Viral pharyngitis: petechial patches, rhinorrhea; usually does not have tonsillar exudate or adenopathy. Usually rhinovirus. Consider influenza, mononucleosis or acute retroviral syndrome. Mono: caused by EBV, 25% will have false negative monospot. Tx with amoxicillin/ampicillin causes maculopapular rash. CMV/HSV6 can cause similiar presentation. Acute retroviral syndrome occurs in 90% for HIV patients – looks alot like mono.
Group A Streptococcus: headache, nausea, vomiting are common. Center criteria: tonsillar exudates, tender anterior cervical adenopathy, no cough, hx/o fever. Consider abx use if has 3-4 or 2-4 and + test. If only 1 factor, no further testing needed. Tx: IM 1.2million PCN G or 500mg PO BID/TID x 10 days. Macrolide resistance coming up on 10%. Single dose dexamethasone decreased pain and shorter duration of pain in moderate/severe cases. Group C and G Strep don’t cause rheumatic fever and if patient clinically is improving, no need to tx. Tx helps reduce risk of RF and PTA, not for glomerulonephritis.
Peritonsillar Abscess: polymicrobial. Fluid between tonsillar capsule and superior constrictor and palatopharyngeus muscles. Fever, sore throat, trismus, muffled voice, uveal deviation. Tx: I&D or needle aspiration. 90% will be successful treated with simple I&D. 18g needle no more than inserted 1 cm midway between base of uvula and maxillary alveolar ridge just lateral of tonsil. Antibiotics: Augmentin 875mg BID, PCK 500mg QID + Flagyl 500mg QID, or clindamycin 150mg QID. Single dose steroid (Solumedrol 125mg) improved pain and severity. Need 24hr f/u after aspiration.
Epiglottis: use to be H.flu, though with vaccines, now most common causes are strep, staph, virus, fungi. 25% still H.flu type b. 3 Ds: drooling, dysphagia, and distress less common now. Inspiratory stridor. Lateral cervical xrays can help with the ‘thumbprint sign” – swollen epiglottis. Vallecula sign: on lateral neck xray with pt’s mouth closed, trace tongue down to hyoid level, locate epiglottis and airpocket extending nearly to the hyoid – vallecula should be deep and roughly parallel to pharynotracheal air column. Tx: ENT consult and prepare to emergent airway. Humidified oxygen helps decrease risk of sudden airway blockage. Consider cric if needed. Abx: ceftriaxone 2g IV or Ampicillin-sulbactam, cefoxtaxime, piperacillin-tazobactam. Steroid help decrease edema (solumedrol 125mg).
Retropharyngeal Abscess: in kids related to abscessed lymph node. In adults, usually extension of something like Ludwig’s angina so usually extends into mediastinum. Strep viridans/pyogenes, though usually PMN/anaerobes. Sore throat, fever, torticollis (twisting neck) and dysphagia, neck extended. CT soft tissue neck imaging study of choice. Lateral cervical xray (deep inspiration with neck extended) will show thickening/protrusion of retropharyngeal wall (should be <7mm at C2, <22mm at C6 in adults and < 14mm in kids). Tx: ENT consult (usually requiring surgery) and IV abx (clindamycin 600-900mg, cefoxitin 2g, Unasyn or Zosyn.
Lemierre’s Syndrome: oropharynx infection, + blood cx/bacteremia, IJ thrombosis and 1 metastatic infection. Tonsillitis that turns septic. Diagnosis by phlebitis of internal jugular vein. Caused by Fusobacterium necrophorum. Tenderness in sternocleidomastoid region of neck. Pulmonary involvement in 80% of cases.
Ludwig Angina: rapid cellulitis/infection of the submental, sublingal and submandibular spaces bilaterally. Usually due to dental infection. Upper neck/floor of the mouth swelling. Usually requires definitive airway since systemic abx can sometimes take a week to fully resolve the swelling. Ask patient to extend tongue past vermillon border of upper lip – if able to do this, unlikely sublingual space involved.
Neck Masses: Squamous cell carcinoma is most common cause of cancer in the neck – RF include smoking/alcohol use. Mucoceles and mucus retention cysts can form. Ranula: sublingual mucus retention cyst. Plunging ranula occurs when it extends into mylohyoid muscles. In adults > 40yo, lateral neck masses that persist > 6 weeks are malignant in 75% of cases. Branchial cleft cyst: painless fluctant masses anterior to anterior border of sternocleidomastoid muscle. Enlarge after sinus infection.
Posttonsillectomy Bleeding: 1-6% after tonsillectomy. Half require surgical intervention. Most bleeding occurs at day 5-10 post-op due to sloughing of fbrinious debris. Higher risk the older you are. Keep head elevated, consider apply gauze pack with soaked thrombin/1% epi. Consider running suture through pack and taping to face to make sure patient doesn’t aspirate the gauze. Can also consider silver nitrate.
Recurrent respiratory papillomatosis: earlier in very young or in your 20s (due to STD). Due to HPV 6/11. Wartlike lesions without ulceration near glottis. Can cause stridor/hoarseness.
Angioedema: 4 types: 1) Hereditary angioedema caused by C1 esterase inhibitor deficiency. AutoDom. Diagnosed by measured C1 esterase inhibitor level. Cinrye, C1 inhibitor approved for use for prophylaxis for known hx. FFP can help though some pts can get more edematous with FFP. ACE inhibtors and estrogens can increase risk of attacks. 2) Angiotensin-converting enzyme inhibitor-induced angioedema: usually within first month of use. More common in blacks. Medication causes increased bradykinin. Other types: immunoglobulin E-mediated type I allergic reaction and idiopathic. Tx: for severe cases, give epi 1:1000 IM 0.3mg max or consider giving racemic epi at same dose. Give every 15-20min. Also give benadryl 25-50mg and high dose steroid (for later rebound swelling). Isolate uvula edema can be early sign of angioedema. If mild, given decadron 4mg IV/PO as single dose.
Tintinalli, Seventh Edition, Chapter 241: Infections and Disorders of the Neck and Upper Airway