
- Air entry
- O2 saturation
- Consciousness level
Croup severity?
Mild
- Occasional cough
- No stridor
- No respiratory distress
- Good O2 sats
Moderate
- Barking cough
- Intermittent stridor
- Mild respiratory distress
Severe
- Severe respiratory distress
- Fatigue
- Altered mental state
- Cyanosis
Management of mild croup?
Reassure parents + home with advice.
If stridor or subcostal recession will need to return to hospital.
Management of moderate croup?
Steroids
- Oral (dex or pred)
- Nebulised (budesonide)
- Reduces severity and duration of croup)
Management of severe croup?
- Oxygen
- Steroids
- Nebulised adrenaline
- Anaesthetist
What is epiglottitis? What causes it?
- Life threatening swelling of the epiglottis and septicaemia.
- Most common in 1-6 year olds
Caused by HiB - now rare due to HiB vaccine.
Presentation of epiglotitis?
- Occurs rapidly within a few hours
- Drooling saliva
- Fever
- Silent voice
- May have slight cough (if any – minimal)
Management of epiglottitis?
Do not examine the throat or lie the child flat or perform lateral X-ray (may cause total obstruction)
- Main priority is differentiating between acute epiglottitis and viral croup
- Alert emergency otolaryngologist and anaesthetist as likely to need intubation and airway support
- Emergency intubation & Admit to ICU
- Blood cultures
- Steroids
- IV Abx
- 2nd/3rd gen cephalosporin – Cefuroxime/Ceftriaxome/Cefotaxime
- 7 days
Rifampicin prophylaxis given to close contacts
What makes up the majority of oral tumours?
- Squamous cell carcinomas (HNSCC) = 90%
- Develop from linings of upper aerodigestive tract
- Uncommon in the UK
Risk factors for oral cancer?
- Smoking
- Alcohol
- Vitamin A/C deficiency
- Nitrosamines (salted fish)
- HPV
- GORD
- Deprivation
Presentation of oral cancer?
- Persistent painful ulcers
- White or red patches on tongue, gums or mucosa
- Otalagia; odonophagia
- Lymphadenopathy
Presentation of trigeminal neuralgia?
- Typically female >50 yrs
- Paroxysms of intense stabbing pain, lasting seconds, in trigeminal nerve distribution.
- Unilateral – usually mandibular or maxillary.
- Triggers = washing affected area, shaving, eating, talking, dental prostheses
Management of trigeminal neuralgia?
Investigation
- MRI necessary to exclude secondary causes
Medical
- Carbamazepine = 1st line
- Lamotrigine, phenytoin
Surgery
- Directed at peripheral nerve, trigeminal ganglion or nerve root.
