Pharyngitis

How do you grade tonsillar enlargement? on what scale?

0-4, 0 being the smallest tonsils, 4 being the largest

What percent of pharyngitis is caused by viruses?

50%

What percent of "sore throats" are due to viral infections? What are some of the main viruses?

90%; adenovirus, coronavirus, rhinovirus

Enteroviruses and Coxsackie viruses

-Hand foot and mouth disease may have oral enanthem plus an exanthema or just on or the other, mouth or throat pain and low-grade fever. -herpangina: abrupt high fever and possibly seizures. malaise, headache, abdominal pain, sore throat are common. Oral lesions are papulovesicular on soft palate, tonsils and uvula. Rash not on hands and feet. Use Tylenol to prevent spikes in fever.

Mononucleosis Diagnostic test and treatment:

-heterophile antibody/agglutination test and monospot test are similar serum tests that are specific but not sensitive. Show results 2-4 essweeks after symptoms appear. -CBC will show granulocytopenia (low), lymphocytosis (high). Lymphocytes will be larger than normal and dark w/ irregularities in cytoplasm and nucleus. -IgM and IgG antibodies as well as PCR for EBV DNA can be useful for confusing cases. TREATMENT: symptomatic (NSAIDS or acetaminophen) :avoid contact sports (splenic rupture) :fatigue can last 3 months :avoid treating w/ amoxicillin if you think it may be strep bc of rash that will appear. :admit patient if severe symptoms like thrombocytopenia, splenic rupture, airway obstruction. :steroids if airway obstruction

GAS streptococcal infections: diagnostic

-rapid antigen detection tests w/ throat swabs are specific and newer ones are sensitive -RADT performed when peds have >2 of the following symptoms and adults have >3 1. temp >38 degrees C or fever history 2. lack of cough 3. tender anterior cervical lymphadenopathy 4. tonsillar exudates -Throat culture kids if RADT comes back negative but clinical suspicion is high. -CBC not specific

Epiglottitis is caused by what?

Can be caused by bacteria, virus, and fungus but the main cause is a bacteria; Haemophilus influenza type b (Hib)

Treatment of gonococcal pharyngitis:

Ceftriaxone 250mg IM x 1 plus azithromycin 1 gram stat.

Epiglottitis diagnosis:

Children-Examination should be done by a specialist (otolaryngologist), bc attempt to visualize epiglottitis can lead to airway obstruction and cardiorespiratory arrest. -in adults, if there appears to be no respiratory compromise, the oropharynx can be examined, but laryngoscopic visualization is the gold standard -radiography is a good option; lateral neck x-ray can show an enlarged epiglottis or "thumb sign".

Diphtheria is caused by what? and spread how?

Corynebacterium diphtheria; it produces a toxin that damages cardiac and CNS tissues; bacteria itself attacks respiratory tract; spread through respiratory droplets

Diphtheria vaccination:

Dtap given at 2,4, 6, 15-18 months then 4-6 and 11-12 yo and every 10 years.

Mononucleosis: Cause, transmission, signs/symptoms

Epstein-barr virus (EBV); once infected you remain a host forever -transmission through saliva -infectious for up to 6 months from initial onset of symptoms SS: Sore throat with or without tonsillar swelling and exudates; petechial may or may not be present on palate, symmetric posterior cervical lymphadenopathy, fever, fatigue, malaise, often with headach, myalgia, anorexia. -50% of patients develop splenomegaly -Generalized maculopapular rash can sometimes be seen (amoxicillin increases this risk)

Streptococcal infections are caused by what strep?

Group A B-hemolytic streptococci (streptococcus pyogenes)

What are common bacteria of pharyngitis infection?

Group A b-hemolytic streptococcus (GAS): 5-15% N. gonorrhoeae F. necrophorum Corynebacteria diphtheriae

Why is epiglottitis uncommon?

Hib vaccine

What is the most resistant bacteria in the world?

N. Gonorrhoeae

Gonococcal Pharyngitis; what's it caused by?

Neisseria Gonorrhea; Part of differential diagnosis for pharyngitis especially if social history supports oral sexual exposure.

Treatment of GAS streptococcal infections:

Penicillin is DOC- oral PCN V, 500 mg tab: 1 po, 2 or 3 times daily x 10 days. (IM options is benzathine penicillin G, 1.2 million units IM x 1) Other options: clindamycin if allergic to PCN; clarithromycin and azithromycin may be considered When to refer: 4 episodes in 1 year, unilateral swelling, chronic airway obstruction w/ apnea, persistent dysphagia

Diphtheria signs and symptoms:

Pharyngeal infection is the most common form and is characterized by false membranous lining that adheres to tonsils and pharynx and interferes with eating and breathing. -Sore throat, nasal discharge, hoarseness, malaise and low-grade fever are common. -complications include arrhythmias, heart block, myocarditis, heart failure. Neuropathies usually involve cranial nerve dysfunction

What are the signs and symptoms of epiglottitis?

Young children: sore throat, stridor with respiratory distress, drooling, fever, refuses to lie down, "tripod" position, muffled voice Adults: severe sore throat, mild respiratory symptoms, anterior neck pain, may or may not have fever, muffled voice

diphtheria diagnosis and treatment:

clinically; culture can confirm diagnosis but treatment should not wait for confirmation -Antitoxin from CDC; Pseudomembrane may be surgically removed from throat to prevent airway obstruction. -PCN and erythromycin are used to eliminate carrier state in patient. Patients must be isolated

Differentials to mononucleosis:

cytomegalovirus infection, acute HIV infection, Herpes simplex virus type 1

What are symptoms of viral pharyngitis caused by influenza?

fever, headache, COUGH, myalgias.

What else does Group A streptococci (streptococci pyogenes) cause?

impetigo, cellulitis, erysipelas, pneumonia,, septic arthritis, rheumatic fever and acute glomerulonephritis.

Laryngitis:

inflammation of the mucous membrane lining the larynx :edema of the vocal cords :usually viral following URI, but can be from use of voice, heavy smoking or exposure to irritating fumes. : Causes HOARSENESS. NO PAIN. may or may not have cough Treatment:just rest the vocal cords

What are some of other EBV syndromes?

lymphomas, gastric carcinoma, COPD, rheumatic disease, chronic fatigue syndrome, oral hairy leukoplakia.

Peritonsillar abscess and cellulitis: diagnosis

made clinically; differentiating between cellulitis and abscess may be difficult without imaging or aspiration that reveals pus. -CT with IV contrast -Lab not required by may include CBC, culture of abscess fluid and throat culture

Treatment of epiglottitis:

maintaining an open airway is the focus of treatment; may need to put in a tube or tracheotomy -hospitalize pts and put on combination of antibiotics: ceftriaxone or cefotaxime AND clindamycin or vancomycin -culture can reveal specific pathogen and antimicrobial susceptibility, may require a change in antibiotics -Steroid use is controversial but may be used to reduce inflammation

Peritonsillar abscess treatment:

presence of an abscess requires drainage -hydration, pain control and supportive care -Antibiotics: pt.s with cellulitis only may or may not be hospitalized for antibiotic treatment but pt's with abscess should be hospitalized and started on -Ampicillin-sulbactam IV or Clindamycin IV. -after fever is gone, switch to oral amoxicillin-cluvulanate or clindamycin so the total antibiotic course is 14 days.

What is another name for peritonsillar abscess?

quinsy

Signs and symptoms of Peritonsillar cellulitis and peritonsillar abscess?

sever sore throat, with intensity of pain localized to one side. Pain maya extend to the ear. Exam will show large swollen tonsil. Swelling causes uvula to move to opposite side and may be visualized externally as neck swelling. -fever, "hot potato voice" -raspy voice Possibly: trismus, drooling, odynophagia, compromised upper airway, and lymphadenopathy

Complications of strep pharyngitis:

sinusitis, otitis media, mastoiditis, peritonsillar abscess, glomerulonephritis, rheumatic fever

Gonococcal pharyngitis signs and symptoms:

sore throat, exudates, lymphadenopathy but may also be asymptomatic -There may be an acute symptom of arthritis that precedes a disseminated infection

What is the most common bacterial cause of pharyngitis? transmitted how?

streptococcus pyogenes; through droplets of infected secretions

signs and symptoms of (GAS) streptococcal infections

sudden onset of fever, sore throat, cervical lymphadenopathy, tonsils become red, swollen, have exudates; cough usually NOT present. :malaise, nausea, headache, pain with swallowing are common :may or may not have "scarlet fever" which is a fine, diffuse rash that resembles sunburn and is most intense in the groin and axilla. The tongue develops red papillae "strawberry tongue"

What are signs of common "viral pharyngitis?

symptoms are mild to moderate, but not severe, often afebrile, URI with rhinorrhea, tonsils DO NOT usually have exudates

Rheumatic fever occurs when and how does it present?

usually 2-6 weeks after strep, presentation with arthritis but carditis is also common. Long term cardiac problems involving the mitral valve.

peritonsillar cellulitis and abscess:

usually a polymicrobial infection including GAS that occurs in the palatine tonsil and tissue of tonsil. Cellulitis is limited to tissue inflammation while abscess includes a collection of pus in the capsule that is created between the tonsil and its overlying tissue