Throat and Skin Flashcards
definition of tonsillitis
An acute infection of the parenchyma of the palatine tonsils.
when should you be concerned when a patient present with ‘sore throat’
night sweats fever weight loss drolling stridor - same data referral SOB dysphagia - > 3 weeks need a 2 week referral
aetiology of tonsillitis
most are virus , 10-30% are bacterial
rhinovirus, coronavirus and adenoviurs
EBV for teenagers
bacterail
- children aged 5-10 –> group A haemolytic strep
- scarlet fever - strep pyogenes
- streptococcus pneumoniae
clinical features of tonsilitis
sore throat
otalgia - earache
dec oral intake (pain when eating/swallowing)
fever - > 38
tonsillar exudate (purulent - esp if caused by group A haemolytic strep)
cervical lymphadenopathy
which criteria is used to estimate the probability that tonsillitis is due to a bacterial infection
CENTOR criteria (>3 = offer Abx)
- fever > 38
- tonsillar exudate
- absence of cough
- tender anterior cervical lympho nodes (lymphadenopathy)
or FeverPAIN criteria - the higher the score, the more likely it is to be bacterial
- Fever (during previous 24 hrs)
- Purulence (pus on tonsils)
- Attend rapidly (within 3 days after onset of symptoms)
- severely Inflammed tonsils
- No cough or coryza (inflammation of mucous membrane in the nose)
what are the investigations required for tonsilitis
CENTOR criteria
FBC, U&E, LFT, CRP, cloting (EBV), monospot or galndular fever, EBV titres (more specific but less likely to be used)
differential for tonsilitis
glandular fever Scarlet fever epiglottitis Quinsy - tonsiliar abscess mouth cancer
what are the red flags for mouth cancer
mouth ulcers - painful and do not heal within several weeks
unexplained persistent (>3 wks) lumps in the mouth/neck
unexplained loose teeth
unexplained/persistent numbness on the lip/tongue
leukoplania/erythoplakia (white/red patches in the mouth)
Mx for tonsilitis
rehydration (avoid hot drinks) simple analgesia (oral/thorat spray)
ABx - if bacterial or hx of rheumatic fever - phenoxymethylpenicillin 500mg QDS for 10 days (if allergic give clarithromycin)
Tonsillectomy - if
> 7 episodes in the last 12 months
> 5 episodes every year for the past 2 years
> 3 every year for the past 3 years
complications of tonsilitis
rheumatic fever
post strep glomerulonephritis
deep facial space infection
peri-tonsillar abscess (quinsy) - inc sore throat (worse on one side), hot potato voice, deviated uvular -away from swelling, swelling above tonsil
definition of acute pharyngitis
= rapid onset of sore throat and pharyngeal inflammation (with or without exudate)
what makes bacterial acute pharyngitis more likely to be bacterial
abscess of cough, nasal congestion and nasal discharge
aetiology of acute pharyngitis
virus –> EBV, adnovarious, enterovirus, influenza A and B, parainfluenza, HIV, gonorrhoea
bacterial - group A strep most likely
clinical features of acute pharyngitis
sore throat pharyngeal exudate - in Group A strep infection pain when swallowing cervical lymphadenopathy fever headache N+V abdo pain
viral infection - coryzal, otalgia, cough
measles - conjunctivitis, maculopapular rash, koplik spots
investigation for acute pharyngitis
rapid antigen test for Group A strep
FBC, monospot for glandular fever
gonococcus or chlamydia throat swab
throat swab culture
management of acute pharyngitis
1) Keep hydrated – avoid hot drinks
2) Salt water gargling, medicated lozenges (containing a local anaesthetic and NSAID or an antiseptic analgesia)
3) Antibiotics if bacterial cause phenoxymethylpenicillin 500mg QDS for 10 days
4) tonsillectomy if 7 times in the past year, if > 5 times in 2 years, if > 3 times in 3 years
what is considered to be upper respiratory tract infection
infection in the nose, sinuses, pharynx, larynx
which translate into conditions such as common cold, sinusitis, pharyngitis, epiglottitis, laryngotracheitis (croup)
aetiology of the URTI
rhinovirus
coronavirus
influenza
clinical features of URTI
rapid onset, with symptoms peaking after 2-3 days and typically resolving after 7 days in adults, 14 days in younger children, although a mild cough may persist for 3 weeks
sore throat cough rhinitis upper airway swelling sneezing general malaise
investigation for URTI
clinical diagnosis
management for URTI
1) Reassure and symptomatic management: keep hydrated, eat well, rest, paracetamol/ibuprofen
2) Reduce transmission via: washing hands, avoid sharing towels/toys
what pathogens causes acute epiglottis
Haemophilus influenza B
or less commonly Strep Pneumoniae
clinical features of acute epiglottis
acute onset not vaccinated against HiB stridor dysphagia, odynophagia drooling SOB +/- tripod position fever toxic looking
investigation for acute epiglottis
clinical diagnosis
laryngoscopy - both to confirm and theraptic
material x-ray - thrumbprinting
management for acute epiglottis
emergency - fast bleep anesthetist and call a senior pediatrician
1) A-E assessment
2) secure airway
3) IV dexamethasone
4) IV cefotaxime
5) inhaled adrenaline
6) O2
what is the most common type of cancer in oral tumours
Squamous cell carcinoma
clinical features of tongue cancers
75% - SCC chronic glossitis large area of swelling speech and swallowing dysfunction pain - can refer to ear can be under the tongue - need to check thoroughly
clinical features of tonsillar cancers
SCC (70%) & lymphoma neck mass cervical lymphadenopathy sore throat, ear pain, foreign body or mass sensation bleeding Trismus - locked jaw weight loss and fatigue
clinical features of buccal mucosa cancer
painless in early stages, then ulcerated and secondarily infection or invades adjacent nerve
pain in later stages
bleeding & difficult chewing
warty exophytic growth - little fixation or deeply ulcerative invasive lesion
when should you refer a patient with suspected oral tumour
persistent and unexplained lump in the neck
unexplinaed ulceration in oral cavity for > 3 weeks
lump on the lip or oral cavity
red/white patch in oral cavity
management of oral tumour
MDT approach
- chemo + radio +/- surgical
if oral - can do brachytherapy
definition of trigeminal neuralgia
- facial pain syndrome in the distribution of more than 1 divisions of trigeminal nerve
- characterised by some combination of paroxysms of sharp, stabbing, intense pain lasting up to 2 minutes and/or a constant component of facial pain, without associated neurological deficit
causes of trigeminal neuralgia
o majority due to nerve compression of the trigeminal nerve root by aberrant vascular loop
o demyelinating disease – MS
o brainstem infarcts and amyloid or calcium deposition along the trigeminal
clinical features of trigeminal neuralgia
• facial pain
o trigeminal distributions and quality, duration and consistency
o bilateral involvement is more common in patient with symptomatic trigeminal neuralgia
investigation of trigeminal neuralgia
Clinical diagnosis
Intra-oral X-ray
MRI – demonstrate presence of abnor vessel loop in association with trigeminal nerve, presence of other pathologies
Trigeminal reflex testing jaw jerk and cornea reflex
tx for trigeminal neuralgia
Anticonvulsants – carbamazepine or baclofen (if unresponsive to carbamazepine)
Open neurosurgical microvascular decompression
Ablative surgery – reserve for persistent conditions
Neurostimulation
what is a macules
flat lesion < 10 mm in diameter
what is a papules
elevated > 10 mm
what plagues
palpable > 10 mm
what is a nodule
elevated
what is a vesicles
fluid filled < 10 mm
what is a bullae
fluid filled > 10mm
what is a pustules
fluid filled with pus
what is a petechia
small subcutaneous bleed
what is a purpura
large subcutaneous bleed
what is acne vulgaris
A skin disease affecting the pilosebaceous unit. Characterised by comedones, papules, pustules, nodules, cysts and/or scarring
aetiology of acne vulgaris
blockage to the pilosebaceous unit due to
- inc sebum production (typically in response to androgen inc such as during puberty)
- the colonisation of bacteria, Propionibacterium, on skin lead to infection
- all of the above lead to inflammation and swelling
Risk factor of acne vulgaris
genetics race/ethnic factors diet - high glycaemic diet truma cosmetics topical corticosteroids oral meds - lithium, corticosteroids, iodides, antiepileptic drugs
what are the different types of acnes
- Mild - predominantly non-inflammed acne
- moderate -widespread with an inc number of inflammatory papules and pustules
3) severe - widespread inflammatory papules, pustules and nodules or cyst, scarring maybe present
acne fulminans - systemic manifestation - fever, arthralgia, myalgia, hepatosplenomeglay, lytic bone lesions
clinical features of acne vulgaris
non-infllammatory lesions - comedones which maybe open (blackheads), closed (Whiteheads) or microcomodones (clinically invisible)
inflammatory lesions - typically, papules and pustules, but can develop into nodules
scarring
pigmentations
seborrhoea - excessive discharge of sebum from the sebaceous gland
differentials for acne vulgaris
rosacea
conglobate - sever form of acne affecting men, presents with extensive inflammatory papules and cyst
acne fulminans - sudden and severe
perioral dermatitis
folliculitis and boils
drug induced
management of mild acne vulgaris
o No treatment may be acceptable if mild
o Topical benzoyl peroxide reduces inflammation, helps unblock the units and is toxic to P.acnes bacteria.
o topical azelaic acid – topical antimicrobial
o Topical retinoids (chemical to vitamin A) -tretinoin/ adapalene topical slow down sebum production if no response, try dapsone topical
management of moderate and severe acne vulgaris
o Topical or oral abx can be used in moderate to severe acne to acute management and maintenance (e.g. lymecycline/ doxycycline for 3 months) topical Abx also used in pregnancy
o Oral contraceptive pill: stabilise hormones and slow production of sebum
• Oral retinoids for severe acne (e.g. isotretinoin) but requires careful monitoring under dermatology
SE of oral retinoid acid
dry skin and kips photosensitivity teratogenic depression, anxiety and suicidal ideation rarely SJS and TEN
definition of eczema
An inflammatory skin condition characterised by dry, pruritic skin with a chronic relapsing course. Caused by a breakdown in the normal continuity of the skin barrier, leading to inflammation.
aetiology of eczema
FHx of atopy
multifactorial theory - overactive immune response to an irritant (not local) which is exposed to the body by breakdown in skin
RF for eczema
- Soap and detergent
- Animal dander
- House-dust mites
- Extreme temperatures
- Rough clothing
- Pollen
- Certain foods
- Stress
clinical features of eczema
periods of flares and remission infants - dry, red, itchy, sore patches of skin - extensors (outside elbows and knees), face, scalp and neck - nappy area is spared
adults
- dry, red, itchy, sore patches of skin
- flexor surfaces (inside knees and elwbos)
- infected - fever, pustules, yellow fluid and crustations
- chronic
- chronic eczema - rough, thick, leathery skin (lichenification)
what is the diagnostic criteria used to diagnose eczema
UK working party criteria
A itchy rash + 3 or more of the following
• Hx of a flexural involvement (antecubital or popliteal fossa, front of ankles, wrist or neck)
• Visible flexural eczema
• Personal Hx eczema or hayfever
• Personal hx or first degree relative Hx of asthma or allergic rhinitis
• Onset of symptoms < 2 years
investigation for eczema?
clinical diagnosis
• can do allergy testing (elevatd), IgE levels (elevated), skin biopsy
Mx for eczema
Acute/mild
1) Emollient
2) Mildly potent topical steroid (hydrocortisone 1%) for inflamed skin : continued for 48hrs after flare controlled
3) Oral Abx if suspected infection flucox?
4) Antihistamine or doxepin cetirizine, loratadine
5) Active follow-up rarely required.
Moderate
Consider need for urgent admission (e.g. eczema herpeticum)
Emollient
Moderately potent topical corticosteroid (betamethasone valerate 0.025% or clobestasone butyrate 0.05%) for inflamed skin: treatment continued till 48hrs after flare controlled (max use 5 days0`
Occlusive dressing/dry bandages
Severe pruritis: non-sedative antihistamine (cetirizine, loratadine)
Prevention/ maintenance
o steroids
- Step down : low potency steroid
- Intermittent : weekend or twice weekly steroid therapy
o Specialist: Topical calcineurins inhibitors (tacrolimus, pimecrolimus) to stop the itchiness
Review emollient annually, review steroid use 3-6 monthly, review antihistamine use 3 monthly.
Severe
Consider need for urgent admission (eczema herpticum)
Emollient
Potent steroid (betamethasone 0.1%) for inflamed areas (max use 5 days)
Occlusive dressing/bandages
Severe itch: non-sedative antihistamine (cetirizine, lordatane)
If severe itch and difficulty sleeping: sedative anti-histamine (chlorphenamine)
If severe itch + psychological distress: oral corticosteroids.
if still resistance UV light therapy + topical coal tar
Prevention/maintenance
o Steroids
- Step down
- intermittent
o Specialist: topical calcineurins inhibitors (tacrolimus)
Review emollient annually, review steroids 3-6 monthly, review antihistamine use 3 monthly.
Infected
Consider the need for admission or referral
Swab skin
Extensive areas: Oral abx (flucloxacillin)
Localized areas: topical abx
After infection cleared prescribe new emollient’s and topical steroids and discard old.
Refer urgently (2 weeks) if not responded to treatment.
when will you refer a patiwth with eczema to skin specialists?
facial eczema 2 episodes of flare up in 1 month treatment application device needed eg bandages contact dermatitis suspected recurrent secondary infection
complication of eczema
eczema herpticum
- Disseminated herpes simplex infection which is indicated by grouped vesicles/ blister and punched out lesions
Systemic features: fever, lymphadenopathy and malaise
Medical emergency
Treat anti-viral
psychological
lichenification
sleep disturbance
bacterial infection from scratching
what is psoriasis
A chronic inflammatory skin disease characterised by erythematous, circumscribed scaly papules and plaques
aetiology of psoriasis
autoimmune, genetics and infections (after URTI, strep pharyngitis)
mean age onset = 28 yrs old
Risk factor/trigger for psoriasis
strep infection eg strep pharyngitis - guatte psoriasis
drugs - lithium, b-blocker. chloroquine, NSAIDs, ACEi, penicillin
UV light exposure
trauma - trigger psoriasis in 7-14 days later - Koebner phenomenon
Hormonal changes - puberty, post-partum and menopause
HIV
psychological stress
smoking, alcohol
what are the different types of psoriasis?
plaque
Guatte
Pustular
erythroderma - erythrodermic psoriasis
clinical features of plaque psoriasis
raised inflammed plaque lesions with superficial silvery white scaly eruption
typically on extensor surface + scalp + face
well demarcated lesions
halo like plaque due to vasoconstriction - Wornoff sign
general psoriasis signs - itchy, irritation, burning pain, bleeding, scaling, pinpoint bleeding (Auspitz’s sign) - where scab is peeled and revealed underlutign
clinical features of guatte psoriasis
following URTI infection eg strep pharyngitis
widespread, erythematous, fine scaly papules (water drop appearance) on trunk, arm and leg
clinical features of pustular psoriasis
Acute generalised pustular: Rapidly developing widespread erythema, followed by the eruption of white, sterile non-follicular pustules which coalesce to form lakes
systemic features - fever, malaise, tachycardia, weight loss, arthralgia.
Palmoplantar pustulosis affects palms and soles of feet.
clinical features of erythrodermic psoriasis
Generalised/diffuse erythema with fine scaling
Associated with pain, irritation and severe itching.
Lesions feel warm and may be associated with systemic illness such as fever, malaise, tachycardia, lymphadenopathy, peripheral odeama.
what are some psoriasis associated conditions?
psoriatic arthritis + nail changes
symptoms - joint swelling pain and stiffness dactylitis enthesis pitting nails onycholysis
metabolic syndrome - obesity, hyperlipidemia, HTN, T2DM, NAFLD
ischaemic heart disease
IBD - crohns
uveitis
anxiety and depression
VTE
non-melaenoma skin cancer
investigation for psoriasis
• clinical diagnosis, can do biopsy if uncertain
management of erythrodermic & pustular psoarisis
- Medical emergency: same-day dermatology review
* oral retinoid (acitretin)
management of plaque psoarisis
mild - topical steriods (hydrocortisone) +/- topical Vit D (Calcipotriol)
mod to severe
- 1st line - phototherapy + methotrexate + apremilast + infliximab + acitretin
- 2nd line - cyclosporin
management of guatte psoarisis
1st line - phototherapy
2nd line - methotrexate, oral retinoid, cyclosporin
complication of psoarisis
psychological
erythrodermic psoarsis - life-threatening due to its impact on temperature regulation, haemodynamic, intestinal absorption and protein and water metabolism.
Genralised pustular psoriasis - life-threatening due to its impact on temperature regulation, haemodynamic, intestinal absorption and protein and water metabolism.
definition of wart
small rough growths which are caused by infection or keratinocytes with certain strains of HPV
which population is most suspectible to wart
children as they have yet to develop immunity to HPv
what are the different types of wart
common wart - verruca vulgaris
flat or plane wart - verruca plana
plantar wart - on the sole of the foot - curruca plantaris
aetiology of wart
HPV virus
investigation of wart
clinical diagnosis
- common wart - resembles a cauliflower (knuckes, knees, fingers)
- plane.flat wart - round, flat-topped and yellow (back of hands)
- filiform warts - long and sender face and neck
- palmar and plantar wart - verruca, may have central dark spots and maybe painful
- moasic warts - when palmar-plantar coalesce into larger plaques on hands and feet
management of wart
no treatment needed - resolve in 2 years
consider treatment if
- wart is painful
- wart is cosmetically unsightly
- patient request treatment and wart is persistent
if so, cryotherapy and topical salicylic acid (12 weeks)
complication of wart
spread by picking at wart
malignant changes - rare except in immunocompromised pts - SCC
cryotherapy can be painful which can also cause blistering, infection, scarring and depigmentation
topical salicytc acid can cause skin irritation
