Etiology:
Ludgwigs's angina, acute epiglottitis, peritonsillar abscess, retropharyngeal abscess, Streptococcal pharyngitis, viral, gonococcal, and F.B. Pharyngitis is usually caused by viruses.
History:
Check VS.
Dysnpea, dysphagia, dysphonia, drooling, "hot-potato voice", cough, wheezing, fever, chills, rash, rhinorrhea, otalgia, otorrhea, conjunctivits, odotogenic infection - dental work, FB (beads, toys, nuts, food - with small bones as in chicken, fish). Allergies to ASA, NSAIDs.
Physical exam:
VS.
Pt. breathes, speaks, and swallows easily = good.
Conjunctivitis - viral synd; scleral icterus - IM, hepatitis, otitis media, coryza, nasal congestion, inferior turbinates, polyps, dental craries, induration of mouth floor (Ludwig's angina), tonsillar hypertrophy, hyperemia, exudate, uvular deviation, cervical LAD, goiter, tenderness. active ROM, heart and lungs.
Skin: scarlatiniform rash
The diagnosis of streptococcal pharyngitis is certain if the following are present:
Centor's criteria
Pain/sorethroat
Exudate
Adenopathy
No cough/hoarseness
Dxtic testing:
Best initial diagnostic test is "Rapid strep test" is a.k.a, Rapid antigen detection testing (RADT). A positive RADT is just as specific as a positive throat culture. The RADT is able to be performed instantly and can tell if the organism is of the type (group A strep) that might lead to rheumatic fever or pyogenic infections. In adults, the sensitivity of the rapid step test is enough. If the RADT is negative in an adult, it does not reliably rule out GABHS, making a culture necessary.
Most accurate diagnostic test: Culture
X-ray soft tissue neck, lateral view.
Fibreotpic nasopharyngoscope.
Serology for EBV (heterophile agglutinin or monospot) and examination of peripheral blood smear for atypical lymphocytes should be performed when IM is suspected.
DDx:
Acute HIV infection should be considered in the differential Dx of pharyngitis with atypical lymphocytosis and negative streptococcus and EBV testing.
Epiglottitis should be considered in the febrile patient who complains of severe sorethroat, odynophagia, new-onset drooling, and dysphagia but in whom minimal findings are noted on inspection of the pharynx. Diagnosis is clinical.
Tx:
Ludwig's angina: ABC. High dose PCN and metronidazole IV. Clindamycin if allergy to PCN. Add aminoglycoside for extended antimicrobial coverage. Consult oromaxillofacial or otorhinolayrngological surgeon for I & D, and hospitalization.
Epiglottitis: ABC, preferably in OR. Keep trach/circothyhrotomy cart ready. Humidifed O2. Consult ENT. Ceftriaxone, 1-2 g IV q24h, or cefotaxime, 1-2 g IV q6-8h.
Peritonsillar abscess: IVF, PCN or ampicillin-sulbactam and clindamycin, analgesia, aspiration of abscess. ENT consult.
Retropharyngeal abscess, seen in pediatric age group 12 months. Rare and almost not seen in 4 year olds. ABC. IVF, ampicillin-sulbactam or cefotaxime and metronidazole, I & D. ENT consult.
Streptococcal pharyngitis. Tx if positive RADT or culture results come positive. Tx if there is strong clinical suspicion, pending culture results. PCN V, 250 mg PO qid or 500 mg PO bid x 10 days, erythromycin, 250 mg PO qid x 10 days, or benzathine PCN G, 1.2 million units IM as a one-time dose.
Gonococcal pharyngitis is treated with ceftriaxone 125 mg IM as a single dose.