Approach to Sore Throat
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Transcript Approach to Sore Throat
APPROACH TO SORE THROAT
& PERITONSILLAR ABSCESS
MR 8/3/09
J.Chen
General Approach
R/O Life Threatening causes
R/O non-infectious causes
Determine whether or not treatment is required
Life Threatening Causes
Airway Compromise
Sitting in sniffing position
Toxic appearing
Drooling
Voice change
Fever
Life Threatening Causes
Epiglottitis
Retropharyngeal abscess
Peritonsillar abscess
Significant tonsillar hypertrophy
Diphtheria
Management
NPO
Supplemental O2
Consider airway adjunct (NP airway)
IV access (if pt can tolerate)
Anesthesia
Non-infectious Causes
Environmental
Irritative
pharyngitis
Smoke
Dry
air
Chemicals
Trauma
Burns
Foreign Body
Retained
Laceration
to posterior pharynx
Non-infectious Causes
Allergic/Inflammatory
Allergens
causing chronic postnasal drip
Eosinophilic esophagitis
Tumors
Rare
in pediatric population
Infectious Causes
Bacterial:
Group
A Beta Hemolytic Streptococcus
Group C Strep
Group G Strep
Neisseria Gonorrhoeae
Tularemia
Chlamydia
Mycoplasma
Diptheria
Infectious Causes
Viral Causes
Adenovirus
Influenza
Parainfluenza
Epstein-Barr Virus
Cytomegalovirus
HIV
Stomatitis
HSV
Coxsackievirus
History
Drooling?
Voice Change?
Fever?
Exposure?
Foreign Body?
Headache?
Abdominal Pain?
URI symptoms?
Immunization status?
Sexual activity?
Physical Exam
General Appearance
Drooling
Stridor
LAD
Pharyngeal erythema/exudate
Asymmetric Enlargement of tonsillar pillar
Deviation of uvula
Cobblestoning of posterior pharyngeal mucosa
Vesicular or ulcerative lesions in oropharynx
Laboratory Aids
Throat Culture
Lateral Neck X-ray
CBC
Monospot
Peritonsillar Abscess
Suppurative infection of the tissues adjacent to the
palatine tonsil
Most common abscess of the head and neck
Background
Gradual onset
Progression from peritonsillar cellulitis
2 mechanisms
Direct
spread of inadequately treated bacterial
tonsillitis
Abscess formed in a group of salivary glands (Weber
glands) in the supratonsillar fossa
30 per 100,000 person/year (25-30% Pediatric)
Cause
Bacterial Growth often polymicrobial
Aerobic organisms
Group A beta-hemolytic streptococcus pyogenes
Staphlococcus aureus
Alpha-hemolytic strep
Coag-negative staph
Streptococcus pneumoniae
Anaerobic organisms
Gram neg bacilli
Provetella
Bacteroides
Peptostreptococcus
Fusobacterium
History
Sore Throat/Dysphagia 5-7 days
Trismus (2nd to inflammation of internal pterygoid
muscle)
Fever
Drooling
Muffled Voice
Referred Ear Pain
Physical Exam
Asymettric swelling of the soft tissue lateral and
superior aspect of tonsil
Fluctuant area palpable
Uvula displaced to contral
Lateral side
Soft palate red/swollen
Physical Exam
Moderately uncomfortable appearing
Febrile
Potential resp distress
Trismus
Halitosis
Cervical adenopathy
Laboratory Tests
CBC with diff-leukocytosis with neutrophil
predominance
Needle aspiration for culture and sensativity
Imaging
CT scan
Sensitivity
100%, Specificity 75%
Abscess appears as low attenuation mass with ringenhancing wall
US
Sensitivity
89%, Specificity 100%
Intraoral approach prefered
Complications
Airway Compromise
Aspiration of abscess contents
Parapharyngeal abscess
Sepsis
Hemorrhage
Contiguous spread to pterygomaxillary space
Treatment
Hydration
Analgesia
Antibiotics
Admit patients for:
Airway Compromise
Dehydration, inability to take PO
Poor Compliance
Systemic complication
Toxic Appearing
Unclear diagnosis
Antibiotics
Augmentin (amox+clavulanate) is DOC
Unasyn (amp+sulbactan) for inpatient
Ceftriaxone and clindamycin or imipenem for
severe or complicated cases
Surgical Drainage
Needle Aspiration
90%
success rate after one aspiration
Another 5-10% after second
Complications: resp distress, aspiration, hemorrhage
Contraindications: uncertain diagnosis, uncooperative,
very young, airway management problem
I&D
Wider
Drainage
More Painful
Containdications: same as needle aspiration
Tonsillectomy
Definitive
Therapy
May decrease overall duration of stay
Requires OR and intubation