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FM46 Family Medicine
Common Presenting Problems
Toronto Notes 2019
Red Flags in Patients with “Sore Throat”
• Persistence of symptoms longer than 1 wk without improvement
• Respiratory difficulty (particularly stridor, croup, etc.)
• Difficulty in handling secretions (peritonsillar abscess)
• Difficulty in swallowing (Ludwig’s angina)
• Severe pain in the absence of erythema
(supraglottitis/epiglottitis)
• Palpable mass (neoplasm)
• Blood in the pharynx or ear (trauma)
■ investigations
◆ evaluate BP, inspect nose, and oropharynx (enlarged adenoids or tonsils) ◆ blood gas not helpful, TSH if clinically indicated
◆ nocturnal polysomnography
■ treatment
◆ modifiable factors: avoid sleeping supine; weight loss; avoid alcohol, sedatives, opioids; inhaled
steroids if nasal swelling present; dental appliances to modify mandibular position
◆ primary treatment of OSA is CPAP: maintains patent airway in 95% of OSA cases
◆ surgery: somnoplasty, uvulopalatopharyngoplasty (UPPP), tonsillectomy, and adenoidectomy
(in children)
◆ report patient to Ministry of Transportation if OSA is not controlled by CPAP
Sore Throat (Pharyngitis)
Definition
• inflammationoftheoropharynx
• maybecausedbyawiderangeofinfectiousorganisms,mostofwhichproduceaself-limitedinfection
with no significant sequelae
Etiology
• viral:adenovirus,rhinovirus,influenzavirus,RSV,EBV,coxsackievirus,herpessimplexvirus,CMV, HIV
• bacterial:GroupAβ-HemolyticStreptococcus(GABHS),GroupCandGroupβ-HemolyticStreptococcus, Neisseria gonorrhoeae, Chlamydia pneumoniae, Mycoplasma pneumoniae, Corynebacterium diphtheriae
Epidemiology
• viral
■ most common cause (90% in adults is viral), occurs year round
• bacterial
■ GABHS (Group A β-Hemolytic Streptococcal Infections)
◆ most common bacterial cause
◆ occurs most often in winter months
◆ 5-15% of adult cases and up to 50% of all pediatric cases of acute pharyngitis ◆ most prevalent between 5-17 yr old
Clinical Features
• viral
■ pharyngitis, conjunctivitis, rhinorrhea, hoarseness, cough
■ nonspecific flu-like symptoms such as fever, malaise, and myalgia ■ often mimics bacterial infection
■ common viral infections
◆ EBV (infectious mononucleosis)
– pharyngitis, tonsillar exudate, fever, lymphadenopathy, fatigue, rash
◆ coxsackie virus (hand, foot, and mouth disease)
– primarily late summer, early fall
– sudden onset of fever, pharyngitis, headache, abdominal pain, and vomiting
– appearance of small vesicles that rupture and ulcerate on soft palate, tonsils, pharynx
– ulcers are pale grey and several mm in diameter, have surrounding erythema, and may
appear on hands and feet ◆ herpes simplex virus
– like coxsackie virus but ulcers are fewer and larger
• bacterial–pharyngitis,tonsillarexudate,fever,lymphadenopathy,fatigue,rash
■ symptoms: pharyngitis, fever, malaise, headache, abdominal pain, absence of cough
■ signs: fever, tonsillar or pharyngeal erythema/exudate, swollen/tender anterior cervical nodes,
halitosis
■ complications:
◆ suppurative: abscess, sinusitis, otitis media, cervical adenitis, pneumonia ◆ non-suppurative: acute rheumatic fever, acute glomerulonephritis
Investigations
• suspectedGABHS
■ see Table 24, FM47 for approach to diagnosis and management of GABHS
■ gold standard for diagnosis is throat culture
■ rapid test for streptococcal antigen: high specificity (95%) but low sensitivity (50-90%) ■ suspected EBV (infectious mononucleosis)
◆ peripheral blood smear, heterophile antibody test (i.e. the latex agglutination assay or “monospot”)