Throat symptom/complaint Flashcards
Predisposing factos for Candida pharyngitis
HIV infection Diabetes mellitus Broad spectrum antibiotics Corticosteroids, including inhalers Dentures Debility
Symptoms and signs of Candida phyaryngitis
Presentation - Milky white growths on palate, buccal, gingival mucosa, pharynx and dorm of the tongue.
If scraped away a bleeding ulcerated surface remains
Metallic taste
Sore throat and tongue
dysphagia
Mx of Candida pharyngitis
Determine underlying cause
Nystatin suspension rinse and swallow QID
or amphotericin 10mg lozenge dissolved slowly in oral cavity, 6hrly for 7-14days.
Presentation of Hand, foot and mouth
fever sore throat dysphagia oral tiny papulovesicles erythematous halo
Cause of Hand, foot and mouth
Coxsackie virus A
Transmission and incubation of hand, foot and mouth
Face - oral and incubation for 2-6 days
Cause of Glandular fever
Epstein Barr Virus (Infectious monocytosis)
Transmission of Epstein Barr Virus
Youth, close contact, saliva, kiss
Incubation time for EBV
1-2 months
Pathogenesis of EBV
EBV infect epithelium cells of the URT and infect B lymphocytes where they start multipling in the B lymphocytes. From there they spread and infect other organs by infected B lymphocytes.
EBV specific CD8+ T cells - defines (atypical lymph)
Symptoms of EBV
15-25 yrs with a painful throat that take 7d to reach the peak. Prodromal fever, malaise, lethargy Anorexia, myalgia Nasal quality voice Skin Rash
Signs of EBV infection
URTI+ Petechiae on palate Enlarged tonsils with or without Periorbital oedema Lymphadenopathy Splenomegaly - enlarged spleen = easy rupture - youth death Hepatitis The rash - Primary rash 5%, Secondary rash when treatment with ampicillin, amoxycillin and some with penicillin
Cx of EBV infection
Hepatitis
Spleen rupture - they can die from minor trauma
Organ failure - fatal
Dx of EBV infection
FBC - Absolute lymphocytosis
Blood firm - atypical lymphocytes
heterophil antibodies or Monospot test or EBV IgM test
Tx of EBV infection
Prognosis - self limited 4-6 wks
Symptomatic support - paracetamol
Parenteral corticosteroids only in most severe cases
Hydration - admit if unable to tolerate fluids
Symptoms of Diptheria
Insidious onset Fever SOB Sore throat Dysphagia Cough Nausea and vomiting
Signs of Diptheria
Pharynx inflamed and swollen with enlarged tonsils Pseudomembrane Hoarse voice Lymphadenopathy Cutaneous diphtheria (non healing ulcer)
Cx of Diptheria
Aspiration of pseudomembrane and airway obstruction
spread of exotoxin to cause myocarditis and HF
Peripheral neuritis
Tx of Diptheria
Throat swabs
Antitoxin
Penicillin or erythromycin 500mg QID for 10 days
Isolate patient
Cause of diptheria
Corynebacterium diphtheria which is gram +ve, pleomorphic bacilli, with exotoxin AB
Prevention of diptheria
DPT at 2m, 4m, 6m, 4yr, 10yr, 15yr and booster every 10yrs
Pathogenesis of diptheria
Infection results in mucosal necrosis with fibrinopurulent exudate (pseudomembrane).
Most common causes of Rhinitis
Rhinovirus most common cause >100 serotypes Other causes Influenza Parainfluenza Corona (SARS) Adenovrius RSV May be bacteria after 7-10 days Allergy - frequent or persistent symptoms
Rhinovirus
Transmission
Incubation period
and epidemiology
Seasonal Highly contagious Transmission Droplet spread by sneezing, coughing, hand contact with the nose, eyes or face. Incubation period 2-4 days Prevention hand hygiene
Pathogenesis of Rhinitis
Acute serous inflammation called Catarrhal = excess mucous
- infection -> mediator ->vasodilation -> excess mucous.
Red flags of rhinitis
Severe facial pain
severe headache
Symptoms of Rhinitis
Sneezing
coughing
Malaise lasting 3-6 days
unilateral symptoms may be foreign body in children or malignancy in adult
Cx of Rhinitis
Secondary bacterial infection is common = suppurative
Sinusitis
Pharyngitis
Tonsilitis
otitis media
Septicemia
Nasal polyps - inflammatory (allergy) - long term complication in hypersensitive people
Tx of Rhinitis
Good health and nutrition
Pseudoephedrine
Presentation of Peritonsillar abscess/Quinsy
Presentation of tonsillitis that is followed by increasing difficulty in swallowing the trismus (spasm of jaw = lock jaw) Usually ill with high fever +/- Dysphagia Odynophagia Most common in teenager and young adults
Signs of peritonsillar abscess/Quinsy
Pooling of secretion in treat
Difficulty moving/uwilling to move their neck
Hyperextension of neck
- usually unilateral
Most likely organism that causes peritonsillar abscess/Quinsy
polymicrobial including staph aureus and street pyogenes
usually GABHS or anaerobes
Occasionally Haeophilus sp and Stagpylococcus aurues
Tx of Peritonsillar abscess/Quinsy
Admit to hospital
Antibiotics - procaine penicillin IM or clindamycin
IV Benzylpenicillin 6hrly
ENT Surgery - Aspiration or drainage
Symptoms of Croup
presentation – coryza present or absent, seal-like harsh barking cough, inspiratory stridor and variable degree of distress, chest wall retraction in 6month to 3yr and increases in winter
Starts with coryza symptoms then Barking cough Inspiratory Stridor - loudness does not correlate with severity of obstruction \+/- Wheeze \+/- Hoarse voice \+/- Fever but no signs of toxicity Increased Work of breathing Worse at night, peaks night 2 or 3. Then settles down.
Signs of Croup
Minimal, don’t examine the throat or upset the child
Characteristics of Mild Croup
Behaviour- normal Stridor - Barking cough, Stridor only when active or upset RR - normal Accessory muscle use - none or minimal Oxygen - None
Characteristics of moderate Croup
Behaviour - some/intermittent irritability
Stridor - some at rest
RR - increased, Tracheal tug, nasal flaring
Accessory muscle- moderate chest wall retraction
O2- none
Characteristics of severe croup
Behaviour - increase irritability and/or lethargy
Stridor- at rest
RR- Marked increase or decrease, tracheal tug, nasal flaring
Accessory muscle - marked chest wall retraction
O2 - Hypoxia is a late sign of significant upper airways obstruction.
Pt who are at risk of severe Croup
Preexisting narrowing of upper airways Down’s syndrome Sub-glottic stenosis or chronic stridor from other cause other neurological disorders Previous admission with severe croup
Causes of Croup
Respiratory syncytial
Parainfluenza virus
DDX for Croup
Inhaled foreign body
Epiglottis
Bacterial tracheitis
Mx for severe croup
Minimal handling
nebuliser adrenalin - 1mL of 1% adrenaline solution plus 3ml Normal saline or 4 ml of adrenaline 1:1000
And
Give 0.6 mg/kg (max 12mg) IM/IV dexamethasone
Improvement - observe for 4 hours post adrenaline then consider discharge once stridor free at rest
Improvement than deterioration - give further doses of adrenaline, Then consider admission/transfer as appropriate
No Improvement - reconsider diagnosis. Acute upper airway obstruction
Mx of mild to moderate Croup
Prednisolone 1mg/kg and prescribe a second dose for the next evening
Or
A single dose of oral dexamethasone 0.15mg/kg
Observe for half an hour post steroid administration
Discharge once stridor-free at rest
When to consult paediatric team or transfer
Consider consultation with local paediatric team when
severe airways obstruction
no improvement with nebuliser adrenaline
Child has risk factors
Consider transfer when
No improvement following nebuliser adrenaline.
> 2 doses of nebuliser adrenaline are required
Children requiring care above the level of comfort of the local hospital
Discharge requirements for croup
Four hours post nebulised adrenaline (if given) and/or half an hour post oral steroid, and stridor free at rest
- Parents should be advised and able to seek help if stridor at rest regardless of whether they have received steroids
DDX for Pharyngitis
Bacteria: Group A Strep pyogenes 15-30% of children with sore throat (3yr to 15yr) Virus: 33% Rhino, Adeno, EBV etc - common cause of sore throat in children. Fusobacterium necrophorum 15% Unknown 22% Uncommon Spirochets (Vincent ́s angina) STI: Gonorrhoea, Chlamydia, Syphilis, HIV Corynebacterium influenza or diphtheria Arcanobacterium haemolytic Streptococci of group C or G Haemophilus influenza TB Cancer in tonsil.
Who get Pharyngitis
Age group - uncommon in
Features of a Streptococcal features
Constitutional symptoms fever >38 Toxicity absence of cough Tonsillar exudate and swelling >6yr Swollen tender anterior cervical LN. Other symptoms difficulty in swallowing Significant pain including pain on talking foul smelling breath
signs of Pharyngitis
Pharynx very inflamed and oedematous
Tonsils swollen with pockets of yellow exudate on surfaces
Very tender enlarge tonsillar LN
Modified Centor criteria
Tonsillar exudate or erythema Anterior cervical adenopathy Cough absent Fever present Age 3-14 +1, 15-45 =0, >45 -1 Score 4-5 Tx ABx Score 2-3 Perform rapid antigen test. + = Abx, - = throat culture Score 0-1 symptomatic tx
Indications for antibiotics in pharyngitis
Servere tonsillitis with above features of GABHS
existing RHD at any age
Scarlet fever
Peritonsillar cellulitis or abscess
pt 2-25 with presumptive FABHS for special communities e.g. remote that have a high incidence of ARF
?Vomiting or diarrhoea
Mx for Streptococcal pharyngitis
Antibiotic if indicated
Phenoxymethyl Penicillin BD for 10 days or Cephalexin or Roxithromycin if allergic
Analgesics
Corticosteroid if severe pain and unresponsive to analgesia
when to admit or transfers to tertiary centre for pt with Pharyngitis
Suspected upper airway obstruction
Systemically unwell patients
Evidence of acute complications e.g. abscess formation, upper airway obstruction
Significant comorbidity e.g. immunosuppression (after discussion with relevant treating team)
Common causes of Sore throat
Pharyngitis 50% virus Coryza prodromata, hoarseness, cough, conjuctivitis, nasal stuffiness Streptococcal GABHS Tonsillitis Chronic sinusitis with postnasal drip Oropharyngeal candidiasis Epstein-Barr mononucleosis
Sore throat, Serious disorders not to be missued
CV- ANGINA, MI
Severe infections
Epiglottitis - Haemophilus influenza in children 2-4 years, Acute onset
short febrile illness, respiratory difficulty but no cough and unable to swallow.
Streptococcal pharyngitis with Cx
Quinsy - peritonsillar abscess
Diphtheria
HIV
Neoplasia - Cancer of oropharynx or tongue. Pharyngeal cancer = painful swallowing +referred ear pain + hoarseness
Blood Dyscrasias - agranulocytosis, Acute leukaemia,
Foreign body- sudden onset of throat pain, then drooling and dysphagia
Sore throat - Diagnostic pitfalls
classic being to Dx exudative tonsillitis of EBM as streptococcal tonsillitis and prescribe penicillins which may precipitate a severe rash
Primary HIV infection may present with sore throat throat.
Sore throat - seven masquerades
Depression Diabetes - Candida Drugs Anaemia -possible Thyroid disorder - thyroiditis Spinal dysfunction - cervical
Red flags of a sore throat
Persistent high fever
Failed antibiotic tx
Medication - induced agranulocytosis
Mouth drooling - consider epiglottis - don’t examine throat
Sharp pain on swallowing - foreign body
Marked swelling of quinsy
Candidiasis - consider diabetes or immunosuppression
What to ask on a hx for someone with a sore throat
differentiate between sore throat, deep pain or neck pain
Ass symptoms
Metallic taste in mouth, fever, URTI,
Other pain e.g. ear pain, nasal stuffiness or discharge and cough
PmHx - Asthma,
Med - Corticosteroid inhaler
Immunisation - especially about diphtheria
Social Hx - Smoker, environmental irritants
Screen for Angina
What to look for on examination of a pt with a sore throat
GI - toxicity , anaemic pallor of leukaemia, Nasal stuffiness of infectious mononucleosis. Characteristic halitosis of streptococcal throat.
Inspect - ears and check sinus areas, oral cavity and pharynx for ulcers, abnormal masses and exudates. Note if uvula and soft palate, tonsils, faces or pharynx are swollen, red or covered in exudate.
Palpate - neck for soreness and lymphadenopathy
Tx for a sore throat
Depends on cause
Supportive symptomatic ts
adequate nothing fluids e.g. icy poles
Analgesia - Aspirin for adults and paracetamol for children
Rest with adequate fluid intake
Soothing gargles
Advise against overuse of throat lozenges and topical sprays ->sensitise the throat. Limit use of decongestants to 3days
