Aaron Barks dale
This chapter covers common causes of pharyngitis, including those disorders that threaten the integrity of the airway; however, Epstein–Barr virus as a cause of pharyngitis is covered in more detail in Chapter 93, Disseminated Viral Infections.
PHARYNGITIS/TONSILLITIS
PATHOPHYSIOLOGY
Pharyngitis/tonsillitis is typically due to an infectious etiology, most commonly viral (also see Chapter 71, Stridor and Drooling, for discussion of disease spectrum in children). Other infectious causes include bacteria, fungi, and parasites.
Group A β-hemolytic Streptococcus (GABHS) is the most common bacterial cause, up to 15% of pharyngitis in adults and 15% to 30 % in children.
Certain virulent strains of GABHS may lead to acute rheumatic fever in children.
Other bacterial causes include group C and G streptococci, Haemophilus influenzae, Mycoplasma pneumo-niae, Chlamydia pneumoniae, Neisseria gonorrhoeae, and Corynebacterium diphtheriae.
Transmission of most cases of pharyngitis is via person-to-person contact with droplets of saliva.
CLINICAL FEATURES
Acute viral pharyngitis is often associated with rhinorrhea and may display a petechial or vesicular pattern on the soft palate and tonsils.
Viral pharyngitis typically lacks tonsillar exudates and cervical adenopathy, except for infectious mononucleosis (see Chapter 93), influenza, and acute retroviral syndrome.
GABHS typically presents with the sudden onset of sore throat, odynophagia, chills, and fever, and lacks cough, rhinorrhea, or conjunctivitis.
Diphtheria (C. diphtheriae) often displays a grayish membrane adhered to the tonsillar or pharyngeal surface.
DIAGNOSIS AND DIFFERENTIAL
The Centor criteria for GABHS pharyngitis are (1) tonsillar exudate, (2) tender anterior cervical adenopathy, (3) fever, and (4) absence of cough.
In patients with two or fewer criteria, most authorities recommend acquiring a rapid antigen test.
In those with three or more criteria, some authorities recommend empiric treatment (such as the American Academy of Family Practice), while the American Academy of Pediatrics recommends rapid antigen testing in this group, using the results to determine treatment.
Most rapid streptococcal antigen detection tests report sensitivities around 90%.
Throat cultures following negative rapid tests should be considered, particularly in children and those with increased Centor scores.
EMERGENCY DEPARTMENT CARE AND DISPOSITION
Nonbacterial causes should be treated with antipyretics, analgesics, and IV fluids if dehydrated.
Penicillin remains the antibiotic of choice for treatment of GABHS pharyngitis. A single dose of benzathine penicillin G 1.2 million units IM or penicillin VK 500 milligrams PO three to four times a day for 10 days may be used.
In penicillin-allergic patients, a macrolide or clindamycin may be used.
A single dose of PO or IM dexamethasone may be considered in moderate to severe cases, which may shorten the duration of pain.
Treatment with antibiotics is recommended in patients with GABHS to help prevent suppurative sequelae, including cervical lymphadenitis, peritonsillar abscess, retropharyngeal abscess, and sinusitis.
Antibiotic treatment of GABHS can help prevent acute rheumatic fever and does not have any effect on the development of poststreptococcal glomerulonephritis.
PERITONSILLAR ABSCESS
PATHOPHYSIOLOGY
Peritonsillar abscess (PTA) is commonly a polymicrobial infection that develops between the tonsillar capsule and the superior constrictor and palatopharyngeus muscles.
Risk factors include prior PTA, smoking, periodontal disease, chronic tonsillitis, and repeat courses of antibiotics.
Most commonly occurs in young adults in the winter and spring months.
CLINICAL FEATURES
Patients may appear ill and often present with fever, malaise, sore throat, odynophagia, varying degrees of trismus, dysphagia, drooling, and potentially a muffled voice (“hot potato voice”).
The involved tonsil is often displaced medially and inferiorly, causing deflection of the uvula to the contralateral side (see Fig. 155-1).
FIG. 155-1. Right peritonsillar abscess (PTA) displacing right tonsil medially and the uvula toward the normal left tonsil. Abscess is between the right tonsil and the superior constrictor muscle.
DIAGNOSIS AND DIFFERENTIAL
The differential diagnosis includes tonsillitis, peritonsillar cellulitis, infectious mononucleosis, retropharyngeal abscess, neoplasm, and internal carotid artery aneurysm.
Diagnosis is typically made through the history and physical examination.
When diagnosis is in question, needle aspiration, CT, or ultrasound may help provide confirmation.
EMERGENCY DEPARTMENT CARE AND DISPOSITION
Needle aspiration of purulent material (18 or 20 gauge) is both diagnostic and therapeutic for PTA and will effectively treat more than 90% of these patients.
Needle penetration should not exceed 1 cm, in order to avoid carotid artery puncture (lateral and posterior to tonsil).
Experienced clinicians may perform incision and drainage (I&D) after local anesthesia.
More severe cases may require otolaryngology consultation.
Following adequate drainage or aspiration, antibiotic therapy is recommended. Penicillin VK 500 milligrams PO four times daily or clindamycin 300 to 450 milligrams three times daily for 10 days can be used.
ADULT EPIGLOTTITIS (SUPRAGLOTTITIS)
PATHOPHYSIOLOGY
This is an infectious process that typically causes inflammation of the epiglottis, but may involve the entire supraglottic region.
The majority of cases are now seen in adults, as a result of the conjugate vaccine for H, influenzae type b.
Most cases are caused by Streptococcus and Staphylococcus species, but may also be the result of viruses or fungi.
CLINICAL FEATURES
Patients typically present with a 1- to 2-day history of worsening dysphagia, odynophagia, and dyspnea (worse when supine).
Patients classically position themselves in an upright, leaning-forward position, and may display drooling and inspiratory stridor.
Other symptoms include anxiety, fever, tachycardia, cervical adenopathy, and pain with gentle palpation of the trachea or larynx.
DIAGNOSIS AND DIFFERENTIAL
Diagnosis is made through history and physical examination, radiographs, and/or fiber-optic laryngoscopy.
Lateral soft-tissue neck radiographs may show an edematous epiglottis (“thumbprint sign”) with loss of the vallecula (see Fig. 155-2).
Direct fiber-optic laryngoscopy classically reveals a cherry red epiglottis.
Differential diagnosis includes pharyngitis, infectious mononucleosis, croup, deep space neck abscess, diphtheria, pertussis, laryngeal trauma, foreign body aspiration, and laryngospasm.
FIG. 155-2. Acute epiglottitis. Arrow points to thickened epiglottis resembling a thumb print on a soft tissue lateral radiograph.
EMERGENCY DEPARTMENT CARE AND DISPOSITION
Patients with suspected epiglottitis require emergent otolaryngology consultation, and the emergency physician must be prepared to establish a definitive airway.
Patients should remain in the upright position and avoid agitation.
Initial airway management consists of supplemental humidified oxygen and comfortable patient positioning. Heliox can be given as a temporizing measure.
Endotracheal intubation may be difficult secondary to anatomic distortion, and is preferably performed by awake fiber-optic intubation in the operating room.
The physician must be prepared to perform a surgical airway, cricothyrotomy or needle cricothyrotomy.
Ceftriaxone 2 grams IV is the recommended first-line antibiotic. Steroids (methylprednisolone, 125 milligrams IV) may reduce airway inflammation and edema.
RETROPHARYNGEAL ABSCESS
PATHOPHYSIOLOGY
Retropharyngeal abscess is most common in children less than 5 years old, but also occurs in adults.
In children, the abscess typically consists of suppurative changes within a lymph node.
In adults, a retropharyngeal abscess is more likely to extend into the mediastinum.
The infection is usually polymicrobial, but common aerobic species include Streptococcus viridans and Streptococcus pyogenes. Bacteroides and Peptostreptococcus are the most commonly isolated anaerobes.
CLINICAL FEATURES
Patients commonly present with fever, sore throat, torticollis, and dysphagia. Additional symptoms include neck pain and stiffness, muffled voice, cervical lymphadenopathy, and respiratory distress.
Stridor and neck edema is more common in children.
In contrast to epiglottitis, these patients tend to prefer a supine position with the neck in slight extension to minimize compression of the upper airway. Sitting them up may worsen their dyspnea.
DIAGNOSIS AND DIFFERENTIAL
An intravenous contrast-enhanced CT of the neck is the gold standard and differentiates cellulitis from an abscess (Fig. 155-3).
FIG. 155-3. Contrasted CT of a left retropharyngeal abscess (arrow).
Differential diagnosis includes retropharyngeal space tumor, foreign body, aneurysm, hematoma, edema, and lymphadenopathy.
EMERGENCY DEPARTMENT CARE AND DISPOSITION
All patients require an immediate otolaryngologist consultation and airway management as indicated.
IV hydration and antibiotics should be initiated in the ED.
Clindamycin 600 to 900 milligrams (10 milligrams/kg) IV or ampicillin/sulbactam 3 grams (50-75 milligrams/kg) IV.
ODONTOGENIC ABSCESS
PATHOPHYSIOLOGY
Odontogenic infections are typically the result of an infected tooth or following tooth extraction. They are usually polymicrobial, consisting of oral aerobes and anaerobes.
CLINICAL FEATURES
Patients often present with pain, fever, and potential swelling and suppurative changes in the adjacent gingival, buccal, sublingual, or submandibular spaces.
Abscesses may extend into the prevertebral, parap-haryngeal, and retropharyngeal spaces, resulting in a neck mass, trismus, dysphagia, or dyspnea.
DIAGNOSIS AND DIFFERENTIAL
A contrast-enhanced CT scan should be acquired when there is concern for a deep neck space abscess.
EMERGENCY DEPARTMENT CARE AND DISPOSITION
Treatment includes analgesics, I&D of abscess, and antibiotics.
Antibiotic therapy in adults includes penicillin VK 500 milligrams PO qid or clindamycin 300 to 450 milligrams PO three times daily for 7 to 10 days.
Airway management should be performed and otolaryngologic consultation should be obtained as indicated by severity of illness.
LUDWIG ANGINA
PATHOPHYSIOLOGY
Ludwig angina is an infection of the submandibular, sublingual, and submandibular spaces bilaterally. It often progresses rapidly, potentially leading to airway compromise.
CLINICAL FEATURES
Patients present with trismus, dysphagia, and odynophagia.
Clinical examination will reveal diffuse edema of the entire upper neck and floor of the mouth.
EMERGENCY DEPARTMENT CARE AND DISPOSITION
All patients require emergent otolaryngology consultation.
Initial management should focus on providing a definitive airway, often acquired by awake fiber-optic intubation or tracheostomy.
NECK MASSES
PATHOPHYSIOLOGY
Neck masses may arise from congenital, infectious, or neoplastic origin.
Squamous cell carcinoma is the most common malignancy of the upper airway and is usually associated with a significant tobacco and/or alcohol history.
In adults >40 years old, a neck mass is likely malignant if it has been present for greater than 6 weeks.
CLINCAL FEATURES
Patients may present with dysphagia, odynophagia, or secondary infections.
Patients with malignant masses may report experiencing night sweats, weight loss, and malaise.
Branchial cleft cysts can present at any age and typically appear as fluctuant, painless masses located anterior to the sternocleidomastoid muscle.
Thyroglossal duct cysts usually occur in children and present as an asymptomatic midline subhyoid neck mass.
DIAGNOSIS AND DIFFERENTIAL
Indeterminate masses should undergo CT with IV contrast.
EMERGENCY DEPARTMENT CARE AND DISPOSITION
Patients may require airway management and/or IV hydration.
Stable patients who can tolerate oral intake can be referred to an otolaryngologist on an outpatient basis.
POSTTONSILLECTOMY BLEEDING
PATHOPHYSIOLOGY
Hemorrhage is a result of sloughing of fibrinous debris from the tonsillar bed and typically occurs between postoperative days 5 and 10.
The incidence of bleeding is significantly higher in the third decade of life.
CLINICAL FEATURES
Bleeding can be severe and sometimes fatal.
EMERGENCY DEPARTMENT CARE AND DISPOSITION
Active bleeding requires immediate otolaryngologist consultation.
Patients should be placed on a monitor, pulse oximetry, and IV access established. They should also be kept in an upright position and remain NPO.
In patients with significant bleeding, obtain a CBC, coagulation studies, and type and cross.
Gauze moistened with thrombin or epinephrine (1:10,000) and 1% lidocaine should be applied with direct pressure to the bleeding area. A suture should be placed through the gauze and taped to the face to prevent airway compromise from accidental displacement.
Establish definitive airway if bleeding is compromising patients’ ability to protect their airway.
LARYNGEAL TRAUMA
PATHOPHYSIOLOGY
Laryngeal injuries may be the result of blunt or penetrating trauma.
“Clothesline injury” is the result of blunt trauma that occurs when a moving victim’s neck strikes a stationary object. This results in damage to the thyroid cartilage and potential laryngotracheal separation.
With high-impact mechanisms, asphyxiation often occurs at the scene.
CLINICAL FEATURES
Patients may present with hoarseness, dyspnea, dys-phagia, stridor, hemoptysis, and in severe cases aphonia and/or apnea.
Physical examination may reveal anterior neck tenderness, laryngeal swelling, tracheal displacement, or subcutaneous emphysema.
Minor laryngeal injuries may progress, due to edema and expanding hematomas, and close observation is needed.
A high level of suspicion for cervical spine injury is appropriate.
DIAGNOSIS AND DIFFERENTIAL
Fiber-optic laryngoscopy, with patient in an upright position, can be used to evaluate the integrity of the laryngeal airway and should be done prior to obtaining a CT.
Those patients with an intact airway should undergo CT to further delineate the degree of injury.
EMERGENCY DEPARTMENT CARE AND DISPOSITION
Emergent otolaryngologic consultation is warranted.
In patients with a compromised laryngeal airway (ecchymosis and/or edema), but the trachéal lumen can be visualized, an attempt at endotracheal intubation is appropriate.
In unstable patients with massive laryngeal trauma or complete obliteration of the laryngeal airway, immediate tracheostomy should be performed. Do not attempt a cricothyrotomy in these patients.
ANGIOEDEMA OF THE UPPER AIRWAY
PATHOPHYSIOLOGY
Angioedema is a non-pruritic, non-pitting swelling of the subcutaneous and deep dermal (mucosa) layers of the skin.
Causes of angioedema include (1) Cl-esterase inhibitor deficiency (hereditary or acquired), (2) IgE-mediated type 1 allergic reaction, (3) adverse reaction to angiotensin-converting enzyme (ACE) inhibitor therapy, and (4) idiopathic reaction.
The incidence of ACE inhibitor–related angioedema is up to 2.2% and is more common in African Americans.
The majority of ACE inhibitor–induced angioedema occurs within a month of initiating treatment, but can occur years later.
CLINICAL FEATURES
Angioedema may involve the face, lips, eyelids, tongue, and larynx, and can progress rapidly.
Patients with airway involvement can present with “throat tightness,” dyspnea, cough, hoarseness, and stridor.
EMERGENCY DEPARTMENT CARE AND DISPOSITION
Patients with potential for airway compromise should receive 0.3 milligram (0.01 milligram/kg) of epinephrine 1:1000, administered IM in the lateral thigh. If the patient is responding to treatment, this can be repeated every 5 to 10 minutes.
Additional medications that should be administered include diphenhydramine 50 milligrams (1 milligram/kg) IV, and methylprednisolone 125 milligrams (2 milligrams/kg) IV.
Patients with hereditary angioedema (CI-esterase inhibitor deficiency) and ACE inhibitor–induced angioedema typically do not respond to the treatments above.
Currently approved medications for treatment of acute hereditary angioedema (HAE) in the United States are Berinert (human Cl-esterase inhibitor) 20 units/kg IV, and Ecallantide (kallikrein inhibitor) 30 milligrams subcutaneously in three 10-milligram injections.
Fiber-optic laryngoscopy can help assess the extent of laryngeal edema.
In those with airway compromise or progressing symptoms, a definitive airway needs to be established. This is best performed by awake fiber-optic intubation or potentially a surgical airway (cricothyrotomy) if the edema is too severe.
For further reading in Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7th ed., see Chapter 241, “Infections and Disorders of the Neck and Upper Airway,” by Rupali N. Shah, Trinitia Y. Cannon, and Carol G. Shores.