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Clin Med Block 1: Pharyngitis & salivary glands

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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)