Are there many primary care office visits for "sore throat"?

do we use antibiotics for sore throat?

• 10% of all primary care office visits are for "sore throat"
• 50% of all outpatient antibiotic use

• Group A β-hemotic streptococcus:
  • Rheumatic fever; Glomerular nephritis
• S. Pnemoniae:
• Neisseria gonorrhoeae;
• Mycoplasma;
• Chlamydia thachomatis; Diphtheria

sore throat, fever, ant. cervical lymphadenopathy, tonsillar exudates, strawberry tongue

no cough

Acute pharyngitis

Centor Criteria:

• Fever > 38ºC
• Tender ant. cervical adenopathy
• Lack of couph
•                   Pharyngotonsillar exudates

Acute tonsilitis

Classic presentation:

• Sore throat
• Fever
• Ant. cervical adenopathy
• Tonsillar exudates

• Both rapid Ag testing (+) > 90% when 3 of 4 Centor criteria are present
• Cx (Blood agar)

Whom do we test for

acute pharyngitis / tonsilitis?

Test everyone and treat (+) results 

↑ cost to pt;  ↑ time; False +/- results

Test everyone:

Decresed pt’s short –term expense

Most effective to prevent related complications

Increased ABX side effects

Increased microbial resistance

Increased cost for ABX

Acute Pharyngitis:

Recommended Guidelines for testing and treatment:

• Test pts w/ 2 or more Centor criteria and treat (+) results
• Test pt w/2 or 3 Centor criteria, treat (+) results and all pts w/ 4 criteria w/o testing
• No testing should be performed and treat pt w/ 3 or 4 Centor criteria

Antibioltics:

- Benzathine penicillin (Bicillin-LA) – 1.2 mln units IM

- Penicillin V (Pen-Vee K) –

                       250 mg PO TID or 500 mg PO BID × 5-10 days

- Alternatives: Erythromycin, Cephalosporins,

                             Macrolides  (Azithromycin)

Additional therapeutic measures:

- Acetaminophen (Tylenol), NSAID (Ibuprophen, Motrin)

- Salt water, topical analgesic lozenges

- Maintain hydration status

- Tonsillectomy

• Peritonsillar Cellulitis
• Peritonsillar Abcess (Bulge of soft palate --- may be lethal)
  • abscess is usually unilateral

• Severe sore throat
• Odynophagia
• Trismus
• Med. deviation of the soft palate and peritonsillar fold
• “Hot potato” voice

What is acute epiglotitis and

who is susceptible to it?

• Acute epiglottitis is a rapidly progressive supraglottic infection that can lead to life-threatening airway obstruction
• Less common in pediatric populations
• it is secondary to Haemophilus influenza type B vaccine, the adult incidence of approx. 1.8 per 100,000 persons and is the most common deep infection of the head and neck that occurs in adults

• 2’ to Haemophilus influenza type B vaccine,
  • most common deep infection of the head and neck in adults
• Streptococcus pneumonia, Group A Strep, Staph aureus, viruses

types of laryngitis

(inflammation of the larynx)

etiology of acute laryngitis

(abrupt onset, self-limiting)

vocal misuse;

exposure to noxious agents;

exposure to infectious agents;

URIs

etiology of chronic laryngitis

(requires symptoms to be present for more than 3 weeks)

inhalation of noxious materials,

 improper use of asthma inhalers;

prolonged vocal misuse,

GERD,

vocal cord nodules/tumors

classic presentation of laryngitis

what do we find on physical exam?

Presentation:

Hoarse voice

URI: fever, cough, rhinitis

PE

Frequency NML or signs of minor URI

Chronic laryngitis would ppt a referral to Otolaryngology for direct visualization: laryngoscopy

• Time, vocal rest, avoidance of irritants
• Humidified air inhalation - assist to clear secretions &exudates
• Smoking cessation
• Eval / Tx of underlying conditions:
• Foreign bodies
• GERD:   PPIs    &    dietary restrictions
• SCC – most common malignancy of the larynx and is a direct result of tobacco use

Aphthous Ulcer (oral cavity)

what is it?

• Common & assoc-d w/ Human Herpesvirus 6
• Present on non-keratinized mucosa (buccal & labial) in single or grouped pattern
• Small, painful, round ulcerations w/ yellow/gray center and surrounded by a erythematous halo

• Herpesvirus: vesicular lesions, Tzank stain (+) for inclusion-bearing giant cells
• Cytomegalovirus: immunocompromised pt, Bx (+) for multinucleated giant cells
• Varicella: Characteristic skin lesion
• Coxsackievirus: Hand/Foot/Mouth/Buttock lesions, typically in children

what is "Thrush" (oral candidiasis)

and what is a causative agent?

• White, creamy, curd-like patches overlying an erythematous mucosa
• Patches are easily rubbed off w/ a tongue depressor leaving a painful lesion
• Candida albicans is the most common infecting agent

How to diagnose Thrush?

who is the most susceptible?

• Lab study for confirmation à wet prep w/ KOH
  •  reveals pseudohyphae
• Most common in pts w/: dentures, immunocompromised, diabetics, having chemo, pts that get corticosteroids/antibiotics

• Infants: generally resolves in 2 wks;
  • Nystatin suspension “swish and swallow”
• Adults:
  • Tx or id underlying problem; improve control of serum glucose in DM; Nystatin lozenges
• HIV infected pts:
  • Ketoconazole (Nizoral) or Fluconazole (Diflucan); HAART

• Directly assoc-d w/ EBV and exclusively occurred in pts that are immunocompromised
• Particularly involved in pts w/ HIV
• Non-painful areas of white plaque along lateral tongue borders usuallly cannot be rubbed off w/tongue depressor
• Appearance changes daily     ---        can’t scrape it off

what causes Acute Bacterial Sialadenitis?

what glands are involved?

classic presentation?

• most common: parotid, sublingual, submandibular gland
• Staph aureus
• Classic presentation:

  • Acute pain and edema of the affected gland

  • Expression of pus from the affected gland w/massage

• Maintain proper hydration
• Antibiotics --- Oral vs Parental ---        Nafcillin 1 g IV q6h
• Warm compress; massage; lemon drops

• calculi near the opening of Wharton’s or Stensen’s duct

• pain and localized edema near the site of the affected duct

• Intraoral stone removal
• Shock-wave lithotripsy
• Fluoroscopic guided basket retrieval
• Complete or partial gland excision

Decribe dental pain and abscess

what are the signs and treatment?

• Dentoalveolar abscess in acute lesion - pus around teeth
• Odontogenic infections: polymicrobial: 4-6 diff. causative bacteria
• Sx: localized pain; heat / cold sensitivity
• PE:    Gingival erythema, warmth & edema, fluctuant mass, pus around teeth, dental erosion, trismus, neck/face edema, Ludwig’s angina
• Tx: analgesia, antibiotics, drainage,  referral to a DDS or oral-maxillofacial surgeon

• very firm woody appearance
• fluctuating mass (infection)
• usually located sublingually

Tx of uncomplicated patient with

dental pain and abscess

no labs or radiological eval req-d    

analgesia, antibiotics, dental referral

Tx of complicated patient with

dental pain and abscess

• CBC,
• Blood culture (prior to ABX),
• aspiration or I&D,
• IV antibiotics,
• A/P and lateral of soft tissue neck,
• CT scan,
• maxillofacial oral surgery consult w/ admission

list antibiotics used to treat

dental pain and abscess

• Penicillin:
  • Pen-Vee K 250-500 mg PO q6h x 10d;
  • Penicillin G 2-24 mln U/d q44-6 hr
• Erythromycin: 333 mg PO tid x 10 d   (more expensive!!!)
• Clindamycin: 150-450 mg PO q6-8h x 10d or 600-1200 mg/d IV divided q 6-8 h

• Airway compromised
• Unable to control oral secretions
• Deep space infection of the face or neck
  • bacteremic or septosemic
• Systemic involvement
• Failure of outpatient therapy

• most common infectious is the EBV    in pt 10-35 yo
• S/S: fever, malaise, sore throat, exudative pharyngitis/tonsillitis, palate petechia, cervical lymphadenopathy, splenomegaly, maculopapular rash in < 15% of cases (present in >90% of pt after the administration of Ampicillin or Amoxicillin)
• The incubation period is ~ 2 wks; pt can remain infectious for up to 6 mo

• Blood smear à lymphocytosis – atypical large lymphocytes
• Heterophil agglutination test “Monopost”

• viral or bacterial pharyngitis
• take cultures !!! be ready for the returning patient

• acute bacterial pharyngitis,
• splenic rupture,
• generally following trauma,
• hepatitis,
• neurological involvement (myelitis, encephalitis, Guillain-Barre Syndrome)

• Symptomatic Tx:
• Acetaminophen, NSAID
• Warm water +/- salt gargles
• Corticosteroids are only indicated for impending airway obstruction
• Avoid Ampicillin and Amoxicillin for 2’ acute bacterial pharyngitis
• Avoidance of significant physical contact
• 95% of pts recover w/o antiviral therapy --- acyclovir