Pharynx and Throat Emergencies

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29 Pharynx and Throat Emergencies

Oropharyngeal Complaints

Acute Pharyngitis and Tonsillitis

An inflammation of the oropharynx, pharyngitis is predominantly an infectious disease. Pharyngeal pain and dysphagia are some of the more common complaints in outpatient clinics and emergency departments (EDs) alike. Though mostly a benign disease, occasionally the immunologic response to the infection causes severe complications both in immediate proximity to the tissues of the airway and also systemically. The local inflammation may give rise to straightforward complications such as otitis media, but more dramatic complications such as dehydration, tissue edema, and airway compromise may also occur.

Pharyngeal irritation and inflammation produce throat pain that is worsened by swallowing. Occasionally, this pain may radiate to the ears or feel pressure-like because the eustachian tubes may also be blocked or swollen. The tonsils and pharynx may be erythematous with or without tonsillar enlargement, exudates, petechiae, or lymphadenopathy. Subtle variations or systemic symptoms may be present to aid in the diagnosis, but exact determination of the specific clinical cause of the pharyngitis from clinical criteria alone is notoriously difficult.

Presenting Signs and Symptoms

Viral

In addition to the characteristic pharyngeal pain and dysphagia, viral causes of pharyngitis may also produce low-grade fevers, cough, rhinorrhea, myalgias, or headaches. Viral causes may produce exudates as well, although cervical adenopathy is less common. Common viral causes include rhinoviruses, adenoviruses, Epstein-Barr virus (EBV), herpes simplex virus (HSV), and influenza and parainfluenza viruses. Less common viruses that may cause pharyngitis include respiratory syncytial virus, cytomegalovirus, and primary human immunodeficiency virus (HIV).

Pharyngitis in young adults may be due to infectious mononucleosis, an infection caused by EBV. It is often characterized by thick tonsillar exudates or membranes, as well as other systemic symptoms and signs. Splenomegaly (50%) is frequently present and generalized lymphadenopathy is usually present. Palatal petechiae and periorbital edema may likewise be seen.

Also a disease of young adults, HSV infection may produce a painful and characteristic pharyngitis. HSV pharyngitis is typically accompanied by painful vesicles on an erythematous base. These vesicles occur in the pharynx, lips, gums, or buccal mucosa. Fever, lymphadenopathy, and tonsillar exudates may also be present and last for 1 to 2 weeks. HSV pharyngitis may be either a primary infection or reactivation of a previous infection. In addition, bacterial superinfection of affected tissues may occur.

Bacterial

The most common cause of bacterial pharyngitis in children is GAβHS. It is less frequently implicated in patients older than 15 years. During epidemics, the incidence may double. Characteristic symptoms include tonsillar exudates, high fevers (temperature > 38.3° C), tender cervical adenopathy, and pharyngeal erythema. Headache, nausea, and abdominal pain may also be found. GAβHS pharyngitis usually lacks the traditional symptoms of viral infections (cough, rhinorrhea, myalgias). It occasionally produces a fine sandpaper-like rash that is termed scarlet fever.

Pharyngitis caused by Mycoplasma pneumoniae occurs in crowded conditions, may be associated with epidemics, and typically produces a mild pharyngitis. Symptoms include exudates and a hoarse voice, and it may also be associated with lower respiratory symptoms such as cough and occasionally dyspnea.

Chlamydia pneumoniae pharyngitis resembles Mycoplasma pharyngitis in its occurrence in epidemic and crowded conditions. This pharyngitis is classically described as severe and persistent with tenderness in the deep cervical lymph nodes and occasional associated sinusitis.

Gonococcal and Chlamydia trachomatis pharyngitis have varying manifestations from exudative to nonexudative, mildly symptomatic to severely symptomatic, and transient or persistent. These infections result from orogenital sexual transmission, and asymptomatic carriers exist and may unknowingly spread the disease.

F. necrophorum, known to be a factor in Lemierre syndrome, frequently causes pharyngitis in young adults and is a common causative agent of recurrent pharyngitis as well.

Differential Diagnosis and Medical Decision Making

Bacterial

Diagnostic testing for GAβHS is a subject of some controversy. Although the diagnosis of GAβHS infection is important in preventing many serious complications of streptococcal pharyngitis, including rheumatic fever, accurate diagnosis of GAβHS pharyngitis is notoriously difficult. The only valid method of diagnosing acute GAβHS infection involves acute and chronic antistreptolysin O titers. However, this method is far from practical in the emergency setting. Throat cultures have a sensitivity of nearly 90% for detecting Streptococcus pyogenes in the pharynx, but their accuracy may vary, depending on recent antibiotic use and culture and collection techniques.

Rapid diagnostic testing for GAβHS detects antigens via varying techniques, including latex agglutination, enzyme-linked or optical immunoassay, and DNA luminescent probes. Specificities are reported to be greater than 90% with sensitivities between 60% and 95%.3 A positive test appears to be a reliable indicator of the presence of GAβHS in the pharynx, but a number of factors must be considered. Some patients with a positive test may be asymptomatic carriers, and rapid tests may be negative in patients with low bacterial counts.

In addition to cultures and rapid streptococcal tests, a number of authors have proposed clinical criteria to aid in the diagnosis of GAβHS pharyngitis. The most well known are the Centor criteria and the McIssac modifications of these criteria. The modified Centor score gives one point each to temperature higher than 38° C, swollen tender anterior cervical nodes, tonsillar swelling or exudates, absence of upper respiratory tract symptoms (e.g., cough, coryza), and age between 3 and 15 years. If the patient is older than 45 years, a point is subtracted. If the score is 1 or less, no further testing or treatment is warranted. For scores of 2 to 3, further testing may be indicated, such as cultures or rapid streptococcal tests. For scores of 4 or higher, no further testing is required and all patients may receive antibiotics for GAβHS pharyngitis (Box 29.1).4,5

In two recent guidelines (from the Infectious Diseases Society of America [IDSA] and the American Society of Internal Medicine [ASIM]), slightly different approaches to patients with pharyngitis have been proposed. In children the guidelines are similar and call for the use of a rapid test in all children; those with a positive test are treated, those with a negative test undergo a throat culture, and those with a positive culture result are treated. The guidelines have suggested different approaches to adults with pharyngitis, however. The IDSA guidelines propose treating all adults in a fashion similar to their pediatric recommendations.6 The ASIM guidelines, though, allow two additional approaches for adults, including performing a rapid test on all adults with a Centor score of 2 or 3 and treating those with a positive test result, as well as empirically treating all patients with a score of 4 or higher. The final approach endorsed by the ASIM suggests testing no adults but treating all adults with a Centor score of 3 or 4 empirically.7 A recent analysis comparing the different recommendations found that an approach using throat cultures had a sensitivity of 100%; approaches using rapid treptococcal tests involving clinical criteria alone had sensitivities of approximately 75%. Furthermore, the specificity of clinical criteria alone was below 50%, thus suggesting that many adults were prescribed antibiotics for pharyngitis unnecessarily.8

Diagnostic testing for other causes of bacterial pharyngitis requires either culture on special media (Thayer-Martin agar for gonococcal infection) or specialized antigen or serologic testing. Mycoplasma infection may be detected by culture, serologic testing, or rapid antigen testing. Antigen detection may also be used for chlamydial infection, as well as culture or serologic testing.

Treatment

Fortunately, most cases of pharyngitis are acute and self-limited. Supportive care with analgesics and antipyretics and perhaps topical anesthetics (lozenges or sprays) helps in alleviating the symptoms. However, even most infectious causes of pharyngitis rarely cause serious complications.

Among viral causes, few allow specific treatment. HSV infection may be treated with acyclovir, famciclovir, or valacyclovir, all of which produce similar earlier resolution of symptoms but do not eradicate the etiologic agent. Infectious mononucleosis has no effective antiviral agent, but some important aspects of disposition remain important. Patients suspected of having infectious mononucleosis should be advised against contact sports for 6 to 8 weeks because of concern for potential serious splenic injury. Patients with infectious mononucleosis in whom tonsillar edema and hypertrophy severely limit adequate oral hydration secondary to dysphagia may receive corticosteroids (dexamethasone, 6 to 10 mg intramuscularly) to aid in relief of symptoms.

Of all bacterial causes, GAβHS is the most common and most often studied. Regardless of the diagnostic strategy used, antimicrobial therapy directed at streptococcal species will probably be very effective. There are two main reasons to treat GAβHS pharyngitis—to improve symptoms and decrease complications. Patients who receive antibiotics during the first 2 to 3 days of symptoms are likely to improve 1 to 2 days faster than those not taking antibiotics. In terms of complications, the most feared complication of GAβHS infection is acute rheumatic fever. Antibiotic treatment within the first 9 days of infection decreases the rate of rheumatic fever after GAβHS infection. However, the incidence of acute rheumatic fever has fallen drastically in the last few decades such that the number needed to treat to prevent one case of rheumatic fever has risen from 63 to now more than 4000. This is due to the amount of antibiotics prescribed for GAβHS infection over the years, as well as the presence of less virulent strains of bacteria and improved living conditions. Antibiotic use also limits transmission to others and the amount of suppurative complications, including peritonsillar abscesses, retropharyngeal and other deep space infections, otitis, and mastoiditis. Use of antibiotics has no effect on the incidence of poststreptococcal glomerulonephritis.

Penicillin remains an effective choice for GAβHS pharyngitis. Benzathine penicillin, 1.2 million units, or a 10-day course of penicillin VK, 500 mg orally twice per day, both effectively treat pharyngitis and reduce symptoms. The intramuscular route may be more effective in treating streptococcal pharyngitis secondary to compliance issues but is associated with more severe allergic reactions. Alternative regimens include macrolide antibiotics (e.g., erythromycin, azithromycin) and clindamycin. Oral cephalosporins have been shown to result in slightly improved cure rates when compared with penicillins and may be taken over a shorter course (5 days).

Mycoplasmal pharyngitis may be treated with a course of macrolide antibiotics or tetracycline or doxycycline. C. pneumoniae pharyngitis is treated for 10 days with doxycycline, trimethoprim-sulfamethoxazole, or a macrolide. C. trachomatis pharyngitis may require repeated courses or prolonged use of antibiotics. F. necrophorum is susceptible to penicillin or clindamycin.

Corticosteroids, in conjunction with antibiotics, decrease the duration of symptoms in patients with pharyngitis without increasing complications. Steroids are particularly useful in patients with profound tonsillar hypertrophy and edema or in patients with severe dysphagia and mild dehydration. By reducing the inflammatory response, steroids allow patients to swallow without significantly reducing the pain sooner.

Peritonsillitis, Peritonsillar Cellulitis, and Abscess

Diagnostic Testing

Plain radiographs do not aid in the diagnosis or treatment of uncomplicated cases of peritonsillitis. Although it is often difficult to distinguish peritonsillar cellulitis from peritonsillar abscess,9 a number of modalities can aid in diagnosis. For patients who cannot lie down or who are unable to cooperate with needle aspiration, intraoral ultrasound is a useful test.10 Computed tomography (CT) is helpful in delineating the extent and scope of the abscess, but it may be difficult for the patient to lie supine during the study.

Epiglottitis and Supraglottitis

Epidemiology and Pathophysiology

Inflammation and edema of the epiglottis may result in rapid and life-threatening airway obstruction if not identified and treated effectively. In addition, the tissues immediately adjacent to the epiglottis (arytenoids, false vocal cords, and pharyngeal wall) may also become edematous and result in a similar infection known as supraglottitis. The signs and symptoms of the two diseases may be remarkably similar, although their populations may be somewhat different. Until introduction of the Haemophilus influenzae type B (Hib) vaccine in the mid-1980s, epiglottitis was a disease of children. The annual incidence decreased dramatically to a very low 0.3 to 0.6 per 100,000 children.11 Adult epiglottitis appears to be on the rise. One study showed a 31% rise in the incidence of adult epiglottitis over an 18-year period.12 Incidence rates for adults cluster near 3 per 100,000, with a case fatality rate reported to be as high as 7%. The lower overall bacteremia rates in adults than in children suggest that adults may have more viral causes, as well as other noninfectious causes. Noninfectious causes include trauma, ingestion of caustic substances, or thermal injuries from illicit drug inhalation. Of organisms recovered in blood cultures, Hib still predominates, but Streptococcus and Staphylococcus species may be isolated as well.

Medical Decision Making

Patients with any sign of respiratory distress (drooling, aphonia, or stridor) should be moved to a critical care room and plans made for obtaining a surgical airway if needed. Any attempt at direct laryngoscopy to visualize the epiglottis should occur only if the personnel and equipment are available to secure a surgical airway (cricothyrotomy or tracheostomy).

A lateral radiograph of patients with suspected epiglottitis has high sensitivity approaching 90% when compared with direct laryngoscopy. Findings on a lateral radiograph may include an edematous and thickened epiglottis (thumb shaped) (Fig. 29.1), disappearance of the vallecula, swelling of the epiglottic folds or arytenoids, or edema of the retropharyngeal spaces. Adults with normal radiographic findings and suspected epiglottitis must undergo laryngoscopy, either direct or indirect. In no pediatric patients should an attempt be made to visualize the epiglottis in the ED. Pediatric patients should be taken to the operating room for direct laryngoscopy while surgical staff members are present to obtain a surgical airway, if needed.

Ludwig Angina

Lemierre Syndrome

Retropharyngeal Abscess

Treatment and Disposition

Retropharyngeal infections require broad-spectrum intravenous antibiotics. The antibiotics must cover anaerobes, as well as gram-positive and gram-negative species. Although most retropharyngeal abscesses require surgical drainage, selected cases may occasionally be managed with intravenous antibiotics alone.19 Even if surgical drainage is deferred, admission to a monitored bed after thorough airway evaluation is required.

Complications from retropharyngeal abscesses include spread of infection inferiorly or laterally (Fig. 29.8) into the mediastinum (Fig. 29.9), pericardium, and nearby vascular structures. Osteomyelitis (see Fig. 29.7), transverse myelitis, and epidural abscesses have also been reported.

References

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