Download Problem 44 -Sore throat

44 – Sore Throat
Structure and Function of Oropharynx
Oropharynx – Middle Part of the Pharynx
This is the part of the pharynx located behind the oral cavity. Air inhaled through the
nose or the mouth travels through the oropharynx on its way into the trachea. Food
swallowed passes through the oropharynx to reach the oesophagus.
Structures in the oropharynx include:
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soft palate – this structure actually marks the boundary between the
nasopharynx and oropharynx. When food swallowed is pushed into the oropharynx
by the tongue, the soft palate immediately stretches to touch the pharyngeal wall,
completely sealing off the oropharynx from the nasopharynx, preventing food from
regurgitating into the nose and instead directing it down towards the oesophagus.
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tonsils – these are lymphoid structures located on either side of the entry to
the oropharynx from the oral cavity. These are the structures removed when a
person undergoes tonsillectomy.
base of the tongue – one-third of the tongue is actually fixed and located in
the oropharynx.
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pharyngeal band – small nodules of lymphoid tissue scattered along the
posterior pharyngeal wall.
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Common Infective Agents
Viral
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adenovirus
influenza virus
Epstein-Barr Virus
Rhinovirus
Coronavirus
Respiratory syncytial virus
Parainfluenza virus
Bacterial
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Group A streptococcus (15-30%)
Staph. Aureus
Strep. Pneumoniae
Bordatella pertussis
Corynebacterium diptheriae
Mycoplasma pnuemoniae
Fungal
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Candida albicans
Tonsillitis/Pharyngitis
Symptoms:
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Sore throat
Cough
Fever
Headache
Nausea
Fatigue
Painful swallowing
Swollen neck glands
What is the treatment for tonsillitis/pharyngitis?
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Not treating is an option as many tonsil infections are mild and soon get
better.
Have plenty to drink. It is tempting not to drink very much if it is painful to
swallow. You may become mildly dehydrated if you don't drink much,
particularly if you also have a fever. Mild dehydration can make headaches and
tiredness much worse.
Paracetamol or ibuprofen ease pain, headache, and fever
Other gargles, lozenges, and sprays that you can buy at pharmacies may
help to soothe a sore throat. However, they do not shorten the illness.
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Most throats do not need antibiotics. Most throat and tonsil infections are caused by
viruses. Without tests, it is usually not possible to tell if it is a viral or bacterial
infection. However, even if a bacterium is the cause of a tonsil or throat infection, an
antibiotic does not make much difference in most cases. Your immune system
usually clears these infections within a few days whether caused by a virus or a
bacterium. Also, antibiotics can sometimes cause side-effects such as diarrhoea,
rash, and stomach upsets.
An antibiotic may be advised in certain situations. For example:
 if the infection is severe
 if it is not easing after a few days
 if you’re immunocompromised.
Epiglottitis
Common infective agents:
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Haemophilus influenza
Streptocci spp.
Moraxella catarrhalis
Commonest symptoms:
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Sore throat
Odynophagia
Muffled voice
Drooling
Fever
Anterior neck tenderness
Signs:
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The tripod sign: patient leans forward on outstretched arms to move the
inflamed structures forward thereby easing the upper airway obstruction.
Symptoms of more severe epiglottitis:
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Dysphagia
Dysphonia
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Dyspnoea
And late on stridor
Due to vaccine epiglottitis is a condition more common in adults than children.
Epiglottitis is an airway emergency and intubation may be required immediately.
Avoid tongue depression as this could cause laryngospasm.
Treatment:
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Intubation if necessary
Antibiotics: cefotaxime +/- penicillin/ampicillin for streptococcal coverage.
Laryngitis
Symptoms:
 Hoarseness or no voice at all
 Dry, sore, burning throat
 Coughing, which can be a symptom of, or a factor in causing laryngitis
 Difficulty swallowing
 Sensation of swelling in the area of the larynx
 Cold or flu-like symptoms (which, like a cough, may also be the causal factor
for laryngitis)
 Swollen lymph nodes in the throat, chest, or face
 Fever
 Coughing out blood
 Difficulty breathing (mostly in children)
 Difficulty eating
 Increased production of saliva in mouth
Causes:
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GORD
Allergies
Infection (bacterial, viral, fungal as above)
Excessive coughing smoking or alcohol consumption
Overuse of the voice
Inhaled corticosteroids
Treatment:
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Treat the cause
Humidifier or nebuliser
Glandular Fever (infectious mononucleosis)
Causes:
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EBV
CMV
Presentation:
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Low-grade fever, fatigue and prolonged malaise. Fatigue and malaise may
persist for several months after the acute infection has resolved.
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Sore throat; tonsillar enlargement is common, classically exudative, and may
be massive; palatal petechiae and uvular oedema.
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Fine macular non-pruritic rash, which rapidly disappears.
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Transient bilateral upper lid oedema.
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Lymphadenopathy, especially neck glands.
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Nausea and anorexia.
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Arthralgias and myalgias occur but are less common than in other viral
infectious diseases and are rarely severe.
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Other symptoms include cough, chest pain and photophobia.
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Older adults and elderly patients often have few throat symptoms or signs
and have little or no lymphadenopathy.
 Later signs include:
 Mild hepatomegaly and splenomegaly (splenic enlargement returns to normal
or near normal usually within three weeks after the clinical presentation) with
tenderness over the spleen.
 Jaundice occurs in fewer than 10% of young adults, but in as many as 30%
of infected elderly patients.
Investigations:
Heterophile antibodies
 EBV-specific antibodies
 Other investigations:
FBC: raised white cell count with lymphocytosis and a relative atypical
lymphocyte count greater than 20%. Thrombocytopenia may occur.
ESR: the ESR is elevated in most patients with infectious mononucleosis (IM)
but is not elevated with group A streptococcal pharyngitis.
LFTs: mild elevation of the serum transaminases (higher increases in serum
transaminase levels suggests viral hepatitis).
Throat swabs: growth of group A streptococci does not identify the cause of
the pharyngitis; 30% of patients with IM have group A streptococcus in the
oropharynx.
Abdominal ultrasound may be required to assess for splenomegaly.
Other investigations may be required to differentiate from other possible
diagnoses, eg lumbar puncture if there is meningism. Abdominal ultrasound
may be required to assess for splenomegaly.
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Epstein-Barr virus (EBV) is also associated with:
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Burkitt's lymphoma.
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B-cell lymphomas in patients with immunosuppression.
Undifferentiated carcinomas, eg cancer of nasopharynx and cancer of salivary
glands.
Duncan's syndrome: rare, X-linked recessive; defective T cells fail to destroy
EBV-infected cells; associated development of autoimmune disease and
lymphoma.
Management
It is not recommended that affected children need to be excluded from schools and
other childcare settings unless appropriate for their own wellbeing.
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Advise patients to avoid contact sports for three weeks - because of the risk
of splenic rupture.
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Avoid alcohol for the duration of the illness.
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Advise paracetamol for analgesia and control of fever.
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No specific antiviral therapy is available.
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There is insufficient evidence to recommend steroid treatment for symptom
control in infectious mononucleosis (IM). Short courses of corticosteroids are
beneficial for haemolytic anaemia, central nervous system involvement or
extreme tonsillar enlargement.
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Ampicillin and amoxicillin cause an itchy maculopapular rash and should not
be given in any patient who might have IM.
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Patients may require hospital admission for intravenous fluids.
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Surgery is usually advocated for spontaneous splenic rupture but nonoperative management may be appropriate.
Complications
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Extreme tonsillar enlargement may result in upper airway obstruction.
Myocarditis and cardiac conduction abnormalities are rare complications.
Splenic rupture is rare but potentially lethal. Splenectomy increases
susceptibility to various infections.
Haemolytic anaemia, thrombocytopenia.
Acute interstitial nephritis, glomerulonephritis.
Neurological, including optic neuritis, transverse myelitis, aseptic
meningitis, encephalitis,meningoencephalitis, cranial nerve
palsies (especially facial palsy) or Guillain-Barré syndrome.
Neoplasms
Cancer of the pharynx is less common than other head and neck cancers. It occurs
in three locations:
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The oropharynx, which includes tumours of the base of tongue, tonsil and the
undersurface of the soft palate.
The hypopharynx, which includes tumours of the postcricoid area,
pyriform sinus and the posterior pharyngeal wall.
The nasopharynx, which is behind the nasal cavity and above the soft palate.
Presentation:
The symptoms of cancer of the pharynx differ according to the type:
Oropharynx: common symptoms are a persistent sore throat, a lump in the
mouth or throat, pain in the ear.
Hypopharynx: problems with swallowing and ear pain are common symptoms
and hoarseness is not uncommon.
Nasopharynx: most likely to cause a lump in the neck, but may also
cause nasal obstruction, deafness and postnasal discharge.
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Other symptoms include bleeding causing haemoptysis, halitosis, trismus (suggests
involvement of the pterygoid muscles) and weight loss.
Investigations:
Liver function tests may raise suspicions of abdominal metastases (in which
case, a CT scan of the abdomen is warranted).
Chest X-ray will identify pulmonary metastases. An urgent chest X-ray is also
warranted in individuals who have an unexplained change in the quality of their
voice (hoarse, husky or quiet) for more than 3 weeks, particularly in smokers
and heavy drinkers.
Biopsy is the only way to establish the diagnosis. A fine-needle aspiration
(FNA) or biopsy may be an alternative for a neck mass, and lesions that are
harder to reach may require endoscopy.
Imaging (CT and MRI) studies should focus on identifying spread: invasion
through the pharyngeal constrictors, bony involvement of the pterygoid plates
or mandible, invasion of the parapharyngeal space or carotid artery,
involvement of the prevertebral fascia and extension into the larynx.
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Oropharyngeal and hypopharyngeal tumours
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90% of all oropharyngeal tumours are squamous cell carcinomas
Other oropharyngeal tumours include adenocarcinomas, lymphomas,
sarcomas and melanomas.
Management
 Resection
 Chemotherapy
 Radiotherapty
 brachytherapy
Prognosis
Five-year survival rates are relatively poor, at about 40% for cancer of the
oropharynx and 20% for the hypopharynx.
Peritonsillar Abscess (Quinsy)
Peritonsillar abscess is a complication of acute tonsillitis. In peritonsillar abscess,
there is pus trapped between the tonsillar capsule and the lateral pharyngeal wall.
Pathophysiology:
The most commonly accepted theory is that an episode of acute exudative tonsillitis
is untreated or inadequately treated and progresses to abscess formation. It usually
starts with acute follicular tonsillitis, progresses to peritonsillitis and results in
formation of a peritonsillar abscess. It can arise without previous tonsillitis.
Causative organisms
Culture nearly always shows a mixed flora. Most common organisms include:
 Streptococcus pyogenes (usually the predominant organism)
 Staphylococcus aureus.
 Haemophilus influenzae.
 Peritonsillar abscess can also be a complication of infectious mononucleosis.
Signs and symptoms:
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Severe throat pain which may become unilateral.
Fever.
Drooling of saliva.
Foul-smelling breath.
Swallowing may be painful.
Trismus (difficulty opening the mouth).
Altered voice quality ('hot potato voice') due to pharyngeal oedema and
trismus.
Earache on the affected side.
Neck stiffness symptoms.
Headache and general malaise.
Examination
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Examination may be difficult as trismus may make it difficult to open the
mouth in up to two thirds of cases.
Breath is fetid.
There may be drooling and salivation.
Look for a temperature.
Tender, enlarged ipsilateral cervical lymph nodes.
Torticollis may be present.
There is unilateral bulging usually above and lateral to one of the tonsils;
occasionally the bulging is inferiorly.
There is medial or anterior shift of the affected tonsil and the tonsil may be
erythematous, enlarged and covered in exudate.
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The uvula is displaced away from the lesion.
Examine for signs of dehydration.
Compromise of the airway is rare.
Spontaneous rupture of the abscess into the pharynx can rarely occur and
can lead to aspiration.
A patient with a suspected peritonsillar abscess should be referred to an
ear, nose and throat (ENT) specialist that day.
Investigations
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The diagnosis is clinical.
CT scanning is not generally needed but may be used in atypical
presentations such as an inferior pole abscess, or if the patient is high risk for a
drainage procedure (eg bleeding disorder). It may also be helpful to guide
drainage in difficult cases.
Screening for infectious mononucleosis may be helpful.
Management
Medical
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Intravenous fluids may be required to correct dehydration.
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Analgesia should be prescribed.
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Intravenous antibiotics give higher blood levels than oral therapy and are
usually used.
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Penicillin, cephalosporins, amoxicillin + clavulanic acid and clindamycin are all
appropriate antibiotics
Surgical
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Antibiotics alone are not usually sufficient as treatment.
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Needle aspiration can be performed to confirm the diagnosis and remove
some of the pus. Sedation may be needed.
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The pus should be sent for Gram stain and culture and sensitivity testing.
Rapid antigen detection tests can also be used to identify the causative
organism(s).
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Complete aspiration can then be attempted or incision and drainage (which
may be superior) can be performed. Sedation and local anaesthesia or general
anaesthesia may be required.
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CT-guided aspiration is occasionally used if surgery is unsuccessful or the
abscess is in a location that is difficult to reach.
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Interval tonsillectomy is usually carried out if there is a background of chronic
or recurrent tonsillitis.
Complications
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The abscess can spread to the deeper neck tissues and can result
in necrotising fasciitis. Infection can spread from the parapharyngeal space
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through the anatomical planes to cause mediastinitis, pericarditis and pleural
effusions.
Airway compromise is rare.
Recurrence of peritonsillar abscess can occur.
Death can occur from aspiration, airway obstruction, erosion into major blood
vessels or extension to the mediastinum.
Diptheria
This disease is notifiable in the UK
Corynebacterium diptheriae produces a fibrinous pseudomembrane on respiratory
mucosa
Presentation
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Very early symptoms may be similar to the common cold. Often it presents
with a nasal discharge that is initially watery and becomes purulent and bloodstained. The nostril can be sore or crusted with the pseudomembrane
sometimes visible within the nostril.
Incubation period is usually 2 to 5 days, but may be up to 10 days.
Spread is via respiratory droplets or contact with exudate from skin lesions.
In diphtheria of the upper respiratory tract, there is a
membranous pharyngitis with fever, enlarged anterior cervical lymph nodes and
oedema of soft tissues giving a 'bull neck' appearance.
The pseudomembrane may cause respiratory obstruction.
Swallowing may be made difficult by unilateral or bilateral paralysis of the
muscles of the palate.
The exotoxin also affects other parts of the body, including the heart and
nervous systems. It may cause paralysis and cardiac failure.
Milder infections resemble streptococcal pharyngitis and the
pseudomembrane may not develop, particularly where they has been previous
vaccination.
Asymptomatic carriage is possible and an important source of transmission.
Cutaneous infection is usually mild, but chronic:
 Typical findings are vesicles or pustules that quickly rupture to form a
'punched-out- ulcer up to several centimetres in diameter.
 It often appears on the lower legs, feet and hands.
 It may be painful in the first week or two and covered with a dark
pseudomembrane which separates to show a haemorrhagic base which may
have exudate.
 The surrounding tissue is pink or purple and oedematous.
 It usually heals in 2 or 3 months to leave a depressed scar.
Effects of toxin
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Cardiomyopathy and myocarditis is usually evident by the 10th to 14th day.
There may be arrhythmias early or late in the illness. Myocardial involvement
accounts for around half of all deaths.
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Neuritis affects motor nerves, firstly with paralysis of the soft palate,
causing dysphagia and nasal regurgitation, then ocular nerves, peripheral
nerves and diaphragm with resulting infection and respiratory failure.
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Nephritis and proteinuria may be features.
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Thrombocytopenia may be seen in the full blood count.
Investigations:
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Bacterial culture from the patient and close contacts.
Toxigenicity tests by specialist laboratories.
Polymerase chain reaction.
Serum aspartate transaminase (AST) and ECG in cardiac cases.
Management:
General measures
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Barrier nursing is required. The disease can be spread by contact with
clothing and bedlinen.
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Cutaneous lesions should be thoroughly cleaned with soap and water.
Antitoxin is of no value for cutaneous diphtheria.
Pharmacological
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Antitoxin should be given within 48 hours of the onset of symptoms, which
can be before bacteriological confirmation:
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Myocarditis and palsies do not respond to corticosteroids or delayed
administration of antitoxin.
Benzylpenicillin IV is followed by oral penicillin V for 10 to 14 days.
Erythromycin is used with penicillin allergy.
Patients should be immunised in the convalescent stage because clinical
infection does not always induce adequate levels of antitoxin. They should
receive a complete course or a reinforcing dose according to their age and
immunisation history.
Urgent tracheostomy may be required for respiratory obstruction.
Management of contacts:
Swab all close contacts, treating with antibiotics and confining to home those
with positive cultures.
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Contacts need treatment to eliminate both incubating disease and to prevent
carriage to others.
The recommended regimen for close contacts is either:
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A single dose of IM benzylpenicillin 600,000 units for children less than 6
years old or 1.2 million units for anyone of 6 years or older.
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Or, 7 days' erythromycin 125 mg every 6 hours for children under 2 years of
age, or 250 mg every 6 hours for children aged 2 to 8 years, or 250 mg or 500
mg every 6 hours for anyone over 8 years of age.
Prognosis:
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Overall there is a 5-10% mortality rate, but it is up to 20% in those younger
than 5 years and older than 40 years.
Recovery is slow and particular caution should be advised after myocarditis.
Complete recovery from neurological damage is usual in those who survive.