ALERTS - Ruggles Service Corporation



ALERTS Peritonsillar abscess Retropharyngeal abscess - <4yrs Epiglottitis Foreign body Trauma AGE CONSIDERATIONS Strep pharyngitis risk - >2yrs Gonococcal & Chlamydial pharyngitis - Adolescents DIFFERENTIAL DIAGNOSIS VIral pharyngitis Herpangina Coxsackie GABHS pharyngitis EBV Post-nasal drip Gonococcal pharyngitis Chlamydia pharyngitis Peritonsillar abscess/cellulitis Retropharyngeal abscess GERD Epiglottitis PFAPA syndrome (Periodic fever, Aphthous ulcers, Pharyngitis, & cervical adenitis) Pharyngeal Foreign Body Trauma EVALUATION HISTORY Onset and quality of pain, associated fever, timing, URI s/sx, malaise, headache, abdominal pain/vomiting, associated neck pain PHYSICAL EXAM HEENT: otoscopic findings, oropharynx, neck, lymph nodes Abdomen Skin DIAGNOSTIC FINDINGS Pharynx: erythema, edema, exudate, uvular positioning, lesions, strawberry tongue, palatal petechiae, trismus Neck/Lymph: ROM, lymphadenopathy Abdomen: tenderness, assess for splenomegaly Skin: rash CONCERNING FINDINGS Peritonsillar/Retropharyngeal abscess: assymetry, uvular deviation, trismus, drooling EBV: splenomegaly, ill appearing Epiglotitis: tongue protruding, drooling, tripod-sit, ill appearing, anxious Foreign body: airway compromise, Trauma: bleeding, airway compromise, shock DIAGNOSTIC TESTS LAB TESTS Rapid strep Throat culture Viral throat culture Monospot, EBVserology (igG, IgM) CBC IMAGING Lateral neck xray CT - neck MANAGEMENT TRANSFER/ADMISSION CONSIDERATIONS Significant tonsillar edema with concern for progression to airway compromise Peritonsillar or Retropharyngeal abscess Dehydration Foreign body Epiglotitis Trauma Complications Peritonsillar and retropharyngeal abscess Uvulitis Cervical lymphadenitis Otitis Media/Mastoiditis Acute rheumatic fever, acute post-streptococcal glomerulonephritis, and acute post-streptococcal arthritis – with Group A strep EBV-induced reactive arthritis Vascular injury (trauma) PEARLS AND PITFALLS Tonsillar lymphoma – asymmetrical enlarged tonsils without signs of infection Small tears in penetrating oral trauma usually do not require repair but prophylactic antibiotics are needed Oral daily penicillin used to prevent recurrent acute rheumatic fever Frequency of tonsillitis needed for tonsillectomy are >6 in the previous year, >5 in the 2 preceding years or 3 episodes per year for 3 years VIRAL PHARYNGITIS TREATMENT Supportive Fever and pain reliever Push fluids Complementary & Alternative Therapies Salt water or Listerine gargles Surgery / Other Procedures FOLLOW UP Anticipatory Guidance Pain reliever Typical duration of sore throat is 7-10 days Typical duration of fever is 3-5 days Signs and Symptoms to return Persistent fever, sore throat, fatigue/malaise Decreased urine output Increasing pain Trismus, drooling Activity, Diet Activity as tolerated Increase fluids PROGNOSIS, COMPLICATIONS Typically self-resolves Can progress to peritonsillar or retropharyngeal abscess GABHS PHARYNGITIS TREATMENT First Line Penicillin VK Amoxicillin (40-50 mg/kg divided BID for 10 days) IM Penicillin G Second Line Erthromycin/Azithromycin Cephalexin (5% cross reactivity with PCN allergy) Clindamycin Supportive Fever and pain reliever Push fluids Complementary & Alternative Therapies Salt water or listerine gargles Surgery / Other Procedures Tonsillectomy if recurrent infections FOLLOW UP Anticipatory Guidance Pain reliever May take 48-72 hours for pain and fever to stop Signs and Symptoms to return Persistent fever, sore throat, fatigue/malaise Persistent vomiting, decreased urine output Increasing pain Trismus, drooling Activity, Diet No school/work until 24 hours on antibiotics Activity as tolerated Increase fluids PROGNOSIS, COMPLICATIONS Typically responds well to antibiotics Can progress to peritonsillar or retropharyngeal abscess Can progress to acute rheumatic fever if untreated ReferenceS Hayden GF, Turner RB. Acute pharyngitis. In: Kliegman RM, Behrman RE, Jenson HB, Stanton BF, eds. Nelson Textbook of Pediatrics. 17th ed. Philadelphia, PA: Saunders Elsevier, 2004. Pantell R. Pharyngitis: Diagnosis and Management. Pediatr. Rev., Aug 1981; 3: 35 - 39. Pichichero M. Group A Beta-hemolytic Streptococcal Infections. Pediatr. Rev., Sep 1998; 19: 291 – 302 Yellon R, McBride T, and Davis H. Otolaryngology. In: Zitelli B and Davis H. Atlas of Pediatric Physical Diagnosis, 5th ed. Philadelphia, PA: Mosby Elsevier, 2007: 921-925 Additional Resources Paradise J, Bluestone C, Colborn DK, Bernard B, Rockette H, and Kurs-Lasky M. Tonsillectomy and Adenotonsillectomy for Recurrent Throat Infection in Moderately Affected Children. Pediatrics, Jul 2002; 110: 7 – 15 Tanz R, Gerber M, Kabat W, Rippe J, Seshadri R, and Shulman S. Performance of a Rapid Antigen-Detection Test and Throat Culture in Community Pediatric Offices: Implications for Management of Pharyngitis. Pediatrics, Feb 2009; 123: 437 - 444. ................
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