1
Q
Another word for sore throat is:
A
pharyngitis
2
Q
What is the duration of acute pharyngitis
A
less than 2 weeks
3
Q
What is the duration of chronic pharyngitis
A
more than 2 weeks
4
Q
What are the causes of pharyngitis?
A
infectious disease
non-infectious disease
viral
bacterial
5
Q
The most common cause of viral pharyngitis is the ___
A
common cold
6
Q
At least 25% of cases of viral pharyngitis are due to ____ and ____
A
rhinoviruses
coronaviruses
7
Q
The most common cause of bacterial pharyngitis is ___
A
Group A beta-hemolytic streptococci (GABHS)
8
Q
Review the viral infectious causes:
A
- Rhinovirus
- Coronavirus
- Adenovirus
- Herpes simplex virus
(HSV) - Influenza A and B
- Parainfluenza virus
- Epstein-Barr virus
- Cytomegalovirus
- Human herpesvirus
(HHV) 6 - HIV
9
Q
Review the bacterial infectious causes:
A
- Group A beta-hemolytic
streptococci (GABHS) - Fusobacterium necrophorum
- Group C beta-hemolytic
streptococci - Neisseria gonorrhoeae
- Corynebacterium diphtheriae
- Mycoplasma pneumoniae
- Chlamydophila pneumoniae
10
Q
Review the non-infectious causes
A
- Persistent cough
- Upper airway cough syndrome
(postnasal drip) - Gastroesophageal reflux
disease - Acute thyroiditis
- Neoplasm
- Allergies
- Smoking
11
Q
What is the general approach to acute pharyngitis?
A
- Rule out serious diagnoses and red flags/alarm symptoms
that prompt emergent/urgent management - determine the specific infectious cause (i.e., viral or
bacterial) - Identify acute sore throat caused by group A beta-hemolytic streptococcal (GABHS) pharyngitis
- Antibiotic treatment may be indicated
12
Q
What are red flags?
A
signs and symptoms found in the patient history and clinical examination that may
indicate possible serious underlying pathology.
13
Q
What is acute epiglottitis?
A
- inflammation of epiglottis and adjacent tissues
- bacterial infection primarily caused by Haemophilus influenzae
- rare but potentially fatal; medical emergency!
14
Q
Acute epiglottitis requires antibiotic therapy and may also require ___
A
intubation
15
Q
What are the 4 D’s for acute epiglottitis?
A
- Dysphagia (difficulty swallowing)
- Drooling
- Dysphonia (muffled, hoarse, abnormal voice)
- Distress (inspiratory stridor, tripod position, severe dyspnea,
irritability, restlessness)
16
Q
In acute epiglottis, we should not use a ____ when examining the oropharynx as it can precipitate ____
A
tongue depressor
airway obstruction
17
Q
What is peritonsillar abscess?
A
- quinsy
- most common deep infection of head and neck
- polymicrobial infection
18
Q
Peritonsillar abscess is most common in young adults (ages 20-40) and has an increased risk in ____ and ____ individuals
A
immunocompromised
diabetic
19
Q
Peritonsillar abscess usually begins as ____ then progresses to ____ and finally abscess formation
A
acute tonsillitis
cellulitis
20
Q
Review the clinical presentation of peritonsillar abscess:
A
- Severe unilateral sore throat
- Dysphagia and odynophagia → pooling of saliva or drooling
- Fever and malaise
- Dysphonia: muffled “hot potato” voice
- Rancid or fetor breath
- Otalgia
- Trismus (66% of patients)
- Oropharyngeal exam: erythematous enlarged tonsil and bulging soft
palate on affected side, uvular deviation to contralateral side - May have severely tender cervical lymphadenopathy
21
Q
What can confirm the diagnosis of peritonsillar abscess?
A
A culture of pus from abscess
22
Q
Treatments for peritonsillar abscess include:
A
drainage, antiobiotic therapy, and supportive care
23
Q
What is retropharyngeal abscess?
A
Retropharyngeal edema due to cellulitis and suppurative adenitis of
lymph nodes in retropharyngeal space
- Preceded by upper respiratory infection, pharyngitis, otitis media,
wound infection following penetrating injury to posterior pharynx
24
Q
How can we treat retropharyngeal abscess?
A
Requires antibiotic therapy, possible surgical consultation for needle aspiration or incision and drainage
25
Review the clinical presentation of retropharyngeal abscess
* Sore throat and dysphagia
* Fever
* Drooling
* Dysphonia (muffled voice)
* Neck stiffness; limited neck ROM (especially hyperextension)
* Stridor
* May see bulging of the posterior wall of oropharynx on clinical
examination
26
Associated symptoms of viral pharyngitis include:
cough, nasal
congestion, conjunctivitis, hoarseness, diarrhea, oropharyngeal lesions (ulcers or vesicles)
27
review viruses most likely to cause pharyngitis in children:
* Common cold (50%) – caused by rhinovirus, coronavirus, adenovirus, parainfluenza
virus, respiratory syncytial virus
* Influenza (5%) – caused by Influenza virus (type A and B) most commonly
* Mononucleosis (5%) – caused by Epstein-Barr Virus (EBV), cytomegalovirus (CMV)
28
Viral causes of pharyngitis do not require _____ unless there is a secondary bacterial infection
antibiotic therapy
29
Streptococcal pharyngitis is an infection of the pharynx caused by _____
group A beta-hemolytic streptococci (GABHS)
30
Review the typical presentation of streptococcal pharyngitis:
* Acute onset fever and sore throat
* Headache, nausea, vomiting, malaise, dysphagia, abdominal pain
* Cough and rhinorrhea usually absent (presence suggests more viral cause)
* Edema and erythema of tonsils and pharynx; non-adherent tonsillar and/or
pharyngeal exudate
* Enlarged and tender anterior cervical lymph nodes
* 1 in 10 cases of streptococcal pharyngitis may evolve into scarlet fever:
scarlatiniform rash and strawberry tongue
* May have palatine petechiae
31
Cross-reactive antibodies produced in reaction to Group A beta-hemolytic
streptococci infection is a result of what non-suppurative complication?
Acute rheumatic fever
32
Poststreptococcal glomerulonephritis is a non-suppurative complication where we see pathology of the ___
kidneys
33
Poststreptococcal glomerulonephritis is an injury to the glomerulus due to deposition of ____ complexes and circulating ____
immune
autoantibodies
34
What is PANDAS?
Pediatric autoimmune neuropsychiatric disorder associated with
group A streptococcal infection
35
In PANDAS, we may observe abrupt onset of severe exacerbations of obsessive-compulsive type behaviours or tics in children following _____ infection
Group A beta-hemolytic
streptococci
36
In PANDAS, the symptoms observed are thought to be due to antibodies cross-reacting with regions in the _____ leading to behavioral and motor disturbances
basal ganglia
37
Review the suppurative complications:
* Peritonsillar abscess
* Retropharyngeal abscess
* Otitis media
* Sinusitis
* Mastoiditis
* Cervical lymphadenitis
* Meningitis
* Bacteremia
38
Describe a clinical decision rule and its importance
- A clinical tool that quantifies the individual
contributions that various components of the history, physical examination,
and basic laboratory results make toward the diagnosis, prognosis, or likely
response to treatment in a patient.
- Attempt to formally test, simplify, and increase the accuracy of clinicians’
diagnostic and prognostic assessments.
- Existing CDRs guide clinicians, establish pretest probability, provide screening
tests for common problems, and estimate risk.
39
The modified centor score is a validated score to help predict the probability of _____ and guide clinical decision making
streptococcal pharyngitis
40
Original Centor Score looked at what 4 features?
1) absence of cough (presence of cough
suggest more viral illness)
2) presence of fever,
3) tonsillar exudates, and
4) anterior cervical lymphadenopathy
41
Modified Centor Score includes what new feature?
age
- Streptococcal pharyngitis is most common in ages 5-15 years
- It is rare in infants (< 3 years) and in adults > 45 years
42
M-Centor mnemonic for modified centor score:
Must be older than 3 years old
Cough — No cough (+1)
Exudates or swelling — Tonsillar exudates/swelling (+1)
Nodes — Anterior cervical adenopathy (+1)
Temperature — Hx of fever or temperature >38 (+1)
Only Young — Patients <15yo (+1)
Rarely Elder — Patients >45yo (-1)
43
Modified Centor Score interpretation:
<1 - low risk - 1-10% of patients with strep pharyngitis - no culture or antibiotics necessary, return if worse
2-3 - moderate risk - 10-28% of patients with strep pharyngitis - RADT/culture all, treat if culture result positive
>4 - high risk - 38-63% of patients with strep pharyngitis - RADT/culture all, treat empirically with antibiotics
44
Review rapid strep test/rapid antigen detection test (RADT)
- Rapid screen for streptococcal antigens → if positive the patient is treated without
follow-up cultures; if negative a throat culture is obtained
- Point-of-care test that can be done in office: rapid turnover time (minutes to 1
hour) compared to throat culture (about 48 hours)
- Swab collected from tonsils and posterior pharyngeal wall of patient
45
What is a disadvantage of rapid point-of-care testing?
It cannot distinguish between carriers of
GABHS and active infection, nor does it indicate antibiotic susceptibility or strain
virulence
46
What is the gold standard for diagnosis of streptococcal pharyngitis
throat culture
- swab collected from tonsils and
posterior pharyngeal wall of patient
- sample from swab placed on a culture in the lab to observe for bacterial
growth
- culture showing growth of streptococcal
species confirms the diagnosis
47
What are the benefits of antibiotic treatment of GABHS pharyngitis?
- Prevents acute rheumatic fever
- Decreases the transmission of GABHS
- Shortens the illness by 1 to 2 days
- Reduces symptoms such as headache, sore throat and fever
- May reduce suppurative complications such as subsequent acute otitis media, acute sinusitis and peritonsillar abscess
48
What are the potential harms of antibiotic treatment?
* Mild reactions: diarrhea, vomiting, abdominal pain, rash (NNH=10)
* Severe reactions: Clostridium difficile-associated diarrhea
* Life-threatening reactions: anaphylactic shock, sudden cardiac death
49
Review the considerations of antibiotic therapy:
* Many international guidelines consider GABHS pharyngitis self-limiting and do not
recommend antibiotic treatment
* Delayed prescriptions decrease antibiotic use with no significant effect on
symptom duration or clinical outcomes
* Populations with a higher incidence of GABHS complications, such as Indigenous
people in Canada, might be more likely to benefit from antibiotic treatment
* Children are at a greater risk of complications (e.g., otitis media, peritonsillar
abscess, rheumatic fever), may initiate antibiotic therapy sooner
* Carriers of GABHS do not require treatment
50
If the likelihood of streptococcal infection is low (i.e., Modified Centor score of 1 or less) or culture is negative, viral pharyngitis is ___
likely
51
What are ways to manage streptococcal pharyngitis?
* Analgesics (NSAIDs, acetaminophen, topical anesthetics)
* Throat lozenges or sprays
* Warm soothing drinks/liquids
* Gargle/rinse
52
What is mononucleosis?
- known as the "kissing disease"
- infection usually caused by Epstein-Barr virus (EBV) – more than 90% of cases
- most common in ages 5-25 years
53
What is the typical presentation of mononucleosis?
* Gradual onset, low-grade fever, sore throat
* Malaise, fatigue
* Tonsillar exudates
* Palatine petechiae
* Lymphadenopathy (especially posterior cervical lymph nodes)
* Splenomegaly (50% of cases) → splenic rupture is an uncommon
complication (0.1-0.5%) – highest risk in first 3 weeks of illness
54
What is a monospot test?
* Rapid screening test that detects heterophil antibody agglutination
* Best initial test for diagnosis of EBV infection – fast, inexpensive, has
high specificity
* Can be conducted in-office
