Transcript Approach to Sore Throat

APPROACH TO SORE THROAT
& PERITONSILLAR ABSCESS
MR 8/3/09
J.Chen
General Approach
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R/O Life Threatening causes
R/O non-infectious causes
Determine whether or not treatment is required
Life Threatening Causes
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Airway Compromise
Sitting in sniffing position
Toxic appearing
Drooling
Voice change
Fever
Life Threatening Causes
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Epiglottitis
Retropharyngeal abscess
Peritonsillar abscess
Significant tonsillar hypertrophy
Diphtheria
Management
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NPO
Supplemental O2
Consider airway adjunct (NP airway)
IV access (if pt can tolerate)
Anesthesia
Non-infectious Causes
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Environmental
 Irritative
pharyngitis
 Smoke
 Dry
air
 Chemicals
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Trauma
 Burns
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Foreign Body
 Retained
 Laceration
to posterior pharynx
Non-infectious Causes
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Allergic/Inflammatory
 Allergens
causing chronic postnasal drip
 Eosinophilic esophagitis
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Tumors
 Rare
in pediatric population
Infectious Causes
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Bacterial:
 Group
A Beta Hemolytic Streptococcus
 Group C Strep
 Group G Strep
 Neisseria Gonorrhoeae
 Tularemia
 Chlamydia
 Mycoplasma
 Diptheria
Infectious Causes
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Viral Causes
Adenovirus
 Influenza
 Parainfluenza
 Epstein-Barr Virus
 Cytomegalovirus
 HIV
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Stomatitis
HSV
 Coxsackievirus
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History
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Drooling?
Voice Change?
Fever?
Exposure?
Foreign Body?
Headache?
Abdominal Pain?
URI symptoms?
Immunization status?
Sexual activity?
Physical Exam
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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
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Throat Culture
Lateral Neck X-ray
CBC
Monospot
Peritonsillar Abscess
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Suppurative infection of the tissues adjacent to the
palatine tonsil
Most common abscess of the head and neck
Background
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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
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30 per 100,000 person/year (25-30% Pediatric)
Cause
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Bacterial Growth often polymicrobial
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Aerobic organisms
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Group A beta-hemolytic streptococcus pyogenes
Staphlococcus aureus
Alpha-hemolytic strep
Coag-negative staph
Streptococcus pneumoniae
Anaerobic organisms
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Gram neg bacilli
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Provetella
Bacteroides
Peptostreptococcus
Fusobacterium
History
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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
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Physical Exam
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Moderately uncomfortable appearing
Febrile
Potential resp distress
Trismus
Halitosis
Cervical adenopathy
Laboratory Tests
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CBC with diff-leukocytosis with neutrophil
predominance
Needle aspiration for culture and sensativity
Imaging
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CT scan
 Sensitivity
100%, Specificity 75%
 Abscess appears as low attenuation mass with ringenhancing wall
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US
 Sensitivity
89%, Specificity 100%
 Intraoral approach prefered
Complications
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Airway Compromise
Aspiration of abscess contents
Parapharyngeal abscess
Sepsis
Hemorrhage
Contiguous spread to pterygomaxillary space
Treatment
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Hydration
Analgesia
Antibiotics
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Admit patients for:
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Airway Compromise
Dehydration, inability to take PO
Poor Compliance
Systemic complication
Toxic Appearing
Unclear diagnosis
Antibiotics
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Augmentin (amox+clavulanate) is DOC
Unasyn (amp+sulbactan) for inpatient
Ceftriaxone and clindamycin or imipenem for
severe or complicated cases
Surgical Drainage
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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
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I&D
 Wider
Drainage
 More Painful
 Containdications: same as needle aspiration
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Tonsillectomy
 Definitive
Therapy
 May decrease overall duration of stay
 Requires OR and intubation