Pharyngitis

What causes a retropharyngeal abscess?

-untreated pharyngitis -trauma from foreign body or penetrating grams -group A streptococcal infection *most common*

A retropharyngeal abscess is most common in what age group?

0-2 years old

Match the mononucleosis EBV antigen finding with it's clinical significance: 1) Infection has just started 2) Infection is happening right now 3) Patient had a prior infection 4) No antigen findings of infection A) IgM is increased, IgG is increased B) IgM is decreased, IgG is increased C) IgM is increased, IgG is decreased D) IgM is decreased, IgG is decreased

1) C 2) A 3) B 4) D

What are the (5) most common bacteria that are known to cause bacterial pharyngitis?

1) Group A streptococcus 2) Group C and G streptococci 3) Mycoplasma pneumonia 4) chlamydia pneumonia 5) gonorrhea tracomatous

What are the MEDICATION treatments for mononucleosis?

1) antiviral (not proven to be effective) 2) corticosteroids (to decrease pharyngeal Edema — rarely used) 3) antibiotics (only if patient is also suffering from infection with group A B hemolytic strep)

What is the CENTOR criteria?

4 POINTS = no further testing, treat with antibiotics 2-3 points = do culture or rapid antigen testing 0-1 point = do not test or treat

What are the 'classic' symptoms of a Peritonsillar abscess?

- *hot potato voice* (muffled) - *trouble opening mouth* (trismus) -fever + sore throat -difficulty swallowing -unilateral neck or ear pain

What are some ways to dx a Peritonsillar Abscess?

- clinically (you see it in PE? No swab necessary) -Rapid strep swab -CT or MRI only if unable to open mouth well for exam to be performed; or to identify deeper involvement

What are some diagnostic tests and findings that you would expect to see in someone suffering from Epstein-Barr virus?

-CBC: increased number of atypical lymphocytes -antibodies: 'monospot' antibody that appears 1st-2nd week of illness (not always + thus CBC is more specific and accurate) -EBV antigens: IgM and IgG -LFT with transaminases and hyperbilirubinema (increased liver fxn. Enzymes) -US of spleen to observe for splenomegaly

A 38 year old patient comes into the ER w/ complaints of fever, anxiety, fatigue, pain in the mouth, and difficulty swallowing. PE: -Pulmonary: stridor in upper quadrants -Constitutional: tripod positioning -HEENT: swelling of mouth floor, jaw stiffness, *suboptimal dental care with yellowing of teeth and gum retraction* What are your next steps?

-Likely dx: Ludwig Angina (cellulitis) —> next step: Admit to ICU for ENT consult -Diagnostic test: CT scan with contrast -Gold standard tx: tracheostomy, IV fluids, airway support, Clindamycin

What are the two unique clinical findings seen in someone suffering from a Retropharyngeal Absess?

-hyper-extended neck (forward leaning) -stridor (high-pitched breathing sound)

List some complications of untreated bacterial pharyngitis?

-rheumatic fever -scarlet fever -postglomerulonephritis -pertonsillar abscess -airway compromise -PANDAS (sudden onset of ticks/OCD post-strep infxn)

What are some of the most common S/S of mononucleosis?

-sudden onset of symptoms -swollen lymph nodes -tender cervical lymph nodes -grey-white exudate -palatial petechiae -fatigue/malaise -sore throat -splenomegaly (50% of patients) -a fever that waxes and wanes -rash on trunk + UE (esp. if treated with PNC)

S/S of bacterial pharyngitis

1) sudden onset of sore throat 2) fever 3) tender cervical adenopathy 4) palatial petechia (little red spots on the palate) 5) RED beefy uvula 6) tonsillar exudate 7) HA 8) *stomach ache* —> unique trait 9) N+V

Bacterial pharyngitis has as least one of the following features:

1) tender cervical lymphadenopathy (>2cm) 2) tonsillar exudates 3) positive strep culture 4) fever > 38.3 Celsius (100.94 F)

What are the SUPPORTIVE treatments for mononucleosis?

1) warm saline gargles for pain 2) NSAIDS or acetaminophen 3) avoid activity for 4x weeks or until CBC returns to normal (perform serial CBCs; patient is unable to play sports until CBC returns to normal)

Epstein-Barr virus, also known as mononucleosis, is most common in those from ______ to ______ years of age.

10-19 years

What is the first line of treatment for a peritonsillar abscess?

1st line: Clindamycin —> 2nd line: Penicillin

A patient comes in to clinic c/o rapid onset sore throat, fever, and swollen cervical lymph nodes. That you assume has streptococcal pharyngitis. What would be the first test you would perform? If this test is negative, what would be your follow up test?

1st test: *rapid antigen testing* — identifies 85-95% of strep pyogenes and is the diagnostic test of choice If patient has a negative rapid antigen test with high clinical suspicion.... 2nd test: Order a blood culture

Patient with suspected strep returns to your clinic after being prescribed antibiotics. On day 3 of treatment, patient c/o continued sore throat and fever. He states that symptoms have increased with antibiotic treatment but denies any rashes or hives. What would be your next diagnostic test?

APTIMA swab to test for chlamydia + ghonnrhea (test for sexually transmitted infections) ——> could also be mono

70% of Cervical Adenitis cases are due to ______________ infections, and viruses.

B hemolytic streptococcal

What is the most common pathogen that cause Ludwig Angina?

B-hemolytic strep

The diagnosis of a Pertonsillar Abscess is a __________, and can often be seen on physical exam.

Clinical diagnosis

How is most pharyngitis diagnosed?

Clinically —> a good H+P is *crucial* in dx pharyngitis

A peritonsillar abscess is most commonly caused by what bacteria?

Group A b-hemolytic streptococcus (also most common cause of strep throat)

Swabbing a patient's throat is based entirely on _________.

History

When would you perform a CT or MRI on a person with a suspected Peritonsillar Abscess?

If patient is unable to fully open mouth for observation; or if there are concerns of deeper involvement and infection

You have a 16 year old M patient that comes into clinic complaining of increased fatigue, malaise and sore throat. PE shows cervical lymph nodes that are are TTP. No other clinical findings. You perform a CBC. What finding would you expect to see that would confirm your clinical diagnosis?

Increased number of atypical lymphocytes (Confirmatory test for Epstein-Barr virus/mononucleosis)

What is the definitive method for diagnosing a Retropharyngeal Abscess ?

Lateral x-ray and/or CT head and neck with contrast!

What is the most common exam finding for peritonsillar abscess? What are some other findings?

Most common/diagnostic: *bulging or fullness of posterior superior soft palate* Other findings: -uvular deviation (classic finding; but not always present) -drooling (d/t inability to close mouth or swallow) -cervical adenopathy -tonsillopharyngitis

You have a 28 year old F patient who comes into clinic with c/o fatigue, fever, swollen tonsils, and swollen lymph nodes. She denies any cough or productive mucous. Based on your CENTOR criteria, you place patient on amoxicillin and ask her to return to clinic in 10 days. Patient returns to clinic and states that symptoms are still present, despite being complicit with antibiotic medication. What would you consider as the cause of her symptoms?

Oral chlamydia/gonorrhea

What is the first line of treatment for streptococcal pharyngitis?

Penicillin or amoxicillin (For all strep throat)

What disease is a common complication of tonsillitis and/or pharyngitis?

Peritonsillar abcess

What is the procedural treatment for a Peritonsillar abscess? What is the pharmacological treatment?

Procedural: *drainage of abscess via needle aspiration or surgical drainage* Pharm: *Clindamyacin* IMMEDIATE ENT CONSULT/ADMIT!!!

A mother presents in the Urgent Care with her 1 year old infant. She states that the infant has been increasingly fussy and ill-appearing for the past 3 weeks. The infant is feverish with drool running down her chin, and appears to have difficulty swallowing. PE shows some swelling of the posterior pharyngeal wall but it is difficult to visualize since you are unable to open the child's mouth fully. On lung examination you hear stridor. What are your next steps?

Suspect: retropharyngeal abscess —>call 911 to admit to ER for stabilization of airways and ENT surgical consult ->dx test: lateral x-ray and/or CT with contrast —> tests: CBC (elevated WBC), blood cultures (r/o sepsis) + throat cultures (etiology of disease)

Patient comes in with large cervical mass swelling, after suffering from a prolonged 'sore throat' What tests would you perform to confirm your suspected dx?

Suspected dx: cervical adenitis -Rapid group A testing -CBC with differential ——>caused by same bacteria as strep throat

What is the gold standard treatment for someone with diagnosed Ludwig Angina (cellulitis)?

Tracheostomy

The most common initiating factor of Ludwig angina is ___________, which occurs in 50% of cases.

Trauma (Injury to the floor of the mouth)

True or False: Ludwig angina is more common in adults than children.

True

True or False: S/S of patient history as well as a CBC with increased count of atypical lymphocytes is enough to dx a patient with mononucleosis.

True!

90% of sore throats with fever are _______ in origin.

Viral Viral = think cold, flu, etc.