approch to patient with Sore throat

Sore throat Done by : Yahyia Al-Abri

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Outline

• Definition and deferential diagnosis • How to approach?• Acute Tonsillitis• Peritonsillar abscess• Viral and bacterial pharyngitis • Adenoid hypertrophy.

Sore throat

Life threatening condition • Epiglottitis • Retropharyngeal abscess • Lateral pharyngeal

abscesses• Peritonsillar abscess• Infectious mononucleosis• Diphtheria

Common conditions• Viral pharyngitis• Bacterial pharyngitis• Infectious mononucleosis• Tonsillitis

Other conditions • Foreign body• Herpetic stomatitis• Irritative pharyngitis

Refers to any painful sensation localized to the pharynx or surrounding anatomy.

How to approach ?

History • Sore throat and respiratory distress

– Epiglottitis, retropharyngeal or lateral pharyngeal abscess, peritonsillar abscess, massive tonsillar hypertrophy

• Fever – Infectious causes

• Fatigue – Particularly when prolonged, characterizes infectious mononucleosis.

• Abrupt onset – pharyngitis, epiglottitis

• Days or weeks.– infectious mononucleosis

• Immunocompromised– Candida albicans

Physical examination • Stridor, drooling, or respiratory distress

– indicate airway obstruction →epiglottitis or retropharyngeal abscess

• An inflamed eardrum – non-oropharyngeal site

• Generalized inflammation of the oral mucosa, in a persistently febrile child– Kawasaki disease

• A foreign body• Significant asymmetry of the tonsils indicates a

– peritonsillar cellulitis

Sore throat



Common conditions• Viral pharyngitis• Bacterial pharyngitis• Infectious mononucleosis• Tonsillitis • Adenoid hypertrophy



Anatomy of tensile

Acute tonsillitis

• Tonsillitis is inflammation of the tonsillitis .

• Group A β-hemolytic streptococci (most common) – Group C or G streptococci– S. pneumoniae, S. aureus, H. influenzae, M.

catarrhalis– EBV

Clinical features

symptoms:– Sore throat– Dysphagia, odynophagia, trismus�– Malaise, fever– Otalgia (referred)

signs:– Tender cervical lymphadenopathy,

• submandibular, jugulodigastric– Tonsils enlarged, inflammation ― exudates/white

follicles.

Investigations

• CBC• Swab for C&S• Rapid Strep Test• Monospot – less reliable in children <2 year

old– infectious mononucleosis

Treatment

Symptomatic – soft diet, ample fluid intake– gargle with warm saline solution– analgesics and antipyretics

Antibiotics:1st line penicillin or amoxicillin (erythromycin if penicillin allergy) x 10 d

Tonsillectomy

• Absolute indications– Enlarged tonsils that cause upper airway

obstruction, severe dysphagia, sleep disorders, or cardiopulmonary complications.

– Peritonsillar abscess that is unresponsive to medical management and drainage documented by surgeon,

– Tonsillitis resulting in febrile convulsions– Tonsils requiring biopsy to define tissue pathology

American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS

Tonsillectomy

• Relative indications– 7 episodes/year in one year or– 5 episodes each/year in two consecutive years or– 3 episodes each/year of tonsillitis in three consecutive

years • Chronic or recurrent tonsillitis in a streptococcal

carrier not responding to beta-lactamase-resistant antibiotics.

• Unilateral tonsil hypertrophy that is presumed to be neoplastic

Contraindication

• Bleeding diathesis• Poor anesthetic risk or uncontrolled medical

illness• Anemia• Acute infection

Sore throat



Common conditions• Viral pharyngitis• Bacterial pharyngitis• Infectious mononucleosis• Tonsillitis



Peritonsillar abscess

• Collection of pus in between tonsil capsule and superior constrictor muscle

• Preceded by peritonsillar cellulitis• Quinsy Triad :

1. Trismus2. Uvular deviation3. Dysphonia

• Other presentation : severe unilateral sore throat, Dysphagia & dribbling, Ipsilateral otalgia and cervical lymphadenopathy

Management

Peritonsillar cellulitis:• Parentral antibiotics

Abscess:• Incision & drainage• Parentral antibiotics

Antibiotic of choice:• Penicillin (most common causative organism

GABS)• Clindamycin

Sore throat






Acute pharyngitis

• Acute pharyngitis is one of the most common conditions encountered in office practice.

• Virus 80%– adenoviruses, enteroviruses, coxsackie, upper

respiratory tract viruses, EBV, CMV• Bacteria 20%– mainly Group A Streptococcus, M. pneumonia

(older children), N. gonorrhea

Epidemiology

• GAS pharyngitis – more common in late winter or early spring– peak incidence at 5-12 year

• viral pharyngitis– All age – all year long

Clinical features of GAS

• Sudden onset of sore throat,• Tonsillar exudate,• Tender cervical adenitis,• fever.• Cough and significant rhinorrhea are usually

absent.

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Investigation

• Rapid antigen detection test – three or more Centor criteria.– Sensitivity from 70 to 90 percent and specificity from 90 to 100

• Throat culture – gold standard– used as a backup test in patients with negative RADT where clinical

concern for GAS or bacterial pharyngitis is still high

• Patient with higher risk (eg, poorly-controlled diabetes mellitus, immunocompromised, on chronic corticosteroids),– throat culture can be obtained at the initial visit.

Treatment

• Patients who do not have GAS – The pharyngitis will resolve in a few – Symptomatic treatment should be offered

• Not improve with symptomatic treatment within five to seven days or who have worsening :– Infectious mononucleosis or primary HIV infection

or a suppurative complication (eg, peritonsillar abscess).

Treatment

• Oral penicillin V is the agent of choice– proven efficacy, safety, narrow spectrum, and low

cost.– 10 days.

• Recurrent GAS infection– Cephalosporin

• Penicillin hypersensitivity,– Cephalosporins (cefuroxime, ceftriaxone)

Sore throat






Adenoid hypertrophy

• Adenoids collection of Lymphoid tissue, located in the post-nasal space.

• Adenoids hypertrophy occurs physiologically in children between the age of 6–10 years, *1

• Atrophy at the age of 16 years *2

2-Yildirim N, Sahan M, Karslioğlu Y;Adenoid hypertrophy in adults: clinical and morphological characteristics.J Int Med Res. 2008 Jan-Feb; 36(1):157-62.

1-Hassmann E, Lipska A, Musiatowicz M:Naive and memory T cells in hypertrophied adenoids in children according to age.Wysocka J, Int J Pediatr Otorhinolaryngol. 2003 Mar; 67(3):237-41

Clinical presentation

• Nasal congestion• Adenoid facies (open mouth, high arched

palate, narrow midface, malocclusion)• chronic or recurrent otitis media • Speech anomalies (hyponasal speech)• Rhinorrhea • sleep-disordered breathing

Diagnosis • Flexible/rigid nasal endoscope• Lateral x-ray of nasopharynx (PNS)

Adenoidectomy

Indications :• Children with recurrent or persistent otitis media • Chronic or recurrent sinusitis• Nasal airway obstructive symptoms .

Contraindication: • Severe bleeding disorder• Recent pharyngeal infection • Short or abnormal palate (cleft or false palate, zona pellucida)

References • www.uptodate.com• www.medscape.com• www.researchgate.net• https://radiopaedia.org/articles/adenoidal-hypertrophy• 1-Hassmann E, Lipska A, Musiatowicz M:Naive and memory T

cells in hypertrophied adenoids in children according to age.Wysocka J, Int J Pediatr Otorhinolaryngol. 2003 Mar; 67(3):237-41

• 2-Yildirim N, Sahan M, Karslioğlu Y;Adenoid hypertrophy in adults: clinical and morphological characteristics.J Int Med Res. 2008 Jan-Feb; 36(1):157-62.

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approch to patient with Sore throat

Health & Medicine