Sore Throat

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Sore Throat

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1. Sore Throat Miss N Su

2. To cover the broad topic of “sore throat”, focusing on conditions of the oropharynx Aims

3. Accidental biting, other trauma and burns all cause mouth ulcers. These should heal within 7-14 days Any patient with a single mouth ulcer persisting for greater than 2-3 weeks should have it further investigated. Mouth ulcers

4. Common, reoccurring episodes of ulcers, usually from childhood or adolescence Aggravating factors: stress, trauma, cessation of tobacco smoking 10-20% have an underlying haematological pathology Recurrent Aphthous stomatitis

5. Recurrent aphthous stomatitis plus genital ulceration and eye disease Genetic background Males 30-40yrs most commonly affected Treated with colchine, steroids and immunosuppressants Bechet’s syndrome

6. What viruses cause oral ulceration?

7. Herpes simplex virus Herpes zoster (look for immunocompromise in young patients EBV Coxsaccie virus (herpangia or hand foot and mouth) A

8. During what stage of syphilis would you find oral ulceration? Bacterial infections

9. Primary syphilis – primary hard or huntarian chancre Secondary – mucous patches and snail track ulcers Tertiary – localised granulation - gumma All 3 stages may present with oral lesions

10. TB Rare but can present with oral lesions- ulceration of dorsum of tongue described as an irregular ulcer with a granulating base. Looks similar to and SCC

11. Overlaps with the common cold, mild form with low grade fever is assoc with rhinovirus, coronavirus and RSV. More severe form is assoc with fever, sore throat, malaise, pharyngitis and cervical lymphadenopathy – caused by adenovirus, influenza virus, enterovirus, EBV, herpes simplex and HIV Viral Pharyngitis

12. 6 yr old boy 48hr history of sore throat, pyrexia and malaise O/E T 38.5 , bilateral tender cervical lymphadenopathy and enlarged erythematous tonsils. Patient 1

13. Bacterial Group A beta-haemolytic streptococcus Groups C and G beta-haemolytic streptococcus Viral Rhinovirus Corona virus Respiratory syncytal virus Parainfluenza EBV Fungal Candida albicans You make a diagnosis of tonsillitis – what are the possible pathogens?

14. Supportive treatment with fluids Calpol ?antibiotics Need to avoid aspirin due to risk of Reye's syndrome Avoid ampicillin How would you manage this patient?

15. Rheumatic fever 0.3% of untreated Pxs Post strep glomerulonephritis Abscess formation Septacaemia Acute OM / mastoiditis Lemierre syndrome Complications of GABHS

16. Rheumatic fever occurs in 0.5-3% of ineffectively treated patients with GABHS. Occurs approx 20 days after the sore throat. Diagnosed on the presence of 2 major criteria, or 1 major criteria and 2 minor criteria Rheumatic fever

17. Antibiotics should not be used to routinely prevent from developing RF or glomerulonephritis Antibiotics do improve symptom control, but only marginally compare to simple analgesia- increased benefit in symptoms occurred 16 hours earlier in patients given antibiotics The role of antibiotics in sore throat

18. Age range 14-25yrs Tonsillitis with thick exudate and palatal petechiae . Up to 50% develop splenomegally 5% have a rash, this will increase to 90% if given ampicillin or amoxicillin. Treatment is largely supportive, can lead to airway compromise requiring tonsillectomy or even tracheostomy EBV infection- infectious Mononucleosis

19. Name 3 different causes of exudate on the tonsils How can you tell these conditions apart?

20. Glandular fever Vincent’s angina Diphtheria If you scrape the exudate off in diphtheria the underlying mucosa bleeds, the underlying mucosa in Vincent’s is erythematous but doesn’t bleed. Answer

21. Present in the unimmunised population Causes a greyish exudate extending from the tonsils to soft palate Spreads via respiratory droplets and infected objects or food Mortality rate remains 5-10% Toxins can cause cardiac and neural toxicity Treatment involves antitoxin and penicillin or erythromycin Diphtheria

22. Primary HIV infection can cause an acute retroviral syndrome: Fever Non-exudative pharyngitis Arthralgia Malaise and lethargy Macculopapular rash in 40-80% HIV

23. Idiosyncratic drug reaction, may present with fever and sore throat. Diagnosed on FBC Drugs implicated: Antiepileptics Antithyroid drugs Antibioitcs – penicillin, chloramohenicol, co-trimoxale Cytotoxic drugs Gold NSAIDs Some anti-depressants and anti-psychotics Agranulocytosis

24. Acute Leukaemia All forms may present with nonspecific sloughing ulcers on the gums, oral cavity and pharynx and possible cervical lymphadenopathy Diagnosis is based on blood film and bone marrow examination

25. What is the differential diagnosis? Unilateral tonsil enlargement

26. Malignancy - asymmetry in normal tonsil – in the absence of cervical lymphadenopathy has a 7% risk of malignancy Chance or malignancy if mucosa abnormality or lymphadenopathy is very high Rare tumours Extramedullary plasmacytomas Hodgkin’s disease Leukaemia and metastatic deposits Infection- candida and actinomycosis Quinsy /parapharyngeal space mass Unilateral tonsil enlargement

27. What is the differential diagnosis? Tonsil ulceration

28. Neoplastic – SCC, salivary gland tumours, lymphoma, melanoma, myeloma Infection – acute strep inf, quinsy, diphtheria, EBV and CMV mononucleosis and Vincent's angina Chronic- syphilis, TB and AIDs Blood disorder- agranulocytosis, leukaemia Miscellaneous: aphthous ulceration, Bechet’s syndrome, colloidal bismuth intoxication Tonsil ulceration

29. Indications for tonsillectomy for recurrent tonsillitis sore throats are due to tonsillitis; the episodes of sore throat are disabling and prevent normal functioning. Seven or more episodes in the preceding year Or five or more episodes of sore throat per year for 2 years 3 or more episodes for the last 3 years Tonsillectomy

30. Asymmetrical adult For obstructive sleep apnoea (OSA) in children in conjunction with adenoidectomy is a well-recognized . In adults with gross tonsil hypertrophy and OSA, or as part of uvulopalatopharyngoplasty (UPPP) or laser-assisted uvulopalatoplasty. Severe haemorrhagic tonsillitis. Severe infectious mononucleosis with upper airway obstruction. Large symptomatic tonsoliths (tonsillar concretions). As long-term management of IgA nephropathy. The long-term prognosis is no longer regarded as benign but with pulsed steroid therapy and tonsillectomy significant increases in clinical remission rates can be obtained (25 percent with tonsillectomy, 13 percent without) also with significant increases in renal survival.49,?50,?51,?52 Other indications for tonsillectomy

32. History of long standing sore throat and discomfort of variable severity. Possible aetiology: Heavy smoking Chronic rhinosinusitis with increased post nasal drip Laryngeal pharyngeal reflux Poor dental hygiene Chlamydia pneumonia Chronic pharyngitis

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