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Emergency Evaluation and Management of the Sore Throat

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Emergency Evaluation and Management of the Sore Throat Emergency Evaluation and Management of the Sore Throat Angela R. Cirilli, MD, RDMS KEYWORDS Streptococcal pharyngitis Uvulitis Infectious mononucleosis Epiglottitis Retropharyngeal abscess Peritonsillar abscess KEY POINTS The chief complaint of sore throat includes broad differential, including streptococcal phar- yngitis, tonsillitis and peritonsillar abscess, retropharyngeal abscess, epiglottitis, uvulitis, and infectious mononucleosis. Tonsillitis can be difficult to differentiate from peritonsillar abscess. Ultrasound can help diagnose and direct treatment in these situations. In the post vaccine era, epiglottitis is now a disease of adults with insidious onset and more subtle symptoms requiring early aggressive airway management in people present- ing with stridor, signs of distress, and systemic disease. Uvulitis has infectious and noninfectious causes, which usually respond to medical treat- ment but occasionally can cause deadly airway obstruction. The diagnostic dilemma of streptococcal pharyngitis and mononucleosis continues, and many recommend the aid of laboratory testing in diagnosis and differentiation from other viral causes of pharyngitis before treatment. INTRODUCTION The chief complaint of “sore throat” can be caused by conditions ranging from common viral pharyngitis to a deadly diagnosis, such as epiglottitis or severe airway obstruction. A patient with a sore throat should not be taken lightly and deserves your immediate attention, evaluation, and emergent treatment. This article reviews the evaluation, diagnosis, and management of common causes of sore throat: periton- sillar abscess, retropharyngeal abscess, epiglottitis, uvulitis, infectious mononucle- osis, and streptococcal pharyngitis. The author has received no financial support or gifts in preparation of this manuscript. Department of Emergency Medicine, North Shore University Hospital, Long Island Jewish Hospital, 300 Community Drive, Manhasset, NY 11030, USA E-mail address: [email protected] Emerg Med Clin N Am 31 (2013) 501–515 http://dx.doi.org/10.1016/j.emc.2013.01.002 emed.theclinics.com 0733-8627/13/$ – see front matter Ó 2013 Elsevier Inc. All rights reserved. 502 Cirilli PERITONSILLAR ABSCESS Peritonsillar abscess (PTA) is a very common problem, representing 30% of all head and neck abscesses. It is believed to be a complication or progression of another oropharyngeal infection, such as tonsillitis. It is a collection of pus behind the tonsil in the superior arch of the soft palate between the tonsil and the constrictor muscle, previously referred to as “quinsy.” It causes significant pain and discomfort. When treated appropriately, with drainage, antibiotics, and pain management, most patients feel significantly better before discharge from the emergency department (ED) and completely recover, with a very low recurrence rate. Symptoms The classic presenting symptoms of PTA are as follows: Fever Malaise Dysphagia Sore throat Drooling Muffled or “hot potato” voice Referred ear pain Clinical Examination Findings Patients typically have inferior medial deviation of the infected tonsil, with uvular devi- ation away from the affected side. The pharyngeal arch is usually inflamed, erythem- atous, and enlarged. They may also have lymphadenopathy on the affected side.1 Trismus, drooling, foul-smelling breath, and a muffled voice are often noted. Periton- sillar abscesses are usually unilateral; however, bilateral occurrences have been described in case reports.2–4 In bilateral presentations, patients may not have the classic uvular deviation or unilateral prominence, making the clinical diagnosis more difficult and therefore requiring a high degree of suspicion for accurate diagnosis. Bacterial Causes The most common bacterial cause is Group A streptococci, usually a complication of preexisting tonsillitis/pharyngitis.5 Many infections are found to be polymicrobial. Other common causative bacteria are Streptococcus pyogenes, Staphylococcus aureus, and Haemophilus influenzae and anaerobic bacteria, such as Peptostrepto- coccus, Fusobacterium, and pigmented Prevotella.1 Diagnostic Tools Diagnosis based on the clinical examination findings alone has been shown to have a sensitivity of only 78% and a specificity of 50%. It can be very difficult to differentiate PTA from other causes of sore throat, such as infectious mononucleosis, tonsillar cellulitis, retropharyngeal abscess, and retromolar abscess. In the past, the diagnosis was confirmed with positive aspiration of pus on needle aspiration. More recently, however, imaging, such as ultrasound or computerized tomography (CT), is being used more often. When the physical examination is combined with ultrasound, the sensitivity increases to 89% and the specificity to 100%. CT has been shown to have a sensitivity of 100% and a specificity of 75% in diagnosing PTA.6 Ultrasound has several advantages over CT: it is easily accessible, has a low cost, and exposes the patient to no radiation, and can be used to guide drainage. The advantage of CT is Evaluation and Management of the Sore Throat 503 that it can reveal retropharyngeal or mediastinal fluid collections, indicating extension into the deep neck spaces. Treatment PTA is usually treated in an outpatient setting and consists of drainage, antibiotics, steroids, pain control, and intravenous (IV) hydration when necessary. A few patients require hospitalization, when the pain and swelling are so significant that they cannot tolerate fluids or oral antibiotics or if there is a concern about airway stability. Pharmacologic Treatment The following medications are typically used: Pain control (anti-inflammatory medications, narcotics) Antibiotics Antipyretics Steroids IV hydration (when the patient is unable to tolerate liquids) The use of steroids in addition to IV antibiotics has not been very well studied and remains somewhat controversial. One study, however, demonstrated that use of a single dose of IV steroid plus an antibiotic was statistically superior to antibiotics alone in reducing hours hospitalized, throat pain, fever, and trismus.7 This study involved hospitalized patients, and a comparison has not been extended to the outpa- tient setting. Empiric Antibiotics Empiric antibiotics should include coverage for Group A streptococci, S aureus, and anaerobes. A study performed in the United Kingdom found that administration of penicillin or a cephalosporin plus metronidazole was effective for treatment in 99.2% of patients treated with aspiration and antibiotics in an outpatient ear, nose, and throat (ENT) clinic.8 Only 1 patient in this series of 118 grew aspirate cultures posi- tive for penicillin-resistant streptococcal species but improved with the use of peni- cillin plus metronidazole. Empiric regimens for the treatment of PTA are presented in Box 1. Box 1 Empiric regimens for the treatment of peritonsillar abscess IV treatment Ampicillin/sulbactam (Unasyn), 3 g every 6 hours Penicillin G, 10 million units every 6 hours, plus metronidazole (Flagyl), 500 mg every 6 hours Clindamycin (Cleocin), 900 mg every 8 hours Oral therapy Amoxicillin/clavulanate, 875 mg twice daily Penicillin VK, 500 mg 4 times daily, plus metronidazole, 500 mg 4 times daily Clindamycin, 600 mg twice daily or 300 mg 4 times daily Data from Galioto NJ. Peritonsillar abscess, a review. Am Fam Physician 2008;77:199–202. 504 Cirilli In areas with an increasing prevalence of methicillin-resistant staphyloccocal infec- tions, clindamycin can be administered intravenously, and vancomycin should be considered if patients fail to improve after 24 hours. For oral administration of antibi- otics in areas of high staphylococcal resistance, clindamycin or linezolid can be used. Surgical Treatment When a fluid collection is present, antibiotic treatment alone is insufficient for the treat- ment of PTA. The mainstay of treatment is surgical drainage. Three drainage options are available: Emergent “quinsy” tonsillectomy or interval tonsillectomy Incision and drainage (performed by an ENT specialist) Needle aspiration (blind or guided by ultrasound imaging) In recent years, incision and drainage and needle aspiration have become favored over tonsillectomy because they can be performed in outpatient settings and EDs, and they avoid the risks associated with general anesthesia and the potential complica- tions of surgery. Emergent tonsillectomy offers no added benefit or effectiveness and is less cost effective than other methods of drainage.9 Comparisons of incision and drainage with needle aspiration have demonstrated no difference in outcomes with the 2 procedures; however, needle aspiration is easily performed by non- otolaryngologists and is usually less uncomfortable for the patient.5 Blind aspiration was used as a diagnostic and therapeutic procedure for PTA. The addition of ultrasound guidance has decreased the number of false-negative drainage procedures In addition, ultrasound is relatively low risk, without complications.10 It can differentiate tonsillar cellulitis from peritonsillar abscess. Ultrasound guidance also aids in avoiding the dreaded complication of puncture of the carotid artery, which lies in close proximity to the peritonsillar space. Ultrasound-guided aspiration is typically performed using an endocavitary probe, the size and shape of which are advantageous for insertion into the mouth to look for anechoic fluid collections. Ultrasound will demonstrate a hypoechoic or anechoic fluid collection within or just superior or posterior
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