Week 2: Sore Throat 2

Question 1

Duration of sore throat

Answer 1

Acute pharyngitis – less than 2 weeks duration

Chronic pharyngitis – more than 2 weeks duration

Question 2

General approach to acute pharyngitis

Answer 2

Rule out serious diagnoses and red flags/alarm symptoms that prompt emergent/urgent management
Most cases of acute pharyngitis are due to infectious cause – determine the specific infectious cause (i.e., viral or bacterial)
Identify acute sore throat caused by group A beta-hemolytic streptococcal (GABHS) pharyngitis
Antibiotic treatment may be indicated

Question 3

Alarm symptoms associated with sore throat

Answer 3

Question 4

ALARM SYMPTOMS ASSOCIATED WITH COUGH

Answer 4

Question 5

Infection –> clinical syndrome

Answer 5

Question 6

Viral pharyngitis

Answer 6

Most pharyngitis cases are viral in origin
Associated symptoms that are more likely to present with viral illness: cough, nasal congestion, conjunctivitis, hoarseness, diarrhea, oropharyngeal lesions (ulcers or vesicles)

Viruses that are most likely to cause pharyngitis in children (aged 5-15):
Common cold (50%) – caused by rhinovirus, coronavirus, adenovirus, parainfluenza virus, respiratory syncytial virus
Influenza (5%) – caused by Influenza virus (type A and B) most commonly
Mononucleosis (5%) – caused by Epstein-Barr Virus (EBV), cytomegalovirus (CMV)

Viral causes of pharyngitis do not require antibiotic therapy unless there is a secondary bacterial infection

Question 7

The common cold is a viral infection of what?

Answer 7

Common cold is a viral infection of the upper respiratory tract

Question 8

Common Cold: What is it? Duration? What viruses can cause it? Clinical presentation? Complications? Treatment? Prevention?

Answer 8

Viral infection of upper respiratory tract with inflammation
Peaks in winter months
Symptoms usually worst 2-3 days then resolve in 7-10 days
Cough may last 2-3 weeks

Can by caused by many viruses
Rhinoviruses are the most common cause
Grows optimally at temperatures near 32.8°C – the temperature inside the human nose
Other viruses: coronavirus, adenovirus, parainfluenza virus, respiratory syncytial virus

Clinical Presentation
Nasal congestion, rhinorrhea, sneezing
Sore throat, cough
Slight body aches
Mild headache
Afebrile or low-grade fever
Malaise
May have conjunctivitis, sinus symptoms
Chest exam is normal – no signs of lower respiratory tract infection

Complications
Asthma/COPD exacerbation
Secondary infection
Acute otitis media
Acute sinusitis
Other infections – pneumonia, streptococcal pharyngitis, croup, bronchiolitis, bronchitis

Treatment/Management
Self-limiting. No antibiotics unless secondary bacterial infection.
Analgesics/antipyretics
Ensure hydration
Steam inhalation
Soothing, warm fluids
Lozenges
Saline nasal rinse

Prevention
Avoid sick contacts
Respiratory etiquette – cough/sneeze into tissues
Proper hygiene – hand washing

Question 9

What alert should we be aware of for children under 6 years old.

Answer 9

For children <6 years old, cough and cold medicines should not be prescribed, recommended, or used because of the risks of adverse effects. Honey can help soothe a sore throat for children >1 year old. Cool-mist humidifiers may help with breathing, and saline nasal drops and bulb suctioning can help with nasal congestion.

Question 10

Influenza: What is it? Duration? What viruses can cause it? Clinical presentation? Complications? Treatment? Prevention?

Answer 10

Infection by Influenza A or B
Peaks in winter months
Symptoms appear 1-4 days after exposure to virus
Contagious period: 1 day before symptoms to 5 days after symptom onset

Clinical Presentation:
Acute onset
Fever
Cough
Myalgia
Other common symptoms: headache, chills, fatigue, loss of appetite, sore throat, nasal congestion, rhinnorhea, diarrhea, nausea, vomiting

Question 11

Allergies, URI vs Influenza?

Answer 11

Question 12

Likelihood Ratio for Influenza

Answer 12

Question 13

Influenza Clinic Decision Rule

Answer 13

Question 14

If it was the flu…what you should do

Answer 14

Watch for complications
Most common complication? Pneumonia – watch for signs of LRTI (tachypnea or tachycardia along with fever, signs of consolidation on chest exam)

Watch for susceptible populations
Which would include? Young children, elderly > 65 yoa, people residing in long term care facilities, diabetes or heart/lung conditions, weakened immune systems

And then, rest and fluids!
If high fever, also watch for signs of dehydration

Question 15

Types of hearing loss

Answer 15

Conductive Hearing Loss
Hearing loss due to dysfunction in one or more parts of auditory pathway from the external ear to the middle ear
For example, can result from dysfunction of external ear canal, tympanic membrane, and/or ossicles

Sensorineural Hearing Loss
Hearing loss due to dysfunction in one or more parts of the auditory pathway between the inner ear and auditory cortex
For example, can result from dysfunction of cochlea, auditory nerve, and/or auditory processing pathway in the central nervous system

Question 16

The ear: 3 parts?

Answer 16

The ear can be divided into three parts: the outer, middle and inner ear. The outer ear comprises the auricle (or pinna) and the ear canal. The tympanic membrane (eardrum), a thin cone-shaped membrane, separates the outer ear from the middle ear. The middle ear comprises the middle ear cavity and the ossicles (the malleus, incus and stapes), which are attached to the tympanic membrane. The oval window connects the middle ear with the inner ear, which includes the semicircular ducts and the cochlea. The middle ear cavity is connected to the nasopharynx by the Eustachian tube.

Question 17

Weber and Rinne Test findings

Answer 17

Question 18

Otitis externa: Symptoms? Risk factors? Typical presentation?

Answer 18

aka “swimmer’s ear”
Inflammation or infection of the external ear canal
Most commonly a bacterial infection – Pseudomonas species or Staphylococcus aureus
Can be a fungal infection (<10%) – Candida albicans, Aspergillus niger
Most common in adolescents

Risk factors
Swimming or repeated water immersion
Mechanical trauma
Narrow ear canals
Cerumen obstruction
Skin conditions like eczema and psoriasis

Typical Presentation
Otalgia, pruritis, or fullness
Possible otorrhea
Hearing impairment
Findings consistent with conductive hearing loss
Periauricular lymphadenopathy
Pain on movement of the auricle or tragus
Erythematous, edematous, inflamed external auditory canal

Question 19

Acute Otitis media: symptoms? Causes?

Answer 19

Acute middle ear inflammation secondary to infection
Most common in children (peak incidence 6-24 months of age)
Susceptibility due to developing immune system and shorter, more horizontal eustachian tube that more easily accumulates fluid
Viral upper respiratory infection  edema and inflammation of nasopharynx and eustachian tube  collection of fluid in middle ear cavity  infection by bacteria
Most common bacterial causes: Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis

Typical Presentation
Otalgia (rubbing, tugging, holding the ear)
Fever, irritability
Possible otorrhea
Anorexia
Sometimes vomiting or lethargy
Hearing impairment
Findings consistent with conductive hearing loss
Bulging, inflamed, cloudy/erythematous, immobile tympanic membrane with obscured landmarks

Question 20

Steps in the pathogenesis of virus-induced acute otitis medi

Answer 20

The child might have a pre-existing nasopharyngeal bacterial colonization, which does not cause symptoms. When the child contracts a common cold, the viral infection initiates inflammation of the nasopharynx and the Eustachian tube, leading to increased adherence and colonization of bacteria and other activating mechanisms. Eustachian tube dysfunction follows, leading to negative middle ear pressure, allowing bacteria and/or viruses in the nasopharynx to move into the middle ear causing infection and/or inflammation.

Question 21

Management of otitis media

Answer 21

Symptomatic management of ear pain and fever with analgesics
In 80% of children, AOM resolves without antibiotics

In children with uncomplicated, non-severe AOM who are not at increased risk of complications, recommend:
Watchful waiting – careful monitoring by caregivers, instructed to return in the case of persistent symptoms or worsening of the child’s condition
or
Delayed antibiotic prescription – prescription given to patient by only filed when symptoms of AOM persist for 48–72 hours

Question 22

Causal pathways for otitis media

Answer 22

Otitis media is a multifactorial disease. Specific host and environmental factors put children at risk for otitis media through various mechanisms, as illustrated in this diagram. Reducing the burden of otitis media will therefore require attention to more than a single risk factor. Given the complex causal pathways for otitis media, public health interventions may need to be prioritized differently for various at-risk populations and geographical regions. URTI, upper respiratory tract infection.

Question 23

Indications for antibiotic treatment of AOM

Answer 23

Benefits are modest and offset by adverse effects
Do not result in early resolution of pain but decrease pain by day 2 to 3 (NNT = 20)
Side effects of antibiotic therapy: vomiting, diarrhea, rash (NNH = 14)
Severe complications like mastoiditis are rare (NNT = 5000)

Amoxicillin is the antibiotic therapy of choice
10-day duration for children <2 years old or with severe symptoms
5-7 days for children 2-5 years old with mild to moderate AOM
5 days for children ≥6 years old with mild or moderate AOM

Question 24

Complications of AOM

Answer 24

Complications of AOM
Perforation of the tympanic membrane

Suppurative (pus-forming) complications of AOM:
Acute mastoiditis
Meningitis
Brain abscesses

Rare given the high incidence of AOM but potentially serious