106 terms

EENT - Disorders of Pharynx

ATSU PA 2013
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Disorders of Salivary Glands
- Sialolithiasis
- Sialadenitis
- Mumps Parotitis
Sialothiasis
AKA Obstructive sialadenitis
- Results from a stone or calculus in the salivary gland or duct
- Can lead to sialadenitis
Where is Sialothiasis most commonly found?
Submandibular (Wharton's) duct
Etiology of Sialothiasis
Stagnation of saliva rich in minerals (i.e. calcium) in a partially obstructed duct is thought to contribute to the development of stones
Clinical Features of Sialothiasis
- Pain, swelling in the involved duct
- Aggravated by eating or anticipation of eating
- Xerostomia (dry mouth)
- If infection (sialadenitis), pain is worsened
- Possible visible small stones
- Rock hard to palpation
Treatment of Sialothiasis
- Most (<2mm) pass w/o complications
- Hydration is important
- Apply moist heat to the area
- Massage gland frequently
- Sialogogues (e.g. lemon drops): used often to promote salivary secretion & expulsion of the stone
- NSAIDS for pain control & inflammation
Sialadenitis
General term describing inflammation of any salivary gland
Most commonly affected glands in Sialadenitis
parotid and submandibular glands
Bacterial Parotitis (Sialadenitis)
- Acute infection of parotid gland
- Usually unilateral
Most common cause of Bacterial Parotitis
Staphylococcus aureus and mixed oral aerobes and/or anaerobes.
Etiology of Bacterial Parotitis (Sialadenitis)
- Debilitation, dehydration, and poor oral hygiene, particularly among elderly postoperative patients
- Ductal obstruction by calculi or tumor may predispose to suppuration
Viral sialadenitis
- Occurs with a concomitant viral illness
- Usually bilateral
- Example: mumps parotitis
How do you distinguish between viral and bacterial sialadenitis?
Viral - Bilateral glands
Bacterial - Unilateral gland (Usually)
Acute Bacterial Sialadenitis (suppurative)
- Sudden onset of firm, erythematous swelling of the pre- & posterior auricular areas
- May extend to the angle of the mandible
- Pain and tenderness of the gland
- Trismus and dysphagia
- Fevers, chills, and marked toxicity is not uncommon in severe cases
- Purulent drainage may be expressed from the submandibular or parotid duct
Imaging and Diagnosis of Sialadenitis
- CT is the most sensitive tool for differentiating suppurative cellulitis and abscesses
- !!Elevated serum amylase!!
- Culture and sensitivity of draining pus
Treatment of Acute Bacterial Sialadenitis (suppurative)
- First Line Tx: IV Broad Spectrum PCN w/ Staph coverage:
• Nafcillin plus metronidazole or clindamycin is a recommended regimen
- IV hydration
- Surgical I and D may be needed in cases unresponsive to ABX therapy w/i 48 h of initiation of ABX (possible abscess)
- Step-down to oral medications is considered with significant improvement & choice of ABX is based on sensitivity results
- Can affect fascia in neck, bone
Mumps Parotitis
Paramyxoviral disease spread by respiratory droplets that produces inflammation of the salivary gland
- Affects parotid gland most often
- Incubation 16 - 18 d
- Prevention: MMR vaccine
- Most common: school-aged children
Clinical Features of Mumps Parotitis
- Mumps w/ nonspecific prodrome consisting of low-grade fever, malaise, headache, myalgias, and anorexia
- Parotid swelling & tenderness present 48 hours p prodrome
- Otalgia
- Swelling last ~ 10 d
Diagnosis of Mumps Parotitis
- Based on Clinical Findings
- !!Elevated Serum Amylase!!
Complications of Mumps Parotitis
- Usually 1-3 w p onset of illness
- Orchitis
- Aseptic Meningitis
- Encephalitis
- Deafness
- Pancreatitis (Abd pain)
Orchitis
- Complication of Mumps Parotitis in male children: 10%-20% of infected males
- Fever and testicular pain with erythema and swelling of the scrotum, sterility is affected but occurs rarely
- Females: Oophoritis (rare)
Treatment of Mumps Parotitis
- Acute, self-limited viral syndrome
- Patient isolated until swelling subsides
- Kept at bed rest during the febrile period
- Analgesics for pain
- Antipyretics
- Topical application of warm or cold packs to the parotid area
Treatment of Mumps Parotitis w/ Orchitis
Also treated symptomatically with bed rest, nonsteroidal antiinflammatory agents, support of the inflamed testes, and ice packs
Prevention of Mumps Parotitis
Vaccination - MMR
Types of Pharyngitis & Tonsillitis
- Viral pharyngitis
- Streptococcal pharyngitis/tonsillitis
- Gonococcal pharyngitis
- Mononucleosis
- Diptheria
Bacterial Etiologies of Pharyngitis
- Group A beta-hemolytic streptococcus (GABHS)
- Mycoplasma pneumoniae
- Chlamydophila pneumoniae
- Corynebactrium diptheriae
- Neisseria gonorrhoeae
Viral Etiologies of Pharyngitis
- Adenovirus
- Coronavirus
- Rhinovirus
- Influenza
- Epstein-Barr virus (EBV)
What is one of the most common conditions encountered in clinical practice?
Pharyngitis
Clinical Manifestations of Pharyngitis
- Sore throat
- Difficulty in swallowing
- Fever
- Erythema of the tonsils and posterior pharynx
- Lymph node enlargement
- Rhinitis
- Cough
PE of pharyngitis
- Includes HEENT exam
AND
- Auscultation of the lungs, palpation of the abdomen, and examination of the skin are important
General Treatment of Pharyngitis/Tonsilitis
- Analgesics & anti-inflammatory agents: acetaminophen or ibuprofen.
- Warm salt water gargle may be soothing
- Anesthetic gargles & lozenges may provide some symptomatic relief
- Adults only: Prescription benzocaine lozenges (dissolved in the mouth x 1st 2 d of Sx)
- Benzocaine lozenges contraindicated in children < 3 years old
Signs and Symptoms of Severe Pharyngitis
- S/Sx of pharyngitis AND
- Sore throat with dysphagia, drooling, dysphonia, "hot potato voice" or neck swelling
PE of Severe Pharyngitis
R/O medical emergencies such as Parapharyngeal space infections, peritonsillar abscess, Ludwig's angina and epiglottitis
Retropharyngeal abscess
- Severe pharyngitis in retropharyngeal space (posterior to the pharynx) produces the symptoms of sore throat, fever, neck stiffness, and stridor
- Emergency!
Most common cause of pharyngitis
Viral infections (90% of cases):
• Rhinovirus
• Coronavirus
• Adenovirus
S/Sx Viral Pharyngitis
- Insidious onset
- Often w/ coryza (rhinitis, congestion, sneezing)
- Erythematous pharynx and tonsils
- Usually lack exudate (but possible)
PE, Diagnosis, & Treatment of Viral Pharyngitis
- Low-grade fever
- Lymphadenopathy possibly present
- Throat culture helpful to R/O streptococcal pharyngitis/tonsillitis in cases where clinical dx is uncertain
- Most viral pharyngitis are self-limited with spontaneous resolution in a matter of days.
- Treatment is supportive in nature.
Cause of Streptococcal pharyngitis
Group A beta-hemolytic streptococcus (Streptococcus pyogenes)(GABHS)
S/Sx of Streptococcal pharyngitis
- Sudden onset of sore throat, tonsillar exudate, tender cervical lymphadenopathy, and fever
- Frequently: halitosis, N/V, malaise, HA, & abdominal cramping
PE of Streptococcal pharyngitis
- Palatal petechiae may be seen on the soft palate
- Cervical Adenopathy
- Classic: tonsils with white or yellow exudate but 30% without exudate
Unusual in children under age of 2 - 3 years
Streptococcal pharyngitis
How will strep pharyngitis may present in children?
Abdominal pain
Clinical predictors for streptococcal pharyngitis (GABHS)
Centor Criteria
Centor Criteria
1. Fever over 38˚ C (100.4˚ F)
2. Tonsillar exudates
3. Cervical lymphadenopathy
4. Lack of viral symptoms (cough, coryza, or congestion)
How many Centor Criteria are needed for likely dx of Streptococcal Pharyngitis (GABHS) ?
* Presence of 3 out of 4 criteria is highly suggestive of GABHS
- With only one criteria, GABHS is unlikely
- With 2 out of 4 criteria, indicates need for culture
Diagnostic Tests for Streptococcal Pharyngitis (GABHS)
- Rapid strep screens
- Throat Culture
Rapid Strep Tests
- False negatives are possible with rapid screens
- A negative rapid strep test does not exclude GABHS, and should be verified with a throat culture
Throat Culture
Diagnostic test of choice for confirming streptococcal pharyngitis
Goal of Tx of Group A Streptococcus
- *Prevent acute rheumatic fever*
- Reduce complications such as peritonsillar abscesses
- Reduce duration of symptoms
- Prevent transmission
Tx of Streptococcal Pharyngitis (GABHS)
- ABX Tx is necessary to prevent development of rheumatic fever
- ABX started 7 to 9 days of onset of strep throat to prevent attack on the heart valves (typically mitral valve)
ABX Treatment of choice for Streptococcal Pharyngitis (GABHS)
- Oral PCN
- 2nd choice if PCN allergy: Erythromycin (macrolide)
- If compliance is an issue: a single IM injection of penicillin (Bicillin L-A)
Supportive Treatment for Streptococcal Pharyngitis (GABHS)
- Analgesics for HA, fever
- Avoid ASA in children - Reye Syndrome
- Salt water gargle
- Anesthetic oral spray
Pearls to know: Streptococcal Pharyngitis (GABHS)
- School-aged children should receive ABX x 1 day before returning to school
- Prophylactic Tx of family contacts not justified / necessary
- Patient should replace toothbrush
Tonsillectomy
Generally reserved for a child, documented S. pyogenes throat infections :
≥ 7 infections during previous year
≥ 5 infections/year x 2 years
OR
≥ 3 infections/year x 3 years
Complications of improper or incomplete treatment of streptococcal pharyngitis include ...
- Acute rheumatic fever
- Rheumatic heart disease
- Glomerulonephritis
- Scarlet fever
- Peritonsillar abscess
- Ludwig's angina
Glomerulonephritis
- Complication of streptococcal pharyngitis
- Inflammation of the glomeruli, or small blood vessels in the kidneys because of lodging of immune complexes (created during infection) in the basement membrane of the glomeruli
- Overall good prognosis in children
- Usually occurs 2-3 w after infection
Scarlet Fever
- Streptococcus pyogenes
- Bacteria produces a toxin that results in erythematous, fine, "sandpaper" rash of scarlet fever, involving the face and skin folds
- Followed by desquamation (peels off) of the affected epidermis
Pastia's Sign
Lines on A/C fossa due to Scarlet Fever
(Scarlatiniform Rash)
Signs of Scarlet Fever
- Initially, "white strawberry tongue"
- White membrane sloughs off 4-5
- Becomes "strawberry tongue"
Treatment of Scarlet Fever
Penicillin (same regimen as with tonsillitis)
Quinsy
- Peritonsillar abscess
- Develops as a complication of tonsillitis or pharyngitis
- Also results from odontogenic spread, recent dental procedures, and local mucosal trauma
Peritonsillar Cellulitis & Abscess
Infection that penetrates the tonsillar capsule leads to cellulitis and peritonsillar abscess, both medical emergencies
Differentiating cellulitis from an abscess
- CT scan of the neck - most sensitive diagnostic test for peritonsillar abscess
- Needle aspiration confirms the abscess
Signs and Symptoms of Peritonsillar Cellulitis or Abscess
- Severe sore throat
- Abnormal muffled ("hot potato") voice.
- Dysphagia
- Drooling
- Trismus
- Medial deviation of the soft palate & peritonsillar fold
- Ipsilateral ear pain
Additional Signs and Symptoms of Peritonsillar Cellulitis or Abscess
- Early, tonsil & anterior pillar are erythematous, appear full, may be shifted medially
- Later, uvula & soft palate are shifted to contralateral side
- Tonsil may feel fluctuant & tender on palpation
Treatment of Peritonsillar Cellulitis or Abscess
- EENT Consult
- I & D of abscess
- IV ABX Therapy: Ampicillin-sulbactam or clindamycin
- Immediate tonsillectomy (consider)
Complications of Peritonsillar Cellulitis or Abscess
Extension to the retropharyngeal, deep neck, and posterior mediastinal spaces
Gonococcal Pharyngitis
- Neisseria gonorrhoeae
- Commonly seen in immunocompromised
When should you consider dx of Gonococcal Pharyngitis?
- Patients w/ pharyngitis AND a Hx of orogenital contact
- Patients with gonococcal conjunctivitis
OR
- Patients with Sx of genital infection
S/Sx/PE Gonococcal Pharyngitis
- Acute onset of severe sore throat
- Exudates (multiple ulcer-type lesions)
- Cervical lymphadenopathy
- Possible concurrent urethritis or cervicitis
Diagnosis of Gonococcal Pharyngitis
- Throat Culture
- Must specify gonococcal culture or request PCR
Treatment of Gonococcal Pharyngitis
- Single dose of IM ceftriaxone 250mg (Rocephin)
CDC Recommended Treatment of Gonococcal Pharyngitis
- Also treat for chlamydia in all pts with suspected or confirmed gonorrhea
- Azithromycin 1 gm single dose
or Doxycycline 100 mg BID x 7 days
Cause of Infectious mononucleosis
- Epstein-Barr virus (EBV)
- Pt. will always have the disease (can remission/shed)
Transmission of Infectious mononucleosis
- Intimate contact
- "Kissing disease"
- Virus shed in saliva, semen, vaginal discharge
With what other infection is mono commonly found?
Streptococcus pharyngitis
Mononucleosis
- Incubation: 1 - 2 mos
- Young children often asymptomatic
- Adolescents (15-24) often symptomatic
- Adults (2%) - symptomatic
Signs and Symptoms of Mononucleosis
- (#1 Sx) Fatigue is prominent & prolonged (4-8 weeks)
- Low-grade fever, malaise, HA
- Followed by sore throat & cervical lymph node enlargement and tenderness
- Sx last 2 - 3 weeks
- N/V, anorexia common
PE of Mononucleosis
- Pharyngeal erythema
- Tonsillar exudate that is white or gray-green
- Petechiae on the mucous membranes (looks a lot like Strep)
- Posterior cervical adenopathy more common than anterior cervical adenopathy
- Splenomegaly, hepatomegaly, jaundice and widespread lymphadenopathy may occur
Labs for Mononucleosis
- CBC shows lymphocytes (50%) with atypical lymphocytosis (10%)
- Positive heterophile antibody test (fingerprick - shows up 3 wks after infection)
- IgM and IgG for Ebstein-Barr virus
- Elevated liver transaminases
Monospot test
- rapid test used to detect heterophile antibody
- Test is useful when positive, but negative test does not R/O mono
- Test is negative once infection resolves/remission
Treatment for Mono
- Self-limiting disease
- Symptomatic treatments used
- NSAIDS recommended fever & sore throat
- Hydrate / Nutrition
- Rest during the acute phase of infection
What should the clinician avoid in pt treatment of mono?
- Ampicillin & amoxicillin for any coinciding bacterial infection
- PCN induces a diffuse rash when given in the setting of mononucleosis
- Can be mistaken for PCN allergy
Complications of Mono
- Splenomegaly present in 50% of patients
- Risk of spontaneous or traumatic spleen rupture 2-21 d after onset of Sx
- No contact sports ≥ 1 month following initial infection
Prognosis of Mono
- Full recovery
- Immunity that controls the virus
- Acute Sx resolve ~ 2 weeks
- Fatigue / poor functional status ~ months
- No work/school restrictions
- Contagious period (6 weeks p onset of Sx)
Diptheria
- Toxins of Corynebacterium diphtheria
Diptheria can cause pharyngitis. With what population is this prevalent?
ETOH patients
S/Sx/PE Diptheria
- Low-grade fever (<102.2 F)
- Severe sore throat
- Toxic appearing patient.

- Late S/Sx: dysphagia, dyspnea, & croupy cough develop and lead to respiratory compromise
Complications of Diptheria
Myocarditis and paralysis of the muscles of respiration
Hallmark Sign of Diptheria
- Formation of a tightly adhering gray membrane termed "pseudomembrane" that bleeds if dislodged
- Can obstruct airway
Treatment Diptheria
- !Medical Emergency!
- Hospitalize
- Monitor signs for respiratory compromise (intubation)
- Monitor for Cardiac arrythmias, myocarditis, HF (EKG, Chest Xray, Echo Doppler)
- Pt. isolation during infection
Mainstay Treatment of Diptheria
- Diphtheria antitoxin
• Administered ASAP with clinical suspicion of diptheria
- ABX kills bacterium & halts further production of toxin: IV or IM PCN G or Erythromycin
Laryngitis
- Most common cause of hoarseness
- Persist ~ 1+ week after URI clears
- Usually caused by virus
- Little/no pain with loss of voice
- Supportive care: analgesics, voice rest, hydration, humidification
Vigorous use of voice such as singing or shouting during laryngitis can foster the development of ...
vocal cord nodules
Epiglottitis
Life-threatening infection of the epiglottis and surrounding tissues that leads to obstructive respiratory disease
Most common cause of Epiglottitis
Haemophilus influenzae type B
Other causes of Epiglottitis
- Other bacteria: Group A beta-hemolytic streptococcus, Streptococcus pneumoniae, or Staphylococcus aureus.
- Thermal injury is a cause of traumatic epiglottitis
Why is Epiglottitis more common in adults than children?
Most children have received the Hib vaccine
Clinical Features of Epiglottitis
- High fever, dysphagia, sore throat, drooling
- "Tripod Position"
- Toxic appearing (Cyanotic, inconsolably irritable, ↑HR, ↑RR)
Tripod Position
Sitting upright with the neck extended, arms supporting the trunk, and the jaw thrust forward
Signs in Children with Epiglottitis
- Severe distress, especially with inspiration
- Anxiety
- Restlessness
- Irritable
Radiology in Epiglottitis
A lateral soft-tissue neck X-ray reveals a thickened epiglottis as a thumb-like projection (the classic "thumb sign").
PE of Epiglottitis
- No action should be taken that could stimulate a child w/ poss. epiglottitis:
• Includes PE of the oral cavity, IVs, blood draws, or separation of child from parent
- Labs or other interventions should not preclude or delay control of airway in a suspected case of epiglottitis
- Similar caution is required in fulminant acute epiglottitis in adults.
When should you visualize the epiglottis of a child with suspected epiglottitis?
Attempted only in a setting where the airway can be secured immediately if necessary (ie. OR, ED, or ICU)
Treatment of Epiglottitis
- Airway management is paramount!
- Immediate Anesthesiology & ENT consult
- Controlled intubation w/ ETT & O2
- IV Therapy
Mainstay of Epiglottitis Treatment
- Until culture-driven therapy is possible, broad-spectrum coverage may be recommended to include Haemophilus influenza and Staphylococcus aureus.
- IV Ceftriaxone
- If MRSA is suspected then add IV vancomycin