HEENT Lecture 2

inflammation of the nasal mucosa is what?

Rhinitis

______ Rhinitis:IgE-mediated inflammatory response to allergens (e.g., pollen, mold, dust mites, animal dander). Often associated with a history of atopic disease.

Allergic

Infectious:Usually viral; _______ is the most common cause of the common cold.

rhinovirus

_______ (Nonallergic): Nonallergic, noninfectious rhinitis triggered by factors such as temperature changes, strong odors, smoke, or humidity.

Vasomotor Rhinitis

Samter Triad / Aspirin-Exacerbated Respiratory Disease (AERD):

Asthma

Chronic rhinosinusitis with nasal polyps

Aspirin/NSAID sensitivity

ClinicalManifestations RHINITIS

______

Nasal congestion. Clear, watery rhinorrhea

Nasal ______ - especially allergic rhinitis

Postnasal ______

Cough

May have associated eye, ear, or throat symptoms

sneezing
itching
drainage

RHINITIS
PhysicalExamination

Allergic

1. Pale or violaceous, boggy turbinates

2. Clear rhinorrhea

3. Conjunctival findings may occur

4. Allergic ____:dark blue-gray/purple discoloration beneath the eyes

5. Allergic ____:repeated upward rubbing of the nose

6. ____ nasal creasemay develop from chronic rubbing

Viral

Erythematous, edematous nasal mucosa/turbinates

____ (Nonallergic)

Boggy nasal mucosa

Nasal congestion and watery rhinorrhea following irritant exposure

Symptoms are often transient

shiners
salute
transverse
vasomotor

MANAGEMENT OF ALLERGIC RHINITIS

Avoidance of allergen and environmental control; exposure _________.

Intranasal ________: Mometasone, ________, Triamcinolone.

Indications: most effective medication for Allergic rhinitis (moderate to severe or persistent) especially with ______ _______

reduction
glucocorticoids; fluticasone
nasal polyps

MANAGEMENT OF ALLERGIC RHINITIS
Decongestants:
-Intranasal: Oxymetazoline, _________, Naphazoline.
_____: Pseudoephedrine.

MOA: may improve congestion but have ____ effect on rhinorrhea, sneezing, or pruritus.

Should not exceed >3-5 days of intranasal decongestant treatment in order to prevent nasal mucosal dependency and ______ __________ (rebound congestion).

phenylephrine
oral
little

Rhinitis medicamentosa

MANAGEMENT OF _______ RHINITIS
2nd-generation oral ________ (eg, _______, Cetirizine, Fexofenadine), antihistamine nasal spray (eg, Azelastine,Olopatadine)

ALLERGIC
antihistamine; loratidine

MANAGEMENT OF ALLERGIC RHINITIS
Mast cell stabilizers (Cromolyn nasal spray).**************

Acute viral Rhinosinusitis (common cold)

Symptomatic inflammation of the _____ ______ and ______ sinuses. Acute if ___ weeks of symptoms.

The vast majority of cases of acute rhinosinusitis (ARS) are due to ____ infection (common cold) -Rhinovirus, influenza, parainfluenza, & other viruses.

nasal cavity
paranasal
<4
viral

Acute rhinosinusitis
CLINICAL MANIFESTATIONS

_____ ______ & obstruction, clear rhinorrhea, hyposmia (decreased smell). 

Viral symptoms: cough, __, malaise.

Symptoms of Eustachian tube dysfunction: ear pain, fullness or pressure, hearing loss, or tinnitus.

facial pain, pressure or fullness that is worse or localized with ___ ____ & leaning forward;headache, malaise, purulent nasal discharge, fever, nasal congestion, maxillary teeth discomfort, ear pressure or fullness, halitosis.

nasal congestion
HA
bending down

Physical examination Acute viral Rhinosinusitis (common cold):

• ______, _____ nasal mucosa without significant intranasal purulence.

erythematous
engorged

MANAGEMENT - Acute viral Rhinosinusitis (common cold):

_______ management as symptoms are self-limited, with symptoms resolution usually within ___ days. Although symptoms may persist >10 days, there is usually some improvement by day 10. If fever is present, it is usually present early in the illness & disappears within the first 24-48 hours.

supportive
7-10

MANAGEMENT - Acute viral _______ (common cold):

Sinusitis: symptomatic management - _____ are considered the mainstay of therapy for Acute sinusitis (eg, _______, NSAIDs), nasal lavage (saline irrigation), & intranasal Glucocorticoids. Decongestants (promote sinus drainage), antihistamines, and mucolytics.

Rhinosinusitis

analgesic
Acetaminophen

_____

Bacteria secondarily infect and inflame the sinus cavity, with <4 weeks duration.

Acute bacterial infection occurs in only 0.5-2% of episodes of Acute Rhinosinusitis (vast majority of sinusitis is viral).

ARBS

TERMINOLOGY - Acute Bacterial Rhinosinusitis (ARBS

Acute rhinosinusitis-symptoms< ___ weeks.Symptoms usually resolveof improve within __ days.

Subacute rhinosinusitis symptoms for 4-12 weeks

Chronic rhinosinusitis symptoms persist >12 weeks

Recurrent acute rhinosinusitis >/= 4 episodes ofAcute Rhinosinusitisper year, with interim symptom resolution.

4
10

Acute Bacterial Rhinosinusitis (ARBS)
PATHOPHYSIOLOGY

____ ___ ___ :most commonly occurs as a complication of viral infection. Allergic or nonallergic rhinitis, mechanical obstruction of the nose, dental infections, impaired mucociliary clearance (eg, Cystic fibrosis), or with cigarette smoking.

MICROBIOLOGY

The most common bacteria associated with ABRS are ____ ___ & _____ ____ (both make up ~75%), and Moraxella catarrhalis (organisms similar to Acute otitis media). Microaerophilic & anaerobic bacteria associated with dental root infections.

impaired sinus drainage
Streptococcus pneumoniae
H influenzaie

more likely to be bacterial or viral if sxs have been going on > 10 days?
acute bacterial rhinosinusitis

bacterial

Acute Bacterial Rhinosinusitis 

CLINICAL MANIFESTATIONS

Acute rhinosinusitis: facial pain. pressure, or fullness worse with bending down & leaning forward, purulent nasal discharge, nasal congestion or obstruction, headache, fever, ear pressure/fullness, halitosis, hyposmia <4 weeks (symptoms can't distinguish ____ vs ____).

bacterial
viral

Acute Bacterial Rhinosinusitis 

Suggestive of bacterial cause; clinical criteria for diagnosis:oPersistent symptoms that last ≥__ days without evidence of clinical improvement.

oA ____ pattern: ("double worsening") -symptoms initially start to improve but then worsen 5-6 days later.

10
biphasic

PHYSICAL EXAMINATION - _______

Erythema/edema over the involved area; watery or purulent drainage in the nose or posterior pharynx.

sinus tenderness to palpation - in order of frequency -Maxillary > ethmoid > frontal > sphenoid.

Maxillary: most common cheek pain or pressure that can radiate to the upper incisors as well as decreased transillumination of the cheek. Ethmoid: tenderness to the high lateral wall of the nose.

Frontal: pain around the eyes and the forehead. Sphenoid: mid head tenderness.

Acute bacterial rhinosinusitis

DIAGNOSIS - Acute ______ Rhinosinusitis

Primarily a ______ diagnosis. Imaging is not indicated if classic presentation & uncomplicated.

___ is the imaging test of choice if imaging is needed [eg, signs or symptoms suggesting spread of infection beyond the paranasal sinuses and nasal cavity (CNS, orbit, or surrounding tissues)]. Sinus radiographs not usually needed. If ordered, Water's view most helpful radiograph view.

• _______ or aspirate: definitive diagnos is but usually not needed in most uncomplicated cases.

bacterial
clinical
CT
biopsy

Acute Bacterial Rhinosinusitis 

MANAGEMENT

Symptomatic management: _____ (eg, NSAIDs), nasal _____ (saline washes), intranasal ______. 

Decongestants may promote sinus drainage, antihistamines, mucolytics.

analgesics
lavage
glucorticoids

Acute Bacterial Rhinosinusitis 

MANAGEMENT

firstly — _____

Antibiotics:

Indications: symptoms should be present for an extended period of ≥ __ days with worsening of symptoms or earlier if severe.

_______ is often the antibiotic of choice.

Second line: _______ (can be used first-line if ___ allergy). Third-generation oral Cephalosporin (eg, Cefixime, Cefpodoxime) with or without Clindamycin.

Respiratory fluoroquinolones (Levofloxacin, Moxifloxacin) usually reserved to ____ resistance.

NSAIDs
10-14
Amox Clav
doxycycline; PCN
prevent

Chronic ________ 

• Inflammation of the nasal cavity and paranasal sinuses for ≥___ consecutive weeks. 

ETIOLOGIES 

may include ______ (acute, chronic), allergies, & immunological or structural diseases. 

Bacterial: _____ _____ -most common, and anaerobes. Pseudomonas aeruginosa. 

Granulomatosis with polyangiitis [Wegener's granulomatosis] often _____. 

Fungal: _____ -most common fungal cause. Mucormycosis -second most common fungal cause. 

Rhinosinusitis
12
infection
staph aureus
necrotic
aspergillus

CLINICAL MANIFESTATIONS - ______ _______

Similar to Acute sinusitis but duration >/=12 weeks[1] nasal obstruction & congestion, [2] facial pain &/or pressureworse with bending down & leaning forward, [3] mucopurulent nasal discharge, & [4] decreased olfaction.Headache, malaise, fever. Cough may be seen in children. 

Chronic rhinosinusitis

Chronic Rhinosinusitis DIAGNOSIS 

Sinus CT imaging or rhinoscopy or nasal endoscopy with decongestant. Allergy evaluation.

______ testing in all patients(often associated with Asthma, Allergic rhinitis, &/or nasal polyps). 

Biopsy or histology -allows for identification of the organism & may direct appropriate management. 

MANAGEMENT 

1. Depends on _____: The goal of therapy is to promote sinus drainage, reduce edema, & eliminate infection oeg, combination of nasal irrigation, intranasal glucocorticoids (or oral), & ENT follow-up 

2. 
   

3. ______ (if bacterial) with ENT referral
   o____—_____ first line. Alternatives include Clindamycin and combinations of Metronidazole with a second-or third-generation Cephalosporin, Macrolides, or Trimethoprim-sulfamethoxazole. 

4. 
   

allergy
etiology
Abx; amox clav

Mucormycosis (Zygomycosis)

Angioinvasive ______ infection that infiltrates the ______, ____, & ____.
- ________: the fungus rapidly dissects the ____ canals and eyes into the brain. High ____-. 

fungal
sinuses, CNS, lungs
angioinvasion
nasal
mortality

MUCORMYCOSIS

Etiologies: 

Non-Aspergillus fungal causes: _______ species (eg, R. oryzae), _____, & _______.Cunninghamella, Saksenaea, and Apophysomycesmay also be causes. 

Rhizopus
Mucor
Rhizomucor

RISK FACTORS for oral hairy leukoplakia

_____ _____ [DKA & hyperglycemia (most common)], other ________ states(eg, post-transplant, chemotherapy, HIV, heme malignancy), Deferoxamine therapy, iron overload states. 

Diabetes mellitus
immunocompromised

_________

CLINICAL MANIFESTATIONS 

Rhino-orbital-cerebral infections: Sinusitis (facial pain/pressure worse with bending down & leaning forward, headache, malaise,purulent nasal discharge, fever & nasal congestion) with rapid progression to the orbit & brain. Lung involvement also common.

PHYSICAL EXAM:±erythema, swelling, necrosis, or black ______ on the palate, nasal mucosa, or face. 

DIAGNOSIS

Biopsy and histopathologic examination of involved tissue _____ _____ ______ with irregular right-angle (90°)branching. PCR testing of the blood and tissues obtained. 

MRI & CT are often obtained but show nonspecific findings. 

MANAGEMENT

The standard management of Mucormycosis involves early diagnosis, reversal of risk factors and underlying illness (eg, hyperglycemia, acidosis, cessation of immunosuppressive agents when possible), early aggressive surgical debridement, and prompt administrationof IV antifungals.

---

________ first line+ __ surgical debridement of necrotic areas. The lipid formulation of Amphotericin B preferred (allows for higher dose delivery with less nephrotoxicity). 

Second line: Posaconazole or Isavuconazoleare alternatives to or in addition to Amphotericin B.

murcormycosis
eschar
non-septate broad hyphae
IV Amphotericin B
aggressive

Nasal Polyps

• _____ _______ most common cause. May be seen with Cystic Fibrosis. 

allergic rhinitis

CLINICAL MANIFESTATIONS - Nasal Polyps

• Most are ______ findings but if large, can cause nasal obstruction or _____ (decreased smell). 

incidental
anosmia

DIAGNOSIS- Nasal Polyps

Direct visualization: _____ boggy mass on the nasal _____.

May have findings associated Allergic rhinitis eg, pale or violaceous, boggy turbinates & ______ mucosa of the conjunctiva. 

pale; mucosa
cobblestone

MANAGEMENT - NASAL POLYPS

_____ ________ most effective pharmacologic therapy for Nasal polyps 

Functional endoscopic sinus surgery if very large or if medical therapy is unsuccessful. 

intranasal corticosteroids

Epistaxis

Anterior Epistaxis

Source: _______ _______ (anterior septum) IMPORTANT TO KNOW

Common Cause: _____ (nose picking, minor injury)

Presentation: Usually _______ bleeding

Usually self-limiting & managed in outpatient settings

Kiesselbach’s plexus
trauma
unilateral

Management of EPISTAXIS
1 -Direct ______≥15 min, seated, leaning forward

2 -Topical _______(oxymetazoline, _______) - spray on gauze, spray in nose, then pressure

3 -_______(silver nitrate/electrocautery) –only if site ______. only if #2 doesnt work

4 -Nasal _______(balloon, tampon, gauze) if persistent. if #1-3 doesn’t work

Check for ______ or anticoagulant use if recurrent/severe

pressure
vasoconstrictors; phenylephrine
cauterization; visualized
packing
coagulopathy

Posterior Epistaxis

Source: ?????

Presentation: _______ bleeding, blood into posterior ______, often heavier

Sphenopalatine artery branches& Woodruff’s plexus
bilateral; pharynx

Management - Posterior Epistaxis
1. ENT consultation/referral

______ _______ (balloon catheter or specialized packs)

Less common but more _____ than anterior epistaxis

May have to reversecoagulopathy or anticoagulant use

posterior packing
serious

• 32 teeth

• back right is #1

Innervation of Oral Cavity Structures

Superior and inferior _____ nerves (branches of CN __)

alveolar
V

Hard Palate

Front 2/3 of the _____ of the mouth

Bony: maxillae and palatine bones

_____ rests against it

roof
tongue

Soft Palate

____ 1/3 of the roof of the mouth

Movable and ends with the _____

posterior
uvela

Salivary Glands

Function: Secrete saliva

Major Glands:

______ - Anterior and inferior to the ear, overlying the mandibular ramus and masseter muscle

_________ - along the body of the mandible, partly above and below posterior half

________ - smallest, deepest; supplied by sublingual and submental arteries

parotid
submandibular
sublingual

Dental Caries

Overview

Definition: Breakdown of tooth hard tissue caused by ______ and _____ from oral bacteria

enzymes; acids

Dental Caries
Progression:

Enamel Demineralization–Early ______ lesion.

whitespot

Dental Caries

Progression:

Enamel Demineralization–Early whitespot lesion.

Cavity Formation–cavity develops if ______.

Pulpitis–Infection reaches pulp → severe ______.

Pulp Necrosis–______ of pulp tissue.

_____ _______–Infection spreads to surrounding bone.

cavity
toothache
death
periapical abscess

Dental Caries

Progression:

Enamel Demineralization–Early whitespot lesion.
Cavity Formation–cavity develops if untreated.

______–Infection reaches pulp → severe ____.

Pulp Necrosis–Death of pulp tissue.

Periapical Abscess–Infection spreads to surrounding bone.

pulpitis
toothache

Dental Caries

Progression:

Enamel _______–Early whitespot lesion.
Cavity Formation–cavity develops if untreated.

Pulpitis–Infection reaches pulp → severe toothache.

____ _____–Death of pulp tissue.

Periapical Abscess–Infection spreads to surrounding bone.

demineralization
pulp necrosis

Dental Caries

Progression:

Enamel Demineralization–Early whitespot lesion.
Cavity Formation–cavity develops if untreated.

Pulpitis–Infection reaches pulp → severe toothache.

Pulp Necrosis–Death of pulp tissue.

_____ _______–Infection spreads to surrounding ____.

Periapical abscess
bone

Dental Abscess

Dental abscess (general term):A localized collection of pus associated with a tooth or supporting structures -Can be periapicalor periodontal.

Periapical abscess:

Located at the apex of the tooth root.

Cause -Usually due to untreated dental caries(see previous slide)

Clinical Features:Severe, throbbing tooth pain

Tender to percussion

Swelling of gingiva/buccal mucosa near root apex

Possible systemic symptoms if spreading

Treatment:Referral to specialist –Dental or Ora &l Maxillofacial Surgery (OMFS)Root canal, incision & drainage, or extraction

Antibiotics only if systemic involvementor delayed definitive care

Dental Abscess only way to confirm

CT Neck w/ contrast (face and down)

Dental Abscess

Periodontal (gingival) abscess:

Located in the _____ ____ (gingiva, periodontal ligament, alveolar bone).

Cause -Foreign body (e.g., popcorn husk, toothbrush bristle) ortraumatogingiva

Clinical Features:
Localized, painful swelling of gum tissue

No pulp involvement

Tooth typically vital

Treatment:Remove foreign body/irritant

Incision & Drainage

Warm saline rinses

Antibiotics ____ needed unless spreading infection.

supporting tissue
rarely

Dental Pain
Treatment

Analgesics: ibuprofen, naproxen; narcotics if needed

Tooth/regional block for temporary relief

Antibiotics:
Mild: ______ 500 mg QID

Moderate: ____-____ 875 mg BID or Clindamycin 450 mg TID

Severe/immunocompromised: ___ antibiotics

pencillin
amoxicillin-clavulanate
IV

Ludwig’s Angina
- deep ____ infection
- commonly caused from tooth infection; which can work its way down to neck
- deep infection close to airway - susceptible to TRUE _____ EMERGENCY at any time
- ____ spread
- involves multiple _____

neck
airway
rapidly
organisms

Ludwig's Angina

Deep Neck Infection - ______

Most common origin: ______ infections

Abscess
Odontogenic

Ludwig angina: Most common neck space infection

1. Rapidly spreading _____ of the _____ of the mouth

2. Usually from mandibular tooth infection

3. _______: can cause rapid airway compromise → may require surgical airwa

cellulitis; floor
emergency

Ludwig’s Angina
ORGANISMS:

Microbiologic isolates include streptococci, staphylococci,Bacteroides, andFusobacterium

Patients with diabetes may have different flora, includingKlebsiella, and a more aggressive clinical course.

RISK FACTORS: most commonly due to spread of oral flora secondary to ____ ____ _____ & dental infections (second or third mandibular molars). Increased incidence in Diabetes & HIV.

poor dental hygeine

CLINICAL MANIFESTATIONS - Ludwig’s Angina

• Fever, chills, malaise, stiff neck, dysphagia, drooling, muffled voice.

•_____ signs: stridor, difficulty managing secretions, & cyanosis (requires emergent airway management).

Swelling of the tongue can lead to airway compromise.

late signs

PHYSICAL EXAMINATION - Ludwig’s Angina

_____, ______ swelling, "woody" induration, & ______ of the upper neck & under the chin (may have palpable crepitus)

_____ on the floor of the mouth

Edema, erythema and tenderness of floor of the mouth

tender
symmetric
erythema

pus

Ludwig's Angina

DIAGNOSIS

????

CT Neck w/ contrast

MANAGEMENT IF IMMUNOCOMPETENT LUDWIG’S ANGINA

Secure the airway if needed
- Endotracheal tube intubation, _______, tracheostomy

Broad Spectrum IV antibiotics:
- ________ (unasyn) OR Ceftriaxone + Metronidazole 

• OR Clindamycin + Levofloxacin.

• Add _______ if MRSA suspected

Emergent ENT Consultation
Surgical drainage usually required

cricothyrotomy
Ampicillin-sulbactam
Vancomycin

MANAGEMENT IF IMMUNOCOMPROMISED - LUDWIG’S ANGINA

Secure the airway if needed.Endotracheal tube intubation,cricothyrotomy, tracheostomy

Broad Spectrum IV antibiotics: _______+ Metronidazole (OR Imipenem, Meropenem, Piperacillin-tazobactam (zosyn)

Add Vancomycin if MRSA is suspected.

Emergent ENTConsultationSurgical drainage usually required

Cefepime

Acute Pharyngitis & Tonsillitis

____ _______ viruses - most common overall cause of pharyngitis - ______, Rhinovirus, Enterovirus, _____, Respiratory syncytial virus, Influenza A & B, Herpes zoster virus.

viral respiratory
adenovirus
EBV

Acute Pharyngitis & Tonsillitis

Bacterial: ____ Streptococcus (S. _____) most common ______ cause of Pharyngitis.

Group A
pyogenes
bacterial

CLINICAL MANIFESTATIONS - _____ _____ _______

Sore throat worsens with swallowing, pain on swallowing or with phonation.

Cervical lymphadenopathy.

Viral symptoms: cough (not always), hoarseness, rhinorrhea, coryza, conjunctivitis, diarrhea

ACUTE PHARYNGITIS & TONSILLITIS

PHYSICAL EXAMINATION - Acute Pharyngitis & Tonsillitis

May have____ _____ ______ erythema, edema, with or without exudate, cervical adenopathy.

Anterior stomatitis: may be associated with discrete ulcers or vesicles; vesicular or petechial pattern on the soft palate and tonsils.

tonsillar and pharyngeal

DIAGNOSIS - ACUTE PHARYNGITIS & TONSILLITIS

Usually _____ . Most cases of viral pharyngitis require no specific diagnostic testing.

There are 3 notable exceptions where testing may be indicated: [1] suspected Influenza, [2] Infectious mononucleosis, or [3] Acute retroviral syndrome (HIV).

Rapid strep or throat culture may be performed to rule out bacterial cause if suspected.

MANAGEMENT

____ _______ mainstay of treatment oral hydration, warm saline gargles, topical anesthetics, lozenges, NSAIDs. Patients unable to tolerate oral hydration may need IV fluids.

clinical
symptomatic mgmt

Streptococcal Pharyngitis (strep Throat)

__________ (Streptococcus pyogenes)

Rarein children <3 years of age.

Highest incidence of Rheumatic fever in untreated children 5-15 years of age.

Group Aẞ-hemolytic Streptococcus

CLINICAL MANIFESTATIONS - STREPTOCOCCAL PHARYNGITIS

Children >/= ___ years: abrupt onset of sore throat & odynophagia, which may be accompanied by fever, chills, headache, abdominal pain, nausea, vomiting, poor oral intake. Myalgias, malaise.

Not usually associated with symptoms of ____ _______:eg, not associated with cough, hoarseness, rhinorrhea, coryza, conjunctivitis, diarrhea, anterior stomatitis, discrete ulcers, nor vesicles.

3
viral infection

Physical examination STREP THROAT:

________ _____ or exudate, tonsillar exudate, and/or petechiae with markedly enlarged erythematous tonsils & tonsillar pillars, palatal petechiae, inflamed uvula (uvulitis).

Enlarged tender ______ ________ lymphadenopathy.

_______ rash(erythematous, finely papularrash which characteristically starts in the groin and axilla and then spreads to the trunk and extremities, followed by desquamation) may be seen.

anterior cervical
pharyngeal edema
Scarlatiniform rash

Streptococcal Pharyngitis (strep Throat)

DIAGNOSIS: 

Whom NOT to test:

Testing may not be necessary in children & adolescents with manifestations clearly suggestive of viral illness (eg, rhinorrhea, conjunctivitis, cough, hoarseness, anterior stomatitis, discrete ulcerative lesions or vesicles, diarrhea).

In children <__ years of age, routine testing is ____ recommended because both GAS pharyngitis and its complication, Acute rheumatic fever, are ____ in this age group.

3
NOT

rare

Streptococcal Pharyngitis (strep Throat)

Whom to test

Testing for GAS is indicated in children>/= 3 years & adolescents with evidence of acute tonsillopharyngitis (fever, erythema, edema, &/or tonsillar exudates) or scarlatiniform rash on physical examination
o AND _____ __ multiple signs & symptoms of viral infections 

Exposure to an individual with ____ at home/school or high prevalence of GAS in the community & symptoms of GAS. 

If ≥3 Centorcriteria[(1) ____≥38°C, (2) absence of ____, (3) swollen ____ ____ _____,(4_____ exudates/swelling (1 point for each)].

Suspected acute rheumatic fever (ARF) or poststreptococcal glomerulonephritis.

absence of
GAS

fever
cough
anterior cervical lymph nodes
tonsillar

STREPTOCOCCAL PHARYNGITIS

is strep likely if there is a cough?

No

Streptococcal Pharyngitis (strep Throat)

Testing options:

_____ ______ detection test (RADT): _____ _____ test.
o if negative, throat cultures should be obtained, especially in children 5-15y).

Throat ______; ______ diagnosis (criterion standard). Will show all the other organisms

rapid antigen
best initial

culture; definitive

MANAGEMENT - Streptococcal Pharyngitis (strep Throat)

Analgesics eg, NSAIDs, Acetaminophen, or Aspirin for pain. Anesthetics: Lozenges, throat sprays. 

Penicillin _____-____ antibiotic (eg, Penicillin V, Penicillin G, or ______) if testing is positive.

Penicillin allergy:

Cephalosporins (eg, ______), ________ (eg, Azithromycin), Clarithromycin, or Clindamycin 

First-line; Amoxicillin
Cefuroxime
Macrolides

Streptococcal Pharyngitis (strep Throat)

COMPLICATIONS

1. ______ _____(preventable with antibiotics). Severe pharyngitis (give IM Dexamethasone)

2. Acute ___________ (not preventable with antibiotics). Peritonsillar abscess.

3. _______: Pediatric autoimmune neuropsychiatric disorders associated with streptococcus.IF LEFT UNTREATED

Rheumatic fever
glomerulonephritis
PANDAS

Peritonsillar Abscess (Quinsy) and Peritonsillar Cellulitis

Abscess between the palatine tonsil & the pharyngeal muscles, resulting from a complication of _____ _____, tonsillitis or pharyngitis. Most common in adolescents & young adults 15-30 years of age.

strep throat

___________
ETIOLOGIES

Often polymicrobial the predominant species include Group A Streptococcus (S. pyogenes),

Staphylococcus aureus, and respiratory/oral anaerobes (eg, Fusobacterium necrophorum).

Peritonsillar Abscess (Quinsy) and Peritonsillar Cellulitis

Peritonsillar Abscess (Quinsy) and Peritonsillar Cellulitis
CLINICAL MANIFESTATIONS

Ill-appearing, severe unilateral pharyngitis, _____, odynophagia, high fever, malaise, ear pain

Muffled "hot potato" _____, difficulty handling oral secretions (_____), _____ (lockjaw).

dysphagia
voice
drooling
trismus

Peritonsillar Abscess (Quinsy) and Peritonsillar Cellulitis
Physical examination

Swollen or fluctuant tonsil, causing uvula _____ to the ______ side, bulging of the posterior soft palate near the tonsil with fluctuance, inferior and medial displacement of the infected tonsil(s), ______ rise of the uvula, & tender anterior cervical lymphadenopathy. 

• _______ Cellulitis: similar symptoms but not associated with fluctuance or deviation.

deviation
contralateral
asymmetric
peritonsillar

Peritonsillar Abscess (Quinsy) and Peritonsillar Cellulitis

DIAGNOSIS

Primarily a ______ diagnosis without need for imaging or labs if classic. ______ ultrasound if unsure.

????? - imaging of choice if imaging is needed to differentiate Cellulitis vs. Abscess or complications.

clinical
intraoral
CT Neck w/ IV contrast

MANAGEMENT - Peritonsillar Abscess (Quinsy) and Peritonsillar Cellulitis

1. ______ (Aspiration or I&D or tonsillectomy) + antibiotics (if cellulitis)
   o Drainage: needle aspiration (preferred) or incision & drainage (I&D).-caution of carotid artery

2. Abx
   o Oral (____ or _____)
   o Parenteral (Ampicillin-sulbactam or Clindamycin), MRSA suspected: IV Vancomycin; Linezolid is an alternative.

3. _________
   o usually reserved for patients who fail to respond to drainage
   o PTA with complications (egimpending airway obstruction)
   o prior episodes of PTA, or recurrent severe pharyngitis.

Drainage
amox clav; clindamycin
Tonsillectomy

right behind the peritonsillar abscess is the _____ _____ which is why it is INCREDIBLY important to be extermely careful

carotid artery

PREVENTION Peritonsillar Abscess (Quinsy) and Peritonsillar Celluli :Prompt treatment of _____ infections.

streptococcal

Retropharyngeal Abscess 

Deep neck space infection located in the potential space behind the ______ _____ ____.

Most common in children ____ years. In adults often a result of ______ trauma (eg, chicken or fish bones, instrumentation, dental procedures, or dental infection).

posterior pharyngeal wall
2-4
penetrating

Retropharyngeal Abscess 
MICROBIOLOGY:

• Similar to Peritonsillar abscess often _______ (eg, Group A Streptococcus, Staphylococcus aureus, & respiratory anaerobes).

polymicrobial

CLINICAL MANIFESTATIONS - RETROPHARYNGEAL ABSCESS

_____

_______, _______, drooling, sore throat, chest pain, muffled "hot potato" voice, trismus. 

Neck: neck _____ especially with neck extension, ______ (unwilling to move the neck secondary to pain and spasms). 

Chest pain with mediastinal extension

Stridor is uncommon.

Fever
odynophagia; dysphagia
stiffness; torticollis

Retropharyngeal Abscess 

DIAGNOSIS

• ??????? imaging of choice & preferred imaging if suspicion is high.

Lateral neck _____; may be performed if ____ suspicion
o increased prevertebral space >50% of the width of adjacent vertebral body (5-7 cm prevertebral widening at the 2nd cervical vertebra). CAVEAT: will not RULE OUT diagnosis

• In smaller children with respiratory distress, evaluation is often performed in the operating room.

CT Neck w/ IV contrast
radiograph; low

________ ABSCESS

FIRST THINGS FIRST: ____ ____

ENT consultation - Referral to specialist 

Large (>/=___cm) abscess on CT:
o surgical ____ & _____ in the Operating Room

o Antibiotics

Small abscesses (<2.5 cm) & children with no _____ compromise may be observed for 24-48 hours with ______ therapy and no drainage. 

Retropharyngeal
Secure Airway
2.5
incision; drainage
airway; antibiotic

Retropharyngeal Abscess 
MANAGEMENT
Antibiotics: IV _______-______ or _______ (similar to PTA). IV Vancomycin if no response."

Ampicillin-sulbactam
Clindamycin

Retropharyngeal Abscess 
COMPLICATIONS - Airway obstruction, Mediastinitis (due to spread of the infection), sepsis, atlantoaxial dislocation

Acute epiglottis (supraglottitis)

Causes

Foreign immigrants or ______ –mc causeH influenza

Vaccinated –mc cause ______ 

unvaccinated
streptococcus

Acute epiglottis (supraglottitis)

Clinical manifestations –"clinically ____ and in respiratory _____"

Acute – Drooling, _____ & distress 

Inspiratory _____

Dysphagia, odynophagia, 

Muffled "hot" potato voice

______ or sniffing position

Respiratory distress –retractions (using ______ muscles to breathe), choking sensation, dyspnea 

ill; distress

dysphagia
stridor
tripoding

Acute epiglottis (supraglottitis)

Diagnosis

Clinical diagnosis

_________ DIRECT VIEW OF EPIGLOTTIS–definitive diagnosis –visualization of an _______ ____ ___ epiglottis 

Laryngoscopy
edematous cherry red

thumbprint sign on xray indicates what

Acute epiglottis

avoid using WHAT for acute epiglotitis

tongue depressor