ENT Part 1 -- Infections of the Throat

Peritonsillar Abscess

* A collection of pus that forms between the capsule of the palatine tonsil and the pharyngeal muscle * - Usually forms superior to the tonsil - Unilateral

Syndenham Chorea

- A self-limitig manifestation of ARF - Lasts for 2-3 years - More common in children - More common in females - Accounts for 25% of first ARF - Neuro and psch effects - Altered mental status - Abrupt rhythmic purposeless movements * Characterized by movements and emotional lability *

Epidemiology of Tonsilitis/Pharyngitis

- Accounts for 10% of all office visits - Accounts for 50% of outpatient ABX use - Peaks during winter and early spring * The focus of diagnosis and treatment is via the indentification of S. pyogenes *

Complicatons of untreated Peritonsillar Abscess

- Airway obstruction - Internal jugular seeding - Pseudo-aneurysm - Septicemia

Mitral regurgitation

- Blowing, hollow - Systolic

Si/Sx specific to Viral Tonsilitis/Pharyngitis

- Coryza - Cough - Malaise - Fatigue - Hoarsness * EBV often presents with posterior LAD, kissing tonsils, and hepatosplenomegaly in addition to these symptoms *

What Si/Sx are common to both Bacterial and Viral Tonsilitis/Pharyngitis?

- Dysphagia - Odynophagia - Sore throat - Fever - Lymphadenopathy - Exudate - Headache - NV, abdominal pain * Note -- exudative tonsils alone are NOT indiciative of bacterial vs viral etiology *

Si/Sx of Specific APGN

- Edema - Hematuria (gross or microscopic) - Hypertension - Proteinuria - Oliguria * 95% of patients will have at least 2 symptoms; 40% will have all 4 symptoms *

Ddx for Peritonsillar Abscess

- Epiglottitis - Retropharyngeal abscess - Ludwig angina - Dental infection - Peritonsillar cellulitis - Infectious mononucleosis

Dx testing for other bacterial etiologies of Tonsilitis/Pharyngitis

- GC throat swab for gonorrhea - Diphtheria swab

Si/Sx of Non-Specific APGN

- General malaise - Weakness - Anorexia - NV

Aortic regurgitation

- High pitched - Diastolic

Si/Sx of Laryngitis

- Hoarsness - Preceding URI - Dysphonia - Odynophonia - Odynophagia * Hoarsness is the most common complaint *

Si/Sx specific to Bacterial Tonsilitis/Pharyngitis

- Lack of coryza - Lack of cough - Sudden onset sore throat - Anterior LAD - Fever (more common vs viral) * Children may experience Scarlet Fever -- strawberry tongue and sandpaper rash *

Function of the salivary glands

- Lubrication to aid in swallowing - Digestive enzymes

Carditis/Valvulitis

- Manifestation of ARF - More common in chldren - Accounts for 30-60% of first ARF - Pancarditis - Mitral valve is most affected - Pericardial friction, rub, murmur * Those who develop at a young age are more likely to have a recurrence; those who have a recurrence are more likely to die *

Sialadenitis d/t Mumps

- Most common - Bilateral parotid enlargement - Prodrome 48 hours before - Complications of deafness, meningitis - Tx -- supportive, bed rest, hydration, sialogogues * Incidence has decreased single 1977 vaccinations *

Epidemiology of APGN

- Most common cause of nephritis in children - More common in developing countries - Occurs in those 5-12 and >60 - More common in males

Epidemiology of Peritonsilar Abscess

- Most common in those 20-40 - GABHS is the most common cause * Other causes include S. aureus, Neisseria, and Corynebacterium *

Sialadenitis d/t HIV

- Most commonly affects parotids - Bilater, tender, erythrematous - Tx -- ARVs and supportive therapy

Work-up for Sialadenitis

- Mumps titer - HIV RNA - Ultrasound - Head CT - Sialadenoscopy

Subcutaneous Nodules

- Rare manifestation of ARF - Associated with carditis - Persists for 1 to 2 weeks - Painless nodules over tendons - Affects the elbows, wrists, ankles, and Achille's tendon

Secondary ppx of Rheumatic Fever

- Relapse is possible - Peni-G 1.2 million units q4w - Duration w/o carditis = 5 years - Duration w/ carditis = 10 years * Recurrence of Rheumatic Fever is more common in those who have had carditis as their initial ARF episode and in children *

Acute Laryngitis

- Resolves in 7-10 days - Usually viral etiology - Other etiologies include: bacterial, GERD, environmental, trauma

Pathogens responsible for Viral Tonsilitis/Pharyngitis

- Rhinovirus -- 20% of office visits - Adenovirus - Coronavirus - Influenza A/B - EVB (mono) - Acute retroviral syndrome * Most cases are caused by Rhinovirus *

Pathogens responsible for Bacterial Tonsilitis/Pharyngitis

- S. pyogenes -- 30% in children - Diphtheria - N. gonorrheae - M. pneumoniae - C. pneumoniae * Most cases are caused by GABHS, these must be treated to prevent complications *

Erythema Marginatum

- Self limiting manifestation of ARF - Affects children - Only 10% of first ARF - Non-pruritic erythrematous - Eruption which occurs on the trunk and upper extremities - Serpiginous * Rare in adults *

Migratory Arthritis

- Self limiting manifestation of ARF - Lasts for about 4 weeks - More common in adults - Accounts for 75% of first ARF - Asymmetric pattern - Migratory, affects the large joints - Knees, elbows, and wrists - Edema and swelling of joints

Si/Sx of Peritonsillar Abscess

- Severe unilateral sore throat - Fever - Ipsilateral ear pain - Fatigue - Irritability - Decreased PO intake - Trismus - Neck pain with movement - Muffled voice (hot potato) - Unilateral fluctuant tonsil - Deviation of uvula - Drooling - Neck swelling - Rancid breath - Erythema and exudate of tonsil

Epidemiology of Rheumatic Fever

- Uncommon in US -- proactive at detection and Tx of GABHS - Average age is 5-15

Interpretation of clinical criterion for GABHS

0-1 symptoms present -- no testing 2-3 symptoms present -- RAPDT All 4 symptoms present -- treat

What are the three pairs of tonsils?

1. Adenoids 2. Palatine tonsils 3. Lingual tonsils * Palatine tonsils are the ones you can visualize and grade as stage 0-4 *

Tx for Bacterial Sialadenitis

1. Augmentin 875 -- BID for 10 days 2. Massage duct 3. Warm compress 4. Sialogogues 5. Abscess drainage if indicated

Dx of Rheumatic Fever

1. Based on Hx and PE 2. Use the Jones Criteria * Must have 2 major, or 1 major and 2 minor symptoms of the Jones Criteria *

How does a Peritonsillar Abscess form?

1. Begins as Tonsilitis/Pharyngitis 2. Cellulitis develops 3. A phlegmon forms and eventually becomes an abscess * Also called a Quinsy *

What are the five manifestations of Acute Rheumatic Fever?

1. Carditis/Valvulitis 2. Migratory Arthritis 3. Erythema Marginatum 4. Syndenham Chorea 5. Subcutaneos Nodules * Note -- these are the major symptoms of the Jones Criteria *

Dx of Peritonsillar Abscess

1. Diagnosis is mostly clinical 2. Head CT w/ contrast 3. Intra-oral ultrasonography * Imaging is typically only done to exclude other pathologies *

Tx of Peritonsillar Abscess

1. Drainage -- needle or I&D 2. Empiric antibiotics 3. Antipyretics 4. Analgesia 5. Single-dose Decadron

What are the four clinical criterion for GABHS?

1. Fever 2. Anterior LAD 3. Tonsilar exudate 4. Absence of cough * The course of action depends on how many of these symptoms are present -- however, this is just a guideline -- you should use your clinical judgement when deciding whether or not to perform a RAPDT *

DOC for Tx of Bacterial/Pharyngitis for those with PCN allergy

1. First-Generation CPN -- Keflex 2. Macrolide -- Azithromycin

Tx of Viral Tonsilitis/Pharyngitis

1. Gargle with warm water 2. Antipyretics 3. Analgesia (DOC is Motrin 600) 4. Rest 5. Single-dose Decadron steroid 6. IV fluids if dehydrated 7. For EBV -- no contact sports 8. For Influenza -- Tamiflu

The Jones Criteria for Dx of Rheumatic Fever

1. Major -- migratory arthritis; carditis/valvulitis; syndenham chorea; erythema marginatum; subcutaneous nodules 2. Minor -- arthralgia; fever; elevated ESR/CRP; prolonged PR-interval * Must have 2 major or 1 major and 2 minor symptoms *

Causes of Viral Sialadenitis

1. Mumps 2. HIV

What are the three parts of the pharynx?

1. Nasopharynx 2. Oropharynx 3. Laryngopharynx

Dx testing for Viral Tonsilitis/Pharyngitis

1. Nothing available for most cases 2. Rapid influenza test 3. EBV -- monospot, CBC w/ lymphs, LFTs * CBC w/ lymphs is the most sensitive for detecting EBV *

What are the three major salivary glands?

1. Parotid 2. Submandibular 3. Sublingual

Tx of Bacterial Tonsilitis/Pharyngitis in adults

1. Peni-G -- 1.2 million units IM 2. Peni-VK 500 -- BID for 10 days * The IM dose is viscous and very painful -- used for non-compliant patients *

Tx of Bacterial Tonsilitis/Pharyngitis in children

1. Peni-VK 250 -- BID/TID for 10 days 2. Amox 50mg/kg QD for 10 days * Amoxicillin is often preferred because it comes in liquid form; increases compliance *

Complications of Tonsilitis/Pharyngitis

1. Peritonsillar Abscess 2. Rheumatic Fever 3. Post-strep Glomerulonephritis

What triad of symptoms is specific to EBV etiology (infectious mononucleosis)?

1. Posterior LAD 2. "Kissing Tonsils" -- grade 3/4 3. Hepatosplenomegaly

Diagnostic work-up for Rheumatic Fever

1. RAPDT 2. Throat culture 3. Anti-Strep titers 4 ESR and CRP -- inflammation 5. EKG -- detection of prolonged PR 6. CXR -- cardiomegaly, CHF 7. Echocardiogram

Dx testing for GABHS

1. Rapid Antigen Detection Test -- 99% sensitive 2. Throat culture -- most reliable, but has a 24-48 hour turnaround * If GABHS is suspected and you get a negative RAPDT, perform a throat culture *

Etiology of Bacterial Sialadenitis

1. Salivary stone -- submandibular 2. Eldery, malnourished -- parotid 3. S. aureus is the most common * Presents with sudden unilateral pain and tenderness with expression of pus *

Two types of APGN

1. Specifc (Classic) 2. Non-specific

Tx of APGN

1. Treat the underlying condition 2. Manage symptooms 3. Restrict salt and water intake 4. Diuretics 5. HTN control 6. Limit activity 7. Dialysis if indicated

Antibiotic Tx for Pertonsillar Abscess

1. Unasyn or Clindamycin IV 2. Augmentin 875 -- BID for 14 days * Choice depends primarily on inpatient vs. outpatient use *

Dx of APGN

1. Urine dip -- hematuria, proteinuria, RBC casts 2. Streptozyme -- measures strep Abs 3. RAPST 4. BUN/Creatining -- renal function 5. Hemolytic component -- C3 6. Renal biopsy

Etiology of Sialadenitis

1. Viral -- most common 2. Bacterial 3. Inflammatory, autoimmune 4. Neoplastic * Pattern can be acute, chronic, or recurrent *

Etiology of Tonsilitis/Pharyngitis

1. Viral -- primarily Rhinovirus 2. Bacterial -- primarily GABHS

Rheumatic Fever

A delayed, non-suppurative sequelae of GABHS pharyngitis involving lesions of the joints, heart, subcutaneous tissue and CNS * Effectss are typically self-limited except for cardiac -- these can be permanent *

What is Scarlet Fever?

A manifestation of Bacterial Tonsilitis/Pharyngitis characterized by strawberry tongue and sandpaper rash -- usually occurs in children

Post-Streptococcal Glomerulonephritis

A post-infectious nephritic seqelae of GABHS

What presentation is pathognomonic for Tonsilitis/Pharyngitis caused by Diphtheria?

Adhererent dense gray pseudomembrane that covers the tonsils * Classic PANCE question! *

Chronic Laryngitis

Any Laryngitis that lasts longer than 3 weeks

How is GABHS etiology diagnosed?

Based on the presence of clinical criterion -- patient recieves a score of 0-4 depending on how many of the criterion they present with

Dx of Laryngitis

Clinical -- based on Hx and PE; rarely nned to visualize the larynx, this can be done by ENT via fiber optic laryngoscopy

Tx of Laryngitis

Conservative and symptomatic -- voice rest, inhaled humidifier

What is the focus of dx and tx of Tonsilitis/Pharyngitits?

Identification of S. pyogenes (GABHS) -- this is to prevent complications of rheumatic fever, and post-streptococcal glomerulonephritis

What is Pharyngitis?

Inflammation of any structure of the pharynx -- including the adenoids and lingual tonsil

Laryngitis

Inflammation of the larynx that can be acute or chronic; vocal cords become edematous * The larynx function in prevention of aspiration and production of voice *

What is Tonsilitis?

Inflammation of the palatine tonsil glands

Are the terms Tonsilitis and Pharyngitis interchangeable?

No -- they are often used interchangeably to refer to inflammation of the palatine tonsils; technically Pharyngitis can include any structures of the pharynx

What is an important counseling point for EBV (infectious mononucleosis)?

No contact sports! -- concern for splenic rupture

Which tonsils can be visualized upon inspection and graded as stage 0-4?

Palatine tonsils -- indicated in Tonsilitis

Tx of Acute Rheumatic Fever in adults

Peni-VK 500 -- BID for 10 days * May also use ASA and corticosteroids *

Tx of Acute Rheumatic Fever in children

Peni-Vk 250 -- BID for 10 days * May also use ASA and corticosteroids *