Sore throat

Aetiology

Most commonly viral - adenovirus, rhinovirus, RSV, EBV

15 - 30% are bacterial - mostly group A beta-hemolytic Streptococcus pyogenes (GABHS)

Epidemiology

• Tonsillitis most often occurs in children; however, the condition rarely occurs in children younger than 2 years

• Tonsillitis caused by Streptococcus species typically occurs in children aged 5-15 years

• Fever
• Sore throat
• Halitosis (foul breath)
• Dysphagia (difficulty swallowing)
• Odynophagia (painful swallowing)
• Mild airway obstruction e.g. mouth breathing

1. Degree of respiratory distress
2. Full examination of oral cavity including the oral mucosa, dentition, salivary ducts. In particular look for: tonsillar erythema, oedema +/- exudate (see pictures above)
3. Tender cervical lymphadenopathy
4. Flexible nasoendoscopy - especially if severe to assess for degree of airway obstruction

Management

1. ABC's

• Airway secured
• Fluid resuscitation

2. Antibiotics

• for acute inpatients - Penicillin IV 2MU Q6h
• for outpatients - Penicillin PO for 10 days

3. Steroids

Reserved for inpatients - usually Dexamethasone either 8mg stat or 8mg TDS for one day

4. Supportive therapy

• Anti-emetics
• Analgesia and antipyretics

Aetiology

Tonsillitis can progress to cellulitis and then via tissue necrosis and pus formation to a peritonsillar abscess
or starts via an infection of minor salivary glands

Microbiology:

• A polymicrobial flora is isolated from peritonsillar abscesses
• Predominant organisms are anaerobes
• Aerobic organisms present are commonly Streptococci, S. aureus and H. influenzae

Epidemiology

Peritonsillar abscess (PTA) usually occurs in teens or young adults but may present earlier and occur in later adulthood

History

Symptoms are the same as for tonsillitis with a few other symptoms that are red flags for PTA and deep neck space infections:

• Neck pain
• Throat pain, more severe on the affected side +/- referred ear pain
• Trismus (lock-jaw) - due to inflammation of chewing muscles
• Voice change - in PTA pharyngeal oedema and trismus can cause a "hot-potato" voice - as if the patient is struggling with a mouthful of hot food

Examination

As for tonsillitis
Apart from the visual findings as noted above:

• Drooling
• Trismus
• More severe dehydration

Some patients with quinsy require flexible nasoendoscopy to rule out epiglottitis

Investigations for tonsillitis and PTA

General:
1. FBC, U+E (especially if dehydrated)
2. Monospot test/heterophile antibody test - to rule out infectious mononucleosis

With PTA or if you suspect deep neck space infections:
1. Lateral neck X-ray
If clinically concerned or X-ray suggestive then proceed to CT scan

Management

Always think ABC's first: In severe circumstances endotracheal intubation or a surgical airway may be required

The cornerstone of PTA treatment is: incision and drainage

In addition the treatment regime includes the same medication and considerations as for tonsillitis
Patients with PTA tend to be more toxic - therefore require more IV fluid resuscitation (and greater care)

Aetiology

Haemophilus influenzae type b (Hib) used to be responsible for >90% of epiglottitis cases
Due to vaccination the incidence has dropped markedly

Now other bacterial pathogens are responsible for the majority of cases including Streptococci, Staphylococcus and a number of gram negative bacilli

History

• Sore throat
• Odynophagia/dysphagia
• Muffled voice - "Hot potato voice"
• Adults may have had a preceding upper respiratory tract infection (URTI)

Always ask about vaccination if you suspect supraglottitis

Examination

• "Toxic" appearance of patient
• Sitting or leaning forward. Extreme = "Tripod position" - Sitting up on hands, with the tongue out and the head forward
• Drooling/inability to handle secretions
• Irritability
• Stridor: A late finding indicating advanced airway obstruction

+ Muffled voice, cervical adenopathy, fever, respiratory distress, mild cough

Flexible nasendoscopy should be undertaken judiciously in children but may be required for diagnosis + assessment of airway (if the patient will tolerate it)

Remember: The progression of supraglottitis can be rapid (i.e. over hours!)

Investigation

Diagnosis is clinical but the following may be used as adjuncts

1. Lateral Neck XR - may be useful (see image below)
Most adults are stable and may safely undergo imaging

2. As mentioned above - judicious use of flexible nasoendoscopy

3. Blood cultures

Management

1. Airway is the priority - ensure early ENT review. You should know where the surgical airway (cricothyrotomy) kit is
Unstable patients/severe respiratory distress may need immediate intubation or surgical airway management

If patient is stable they may still need monitoring in ICU

Minimise distress - particularly important in paediatric patients

2. Antibiotic - 1st choice is ceftriaxone (needs to be checked with local hospital policy)

3. Supportive therapy
Analgesia, anti-emetics, IV fluid