throat infections Flashcards
what is tonsillitis
Immune deficiency and a family history of tonsillitis or atopy
causes of tonsillitis
Bacterial - Beta haemolytic streptococci - Staphylococci - Streptococcus pneumonia - Haemophilus influenzae - Escherischia coli Viral - Rhinovirus - Adenovirus - Enterovirus - EBV
symptoms of tonsillitis
- Severe and may last more than 48 hours along with pain on swallowing
- Referred to the ears the pain – otalgia
- Headache
- Loss of voice or changes in the voice
- Dysphagia
- Odynophagia
- Trismus
- Halitosis
signs of tonsillitis
- The throat is reddened, the tonsils are swollen and may be coated or have white flecks of pus on them.
- Possibly a high temperature - pyrexia
- Swollen regional lymph glands.
- Classical streptococcal tonsillitis has an acute onset, headache, abdominal pain and dysphagia.
- Examination shows intense erythema of tonsils and pharynx, yellow exudate and tender, enlarged anterior cervical glands.
DD for sore throat
- Common cold
- Coxsackievirus – small blisters develop on the tonsils and the roof of the mouth – erupt followed by a scab which are painful
- Glandular fever – very large and purulent tonsils, enlarged spleen
- HSV
- EPGLOTTIS EMERGENCY
- Unilateral enlargement – indicate malignancy
- HIV – cervical lymphadenopathy, oroesophageal candidiasis and otitis media
diagnosis for tonsillitis
Centor criteria
- History of fever
- Tonsillar exudates
- No cough
- Tender anterior cervical lymphadenopathy
3 OR 4 THEN ITS MORE LIKELY A BACTERIAL INFECTION
Abx for tonsillitis
WHEN TO GIVE Abx – 5-10 DAY COURSE PHENOXYMETHYLPENICILLIN ALTERNATIVE CALRITHROMYCIN
NO AMOXICILLIN AS THIS WILL CAUSE A MACULOPAPULAR RASH IN THE PRESENCE OF EBV
indications for ABx for tonsillitis
- Features of marked systemic upset secondary to the acute sore throat.
- Unilateral peritonsillitis.
- A history of rheumatic fever.
- An increased risk from acute infection (such as a child with diabetes mellitus or immunodeficiency).
- Acute tonsillitis with three or more Centor criteria present (see ‘Diagnostic criteria’, above).
referring a tonsillitis patient
- Breathing difficulty.
- Clinical dehydration.
- Peritonsillar abscess or cellulitis, parapharyngeal abscess, retropharyngeal abscess, or Lemierre’s syndrome (as there is a risk of airway compromise or rupture of the abscess).
- Signs of marked systemic illness or sepsis.
- A suspected rare cause such as Kawasaki disease, diphtheria, or yersinial pharyngitis.
when to consider tonsillectomy
7 episode in a year or 5 per year for 2 years or 3 per year for 3 years REFER TO ENT SPECIALIST
• Sore throats are due to acute tonsillitis.
• The episodes of sore throat are disabling and prevent normal functioning.
• Suspected malignancy
• Presence of sleep apnoea
• Two previous peritonsillar abscesses
surgical methods used in tonsillectomy
- Cold steel - this is the traditional method which involves removal of the tonsils by blunt dissection followed by haemostasis using ligatures.
- Diathermy - this uses radiofrequency energy applied directly to the tissue. It can be bipolar (the current passes between the two tips of the forceps) or monopolar (the current passes between the forceps’ skin and a plate attached to the patient’s skin). The heat generated may be used to dissect the tonsils away from the pharyngeal wall and also to promote haemostasis. Diathermy is sometimes used as an adjunct to cold steel surgery to achieve haemostasis.
- Coblation - this involves passing a radiofrequency bipolar electric current through normal saline. The resulting plasma field of sodium ions can be used to dissect tissue by disrupting intercellular bonds and causing tissue vaporisation. This method generates less heat than diathermy.
complications for tonsillitis
•otitis media
quinsy - peritonsillar abscess
rheumatic fever and glomerulonephritis very rarely
Peritonsillar abscess.
• Acute otitis media.
• Lancefield’s GABS can cause rheumatic fever, Sydenham’s chorea, glomerulonephritis and scarlet fever.
• Streptococcal infection may cause a flare-up of guttate psoriasis.
• Enlarged and chronically infected tonsils interfere with children’s sleep[11].
• Complications of tonsillectomy include otitis media and haemorrhage which can be very difficult, especially where there is an undiagnosed bleeding tendency such as haemophilia. Altered taste sensation has been reported
• Patients who have had tonsillectomy are more susceptible to bulbar poliomyelitis.
• Deep space neck infection
o Parapharyngeal – CT SCAN WITH IV CONTRAST GOLD STANDARD
o Reteropharyngeal
Reduced neck movement, cervical pain or torticollis
what is quinsy
Peritonsillar abscess is a complication of acute tonsillitis, where a collection of pus forms in the peritonsillar space. This pushes the affected tonsil inferomedially into the oropharyngeal space.
red flags of throat
- Severe sore throat, hoarse/croaky voice, severe dysphagia and fever is epiglottitis until proven otherwise. Stridor may be a late sign and patients can decompensate rapidly.
- Beware of severe sore throat with severe dysphagia - without any signs of tonsillitis/pharyngitis in the oropharynx. This should be treated as epiglottitis until proven otherwise.
- Rarely, patients with quinsy can present with profound sepsis.
clinical features of quinsy
- Sore throat
- +/- otalgia
- ‘thick’ or ‘hot potato’ voice (NOT HOARSE OR CROAKY VOICE)
- Stretor sounds like snoring
- Trismus
- Inability to swallow more than saliva or a sip or water
differentiate between quinsy v tonsillitis
- There frequently a degree of trismus
- On the affected side, the anterior arch will be pushed medially
- On the affected side, the palate will bulge towards you ie the normally concave palate becomes convex
- The uvula may be pushed away from the affected side
- On the affected side, the mucosa of the arch and palate may look angrily erythematous
Why is it important to recognise Quinsy?
- Become complicated and cause deep neck space infections – AIRWAY EMERGENCIES
- Recognise peritonsillar abscess as you usually need aspiration
manage quinsy
- Abscesses – aspiration following topical anaesthetic or incision and drainage with further opening via use of Tileys’ forceps
- Sometimes if unsure just warn it may be a “dry tap”
- If difficult to open mouth
o IV treatment
- IV access
- FBC, U&Es, LFTs, glandular fever screen
- Regular basic IV/PO analgesia e.g. paracetamol and ibuprofen, with stronger PRNs
- Topical analgesic spray e.g. benzydamine spray
- Fluid resuscitation - the vast majority of patients are young and dehydrated, and perk up after 1L of normal saline
- Some surgeons prescribe a single dose of steroid (eg 6.6mg dexamethasone IV) to kick-start recovery, especially in those who have stertor
- Advise those with increased snoring or stertor to sleep semi-upright
- TONSILLECTOMY CONSIDERED AFTER IN WEEKS
what is laryngitis
inflammation of the mucosa lining the vocal folds and larynx
causes of acute laryngitis
Viral infection: Rhinoviruses Adenoviruses Influenza viruses Parainfluenza viruses Herpes viruses HIV Coxsackievirus
Bacterial infection - may co-exist with viral infection: Haemophilus influenzae type B. Streptococcus pneumoniae. Staphylococcus aureus. Group B beta-haemolytic streptococci. Moraxella catarrhalis. Klebsiella pneumoniae. Less commonly in the developed world, mycobacterial and syphilitic infection.
Fungal Infection:
Candidiasis.
Immunosuppression and the use of steroid inhalers are risk factors.
Trauma:
Trauma due to voice misuse - screaming, yelling, loud singing.
Trauma due to excessive voice use - more common in certain professions such as teachers, actors and singers.
Coughing.
Penetrating or blunt external force.
Habitual throat clearing.
causes of chronic laryngitis
Allergy - allergic rhinitis, asthma.
Laryngopharyngeal reflux.
Trauma
Smoking
Autoimmune disease - chronic laryngitis may be a feature of systemic disease in conditions such as rheumatoid arthritis, systemic lupus erythematosus, amyloidosis, pemphigoid.
Sarcoidosis.
Medication
Angiotensin-converting enzyme (ACE) inhibitors by causing cough.
Inhaled steroids by promoting fungal infection.
Antihistamines, anticholinergics and diuretics - all by resulting in drying of the mucosa.
Bisphosphonates by causing a chemical laryngitis.
Danazol and testosterone.
symptoms of acute laryngiitis
Hoarseness or a breathy voice.
Pain or discomfort anteriorly in the neck.
MAY Symptoms of upper respiratory tract infection (cough, rhinitis). Dysphagia. Globus pharyngeus (feeling of a lump in the throat). Continual throat clearing. Myalgia. Fever. Fatigue and malaise.
what do you do if symptoms persist more than 3 weeks
indirect laryngoscopy
DD for acute laryngitis
Early chronic laryngitis.
Spasmodic dysphonia.
DD for chronic laryngitis
Nodules, polyps and cysts affecting the vocal cords.
Malignancy - laryngeal cancer, lymphoma, thyroid cancer, lung cancer.
Chondronecrosis of the larynx.
Glottic or subglottic stenosis.
Iatrogenic vocal cord scar.
Medication side effect - eg, antipsychotics can cause laryngeal dystonia, warfarin increases the risk of haematoma, drying effect of anticholinergics, etc.
Vascular lesions of the vocal cords.
Laryngeal nerve palsy.
Idiopathic ulcerative laryngitis (prolonged ulceration of the mid-membranous vocal folds, cause unknown)
features seen on indirect laryngoscopy
find redness and small dilated vasculature on the inflamed vocal folds.
