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pharyngitis Sore throat, causes include viral pharyngitis, bacterial (usually strep), tonsillitis, peritonsillar abscess (rarely), and acute epiglottitis petechia small red spots that result when blood escapes from capillaries into the tissues. Oral petechiae may be due to infection of decreased platelets, as well as to trauma. Lymphadenopathy refers to enlargement of the nodes, with or without tenderness. Streptococci gram-positive globular or coccoid bacteria that grow in chains. Streptococci may cause complete (beta), incomplete (alpha), or no (gamma) hemolysis. Hemolytic streptococci can be classified into types A through O Scarlet fever Mild forms of the illness have been referred to as "pharyngitis with a rash" or benign scarlet fever." In contrast, malignant forms are described as either septic or toxic. Septic refers to the development of local invasion of the soft tissues of the neck and complication such as upper airway obstruction, otitis media with perforation, meningitis, mastoiditis, invasion of the jugular vein or carotid artery, and bronchopneumonia. The toxic form is rare, but presents with severe sore throat, marked fever, delirium, skin rash, and painful cervical lymph nodes initially develop. These malignant forms of scarlet fever have been less common in the antimicrobial era. Rheumatic fever: an inflammatory disease that occurs as a delayed, nonsuppurative sequela of upper respiratory tract infection with group A strep. Its clinical manifestation include polyarthritis, carditis, subcutaneous nodules, erythema marginatum (a macular, serpiginous, erythematous rash with a sharply demarcated border appears primarily on the trunk and the extremities; the face is usually spared), and chorea in varying combinations. In its classic form, the disorder is acute, febrile, and largely self-limited. However, damage to heart valves may be chronic and progressive and cause cardiac disability or death many years after the initial episode. Epstein barr virus (EBV) a member of the gamma human herpesvirus family, is the etiologic agent of infectious mononucleosis. In addition, the etiologic role of EBC in the pathogenesis of a number of neoplastic syndromes is increasingly becoming apparent. EBC is found in 90-95% of adults throughout the world. The virus resides in B lymphocytes and is intermittently shed asymptomatically in oropharyngeal secretions, which accounts for the bulk of its transmission in the human population. Ludwigs's angina Most common encountered deep neck space infection. Usually caused by a bacterial infection of the floor of the mouth. Ludwig's angina is a type of cellulitis that involves inflammation of the tissues of the floor of the mouth, under the tongue. It often occurs after an infection of the roots of the teeth (such as tooth abscess) or a mouth injury. Lemierre's syndrome is a rare condition usually caused by the bacterium Fusobacterium necrophorum, and usually affects young, healthy adults. Lemierre's syndrome can affect carotid artery or internal jugular vein casuing septic emboli. Pharyngitis - MC cause viral (90% adult, 50% kids), bacterial, other GABHS MC bacterial cause of pharyngitis & has severe sequela of rheumatic fever, rheumatic heart disease (mitral valve), & glomerulonephritis Pharyngitis - clinical presentation sore throat, fever (often low grade), anterior cervical lymphadenopathy, tonsillar exudate Pharyngitis - DDx Bacterial (10% adults, 50% kids; strep, diptheria); viral (90% adults, 50% kids; Mono (EBV), Coxsackie virus (hand/foot/mouth)); peritonsillar abscess; acute epiglottitis GABHS S/Sx abrupt onset, scarlatiniform rash, WBC w/ left shift, recent strep exposure, white purulent exudate; RARELY: cough, hoarse, stridor. Mono (EBV) S/Sx posterior cervical lymphadenopathy, petechiae to soft palate, significant plaque-like amounts of shaggy white/purple exudate, splenomegaly/hepatomegaly; if given ampicillin can get pruritic maculopapular rash all over body Diptheria S/Sx RARE, but many carriers dt TDaP; low-grade fever, edema (bullneck), laryngeal involvement (hoarseness, stridor), grayish adherent membranous exudate to pharynx that bleed on removal; VERY SICK KID. Findings suggestive of Strep 3-5 of these: temp >38C/100.4F, tender anterior cervical nodes, lack of cough, pharyngotonsillar exudates, age 5-15. If 3-5, do rapid strep test. Rapid strep antigen test cheap, fast (15min), moderate sensitivity, high specificity; if negative, swab for culture & hold abx pending results Strep throat culture faster, more expensive; only do if negative rapid strep. reasons to treat strep rheumatic fever, rheumatic heart disease, acute streptococcal glomerulonephritis; tx shortens illness by 1d. strep tx PCN V 250mg PO BID to TID - 10 days; alt. PCN G IMx1 for noncompliant; if allergy, keflex (not if anaphylaxis to PCN), amox, erythro/azithro; tx symtoms: analgesics, antipyretics, salt-water gargs, anest gargs Mono (EBV) tx if give ampicillin or deriv, rash develops (dt meds, not virus); provide supportive care: acetaminophen/NSAID, salt water garg, rest, no contact sports (dt splenomegaly) DDx peritonsillar abscess vs. pharyngitis peritonsillar: starts from oropharynx & penetrates capsule; starts as cellulitis (superficial) & progresses to deep abscess. S/Sx: severe sore throat, odynophagia (painful swallowing), trismus (can't open mouth), fever, drooling/SOB, muffled voice. Clinical exam: trismus, asymmetric swollen area (bulge) of soft palate extending from tonsillar area; deviated uvula Peritonsillar abscess tx & complications IV abx (clinda or PCN G + Flagyl) & aspiration of pus; complications: airway probs, can spread to deep spaces, aspiration pus into lungs, vascular structures (ICA) to rest of body Indications for tonsillectomy/adenoidectomy sleep apnea, disease, or airway obstruction; recurrent strep tonsillitis causing time away from school/work; peritonsillar abscess > 5/2yr, >7/1yr Tonsillectomy/adenoidectomy complications post-op bleeding: 1st 24 hrs (2-4%); 5-8d later - more common, inform pt to contact you! DDx sialolithiasis v. sialadenitis 1. Sialolithiasis: calculus in duct; post-prandial pain, painful lump at affected gland; swelling of duct & h/o sialadenitis; MC Wharton's gland (submandibular, 70%), Stensen's gland (parotid) 2. Sialadenitis: infection/inflammation of salivary gland & duct; MC parotid; MC Staph aureus; MCC ductal obstruction from calculi or mucus plug causes stasis & infection; foul-tasting discharge post-prandial, painful lump, chills/fever; w/ dehydration & chronic illness Sjogren's syndrome autoimmune, attacks glands that produce moisture Sarcoidosis autoimmune, can affect any organ, dx of exclusion Salivary gland tumors - Parotid: MC (80% of tumors, 80% benign. Submandibular/sublingual: less common, 50% malignant Minor glands: least common, 80% malignant sialolithiasis tx tx sx: sialogogues, hydration, warm compresses & massage of gland sialadenitis tx oral abx: diclox OR cephalexin 500mg QID 7-10d DDx laryngitis v. pharyngitis laryngitis: acute = usually post URI; chronic = dt nodules, polyps dt viral, bacterial, heartburn, tobacco, EtOH; MCC hoarseness = inflammation; Tx: rest voice, do not clear throat, no abx (viral); refer if >14d or recurrent (>1/6mo)