Monday, 8 June 2015

Sore Throat - Tonsillitis

Most sore throats are not caused by a bacterial infection. Make sure there is no epiglottitis or scarlet fever. Scarlet fever would be seen with a rough textured macular rash, with Pastia's lines, and red cheeks with perioral sparing.
There could also be Lemierre's syndrome, retropharyngeal abscess, diptheria, bacterial tracheitis, Ludwig's angina or angioedema.

Red flags for sore throat including significant systemic upset, severe pain, stridor, severe neck stiffness, inability to swallow or tripod position.

Causes
Group A β haemolytic streptococcus - 5-15%
Can cause rheumatic fever in some patients, toxic shock syndrome, necrotising fascitis and post-strep glomerulonephritis. GABHS can be carried asymptomatically - mostly between 3 and 15yrs old (carriage rates 5 - 21%). Adults have much lower carriage rates.
Complications can be suppurative (otitis media, sinusitis, peritonsillar abscess) or non-suppurative (rheumatic fever).
Treat with pen V, 500mg QDS for 10 days.

Viral Tonsillitis
Tonsillitis/pharyngitis are: rhinovirus; coronavirus; adenovirus; herpes simplex; parainfluenza; echovirus; coxsackie A; Epstein-Barr; CMV.

Epstein-Barr Virus
This causes infectious mononucleosis which presents with malaise, headache, fever, pharyngitis, posterior cervical node enlargement, splenomegaly and hepatomegaly. There is a lethargy lasting for six to eight weeks, with suffers being infective for weeks to months. Glandular fever causes anterior and posterior chain lymphadenopathy - bacterial is normally just the upper anterior cervical chain.
Diagnosis is supported by monospot, and there may be atypical lymphocytes and deranged liver enzymes.
90% of patients get an amoxicillin rash with EBV - 5% do with no EBV.

Viral Pharyngitis
Viral infection will often affect immunocompromised and elderly patients. You normally see a unilateral erythema with ulceration. The lesions are often mirrored in the distribution of the glossopharyngeal nerve.

CMV Tonsillitis
This presents very similarly to EBV, and if symptoms persist but the monospot remains negative it should be considered. There is a lot of fever and malaise.

HIV Tonsillitis
Uncommon but should be considered if there is no exudate, tonsillar hypertrophy, rash and mucocutaneous ulceration.

Globus Pharyngeus
This is painless, and patients complain of having "something in the throat", with symptoms improved by swallowing.

Agranulocytosis
Can present with a sore throat, and can be caused by a number of drugs, carbimazole in particular.

Quinsy - peritonsillar abscess
Full, erythematous appearance of the peritonsilar area.
-Deviation of the uvular
-Trismus
- Lateralising pain
- Fullness of the soft palate on the affected side
- Reduction in neck mobility
There is a risk of re-accumulation after drainage. There is no evidence for antibiotics after drainage, but they are generally given.
Quinsy can spread to the parapharyngeal abscess which can be fatal if not treated. Signs can be subtle, and underlying masses might not be fluctuant.

Treatment
Single doses of prednisolone or dexamethasone can be very helpful in major cases - in minor cases they decrease pain by six hours.

Despite their regular use, antibiotics are rarely indicated. Even the SIGN guidelines suggest we use CENTOR guidelines!

The Centor Score - sensitive 97% and specificity 78%
History of fever or temperature > 38oC              +1
Absence of cough                                               +1
Tender anterior cervical lymphadenopathy         +1
Tonsillar swelling or exudates                             +1

Age ≥45 years                                                     -1
A score of 4-5 means that antibiotics should be prescribed.

Antibiotics should be given if there is an increased risk of complications - immuo-suppressed patients, history of valvular heart disease, history of rheumatic fever. If there is an outbreak of GABHS infection within an institution, and a history of repeated episodes of proven GABHS infection.

Streptococcal Score Card - for children 
5 to 15 years
Season (late autumn, winter, early spring)
Fever (≥38.3°C)
Cervical lymphadenopathy
Pharyngeal erythema, oedema, or exudate
No symptoms of a viral upper respiratory infection (conjunctivitis, rhinorrhoea, or cough)

If 5 of the criteria are met, a positive culture for GABHS is predicted in 59% of children; if 6 of the criteria are met, a positive culture is predicted in 75% of children.

Tonsillectomy
Patients with seven attacks in one year, five in two consecutive years, or three attacks in three consecutive years warrant referral to an ENT department.




References
http://www.annemergmed.com/article/S0196-0644(13)00687-2/pdf
http://rebelem.com/patients-strep-throat-need-treated-antibiotics/
http://www.smartem.org/podcasts/treatment-acute-pharyngitis
http://radiopaedia.org/cases/tonsillitis
http://lifeinthefastlane.com/ent-equivocation-002/
http://www.ncbi.nlm.nih.gov/pubmed/?term=Hayward+G%2C+Thompson+MJ%2C+Perera+R%2C+et+al.+Corticosteroids+as+standalone+or+add-on+treatment+for+sore+throat.+Cochrane+Database+Syst+Rev.+2012%3B10%3ACD008268.+http%3A%2F%2Fdx.doi.org%2F10.1002%2F14651858.CD008268.pub2
http://learning.bmj.com/learning/module-intro/sore-throat-diagnostic-picture-tests.html?moduleId=6058292&searchTerm=%E2%80%9Cthroat%E2%80%9D&page=1&locale=en_GB
http://www.sign.ac.uk/guidelines/fulltext/117/index.html
http://www.rcemlearning.co.uk/modules/acute-sore-throat/
http://dontforgetthebubbles.com/tonsillitis/
http://www.rcemlearning.co.uk/references/acute-sore-throat/
http://www.rcemlearning.co.uk/modules/psor-throat/
http://www.rcemlearning.co.uk/modules/sore-throat-with-a-fruity-appearance/

http://www.rcemlearning.co.uk/modules/holiday-sore-throat-are-antibiotics-required/
http://www.aliem.com/modern-em-case-1-and-2-strep-throat/
http://www.aliem.com/paucis-verbis-card-strep-pharyngitis/

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