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Waldeyer's Ring

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Vertically oriented ring of lymph tissue in pharynx, functions in early life as barrier to infection.

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Tonsil Grading Scale

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1-4; 0= surgically removed. 1= can see tonsils but have clear view of both pillars. 2= slightly beyond, not seeing posterior pillar well. 3= close to uvula. 4= meet in midline, "kissing tonsils"

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Acute Tonsillitis

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Refers to inflammation of palatine tonsils

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Acute Pharyngitis

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Inflammation of palatine tonsils that extends to adenoids and/or lingual tonsils. Can also use pharyngotonsillitis.

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Acute Tonsillitis Epidemiology

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Acute sore throat, accounts for up to 2% of all office/ED visits. May be viral (>50%) or bacterial (15-30%), with uncommon causes making up the rest. Usually kids 5-15yo, rare in kids under 2 d/t Waldeyer's ring. All ages can be affected; seen commonly in adults. Peak in late winter/early spring.

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Viral Pharyngitis/Tonsillitis Pathogens

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Rhinovirus = MC, 20%, coronavirus, adenovirus (these 3= URI bugs). also parainfluenza, HSV, coxsackie A, EBV

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Viral Pharyngitis/Tonsillitis Sx/Sxs

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Sudden onset throat pain, dysphagia, odynophagia. Rhinorrhea, cough, conjunctivitis, blocked ears*, +/- fever (usually none). *clue you in that it is viral!

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Viral Pharyngitis/Tonsillitis PE Findings

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Erythema of pharynx, BL tonsil enlargement (kids already have big tonsils, can be tough to tell), +/- fever, +/- cervical LAD (if present, usually mono or EBV), +/- tonsillar exudates (if present, usually mono or EBV)

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Coxsackie A Virus PE Findings- Herpangina

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1-2mm red-ringed vesicles on tonsils, uvula, and soft palate (anywhere in oropharynx). Extensive, painful, patients won't want to eat or drink.

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Coxsackie A Virus PE Findings- Hand, Foot and Mouth

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4-8mm ulcers on tongue and buccal mucosa. Vesicles on palms and soles. Kids 16 and under, also with HA, fever, anorexia, dysphagia, odynophagia. Self-limiting within a week, seen in summer.

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HSV Pharyngitis Findings

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Painful, shallow ulcers on soft palate, uvula, pharynx, gums and/or lips. Fever and cervical LAD usually. Patients are miserable, might feel electrical sensation before noticing vesicles

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Viral Pharyngitis/Tonsillitis Work Up

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Clinical diagnosis, can do rapid antigen testing if not sure (if exudates, fever present). HSV viral culture if ulcers noted. Get a good history. Self-limiting.

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Viral Pharyngitis/Tonsillitis Treatment

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Supportive care (rest, hydration, pain control). OTC APAP, ibuprofen. Take work/school off, lots of water. If HSV and found within 1st 72 hours: acyclovir 200mg 5x a day for 5 days or valacyclovir 500mg BID x 5 days (shortens course but does not cure). After 72 hours has no benefit.

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Infectious Mononucleosis

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Caused by EBV (herpes family), oral transmission. Manifests as fever, malaise, LAD, HSM and pharyngitis. May have prodrome of malaise, anorexia, chills and HA, then other sxs occur 5-14 days later. Mostly spleen swelling but can also have liver swelling. Can occur with strep pharyngitis up to 1/3 of cases.

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Infectious Mono Presentation

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Severely enlarged tonsils. Grayish-white membranous tonsillar exudate. Sometimes enlarged to point of airway compromise (admit these pts). Sxs mild in younger patients and more severe in older patients. Enlarged tonsils can last up to 10 days, HSM can last up to 3 weeks.

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Infectious Mono Work Up

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Monospot test (95% sensitive), CBC (atypical lymphocytes in peripheral smear), EBV titer, heterophile test. If deciding b/w mono and strep, get tests for both.

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Infectious Mono Treatment

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Supportive (fluids, hydration, analgesics). If significant tonsil enlargement, steroid taper. Avoid contact sports for 6 weeks d/t risk of splenic rupture. Don't confuse with strep b/c want to avoid amoxicillin in mono pts d/t severe rash.

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Bacterial Pharyngitis/Tonsillitis Pathogens

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Group A beta-hemolytic strep (strep throat), group C beta-hemolytic strep, mycoplasma pneumoniae, chlamydia pneumoniae, anaerobes (peptostrepto, bacteroides), neisseria gonorrhea. GABHS = droplet spread, 2-5 day incubation, usually + sick contacts.

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Sx/Sxs Bacterial Pharyngitis/Tonsillitis

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Sudden onset throat pain, dysphagia, odynophagia, fever. Similar to viral but usually HAS fever. Might also have HA, abdominal pain, nausea (rare).

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Bacterial Pharyngitis/Tonsillitis PE Findings

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Tonsillar and pharyngeal erythema, tonsillar enlargement (more likely with viral), purulent white exudate on tonsils*, tender/enlarged cervical lymph nodes, fever. LACKS rhinorrhea/cough/blocked ears (viral).

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Bacterial Pharyngitis/Tonsillitis Work Up

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Throat culture on 5% sheep blood agar plate = gold standard but takes 24 hours. Rapid strep test or rapid antigen detection provide quicker results. 90% specific (true neg) 80% sensitive (true pos). Special culture swab if concerned about gonorrhea.

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Centor Criteria/Modified Strep Score

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If you don't have rapid strep testing, or useful even if you do. Criteria get points, score indicates testing/treatment.

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Criteria for Centor Score

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Temp >38C/100.4F, NO cough, swollen/tender anterior cervical nodes, tonsillar swelling or exudate, age 3-14 = each get 1 point. Age 15-44 = 0 points. Age 45+ = -1 points (less common in older adults)

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Centor Score Interpretation

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0= 1-2.5% risk strep, 1 = 5-10% risk strep; no futher tests and no abx. 2= 11-17% risk strep, 3=28-35% risk strep; culture all, abx for positive cultures. > or = 4, 51-53% risk strep, treat empirically with abx and/or culture

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Bacterial Pharyngitis/Tonsillitis Medical Treatment

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-10 day course of penicillin V = DOC. -Amoxicillin = common substitute. -IM penicillin G can be given single dose if compliance issue. -Cephalosporins may be better 1st choice: cefuroxime 250mg BID x 10 days, Keflex 500mg BID/TID x 10 days (also for recurrent infections). -PCN allergy or concominant mono infxn: Azithromycin 500mg/day x 3 days or Clindamycin 150-300mg TID x 7-10days.

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Bacterial Pharyngitis/Tonsillitis Surgical Tx

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Tonsillectomy

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Tonsillectomy Indications

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7 episodes in last year; 5 episodes/year for past 2 years; 3 episodes/year in last 3 years. 2 peritonsillar abscesses.

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Tonsillectomy Complications

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Post-tonsillectomy bleed (3% of pts). Primary = within 24 hours of surgery. Secondary = between post op day 5-10 (premature separation of eschar). Secondary more likely, can be serious emergent, need OR d/t bleeding into airway. Internal carotid 5-30mm away, risk of dental injury, laceration, N/V

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Reason for Quick Tx of Bacterial Pharyngitis

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Infection would likely self-resolve in most pts but complications (suppurative or non-suppurative) are too risky

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Non-Suppurative Complications of Bacterial Pharyngitis

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Scarlet fever, rheumatic fever, post-streptococcal glomerulonephritis

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Scarlet Fever

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NS complication of bacterial pharyngitis. Secondary to endotoxin produced by bacteria during acute infection. Erythematous rash, fever, LAD, yellowish membranous film over pharynx and tonsils. Red tongue and desquamation of papilla ("strawberry tongue")

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Rheumatic Fever

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NS complication of bacterial pharyngitis. 1-4 weeks after infection. Infection produces cross-reactive antibodies to heart muscle leading to endocarditis, myocarditis or pericarditis. Usually damaging and non-reversible.

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Post-streptococcal Glomerulonephritis

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NS complication of bacterial pharyngitis. 1-2 weeks after infection.

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Suppurative Complications of Bacterial Pharyngitis

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Peri-tonsillar abscess (MC of 3), retropharyngeal abscess, Lemierre's syndrome (rare; septic thrombophelbitis of internal jugular vein. Pus obstructs vein).

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Peritonsillar Abscess

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Progression of exudative tonsillitis first into peritonsillitis then into abscess formation. Can occur in treated and untreated pts. Also reported in pts with no hx of tonsillitis.

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Peritonsillar Abscess Patho

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Localized accumulation of pus. Forms as result of spread of infection from superior pole of tonsil into potential space b/w pharyngeal muscle bed (superior pharyngeal constrictor) and tonsillar capsule. Abscess can have large and significant effect on airway b/c pyriform is next to larynx.

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Potential Space of Pharynx

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Defined by anterior and posterior tonsillar pillars, torus tubarius superiorly and pyriform sinus inferiorly.

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Peritonsillar Abscess Epidemiology

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30 cases per 100,000. Age varies 1-76, highest in 15-35yo. No seasonal variation. Smoking may be RF. Any organism that causes tonsillitis can cause PTA, not just strep.

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PTA Sx/Sxs

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Unilateral* severe throat pain, dysphagia/odynophagia (if can swallow at all), trismus (can barely open mouth more than 5mm-1cm), hot potato voice (hoarse, raspy), fever, cervical LAD, referred otalgia common, +/- difficulty with secretions (drool a lot)

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PTA Referred Otalgia Patho

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Pain refers to ear from throat d/t Jacobson's nerve off of glossopharyngeal nerve that goes to ear and main part of pharynx.

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PTA PE Findings

answer

Unilateral swelling of soft palate, medial displacement of tonsil and uvula shifted to contralateral side. Palpation of soft palate reveals area of fluctuance (fluid collection). Airway can be very narrowed.

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PTA Work Up

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Clinical diagnosis. If feel pocket, don't usually send for imagaing; just drain in office. If not clear but concern is high, send for CT with contrast of neck. CT will show rim enhancing fluid collection within a large/inflamed tonsil.

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PTA Treatment

answer

Typically managed in outpatient setting. Needle aspiration vs I&D (send aspirate for culture/sensitivity). PO abx, pain control (but feel better immediately after drainage), tonsillectomy. Once cavity open, can send home on abx. If cannot tolerate PO after drainage, admit 1-2 days to reestablish PO intake and control pain.

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PTA Tx - PO Abx

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Augmentin 875-125mg BID x 7-10 days OR clindamycin OR amoxicillin AND flagyl.

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PTA Tx- Needle Aspiration

answer

Localize pocket, drain with needle. Can numb with lidocaine first. Gives good sample for lab. Kids under 7 might do OK with just this but I&D is better because leaves pocket open for drainage and won't let abscess reaccumulate pus.

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PTA Tx- I&D

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Better method because leaves pocket open for continued drainage. Can numb with lidocaine first and needle aspirate. Use 15 blade, small curved hemostat pops thru capsule to break up loculations. Let it drain on its own a few minutes, then swish and spit water to evacuate pocket. Leave it open, F/U in 1 week.

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PTA Tx- Tonsillectomy

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If 2nd or 3rd PTA, refer to ENT for removal. Rarely, abscess so huge that can't drain in office may need tonsillectomy as means of I&D.

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PTA Complication

answer

If left untreated or undertreated, abscess can spread down fascial plane into mediastinum causing necrotizing mediastinitis (rare but lethal infection)

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3 Major Salivary Glands

answer

Parotid, submandibular, sublingual

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Parotid Gland

answer

In cheek, lateral to masseter/posterior to SCM a little/wraps behind angle of mandile. Superficial lobe can be palpated. Deep lobe only felt thru mouth. Contains Stensen's duct, provides 20% of saliva. Produces serous saliva.

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Submandibular Gland

answer

In SM triangle, on each side of jaw below mandible. Contains Wharton's duct, provides 65-70% of saliva. Produce mucinous saliva.

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Sublingual Gland

answer

Submucosa superficial to myelohyoid, two meet under tongue. Makes up difference of saliva (10-15%). Produce mucinous saliva.

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Salivary Gland Components

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Acinar cells: produce saliva (serous and mucinous acinar cells produce the watery and mucous components of saliva) Epithelial cells: make up the duct.

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Saliva

answer

Complex mix of electrolytes and macromolecules.

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3 Things Stimulating Saliva Production

answer

Mechanical act of chewing, gustatory sense, olfactory sense.

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Function of Saliva

answer

Lubrication to aid swallowing, buffering and clearance, maintain tooth integrity, antibacterial activity, taste and digestion.

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Sialolithiasis

answer

Formation of calculi (calcium phosphate and hydroxyapatite) in ductal system of salivary glands. MC in pts in 5th-8th decade, MC men>women. 80-90% = Wharton's (submandibular), 10-20% = Stensen's (partoid), 1% = sublingual

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Sialolithiasis Etiology

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Etiology uncertain, Wharton's duct is larger in caliber and angles against gravity at one point causing slower flow rate and aggregation of mineralized debris. Saliva here has more mucous, calcium and is more alkaline.

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Sialolithiasis RF

answer

Long illness with dehydration, gout, DM, HTN

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Sialolithiasis Sx/Sxs

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Postprandial salivary colic, gritty, sand-like foreign body in mouth. Submandibular gland gets huge when patient eats (colic), saliva backs up behind stone and can't get into mouth. 1-2 hours post meal pain goes away. If stone at distal end of duct = gritty feeling. May have hx of acute bacterial infection of gland.

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Sialolithiasis PE Findings

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Bimanual exam often reveals palpable stone in anterior 2/3 of Wharton's (submandibular) duct. If stone is in proximal duct or body of gland it may not be palpable. Parotid stones may be seen at orifice of Stensen's duct.

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Sialolithiasis Work Up

answer

Plain films (intra-oral or occlusal views): good for radiopaque stones (submandibular) CT scan of neck with fine cuts = extremely accurate at detecting (parotid = more serous/radiolucent, don't show up on plain films as well)

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Sialolithiasis Non-Surgical Treatment

answer

Sialogogues (sour things to suck on to stimulate gland to produce a lot of saliva, lemon wedges) Local heat (heating pad) Massage of affected gland

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Sialolithiasis Surgical Intervention

answer

Intra-oral extraction: stone must be palpable and no more than 2cm from duct orifice. Can insert catheter until it fits around stone, then milk duct around stone to get it out. Not great for submandibular stones b/c tend to scar down more. Excision: larger stones embedded in hilum or body of gland, might need excision of gland itself.

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Sialolithiasis Complications

answer

Acute suppurative sialadenitis, chronic sialadenitis, sialectasia (fluid filled sac on side of face, cystic mass; have to remove gland). Prognosis = recurrence of stones around 20%

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Sialadenitis

answer

Inflammation of salivary glands. Infectious, non-infectious/inflammatory, non-infectious/non-inflammatory

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Infectious Sialadenitis

answer

Viral or bacterial

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Noninfectious, inflammatory sialadenitis

answer

Sjogren's syndrome, sarcoidosis, sialolithiasis

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Noninfectious, non-inflammatory sialadenitis

answer

Sialadenosis, mucoceles, congenital cysts

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Viral Sialadenitis

answer

Causative agent: Mumps (paramyxovirus) = MC cause. Also coxsackie virus, influenza, HIV, rabies. Infection spread by blood.

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Viral Sialadenitis Epidemiology

answer

Mumps = MC cause of acute nonsuppurative viral sialadenitis/parotitis. 85% cases kids under 15yo. Peak in kids 4-6yo. Virus enters thru upper respiratory tract, incubation 14-21 days, peak in spring. Virus multiplies in upper respiratory tract epithelium and parotid glands, then localizes to any biologically active glandular tissue and CNS tissue.

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Sx/Sxs Mumps (MC Viral Sialadenitis)

answer

Prodrome: low grade fever, HA, arthralgia/myalgia, anorexia, malaise. Facial swelling and pain (worse with chewing). Otalgia (d/t swelling not referred pain), trismus, dysphagia.

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Mumps PE Findings

answer

75% = BL parotid swelling that displaces pinna (one gland swells 1st, 2nd one follows in 1-5days). Non-pitting edema of involved gland; tense and firm. Overlying skin stretched and firm but not red or warm. Morbilliform rash. Active glandular tissue affected (thyroiditis, pancreatitis, orchitis/oovaritis (50% post-puberty males get swelling of one or both testes with rapid onset fever, N/V and lower abd pain). As fever subsides, so do other sxs.

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Mumps Work Up

answer

Labs: Mumps S antibody, mumps V antibody, hemagglutinin antigen, amylase.

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Mumps Treatment

answer

Typically self-limiting; supportive care. Bed rest, oral hygiene, dietary modifications to minimize glandular secretions. Fever subsides before glandular edema which can take several weeks.

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Viral Sialadenitis - Adults

answer

Painless, BL parotid gland enlargement +/- cervical LAD, must consider HIV. Commonly causes lymphoepithelial cysts in parotid glands. Serologic testing for HIV antibodies, referral to ID and ENT

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Bacterial Sialadenitis Pathogens

answer

90% = staph aureus (MRSA in hospitalized pts), strep pneumoniae, E coli, H influenzae. Infection occurs by retrograde bacterial spread along salivary ducts from oral cavity. Parotid = most affected (serous fluid of parotid lacks lysosomes, IgA abs and sialic acid)

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Bacterial Sialadenitis Epidemiology

answer

Common in post-op pts in 1st 2 weeks (0.03% of all admissions), 1 in 1000 operative procedures. 25% will have malignant lesion that led to infection. 50% will have preexisting infection elsewhere in head/neck. Pts b/w 50-60yo.

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Bacterial Sialadenitis RF

answer

Dehydration, immunosuppression, trauma, debilitation, radiation/chemo, sialolithiasis, Sjogren's syndrome. Meds that cause dry mouth.

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Sx/Sxs Bacterial Sialadenitis

answer

Acute painful swelling of one salivary gland which onsets rapidly. Fever. Foul taste in mouth (pus), trismus. Bilateral bacterial = incredibly rare.

question

Bacterial Sialadenitis PE Findings

answer

Parotid swelling, tender to palpation. May be warmth/induration of overlying skin. Bimanual exam of affected gland (posterior to anterior) results in purulent drainage from affected duct orifice. +/- dry mucus membranes, +/- cervical LAD

question

Bacterial Sialadenitis Work Up

answer

Clinical diagnosis. Culture any purulent drainage to guide abx therapy, but start on abx before results are back.

question

Bacterial Sialadenitis Treatment

answer

Hydration (PO, IV), oral hygiene, sour sialogogues, warm compresses, gentle massage. Antibiotics, pain control.

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Bacterial Sialadenitis Antibiotic Tx

answer

Augmentin 875/125mg PO BID x 10 days PCN allergy: Clindamycin 300mg PO BID x 7 days Long hospitalization pt or nursing home: Bactrim 160/800mg PO BID x 7-10 days (cover for MRSA). Response should be seen in 48-72 hours, if not get CT/US to r/o abscess.

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Bacterial Sialadenitis Follow Up

answer

After resolution of infection, consider MRI to r/o sialolithiasis and salivary neoplasm, especially if infection was in submandibular gland. Most pts respond to med tx.

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Noninfectious Sialadenitis (Sjogren's Syndrome)

answer

Chronic autoimmune d/o of exocrine glands (primarily affects salivary and lacrimal glands). MC in 4th-5th decade. 90% affected are women. Uncertain etiology. Primary = just exocrine glands. Secondary = sxs of Sjogren's plus other diagnosis like rheumatoid

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Sx/Sxs Sjogren's Syndrome

answer

Dryness of mouth and eyes. Difficulty swallowing b/c food sticks to buccal mucosa. Altered taste. Facial swelling. Foreign body sensation in eye b/c dry.

question

Sjogren's Syndrome PE Findings

answer

Dry, sticky oral mucosa. Poor dentition. Tongue is smooth with fissures. Parotid gland enlargement (66% of pts; starts unilaterally, most develop BL). Absence of pooled saliva in floor of mouth. Systemic = fever, arthralgia/myalgia.

question

Sjogren's Syndrome Work Up

answer

Serology: autoantibodies to ribonuclear proteins Ro (SS-A) and La (SS-B) = 2 main tests. Also ACE level to r/o sarcoidosis. HIV and rheumatoid factor. Gold standard = minor salivary gland biopsy (lymphocytic infiltrate causing chronic focal sialdenitis)

question

Sjogren's Syndrome Treatment

answer

Refer to rheum. Mostly symptomatic and preventive. Sialogogues and pilocarpine 5mg PO TID-QID to increase saliva. Dental fluoride tx. Nystatin mouth rinse standing order for fungal colonization. Lubricating eye drops. Systemic steroids or cytotoxic drugs reserved for severe cases. Parotidectomy if recurrent infections.

question

Sjogren's Syndrome Complications

answer

10% incidence of lymphoma. Prognosis otherwise favorable.

question

Sialadenosis

answer

Rare, non-infectious/non-inflammatory condition causing BL, diffuse, painless enlargement of salivary glands. Associated with obesity, cirrhosis, hyperlipidemia, hypothyroidism etc.

question

Sialadenosis Diagnosis

answer

Diagnosis of exclusion, run all the labs but often all normal. CT or MRI (no mass, possible fatty infiltration). Biopsy (acinar enlargement). Treat underlying dz (get obesity/DM under control)

question

Laryngitis

answer

Inflammation of larynx. Abrupt onset, usually self-limited.

question

Laryngitis Causes

answer

Infection: viral (similar to URI, 90%), fungal (steroid inhalers), bacterial (rare) Vocal misuse GERD Exposure to noxious agents

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Sx/Sxs Laryngitis

answer

Typical URI sxs (cough, rhinitis, sore throat, dysphagia, fatigue). Hoarseness/dysphonia*. PE findings = same as viral URI

question

Laryngitis Work Up

answer

Clinical diagnosis.

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Laryngitis Treatment

answer

Supportive care. Sxs should resolve in 7-10 days. Voice rest (don't whisper or yell b/c both strain vocal cords. Talk like person is arms length away).

question

Laryngitis Follow Up

answer

1-2 weeks to ensure resolution. If persistent sxs, refer to ENT. Any pt with hoarseness >2 weeks needs ENT eval and flexible laryngoscopy.

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