Throat/Tonsil/OSA Flashcards
A 47-year-old female presents to your office with a 3-day history of sore throat, a fever of 100.9°F, and a dry cough. On examination she has tender anterior cervical lymphadenopathy and swollen tonsils without exudate. Her lungs are clear to auscultation. A point-of-care streptococcal rapid antigen detection test is negative.
Which one of the following would be the most appropriate next step in management? (check one)
Supportive care only
Penicillin V potassium
A repeat streptococcal rapid antigen test
A throat culture
Laryngoscopy
Supportive care only
This patient presents with symptoms of pharyngitis that are most likely attributed to a viral infection. However, many patients expect to receive prescriptions for antibiotics when evaluated for common respiratory infections. Use of the Modified Centor Criteria can assist with determining the likelihood of a group A streptococcal infection before prescribing antibiotics. The Modified Centor Criteria gives points for age, absence of cough, fever, tender anterior cervical lymphadenopathy, and tonsillar exudates or swelling. This patient would receive 0 points because she has a cough, –1 point because she is older than 45, 1 point because she has a fever ³100.4°F, 1 point because she has tender anterior cervical lymphadenopathy, and 1 point because she has tonsillar swelling. Therefore, her total Modified Centor Criteria score is 2, and she should be additionally evaluated with a rapid antigen detection test for group A Streptococcus (GAS).
Rapid streptococcal antigen tests can reduce inappropriate antibiotic prescriptions for adults at the point of care without adverse consequences (SOR A). Since this adult patient’s test is negative she does not require treatment with antibiotics, and supportive care is recommended. There is no role for repeating a rapid streptococcal antigen test due to the high specificity of these tests. A confirmatory throat culture is not required in adults due to the low incidence of GAS pharyngitis and rheumatic fever in this age group. In contrast, children and adolescents with negative rapid streptococcal antigen test results should have confirmatory throat cultures because of the high prevalence of GAS. An order for laryngoscopy is not appropriate in this patient without symptoms of epiglottis.
A healthy 24-year-old male presents with a sore throat of 2 days’ duration. He reports mild congestion and a dry cough. On examination his temperature is 37.2°C (99.0°F). His pharynx is red without exudates, and there are no anterior cervical nodes. His tympanic membranes are normal, and his chest is clear.
Which one of the following would be most appropriate at this point? (check one)
Analgesics and supportive care only
A rapid strep test
A throat culture and empiric treatment with penicillin
Azithromycin (Zithromax)
Analgesics and supportive care only
The Centers for Disease Control and Prevention (CDC) assembled a panel of national health experts to develop evidence-based guidelines for evaluating and treating adults with acute respiratory disease. According to these guidelines, the most reliable clinical predictors of streptococcal pharyngitis are the Centor criteria. These include tonsillar exudates, tender anterior cervical lymphadenopathy, absence of cough, and history of fever. The presence of three or four of these criteria has a positive predictive value of 40%–60%, and the absence of three or four of these criteria has a negative predictive value of 80%.
Patients with four positive criteria should be treated with antibiotics, those with three positive criteria should be tested and treated if positive, and those with 0–1 positive criteria should be treated with analgesics and supportive care only. This patient has only one of the Centor criteria, and should therefore not be tested or treated with antibiotics.
A 7-year-old male presents with a 3-day history of sore throat, hoarseness, fever to 100.4°F (38°C), and cough. Your examination reveals injection of his tonsils, no exudates, shotty lymphadenopathy, and normal breath sounds.
Which one of the following would be most appropriate?
(check one)
Symptomatic treatment only
Empiric treatment for streptococcal pharyngitis
A rapid antigen test for streptococcal pharyngitis
A throat culture for streptococcal pharyngitis
An office test for mononucleosis
Symptomatic treatment only
Pharyngitis is a common complaint, and usually has a viral cause. The key factors in diagnosing streptococcal pharyngitis are a fever over 100.4°F, tonsillar exudates, anterior cervical lymphadenopathy, and absence of cough. The scenario described is consistent with a viral infection, with no risk factors to make streptococcal infection likely; therefore, this patient should be offered symptomatic treatment only. Testing for other infections is not indicated unless the patient worsens or does not improve.
An obese 10-year-old male with tonsillar hypertrophy is brought to your office because of snoring. There is no history of recent or past visits for tonsillitis. Polysomnography shows moderate obstructive sleep apnea syndrome.
Which one of the following is the treatment of choice for this patient?
(check one)
Continuous positive airway pressure
Intranasal corticosteroids
Extended antibiotic therapy
Adenotonsillectomy
Adenotonsillectomy
Childhood obstructive sleep apnea syndrome has a prevalence rate of 5.7%. It is associated with growth, cardiovascular, and neurobehavioral abnormalities. Adenotonsillectomy is the treatment of choice. Although CPAP can be effective, compliance is poor and it is therefore not a first-line treatment. Intranasal corticosteroids may also be helpful, but the benefit appears small.
A 5-year-old African-American male presents with behavior problems noted in the first 3 months of kindergarten. The mother explains that the child does not pay attention and often naps in class. He averages 10 hours of sleep nightly and is heard snoring frequently. The mother has a history of attention-deficit disorder and takes atomoxetine (Strattera). The boy’s examination is within normal limits except for his being in the 25th percentile for weight and having 3+ tonsillar enlargement. The most reasonable plan at this point would include which one of the following? (check one)
An electroencephalogram
Polysomnography
Atomoxetine
Methylphenidate (Ritalin)
Polysomnography
Obstructive sleep apnea is increasingly recognized in children. The peak incidence is in the preschool-age range of 2–5 years when adenotonsillar tissue is greatest in relation to airway size. It is associated with obesity in older children. Common clinical manifestations include snoring with sleep interruptions and respiratory pauses. Polysomnography is the gold standard for the diagnosis. Although the child has inattention, excessive drowsiness is not seen in attention-deficit/hyperactivity disorder (ADHD) and medications for that condition are not indicated. None of his symptoms suggests a seizure disorder, so an EEG would not be helpful.
A 39-year-old male presents during influenza season with symptoms of nasal congestion and sore throat associated with a cough. He is most bothered by his severe laryngitis, and is concerned about a planned conference where he will be speaking next week. He would like the symptoms to resolve quickly, and is being proactive so it does not lead to pneumonia. His symptoms started 5 days ago and have been constant. He had a fever of 100°F for the first 3 days.
On examination he has a fever, appears tired and mildly ill, and has a red pharynx and a very hoarse voice. The remainder of the examination is normal.
Which one of the following should you recommend for management of this patient’s condition? (check one)
Reassurance and vocal rest
Inhaled fluticasone (Flovent)
Amoxicillin/clavulanate (Augmentin)
Levofloxacin
Oseltamivir (Tamiflu)
Reassurance and vocal rest
Laryngitis and an accompanying hoarse voice are viral symptoms, and antibiotics will not help. Fluticasone is effective for the treatment of asthma, but has no value in acute laryngitis. Oseltamivir can be used during influenza season for empiric treatment for influenza-like illness, but is only effective if started within the first 3 days of illness.
A 19-year-old male presents with a 3-day history of fever, fatigue, and sore throat. He states that his girlfriend has been experiencing similar symptoms for the past couple of weeks. His past medical history is unremarkable. His vital signs include a temperature of 38.3°C (100.9°F), a heart rate of 92 beats/min, and a respiratory rate of 18/min. On examination you note tonsillar erythema, palatal petechiae, and anterior and posterior cervical lymphadenopathy. An abdominal examination reveals splenomegaly. A rapid streptococcal test is negative and a heterophile antibody test is positive. A CBC with differential demonstrates atypical lymphocytes.
Which one of the following would be the most appropriate pharmacotherapy for this patient’s condition? (check one)
Amoxicillin
Dexamethasone
Foscarnet (Foscavir)
Ibuprofen
Valacyclovir (Valtrex)
Ibuprofen
Supportive therapy including medication, adequate hydration, and rest is the standard of care for the treatment of infectious mononucleosis. For example, ibuprofen is recommended as an antipyretic and an analgesic. Since streptococcal pharyngitis is most common in ages 5–15 and this patient’s rapid streptococcal test is negative, it is highly unlikely as a concomitant diagnosis. Thus, amoxicillin therapy would not be appropriate. Though Epstein-Barr virus and cytomegalovirus are the etiology of infectious mononucleosis, there is insufficient evidence to recommend the use of antivirals (including foscarnet or valacyclovir) or corticosteroids for the treatment of infectious mononucleosis.
A 55-year-old female with a BMI of 50 kg/m2 and recently diagnosed severe obstructive sleep apnea (OSA) presents for follow-up after a sleep study. She was unable to tolerate positive pressure therapy.
Her OSA could be most effectively addressed by which one of the following interventions? (check one)
Use of a nasal dilator device
A positional sleep alarm to avoid the supine position
Clonidine, 0.1 mg orally before bedtime
Uvulopalatopharyngoplasty
Bariatric surgery
Bariatric surgery
Obstructive sleep apnea (OSA) is a common disorder that, if left untreated, can be associated with other serious health conditions such as atrial fibrillation, depression, heart failure, and stroke. Positive pressure therapy is effective and considered the first-line treatment for OSA, although some patients are unable to tolerate this therapy. In obese patients with OSA, bariatric surgery has been shown to reliably result in improvement in >75% of patients and result in remission in 40% of patients after 2 years. Nasal dilator devices and pharmacologic interventions such as clonidine have not been shown to improve symptoms or to be effective for treatment. Positional therapy is not recommended as a long-term solution for severe OSA due to poor long-term compliance. Currently there is insufficient evidence to support oral procedures such as uvulopalatopharyngoplasty as primary interventions for OSA.
A 39-year-old male with no known previous medical history sees you for follow-up of recently diagnosed depression. He works as a home renovation contractor and does not smoke. A physical examination is normal other than a BMI of 36 kg/m2. Laboratory studies reveal a normal TSH level and a hemoglobin level of 17.4 g/dL (N 13.3–16.2).
You suspect that which one of the following is a cause of his polycythemia? (check one)
Alcohol use
Hemochromatosis
Hereditary spherocytosis
Lead exposure
Obstructive sleep apnea
Obstructive sleep apnea
Secondary polycythemia, or elevation of red blood cells, can have multiple causes. Conditions that affect oxygenation such as obstructive sleep apnea may cause secondary polycythemia. While hemochromatosis causes elevation of iron levels, it does not typically cause polycythemia. Hereditary spherocytosis causes hemolytic anemia. Smoking cigarettes is a common cause of secondary polycythemia, but alcohol use is often associated with macrocytic anemia. This patient may be at risk for lead toxicity, which can lead to anemia.
A 56-year-old female comes to your office for evaluation of fatigue and shortness of breath. She has a history of type 2 diabetes mellitus, hypertension, hyperlipidemia, and obesity. Her diabetes has been well controlled, and a recent hemoglobin A1c was 6.7%.
She reports that she has been more tired than usual for the past several months and that walking more than a block or going up a flight of stairs has now become difficult. She has no chest pain, palpitations, dizziness, or cough. She has had mild, stable lower extremity edema for years, and this is unchanged. She lives alone and is not sure if she snores. She has had difficulties with sleep for years and does not feel refreshed upon awakening. She does not use tobacco or drink alcohol.
On examination she has a blood pressure of 128/78 mm Hg, a pulse rate of 76 beats/min, a respiratory rate of 14/min, a temperature of 37.1°C (98.8°F), an oxygen saturation of 95% on room air, and a BMI of 38.2 kg/m2. Auscultation of the heart reveals a regular rate and rhythm with no murmur. Her lungs are clear to auscultation bilaterally. She has 1+ pitting edema of both lower extremities.
A chest radiograph is normal and an EKG reveals normal sinus rhythm. Echocardiography shows a left ventricular ejection fraction of 60% without impaired diastolic function.
Which one of the following evaluations is most likely to reveal the cause of her fatigue? (check one)
24-hour ambulatory blood pressure monitoring
Spirometry
A sleep study
CT angiography of the chest
Left heart catheterization
A sleep study
This patient has pulmonary hypertension that, based on her history, is most likely related to obstructive sleep apnea (OSA). Most patients with pulmonary hypertension have an underlying disease of the heart or lungs that leads to elevated pulmonary artery pressures. Common underlying conditions include chronic lung disease such as COPD, OSA, and left heart failure (with a reduced or preserved ejection fraction). Additional considerations include chronic thromboembolic disease and primary pulmonary arterial hypertension.
This patient’s obesity and unrefreshing sleep make OSA the likely underlying cause of her pulmonary hypertension. She does not have clinical features of thromboembolic disease or a history of COPD. Her echocardiogram does not show heart failure, and she has no symptoms to suggest obstructive coronary disease. Ambulatory blood pressure monitoring can aid in the diagnosis and optimal treatment of hypertension, but this would be unlikely to relate directly to her pulmonary hypertension.
A 56-year-old male with hypertension and a BMI of 39 kg/m2 comes to your office for follow-up after a full-night study in the sleep laboratory for evaluation of snoring and fatigue. The study revealed an apnea-hypopnea index (AHI) of 12 events per hour of sleep. He has several questions about his treatment options. He reports that he is very concerned about this problem and is willing to try anything, but a family member suggested he consider the newer procedures.
In addition to diet, exercise, and behavioral modifications, which one of the following would be the most appropriate intervention at this time? (check one)
An oral appliance
CPAP therapy
Hypoglossal nerve stimulation
Pharyngeal soft-tissue modification
Bariatric surgery
CPAP therapy
This patient has obstructive sleep apnea (OSA) based on an apnea-hypopnea index (AHI) of 5 in the presence of symptoms and cardiovascular disease, such as hypertension. CPAP therapy is considered the most effective treatment for OSA if used correctly and consistently and is the first-line treatment recommendation. However, many patients struggle with tolerating CPAP, which results in poor adherence and undertreatment. An oral appliance may be tried for mild sleep apnea (an AHI of 5 to <15) and is better than no treatment for patients who do not tolerate CPAP. Given the development of newer surgical treatments, the American Academy of Sleep Medicine (AASM) recommends that clinicians discuss referrals for additional treatments if adult patients with obesity cannot tolerate or do not accept CPAP. The AASM recommends that clinicians who treat OSA discuss referral to a sleep surgeon who can perform upper airway surgery (pharyngeal soft-tissue modification, skeletal modification, and upper airway stimulation such as hypoglossal nerve stimulation) with adult patients who have a BMI >40 kg/m2 and are intolerant or unaccepting of CPAP (Strong Recommendation). It also recommends discussing referral to a bariatric surgeon with adult OSA patients with obesity (class II/III, BMI 35 kg/m2) who are intolerant or unaccepting of CPAP (Strong Recommendation). Discussing a referral does not necessarily have to result in a referral, but patients should be informed that other viable alternative treatments exist and can reduce disease burden.
A 62-year-old male presents with daytime fatigue, sleepiness, snoring at night, and a BMI of 41 kg/m2. You are concerned that he may have obesity hypoventilation syndrome (OHS) in addition to possible obstructive sleep apnea.
Which one of the following tests is most appropriate for establishing a diagnosis of OHS? (check one)
Daytime awake serum HCO3–
Daytime awake PaCO2
Daytime awake PaO2
Nighttime serial measurement of peripheral oxygen saturation during sleep
Nighttime serum HCO3– within 2 minutes of awakening
Daytime awake PaCO2
Obesity hypoventilation syndrome (OHS) is characterized by obesity and alveolar hypoventilation while awake, which is defined by an awake PaCO2 level >45 mm Hg. Ninety percent of patients have coexistent obstructive sleep apnea (OSA). The pathogenesis is related to the increased physical demands on breathing caused by obesity. While decreased PaO2 or oxygen saturation is often present, it is not part of the diagnostic criteria. In obese patients with lower risk (often with lower BMIs), a serum HCO3– level <27 mmol/L may obviate the need for an arterial blood gas measurement as OHS becomes very unlikely. If the HCO3– level is ≥27 mmol/L (a renal compensatory mechanism for hypoventilation-induced acidosis), a PaCO2 measurement should be obtained to establish the diagnosis. The first-line treatment for ambulatory patients with this condition is CPAP. Nighttime measurement of peripheral oxygen saturation during sleep is a key component of sleep studies that are used to diagnose OSA, but it is not used to diagnose OHS.
A 36-year-old female singer presents with a 10-day history of hoarseness. She has never smoked and does not take any medications. Her vital signs are normal. An oropharyngeal examination is normal, her chest is clear to auscultation, and there is no cervical adenopathy and no masses. She is anxious to be able to sing again as soon as possible.
Which one of the following would you advise at this time? (check one)
No talking, whispering, or throat clearing for 48 hours
No singing or loud talking for 5–7 days
Nebulized hypertonic saline treatments 3 times daily for 2–3 days
Nebulized ribavirin twice daily for 3 days
Inhaled corticosteroids twice daily for 5 days
No talking, whispering, or throat clearing for 48 hours
Complete vocal rest, including no whispering or throat clearing, is the most effective and quickest initial remedy for short-duration laryngitis, whether viral or due to vocal overuse or abuse. Limiting voice use or whispering, as opposed to complete vocal rest, will likely prolong and possibly worsen hoarseness. Clearing the throat of mucus should also be avoided for the same reason. Inhaled corticosteroids and antibiotics are not effective treatments for laryngitis. Hypertonic saline nebulization treatments would likely cause violent coughing fits that would worsen the condition. Nebulized ribavirin is never indicated for use in adults.
A 10-year-old male is brought to the emergency department with a history of group A β-hemolytic Streptococcus confirmed with a throat culture 2 weeks ago. His parents gave him antibiotics for 3 days then stopped them because his symptoms were gone. He now has a temperature of 38.9°C (102.0°F), a heart rate of 122 beats/min, and right hip and left knee pain with swelling.
Which one of the following would be the most appropriate initial pharmacologic therapy for acute rheumatic fever in this patient? (check one)
Acetaminophen
Gabapentin (Neurontin)
Hydrocodone
Naproxen
Naproxen
Once the diagnosis of acute rheumatic fever is made, NSAIDs such as aspirin or naproxen should be
administered (SOR B). The therapeutic response to NSAIDs is often remarkable. Acetaminophen has not
been shown to be a superior analgesic for acute rheumatic fever. Gabapentin is not indicated, especially
considering that the pain does not have a neuropathic etiology. Opioids would not be considered first-line
treatment because of their adverse effects and the dramatic response of NSAIDs alone.
