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.
what is glandular fever
infection most commonly caused by the Epstein-Barr virus (EBV)
how is glandular fever transmited
contact with saliva, usually from asymptomatic carriers, such as through kissing or sharing food and drink utensils
sexual contact
complications of glandular fever
hepatits upper airway obstruction cardiac complications renal complications neuro complications - encephalitis haem complications - mild thrombocytopenia splenic rupture chronic fatigue cancer esp lymphoproliferative - hodgkin's lymphoma + Burkitt lymhoma MS Abnormal LFTs
type of renal complications seen in EBV
interstitial nephritis, myositis-associated acute kidney injury, haemolytic uraemic syndrome, and jaundice-associated nephropathy
type of neuro complications seen in EBV
aseptic meningitis, facial nerve palsy, transverse myelitis, Guillain-Barré syndrome, and optic neuritis
when to suspect glandular fever
fever
lymphadenopathy - bilateral posterior cervical lym
sore throat
Ix for EBV suspicion
immunocompetent adutlts
- FBC + monospot test
DD for glandular fever like symptoms
cytomegalvirus - splenomegaly, hepatomegaly, and a negative monospot test. NO SORE THRAOT or LYMPHADENOPATHY
Acute toxoplasmosis
Acute viral hepatitis — may cause malaise, fever, lymphadenopathy, and atypical lymphocytosis.
Primary HIV infection — may present with pharyngitis, fever, and lymphadenopathy, rash, diarrhoea, weight loss, nausea, and vomiting.
Rubella — may rarely present with fever, lymphadenopathy, and atypical lymphocytosis
Mumps — typically presents with parotitis and there may be low-grade fever and malaise
Herpes simplex virus-1 — typically presents with acute onset of symptoms and high fever with myalgia, arthralgia, and cough.
when to refer an EBV patient urgently
Develop stridor or respiratory difficulty.
Have difficulty swallowing fluids or have signs of dehydration, such as reduced urine output.
Become systemically very unwell.
Develop abdominal pain (may indicate splenic rupture).
features seen in children with adenoidal hypertrophy
nasal obstruction
nasal discharge.
indications for adenoidectomy
OME
chronic nasal obstructions and discharge
sleep apnoea with tonsillectomy
contradictions for adenoidectomy
bleeding disorders
recent pharyngeal infection
short or abnormal palate
complications of adenoidectomy
reactionary haemorrahge
persistent nasal bleeding
haematemesis
common oral lesions
herpes labialis
recurrent aphthous stomatits
what is mumps
acute infectious disease caused by a paramyxovirus characterised by bilateral parotid swelling.
how is mumps spread
respiratory droplets, fomites or saliva, and replicates mainly in the upper respiratory mucosa.
complications of mumps
parotitis
- obstruction of lymph drainage
- sialectasia or sialadenitis
epididymo-orchitis - infertility?
encephalitis
oophoritis
aseptic meningitis
transient hearing loss
myocardial complications
pancreatitis
spontaneous abortion
diagnosis of mumps
clinical
laboratory saliva - detect immunoglobulin
when to suspect mumps
parotitis
low-grade fever, headache, earache, malaise, muscle ache, and loss of appetite
other causes of parotitis
infection - viral - EBV. parovirus B19
acute suppurative parotitis - staph aureus
Non infection cause
parotid duct obstrcution - salivary stones, cysts or tumours
drugs - thiazides, phenothiazines, thiouracil
metabolic disorders - diabetes, cirrhosis, uraemia
autoimmune disease - sarcoidosis, sjogrens, wegner’s
what is croup
sudden onset of a seal-like barking cough, often accompanied by stridor, voice hoarseness, and respiratory distress.
risk factors for croup
6 months - 6 years
male
previous intubation
diagnosis for croup
seal-like barking cough
stridor
chest wall (intercostal) or sternal indrawing.
worse at night and increase with agitation.
coryza, non-barking cough, mild fever) may have been present for between 12 and 48 hours.
hoarse voice
DD for croup
bacterial tracheitis
epiglottitis
foreign body in upper way
quinsy
angioneurotic oedema - dyspnoea and stridor
allergic reaction
management if croup
dexamethasone
what is pertussis/whooping cough
infectious disease caused by the bacterium Bordetella pertussis
sharp inhalation of breath during bouts of paroxysmal cough.
complications of whooping cough
Apnoea.
Pneumonia (usually caused by secondary bacterial infection).
Seizures.
Encephalopathy (rare in adults).
prolonged coughing can cause:
Pneumothorax.
Umbilical and inguinal hernias, and rectal prolapse.
Rib fracture and herniation of lumbar intervertebral discs.
Urinary incontinence.
Subconjunctival or scleral haemorrhage, and facial and truncal petechiae.
name the 3 phases of whooping cough
catarrhal phase
paroxysmal phase
convalescent phase
what is the catarrhal phase (pertussis)
lasts between one and two weeks.
Nasal discharge. Conjunctivitis. Malaise. Sore throat. Low-grade fever. Dry, unproductive cough.
what is paroxysmal phase
1 week after the catarrhal
duration 1-6 weeks
Typically consist of a short expiratory burst followed by an inspiratory gasp, causing the ‘whoop’ sound
more common at night
thick mucous plugs or watery secretions
what is the convalescent phase
lasts up to 3 months, during which there is a gradual improvement in cough frequency and severity.
how to make clinical diagnosis of whooping cough
acute cough that has lasted for 14 days or more without another apparent cause, and has one or more of the following features:
Paroxysmal cough.
Inspiratory whoop.
Post-tussive vomiting.
Undiagnosed apnoeic attacks in young infants.
management of whooping cough
onset of cough within 21 days
macrolide
1st line
Prescribe clarithromycin for infants less than 1 month of age.
Prescribe azithromycin or clarithromycin for children aged 1 month or older, and non-pregnant adults.
erythromycin for pregnant women
co-trimoxazole if macrolide contradicted
what medication can increase salivation
pilocarpine
pilocarpine side effects
Sweating. Dizziness. Runny nose. Blurred vision. Frequent trips to pass urin
what is the centor criteria
presence of tonsillar exudate
tender anterior cervical lymphadenopathy or lymphadenitis
history of fever
absence of cough
define fever pain score
Fever over 38°C. Purulence (pharyngeal/tonsillar exudate). Attend rapidly (3 days or less) Severely Inflamed tonsils No cough or coryza
indications for tonsillectomy
sore throats are due to tonsillitis (i.e. not recurrent upper respiratory tract infections)
the person has five or more episodes of sore throat per year
symptoms have been occurring for at least a year
the episodes of sore throat are disabling and prevent normal functioning
other established indications for tonsillectomy
recurrent febrile convulsions secondary to episodes of tonsillitis
obstructive sleep apnoea, stridor or dysphagia secondary to enlarged tonsils
peritonsillar abscess (quinsy) if unresponsive to standard treatment
differentials of tonsiliitis
- 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
is amoxicillin appropriate for tonsillitis
NO AS IT MAY BE CUASED BY EBV
CAUSING MACULOPAPULAR RASK
