Throat - clinical Flashcards
What are the main types of ulceration seen in the mouth?
- Traumatic ulceration
- Apthous Ulceration
- Infective ulceration
What are apthous ulcers?
Common mouth ulcers
Where do apthous ulcers most commonly occur?
Around the edges of the toungue
What are features of herpes simplex associated ulcers in the mouth?
Appearence similar to apthous ulcer, but with mild pyrexia and malaise
What is the following?
Leukoplakia - white patch in the mouth, caused by hyperkeratosis of the oral mucosa
What is important to do if you find leukoplakia?
Biopsy - 3% can be malignant
What is erythroplakia?
Red patches in the mouth
What is pharyngitis?
Inflammation of the pharynx
What are features of acute pharyngitis?
- Tender anterior cervical lymph nodes
- Sore Throat
- Fever
- Inflamed tonsils
- Reddened oropharynx and soft palate
What is the definition of acute pharyngitis?
Characterised by the rapid onset of sore throat and pharyngeal inflammation (with or without exudate). Absence of cough, nasal congestion, and nasal discharge distinguishes bacterial from viral aetiologies.
What are the causes of pharyngitis?
- Adenovirus is most common cause
- Can be strep pneumoniae
How would you manage pharyngitis?
Most are self limiting - symptomatic control
How would you manage strep throat?
- Oral penicillin for 10 days, or
-
If allergic to penicillin
- Clindamycin/clarithromycin for 10 days
- Azithromycin for 5 days
What is laryngitis?
Inflammation of the larynx
What is the most common cause of laryngitis?
Bacterial
What are the features of acute laryngitis?
- Hoarseness
- Sore throat
- Fever
- Cough
- Rhinitis
- Odynophagia/dysphagia
How would you treat laryngitis?
Symptomatic management
What is tonsilitis?
Acute tonsillitis is an acute infection of the parenchyma of the palatine tonsils. This definition does not include tonsillitis as part of infectious mononucleosis, although tonsillitis may occur in isolation or as part of a generalised pharyngitis. The clinical distinction between tonsillitis and pharyngitis is unclear in the literature, and the condition is often referred to simply as “acute sore throat”
What bacteria are implicated in acute tonsilitis?
- Group A beta haemolytic strep - S. Pyogenes
- H. Influenzae
- T. Pallidum
- N. Gonnorhoea
What viruses can cause acute tonsillitis?
- Rhinovirus
- Coronavirus
- Adenovirus
What are symptoms of tonsillitis?
- Dysphagia
- Painful Cervical lymphadenopathy
- Fever
- Rhinorrhoea
- Headache
- Abdominal pain
What are signs of tonsillitis?
- Inflamed fauces/pharynx upon examination
- Enlarged tonsils
- Tonsillar exudates
- Palatal Petechia
- Enlarged cervical lymph nodes
How might you investigate someone with tonsillitis?
- Swabs - Throat, Nasal
- Blood/Serology
- Blood film
How would you treat tonsillitis?
- Symptomatic therapy - Ibuprofen +/- paracetamol etc
-
If CENTOR> 3/4
- If persistent - penicillin V for 10 days/macrolide 5 days if allergic
What are CENTOR Criteria?
Criteria which give an indication of the likelihood of a sore throat being due to bacterial infection
What are complications of tonsillitis in children?
- Otitis media
- Sinusitis
- Retropharyngeal abscess
- Parapharyngeal/hypopharyngeal abscess
- Quinsy - peritonsillar abscess
- Febrile convulsion - children
What is quinsy?
Tonsillitis infectiion spreads to the tissues lateral of the tonsil, and an abscess develops
What are features of a peritonsillar abscess?
- Tonsil pushed medially
- Displaced uvula
- Unwell patient
- Drooling
- Fetor
- Trismus
How would you manage a quinsy?
- Aspiration/drainage
- Antibiotics
What would be your differential diangosis for someone presenting with features of tonsilitis?
- EBV
- Agranulocytosis
- Leukaemia
- Scarlet fever
- Diptheria
What would you not give to someone to treat tonsillitis?
Amoxicillin - incase of EBV
What are absolute indications for a tonsillectomy?
- Adenotonsillar hyperplasia with obstructive sleep apnea
- Failure to thrive, or abnormal dentofacial growth
- Suspicion of malignant disease
- Haemorrhagic tonsillitis.
What are relative indications for tonsillectomy?
- Recurent sore throat due to tonsillits
- Episodes of tonsillitis are disabling and prevent normal function
- >/= 7 clinically significant, adequately treated sore throats in last year
OR
>/= 5 episodes in last 2 years
OR
>/= 3 episodes in last 3 years
What is the most common complication of tonsillectomy surgery?
Bleeding
Where are the adenoids found?
What are causes of snoring and sleep apnoea?
- Large tonsils
- Large adenoids
- Nasal obstruction
- Deviated septum
- Long palate
- Big tongue
- Small jaw
What is stridor?
https://www.youtube.com/watch?v=1Enq2BvX9aw
A muscial noise in inspiration from partial obstruction at the larynx and large airways
What are congenital causes of stridor?
- Laryngomalacia
- Stenosis
- Vascular rings
What are inflammatory causes of stridor?
- Laryngitis
- Epiglottitis
- Laryngotracheobronchitis
- Anaphylaxis
What are traumatic causes of stridor?
- Fractured larynx
- Thermal - airway burns
- Chemical
- Intubation
What tumours can cause stridor?
- Hemangioma
- Papillomas
What other signs might you look for in someone with stridor?
All grave signs, signify impending obstruction
- Swallowing difficulties
- Pale/cyanosed
- Drooling
- Accessory muscle use
- Tracheal tug
What are intrinsic causes of dysphonia?
- Decreased lubrication
- Laryngoceles
- Granulomas
- Sarcoidosis
- TB
- Syphillis
What are extrinsic pressure causes of stridor?
- Goitre
- Carotid body tumour
What are neoplastic causes fo dysphona?
- Pancoast syndrome
- Larynx/thymus cancer
- Lymphoma
- Glomus tympanicum tumour
What are bacterial causes of dysphonia?
- H. flu - epiglottits
- Diptheria
- Abscess
- Aortitis
What are CNS causes of dysphonia?
- Vagus lesion
- Guillain-Barre
- Myasthenia
What are endocrine causes of dysphonia?
- Acromegaly
- Addison’s
- Myxoedema
When would you consider investigating hoarseness?
>3 weeks
If someone presented with dysphonia, what would you want to ask about?
- GORD
- Dysphagia
- Smoking
- Stress
- Singing/Shouting
How would you investigate horseness?
Laryngoscopy
What are features of vocal cord paralysis?
- Hoarseness with breathy voice
- Weak cough - bovine
- Repeated cough/aspiration
- Exertional dyspnoea
What tests would you do if someone presented with features of vocal cord paralysis?
- CXR
- Barium swallow
- MRI
- Panendoscopy
What are malignant causes of dysphagia?
- Oesophageal Cancer
- Pharyngeal cancer
- Gastric cancer
- Extrinsic pressure
What are neurological causes of dysphagia?
- Bulbar palsy
- Myasthenia gravis
- Stroke
- MND
- MS
- Encephalitis
What is FOSIT?
Feeling of something in the throat - Globus pharyngeus
What tests would you want to do in someone presenting with dysphagia?
- Bloods - FBC, ESR
- Barium Swallow
- Rigid Endoscopy
- Oesophageal motility disorders
- CXR
If someone found it difficult to make the swallowing movement, what might you suspect as being the cause of dysphagia?
Bulbar palsy
What might be the problem if someone was complaining of dysphagia and a neck bulge or gurgling on drinking?
Pharyngeal pouch
What is a pharyngeal pouch?
Type of hernia (pulsion-type diverticulum), affecting the wall of the pharynx at its junction with the upper oesophagus
What age group do pharyngeal pouches most commonly occur in?
>50 years
What are features of pharyngeal pouch?
- Progressive dysphagia
- Regurgitation of undigested food
- Halitosis
- Gurgling emenating from neck
How would you investigate suspected pharyngeal pouch?
Barium-swallow
What are GI causes of dysp[hagia?
- Benign oesophageal stricture
- Pharyngeal pouch
- Achalasia
- Oesophagitis
How would you manage a pharyngeal pouch?
Pharyngeal stapling
What is the following?
Acute Sialadenitis - acute inflammation of the parotid gland or submandibular gland
Who does parotitis most commonly occur in?
Old dehydrated people with poor oral hygeine
What are signs of parotitis?
- Swollen gland - parotid/submandibular
- Tenderness
- Pus - opening to parotid duct
What are the main criteria used in the CENTOR criteria for tonsillitis?
Presence of 3/4 suggest strep infection (positive predictive value approx 50%)
- Presence of tonsillar exudate
- Presence of tender anterior cervical lymphadenopathy
- History of fever
- Absence of cough
If all 4 absent - negative predictive value is 80%
If someone presented with Hoarsness lasting >3 weeks, what would your main differentials be?
- Laryngeal cancer
- Vocal cord Palsy
- Laryngitis
- Reflux laryngitis
- Reinke’s oedema
- Vocal cord nodules
What are symptoms of sialadenitis?
- Painful diffuse swelling
- Fever
- Pus from gland when pressed
How would you treat sialadenitis?
- Antibiotics
- Good Oral hygeine
- Sialogogues - lemon drops - increase salivary secretions
What is sialolithiasis?
Salivary stones
What are features of sialolithiasis?
- Pain
- Tense swelling of gland after eating
- Palpable stone in mouth
What imaging might you use to diagnose sialolithiasis?
- Plain x-ray
- Sialogram
How might you manage sialolithiasis?
-
Small stone - may pass on their own
- Fluids
- Silogogues - lemon drop
- Large stone - surgical removal
What features of tonsillitis suggest a viral cause?
- Headache
- Nasal congestion
- Cough
What features of tonsillitis can suggest a peritonsillar abscess?
- Trismus
- Change in voice quality
What would you do if an individual had a CENTOR score of 2-3?
Throat culture/rapid antigen testing
What would be your differential diagnosis for somoene presenting with features of tonsillitis?
- Tonsillitis
- Pharyngitis
- Oral thrush
- Phayngeal syphilis
- EBV
- Diptheria
What might the following be?
Tonsillar/pharyngea Diptheria
What might the following be suggestive of in an unvaccinated child?
Diptheria - bull neck
What are features of diptheria?
- Nasal - bloody rhinorrhoea
- Gray/white pseudomembrane over posterior pharyngeal wall/tonsils
- Bull neck
- Foul breath
- Myocarditis
What would you do if you suspected diptheria?
- Throat swab
- ECG - check for myocarditis
- Consider serial cardiac markers - myocarditis
How would you manage diptheria?
- Isolated ASAP
- Penicillin G/IV erythromycin
- IV diptheria antitoxin
- Airway support
What are clinical features of diptheria caused by?
Exotoxin - IV antitoxin is cornerstone of treatment
Is diptheria a notifiable disease?
Yes
