throat issues
A young woman complains of two months of pain and swelling under her tongue. It occurs with every meal, and typically subsides within an hour. On examination, you appreciate submandibular edema and warmth. Palpation under the jaw reproduces pain. While her tongue is lifted up, you see an excess of saliva and mucopurulent discharge coming from Wharton's ducts. Which of the following is the most likely diagnosis?
sialadenitis Stones in the salivary ducts are called sialolithiasis. The exact cause is unknown. Partial obstruction leads to increased saliva production, pain, and swelling during eating. Symptoms are usually transient and resolve within an hour, but often recur with each meal. When a stone completely obstructs a duct it can cause sialadenitis which is marked by constant pain, swelling and infection. Complications include scarring with stenosis and fistula formation. Diagnosis is clinical but is aided by radiographs (low yield) and CT scan. Treatment is supportive with sialogogues and local massage. If persistent, stone removal is necessary via extracorporeal shock wave lithotripsy. Antibiotics are prescribed for signs of infection.
A 42-year-old woman complains of two days of pain and swelling in the right submandibular area. She complains of dry mouth and worsening of the swelling and pain during mealtime. Which of the following is the first-line treatment for this condition?
sialogogues This patient has obstructive sialoadenitis, which occurs from outflow obstruction by a stone or calculus in the salivary gland or duct. The submandibular location is most commonly involved because it is has more viscous secretions and runs an uphill course. Patients with sialolithiasis note xerostomia (dry mouth) along with increasing swelling and pain during mealtime. Most salivary stones pass spontaneously. To aid in passage, patients should be started on sialogogues (e.g., sour lozenges), which stimulate salivary secretions and help expel the stone.. Another option to treatment is massage of the gland
A 46-year-old woman presents with unilateral facial pain that began yesterday. Physical exam reveals right parotid gland swelling with overlying erythema and warmth, trismus, and purulent ductal discharge. Which of the following is the most likely causative pathogen?
staph aureus
A 5-year-old boy presents to the emergency department with a sore throat. On physical examination, he has pharyngeal erythema, tender cervical adenopathy, and bilateral tonsillar exudates. His rapid strep screen is positive. His mom reports history of a severe penicillin allergy. Which of the following medications is the most appropriate therapy at this time?
Clarithromycin, cephalexin, azithromycin, and clindamycin are all suitable alternatives.
Which of the following is most correct regarding treatment of Group A Strep pharyngitis?
treatment prevents rheumatic fever but not glomerulonephritis
- bacterial tracheitis - croup - epiglotittis
- bacterial tracheitis: Bacterial tracheitis is a rare but life-threatening disease with a peak incidence at 3 to 4 years of age. It is caused by severe inflammation of the tracheal epithelium and the production of thick mucopurulent secretions. The lining of the trachea forms a loosely adherent membrane that sloughs into the lumen. It may be confused clinically with croup and epiglottitis. The condition typically begins with a viral prodrome similar to croup (barky cough, stridor, rhinorrhea) that intensifies to the point that the child appears toxic and may exhibit signs of airway obstruction. Features that suggest bacterial tracheitis (rather than croup or epiglottitis) include a viral prodrome followed by acute decompensation; symptoms atypical for croup (high fever, cyanosis, and severe distress); a poor response to traditional croup treatment (aerosolized epinephrine and steroids); and the presence of both inspiratory and expiratory stridor. A soft tissue neck radiograph is nonspecific and may reveal subglottic narrowing, a ragged edge of the usually smooth tracheal column, and a hazy density within the tracheal lumen. - croup: most common cause of upper airway distress and obstruction in childhood with a peak incidence at 2 years. It is associated with a barky (seal-like) cough with stridor that is worse with agitation. A patient with moderate croup may be fussy but alert, interactive, and usually comforted by parents. High fever is uncommon - epiglotittis: rarely seen in vaccinated children. It is also an invasive bacterial disease that causes inflammation and edema of the epiglottis, aryepiglottic folds, and surrounding supraglottic tissues. As these structures become inflamed and distended, they protrude downward and over the glottis opening. A lateral neck radiograph typically shows an enlarged epiglottis ("thumbprint sign").
A 14-year-old girl present with a pruritic rash since yesterday. She began amoxicillin for acute pharyngitis three days ago. She still complains of sore throat, pain with swallowing, fatigue, and cervical lymphadenopathy. Physical exam reveals a diffuse, morbilliform rash. Which of the following is the most appropriate test to order?
A monospot (heterophile monospot) should be considered in this patient because of the history of pharyngitis and the development of a rash with amoxicillin treatment. Mononucleosis presents with exudative pharyngitis, generalized adenopathy, and prolonged fever that is sometimes mistaken for strep pharyngitis. Signs and symptoms include a two to three day prodrome of malaise and anorexia followed by a febrile illness. Splenomegaly is present in about 50-75 percent of patients. Initiating treatment with amoxicillin will cause the patient to develop a characteristic pruritic, morbilliform rash in response to the antibiotic. Mononucleosis is caused by an infection with the Epstein-Barr virus (EBV); therefore antibiotics are not helpful. Treatment is supportive and includes rest, analgesics, antipyretics, and hydration.
A 26-year-old man presents to an express care center with concerns for hoarseness. He states that has been experiencing clear rhinorrhea, a mildly sore throat, and a slight cough for the last few days. He became more concerned this morning when he lost his voice. Which of the following is the most likely etiology for the diagnosis?
A viral etiology is the most common cause of acute laryngitis. Acute laryngitis secondary to a viral illness is typically associated with hoarseness, rhinorrhea, cough, and mild sore throat. It is self-limiting and usually lasts less than three weeks. Moraxella catarrhalis, Haemophilus influenzae, and Streptococcus pneumoniae are less common causes of acute laryngitis. Patients should be counseled to use humidified air, hydration, and vocal rest to improve symptoms. Individuals who strain to speak through the condition can cause damage to the larynx which can result in permanent vocal changes. Antibiotics are typically not warranted. Systemic glucocorticoids can be used to reduce laryngeal inflammation and improve vocal quality; however, the risks versus benefits of administering this medication should be weighed carefully.
A 39-year-old man presents with a worsening sore throat and difficulty swallowing for the past day. He is dyspneic. Palpation of the neck reveals bilateral cervical adenopathy and pain with gentle palpation of the anterior neck. A soft tissue lateral neck radiograph demonstrates a "thumbprint" sign. Which of the following is the most appropriate pharmacotherapy?
IV Ceftriaxone Epiglottitis, or supraglottitis, is inflammation, usually from infection, of the epiglottis or entire supraglottic region. Symptoms include rapid onset of fever, odynophagia, dysphagia, dyspnea, and inspiratory stridor. Patients may find that sitting forward with the neck extended is more comfortable than lying supine. Diagnosis can be confirmed with a soft tissue lateral neck X-ray or a CT scan of the neck, but these diagnostic imaging studies are often not necessary to make the diagnosis.
A 46-year-old man presents with two days of worsening dysphagia. He now is complaining of dyspnea that is worse with a supine position. Physical exam reveals bilateral cervical lymphadenopathy and pain with gentle palpation of the upper trachea. His heart rate is 112 beats/minute, temperature is 102.3°F, and oxygen saturation is 94% on room air. Which of the following findings is most consistent with the suspected diagnosis?
Inspiratory stridor that is typically softer and lower pitched than croup is consistent with epiglottitis. Epiglottitis, or supraglottitis, is an inflammation, usually from infection, of the epiglottis or entire supraglottic region. Before the introduction of the vaccination against H. influenzae, epiglottitis was most commonly seen in children and was an important cause of life-threatening airway obstruction. Now, it most commonly is seen in adults with a mean age of 46 years. Symptoms include odynophagia, dysphagia, dyspnea, and inspiratory stridor. Patients may feel more comfortable sitting forward with the neck extended. Diagnosis can be confirmed with a soft tissue lateral neck X-ray or a CT scan of the neck; however, these diagnostic imaging studies are often not necessary to make the diagnosis. Treatment requires immediate consultation with an otolaryngologist and preparations must be made for immediate intubation. Humidified oxygen, heliox, intravenous hydration, and intravenous antibiotics are all treatment options. Appropriate pharmacologic treatment includes intravenous ceftriaxone and methylprednisolone.
A 44-year-old previously healthy woman presents with unilateral facial pain that began several hours ago. She now has swelling in the left side of her face and tenderness in this area. Physical exam reveals left-sided parotid gland swelling, trismus, and purulent ductal discharge. Which of the following is the best pharmacologic treatment?
Intravenous nafcillin is the first-line treatment recommended for acute suppurative sialadenitis. In addition to intravenous antibiotics, treatment includes warm compresses and analgesics, massage of the gland, sialogogues, improved oral hygiene, and rehydration. Most patients recover completely; however, higher mortality rates are seen in immunocompromised and debilitated patients.
A 6-year old girl presents with one day of fever, mild sore throat, abdominal pain, and two episodes of non-bloody, non-bilious emesis. Abdominal exam is significant only for mild epigastric tenderness, but exudative pharyngitis and bilateral anterior cervical lymphadenopathy are noted. What is the most likely diagnosis?
Patients with Group A Strep pharyngitis may present with primary complaints of vomiting, abdominal pain, and fever with mild or no complaints of sore throat. A physical examination is essential to making the correct diagnosis. Children with Group A Strep pharyngitis classically have exudative pharyngitis, bilateral tender anterior cervical nodes, and a lack of nasal congestion or cough. Viral upper respiratory infections (D) are a common cause of pharyngitis and anterior cervical lymphadenopathy. However, viral upper respiratory infections typically present with nasal congestion and cough. Moreover, the typical viruses that cause upper respiratory infection (ex. adenovirus) are more likely to cause diarrhea than vomiting.
A 35-year-old man presents to the emergency department with pain and swelling under the tongue for the last 3 days. The pain worsens when eating. Physical exam reveals normal range of motion of the jaw and tongue. The oropharynx is normal. At the base of the tongue, there is a tender, firm, mobile mass without purulent discharge. There is no erythema or swelling of the external, submandibular region. Which of the following is the most appropriate next step in management?
The patient has a salivary gland stone in the submandibular duct (a.k.a. Wharton's Duct). Salivary stones (sialolithiasis) are formed from crystals of calcium phosphate and hydroxyapatite. The exact etiology is unknown, but relative stagnation /or partial obstruction of saliva or both is thought to allow precipitation of the crystals. Patient factors which predispose to stone formation include dehydration, diuretics, anticholinergics, trauma, gout and smoking. There are three major salivary glands, the submandibular, parotid and sublingual glands. There are also numerous, minor salivary glands which are located in the buccal, labial, lingual, and palatal mucosa of the oropharynx. Stones can form in any of the salivary glands or ducts., although most are located in the submandibular gland. This duct is thought to be more susceptible to stone formation because the saliva formed there is more viscous, the duct is longer and more tortuous and the saliva must flow against gravity in this location. Patients with sialolithiasis present complaining of pain and swelling in the area of the involved duct or gland. The pain is usually exacerbated by eating or the thought of eating as this causes increased secretion of saliva and increased pressure in the duct and gland. Palpation of the involved gland reveals a small, rock hard mass which may be smooth or irregular. There should not be fever, chills or purulent discharge from the gland as this would indicate an infection of the gland, called sialoadenitis. Patients should be instructed to suck on hard candies as often as possible as this increases salivation (sialogogues). They should discontinue medications which have anticholinergic side effects. Physicians should instruct patients on how to massage or "milk" the duct in the direction of duct drainage. NSAIDs can be recommended for pain control.
A 20-year-old man presents with a sore throat that has been worsening over the last two days. Physical exam reveals trismus and a muffled voice. Exam of the posterior oropharynx reveals a swollen uvula that is displaced toward the left. There is inferior and medial displacement of the right tonsil. His temperature is 102.8°F. A needle aspiration is performed. Which of the following is the most likely causative pathogen?
This man has peritonsillar abscess caused by Group A Streptococcus; happens as a complication of Group A Strep throat It is most common in young adults in the spring and winter months and symptoms include trismus, muffled voice, sore throat, and dysphagia. Patients sometimes complain of pain radiating toward the ear on the affected side. Physical exam reveals displacement of the tonsil and uvula, lymphadenopathy, and drooling. The diagnosis can be confirmed with a needle aspiration of the purulent material. If the diagnosis is uncertain, a CT scan of the neck will demonstrate a fluid collection. Treatment depends on clinical symptoms, but typically includes needle aspiration or incision and drainage. Appropriate antibiotic treatment includes ten days of amoxicillin/clavulanic acid or clindamycin.
A 25-year-old man with a history of hereditary angioedema presents with swelling of the tongue and lips for 30 minutes. The patient appears to have difficulty breathing if he lies flat but is comfortable when sitting up. Visualization of the mouth and posterior pharynx is completely obstructed by the tongue. What management should be initiated?
This patient presents with hereditary angioedema. Angioedema reactions, in general, are similar pathophysiologically to urticaria but involve deeper dermal and subcutaneous tissues. However, when angioedema presents in the absence of hives, it suggests involvement of bradykinin as opposed to mast cell degranulation. Hereditary angioedema (HAE) is due to a deficiency of C1 esterase inhibitor. In cases of severe angioedema, fresh frozen plasma (FFP) has been used with successful results. FFP replaces C1 esterase inhibitor and contains kininase II, which breaks down bradykinin. Angiodema is different from hives and anaphylaxis; Patient will be complaining of swelling of the tongue, face, and neck in the absence of hives. Drug induced ACE inhibitors are the most common. The hereditary form is autosomal dominant. With angioedema, vasodilation and edema occur in the deeper dermal layers causing swelling but often no superficial skin changes in color. Signs include edema of the airway, face, genitals and extremities. Abdominal pain associated with nausea, vomiting and diarrhea may also occur Epinephrine (B), diphenhydramine (A) and methylprednisolone (D) are effective in the treatment of allergic reactions and anaphylaxis but not in the treatment of angioedema. Epinephrine's alpha-agonist effects increase peripheral vascular resistance, decrease vascular permeability and reduce systemic hypotension. Beta-agonist effects lead to bronchodilation and increased cardiac inotropy and chronotropy. Diphenhydramine is a histamine 1 receptor blocker and blocks the peripheral effects of histamine. Steroids, like methylprednisolone, stabilize mast cells leading to decreased release of inflammatory mediators involved in allergic reactions.
A previously healthy teenage woman presents with a painful mouth ulcer. Examination reveals two discrete ulcers on the buccal mucosa, one 0.5 cm in diameter, and the other 0.8 cm in diameter. She denies a family history of mouth ulcers. Ear, eye, nose and genital examination reveals no abnormalities. Serum laboratory testing is negative for antinuclear antibodies and HLA-B27 antigen, but positive for microcytic anemia. Which of the following is the most likely diagnosis?
apthous ulcer Although aphthous ulcers have an unclear etiology, they are a common painful condition. There are some risk factors that are associated with aphthous ulcers, such as family history, stress, chemical or physical trauma, food sensitivity and infection. Three types exist: minor, major and herpetiform. Treatment includes tetracycline, minocycline, over-the-counter benzocaine preparations, viscous lidocaine and topical triamcinolone.
Describe each - bacterial tracheitis - epiglottis
bacterial tracheitis: affects children ages three to five years and presents with rapid progression of fever, barky cough and stridor. While this presentation may be somewhat similar to croup, these patients are often toxic-appearing. Aggressive airway management and intravenous antibiotics are the mainstays of management. epiglotittis: present with sore throat, drooling and fever. On a lateral soft tissue neck radiograph, the inflamed, swollen epiglottis will appear as a "thumbprint sign."
Tranismitted by saliva fever and malaise exudative pharyngitis cervical lymphadenopathy rash following amoxacillin
epstein barr virus
A 23-year-old woman presents with sore throat and trismus. Physical exam reveals a swollen uvula that is displaced to the right of the midline and medial displacement of the left tonsil. A needle aspiration is performed. Which of the following is the most appropriate pharmacotherapy?
oral amoxacillin clavulanate Oral amoxicillin/clavulanic acid is the most appropriate pharmacotherapy of those listed in treating the infection typically associated with a peritonsillar abscess (PTA). Group A Streptococcus is the most common cause of a PTA, which is a fluid collection between the tonsillar capsule and the superior constrictor and palatopharyngeus muscles. It is most common in young adults in the spring and winter months and symptoms include trismus, muffled voice, sore throat, and dysphagia. Patients sometimes complain of pain radiating toward the ear on the affected side. Physical exam reveals displacement of the tonsil and uvula, lymphadenopathy, and drooling. The diagnosis can be confirmed with a needle aspiration of the purulent material. If the diagnosis is uncertain, a CT scan of the neck will demonstrate a fluid collection. Treatment depends on clinical symptoms, but typically includes needle aspiration or incision and drainage. Appropriate antibiotic treatment includes ten days of amoxicillin/clavulanic acid or clindamycin
A 10-year-old boy presents with a two day history of sore throat, fever and headache. He denies cough, significant rhinorrhea or head congestion. Physical exam is remarkable for enlarged, erythematous tonsils with a pharyngeal whitish exudate. He has marked lymphadenopathy over his anterior and posterior cervical lymphoid chain. What is the most likely diagnosis?
strep pharyngitis "Strep throat," caused by Group A Beta-hemolytic streptococcus (Streptococcus pyogenes or GAS), is a common etiology of acute pharyngitis especially in children ages 5 to 15. It is characterized by inflammation of the pharynx or tonsils (tonsillar exudates) associated with symptoms of fever, malaise and sore throat, as well as the absence of other URI symptoms such as nasal congestion and cough. Cervical lymphadenopathy is often found on exam, as is a whitish exudate over the pharynx and tonsils. A rapid streptococcal antigen test is recommended in order to determine if treatment with antibiotics is warranted, as other conditions which do not require antibiotic treatment may mimic streptococcal pharyngitis. A throat culture to rule-out GAS infection is recommended in children if rapid antigen testing is negative (90% sensitivity), in order to limit transmission and prevent complications such as rheumatic fever. Other complications of strep throat may include acute glomerulonephritis, peritonsillar abscess, bacteremia, sinusitis and pneumonia. Penicillin-based antibiotics (benzathine penicillin IM or oral penicillin VK) are the treatment of choice. For penicillin allergic patients, azithromycin is an alternative.
A 62-year-old man presents to the emergency department with right sided facial pain. His pulse is 99 beats/min, blood pressure is 108/62 mm Hg, and temperature is 102.1°F. On exam, there is erythematous, pre-auricular swelling that extends to the angle of the mandible. The area is exquisitely tender and purulent material can be expressed from Stensen's duct. Which of the following is the most likely diagnosis?
supporitive parotitis Staphylococcus aureus is the most common cause of acute bacterial parotitis. Suppurative parotitis most commonly occurs in the setting of debilitation, dehydration, advanced age, and poor oral hygiene. Other risk factors include ductal stones, extensive teeth cleaning, anticholinergic drugs, malnutrition, and oral cavity neoplasms. The parotid glands are located on the lateral sides of the face, between the external auditory canal, the superior angle of the mandible, and the inferior border of the zygomatic arch. Much of the gland lies superficial to the masseter muscle. Acute suppurative parotitis can be life-threatening due to potential spread to deep fascial spaces of the head and neck. Patients with suppurative parotitis typically present with acute onset of erythematous, painful swelling of the cheek. They may also complain of trismus and dysphagia. On physical exam, purulent material can often be expressed from Stensen's duct. Fluctuance is uncommon. Fever, chills, and other signs of systemic toxicity are generally present. tx: nafcillin + MTZ or ampicillin/slbactam
A healthy 22-year-old woman presents with a 3-day history of sore throat. She reports nasal congestion and a dry cough. Vital signs are BP 115/60, HR 88, RR 14, and T 99°F. On exam, her pharynx is erythematous without exudates and there is no lymphadenopathy. Which of the following is the most appropriate next step in management?
supportive care The patient presents with pharyngitis. Most cases of pharyngitis are viral in origin. However, the most common bacterial causes include Streptococcal pharyngitis which is caused by Group A Beta-hemolytic Streptococcus. The Centor criteria are often used to help identify which patients with pharyngitis should undergo further diagnostic testing and treatment. The criteria 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% for streptococcal pharyngitis. This patient has a Centor criteria score of 0. Therefore, no further testing or treatment is recommended other than supportive care.
PE will show a firm, erythematous swelling of the pre- and postauricular areas that extends to the angle of the mandible
supportive parotitis
A 22-year-old man presents with 4 days of bilateral facial enlargement and fever. These symptoms began insidiously and have persisted. Examination reveals generalized warmth and tenderness just anterior to the ears near the temporomandibular joints. He has not had any recent travel, but he did live in Africa between the ages of 3 and 7. Which of the following is the most likely diagnosis?
viral parotitis Acute viral parotid gland infection is called parotitis, or mumps. Transmission of the paramyxovirus is by direct spread of oropharyngeal secretions. Mumps is classified by nonprogressive parotid gland pain and swelling which usually resolves within nine days of onset. Associated symptoms include fever, malaise and anorexia. Bilateral involvement is usual. Mumps is rare in developed countries because of immunization at one year and 4-6 years of age. Outbreaks are possible however in teenagers and young adults who never received the second vaccine, which is possible in people who lived abroad between the ages of 4 and 6 years. Symptoms include local pain, erythema and edema, ipsilateral otalgia and uncomfortable chewing. Bacterial parotitis (B) is caused by ascending bacteria from the mouth. It most frequently occurs in the elderly or chronically ill. A key to distinguishing a viral etiology over a bacterial etiology is that viral parotitis is typified by a nonprogressive and short-lived course in otherwise healthy, and typically younger, adult.
A three-year-old girl is brought to the clinic by her mother due to complaints of a sore throat and decreased oral intake. She has had elevated temperatures with a Tmax of 99.9°F. She has also had nasal congestion, occasional cough, and general malaise. On examination, the child appears tired but non-toxic and well-hydrated. Her conjunctiva are mildly injected bilaterally. Clear-to-white nasal discharge is present in the bilateral nares. Her oropharynx is erythematous with 2+ tonsils and cobblestoning of the posterior pharynx. She has shotty, non-tender bilateral cervical adenopathy. Her lungs are clear to auscultation. Her heart rate is regular with no murmurs, rubs, or gallops. Her abdomen is soft, non-tender, and non-distended. Her extremities are warm and well-perfused. What intervention is indicated?
viral pharyngitis - treatment with supportive care The child's presentation is most consistent with viral pharyngitis. Viral pharyngitis is the most common cause of sore throats. She has multiple signs and symptoms of upper respiratory infection, including a low grade fever, conjunctival injection, nasal discharge, sore and erythematous throat, posterior pharyngeal cobblestoning, and shotty cervical adenopathy. Rapid streptococcal antigen testing (C) is used to diagnose Streptococcal pharyngitis. The presentation of Group A Strep pharyngitis typically includes a fever, exudative pharyngitis, and bilateral cervical lymphadenopathy. Other suggestive features include palatal petechiae, an inflamed uvula, and a scarlatiniform rash. A cough is classically absent. This child's age, as well as her lack of fever and exudate and conjunctivitis make Streptococcal pharyngitis unlikely, and thus testing is unnecessary. this child's concomitant conjunctivitis, sore throat, and non-tender adenopathy make Streptococcus less likely than a viral upper respiratory infection.
