SORE THROATDr. Amiri

Three anatomically distinct regions of the pharynx

NASOPHARYNXSuperior to the oral cavity.Between the base of the skull and theSoft palate.

Three anatomically distinct regions of the pharynx

OROPHARYNXDirectly visible on examinationLying behind the oral cavityBetween the uvula and hyoidIncluding the vallecula and epiglottis

Three anatomically distinct regions of the pharynx HYPOPHARYNXThe most caudal aspect of the pharynxInferior to the Epiglottis.Terminates where the aerodigestive paths become distinct ,

at the esophagus and larynx.Vocal cords define theInferior pole.

Waldeyer’s tonsillar ringconsists of:

the pharyngeal (adenoids),

tubal,palatine,lingual tonsils.

DIAGNOSTIC APPROACH

Airway Assessment and General Appearance

Evaluation of sore throat begins with a simultaneous assessmentOf the airway and the patient’s general appearance.Examination Begins With Direct Observation.

DROOLING

Inflammation or pathology in the oropharynxOr hypopharynx.sign of an advanced airway process,requiring prompt preparation for detailed evaluation and intervention.

MUFFLED VOICE

Prompts consideration of asupraglottic threat to airway patency.

The floor of the mouth should be visualized , and the submental region palpated as“brawny” induration or tenderness in this area is classically associatedwith Ludwig’s angina.

Stridor

High-pitched noise heard on inspiration indicates a process involving the glottis or infraglottic structures.Stridor indicates a true airway emergency,except when occurring in young children (<10 years old) with croup

Stridor is associated with ominous conditions such as: Epiglottitis, Retropharyngeal Abscess, and Angioedema

General AppearancePatients, particularly children, with significant pain from uncomplicated pharyngitis often have difficulty with oral intake and may become dehydrated.A prolonged fever (greater than 5-7 days) in children may be associated with Kawasaki disease.

Source of Pain Visualized on Examination

Direct visualization of the pharynx is typically the most helpful portion of the encounter in establishing a diagnosis.Lingual resistance may require coaching or stimulation of a gag reflex.If tonsillar erythema or exudates areobserved in a symmetrical distribution and the patient has no signs of airway involvement, Acute Tonsillitis is present .

Viral versus Bacterial PharyngitisCentor Criteria

Systemincorporate components of the history and physical examination to generate an estimate of group A streptococcus (GAS) infection.FEVER,

TENDER ANTERIOR CERVICAL ADENOPATHY,

TONSILLAR EXUDATES

ABSENCE OF COUGH

Viral versus Bacterial Pharyngitis

Modified Centor Score (If Age Was Greater Than 45 Years, 1 Point

Subtracted)prevalence of GAS was

1% with a score of −1 to 0,10% with a score of 1,

17% with a score of 2, 35% with a score of 3 ,

and 51% when the score was 4 or more.

Viral versus Bacterial Pharyngitis

The Distinction BetweenViral And Bacterial Disease Is, However, Largely Academic.With Increasing Emphasis On Symptomatic ReliefAnd Decreasing Emphasis On Eradication Of The Infecting Agent, Treatment, Prognosis, And Follow-up Are Virtually Identical Regardless Of Microbiologic Cause

Special Considerations on History

Patients with human immunodeficiency virus (HIV) are at risk for oral candidiasis or thrush.

In addition, primary HIV infection can manifest with upper respiratory infection (URI)–like symptoms, including acute pharyngitisin up to 75% of cases

Special Considerations on History

Angiotensin-converting enzyme inhibitors predispose patients to Angioedema, and although the lips and face are often visibly edematous, the process can belimited to the tongue, oropharynx, or hypopharynx.

Special Considerations on History

Dental procedures, particularly involving the lower third molars , can be complicatedby postoperative infections, the most potentially seriousof which is Ludwig’s angina.

Special Considerations on History

Pharyngitis in teenagers or young adults with significant cervical lymphadenopathy and fatigue suggests Infectious Mononucleosis caused bythe Epstein-Barr virus.

Ancillary TestingLaboratory testing is of very limited use in the context of acute pharyngitis.Treatment of proven GAS pharyngitis with antibioticsconfers only a modest reduction in the duration of symptoms,

and most western nations have abandoned this approachbecause the inaccuracy and risks of testing and treatment for GASseem to outweigh the benefits in industrialized settings whererheumatic fever tends to be exceedingly rare.

Ancillary Testing

Heterophile antibody testing for Mononucleosis may be consideredin patients with an extended clinical course or treatment failure ;

however, confirmation of this disease is important only toexclude “treatable” causes of pharyngitis and to ensure appropriateadvice regarding contagion, limitations of activity, and so on.

ImagingAlthough radiographic imaging has long been recommended forevaluation of the epiglottis and structures in the hypopharynx,Direct Visualization of the structures of interest by examination ispreferable, providing:definitive diagnosis,assessment of the extent of the threat to the airway ,

and the ability to either plan for or perform intubation.

ImagingIn adults with possible epiglottitis, particularly those with severe symptoms such as Drooling, Distress, or Muffled voice ,

examination via Nasopharyngoscopy at the bedsideor via in the operating room settingis the best approach.

Examination of this sort, however, should occur under a “Double Setup ”,

with availability of and preparation for an emergent rescue airway ,

usually Cricothyrotomy.

Imaging

plain film radiography can be used for screening purposes.Findings on plain film suggestive of Epiglottitis include the “Thumb Sign” (widening of the epiglottis silhouette)and the “Vallecular Sign” (opacification of this space).

ImagingThumb Sign

▪widening of the epiglottis silhouette

Vallecular Sign▪opacification of this

space

ImagingUltrasoundis an emerging technology with applications for thedetection of hypopharyngeal conditions including epiglottitis

ImagingIn children with a sore throat and a Visible Inflammatory Neck Mass, Ultrasounddiagnosis can be definitive .

ImagingIn a child or adult with signs and symptoms of a Deep Neck Infection, such as Retropharyngeal Abscess the most useful imaging modality isComputed Tomography of the neck.CT IS THE DEFINITIVE EVALUATION FOR DEEP NECK INFECTION.in lower-risk patients a normal film

(no widening of the prevertebral space, normal lordotic curve of the spine, and absence of soft tissue air )

can be a useful risk stratification tool.

EMPIRICAL MANAGEMENT

EMPIRICAL MANAGEMENT

Airway compromiseand impending airway compromise, when present ,

must be addressed First.

EMPIRICAL MANAGEMENT

PAIN MANAGEMENT with Acetaminophen orNonsteroidal Anti-inflammatory Drugs (NSAIDs) is the mainstayof care and the Most Important initial step in empirical management.Regimented administration of these agents, rather thanuse of As-needed approaches.Antibiotics have not been shown to besuperior to NSAIDs for symptom reduction and therefore shouldnot be used for this purpose.

EMPIRICAL MANAGEMENTCORTICOSTEROID therapy reduces pain and duration of pain,

0.6 mg/kg (maximum dose 10 mg) of DEXAMETHASONE, orally or parenterally, in a single dose.

OPIOIDis appropriate in select cases of more severe pain ,

but the consideration of opioid analgesia may also indicatea more severe syndrome requiring additional evaluation.

EMPIRICAL MANAGEMENTA Fluctuant Unilateral Peritonsillar Mass should be DRAINED whenever possible.

Drainage in such cases constitutes definitive care.

EMPIRICAL MANAGEMENT

ANTIBIOTICS often are used in cases of unilateral swelling and redness that appearsnot to be fluctuant (i.e., “Peritonsillar Cellulitis”)

For patients with manifestations of Severe, Systemic illness )i.e., those requiring hospitalization or those with impending

airway compromise,( ANTIBIOTIC coverage for streptococcal and anaerobicbacteria may theoretically be helpful, and therefore we recommendantibiotic administration in this setting.

EMPIRICAL MANAGEMENT

Acute pharyngitis should not typically be treated with Antibiotics.The great majority of cases are viral in origin ,

and suppurative complications following streptococcal infection are both easily treated and too rare to justify routine use of antibiotics.Antibiotics should therefore be used

to prevent rheumatic fever and other nonsuppurative complications only in endemic and epidemic settings.

EMPIRICAL MANAGEMENT

It is important to note that adverse events caused by antibiotics are common.Thus for both public health reasons and the prevention of unnecessary harm to individual patients ,

Antibiotics should be avoided in the management ofthis common, mostly self-limited condition.Education Of Patients:

(1 )the self-limited nature of infectious pharyngitis ,(2 )the lack of symptomatic benefit with antibiotics,

(3 )the potential harm of antibiotics (individual and population resistance,

fungal infections in women, rashes, gastrointestinal effects ,

recurrence of pharyngitis, and occasionally dangerousallergic reactions.)