Infectious and inflammatory disorders (PEARLS)
Aphthous ulcers (ReelDx) |
Single or multiple small, shallow ulcers with a yellow-gray fibrinoid center with red halos, a biopsy should be considered for ulcers lasting more than 3 weeks
TX: viscous lidocaine 2–5% applied to ulcer QID after meals until healed |
Candidiasis (ReelDx) |
Immunocompromised, young patients
- Painful, white fluffy patches that can be scraped off and may bleed when scraped (candidiasis can "come off") leaving an erythematous, friable base
- Potassium Hydroxide (KOH) prep for diagnosis
TX: Antifungals, which are available in several forms (i.e., ketoconazole or fluconazole orally, clotrimazole troches, nystatin liquid rinses) |
Deep neck infection |
Deep neck space infections most commonly arise from a septic focus of the mandibular teeth, tonsils, parotid gland, deep cervical lymph nodes, middle ear, or sinuses
- Classic manifestations of these infections include high fever, systemic toxicity, and local signs of erythema, edema, and fluctuance
- Computed tomography (CT) is the imaging modality of choice for the diagnosis of deep neck space infection
- The most common organisms isolated from deep neck space infections are viridans streptococci
TX: Antibiotics, aspiration or surgical drainage should be performed |
Epiglottitis |
Unvaccinated patient leaning forward, drooling, stridor and distress (tripod position, muffled voice)
TX: Secure airway, admit, IV Ceftriaxone, and IV fluids |
Herpes simplex (ReelDx) |
HSV type 1, vesicular lesions all in the same stage of development, a prodromal period of tingling discomfort or itching
TX: Symptomatic treatment with antipyretics and analgesia is recommended. IV hydration is sometimes needed in cases of decreased oral intake
- Oral acyclovir (15 mg/kg/dose five times per day for 7–10 days; max 200 mg per dose) may decrease the duration of illness if started within 72 hours at the onset of symptoms
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Laryngitis |
Almost always viral, hoarseness following a URI
- M.cat, H.flu
- Consider squamous cell carcinoma if hoarseness persists > 2 weeks, history of ETOH and or smoking, laryngoscopy is required for symptoms persisting > 3 weeks
- Absence of pain or sore throat
TX: Relax voice (vocal rest), supportive therapy
- Oral or IM corticosteroids may also hasten recovery for performers but requires vocal fold evaluation before starting therapy
- Bacterial → erythromycin, cefuroxime, or Augmentin for cough or hoarseness
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Peritonsillar abscess (ReelDx) |
Presents with a severe sore throat, lateral uvula displacement, bulging tonsillar pillar
- Hot potato (muffled) voice and deviation of the uvula to one side
- + Streptococcus pyogenes
TX: Aspiration, incision and drainage, and/or antibiotics
- Parenteral amoxicillin, amoxicillin-sulbactam, and clindamycin
- In less severe cases, oral antibiotics can be used for 7 to 10 days (i.e., amoxicillin, amoxicillin-clavulanate, clindamycin)
- Tonsillectomy may also be considered in about 10% of patients
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Pharyngitis (ReelDx) |
Usually viral - adenovirus most common
- Mononucleosis: Epstein Barr virus, fever, sore throat, lymphadenopathy, splenomegaly, atypical lymphocytes, + heterophile agglutination test (monospot)
- Consider gonorrhea pharyngitis in patients with recent sexual encounters, or with non-resolving pharyngitis
- Fungal in patients using inhaled steroids
Strep pharyngitis
- Group A B-hemolytic streptococci (GABHS)
- Centor criteria: 1. Absence of a cough, 2. exudates, 3. fever (> 100.4 F), 4. cervical lymphadenopathy
- Not suggestive of strep - coryza, hoarseness, and cough
- If 3 out of 4 Centor criteria are met get a rapid streptococcal test (sensitivity > 90%)
- If negative → throat culture is the gold standard
TX:
- Group A Strep: Penicillin is first line, azithromycin if penicillin allergic. Complications: Rheumatic fever and post-strep glomerulonephritis
- Viral: supportive
- Mononucleosis: Symptomatic and avoid contact sports, antibiotics such as amoxicillin or ampicillin may cause a rash
- Fungal: clotrimazole, miconazole, or nystatin
- Gonorrhea pharyngitis: follows the same principles for the approach to therapy of uncomplicated urogenital gonococcal infections, with a preferred regimen of intramuscular ceftriaxone (250 mg) and azithromycin as a second agent
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