Chapter 153: Neck and Upper Airway Disorders

PHARYNGITIS AND TONSILLITIS

Clinical Features

Viral pharyngitis/tonsillitis may present with fever, odynophagia, and petechial or vesicular lesions on the soft palate and tonsils. Compared to bacterial pharyngitis, viral pharyngitis is more often associated with cough, rhinorrhea, and congestion. Viral infections typically lack tonsillar exudates and cervical adenopathy. Bacterial pharyngitis, particularly group A β-hemolytic streptococcus (GABHS) pharyngitis, presents with acute onset of fever, sore throat, odynophagia, and often headache. Patients often display tonsillar erythema, exudates, and tender anterior cervical adenopathy. Cough, conjunctivitis, and rhinorrhea are typically lacking.

Diagnosis and Differential

The Centor criteria for GABHS pharyngitis are (1) tonsillar exudates, (2) tender anterior cervical adenopathy, (3) absence of cough, and (4) fever. Perform a rapid antigen test on patients with two or more criteria and treat based on the results on the rapid test. Additional diagnostic testing should be performed if mononucleosis, influenza, or acute retroviral syndrome is suspected.

Emergency Department Care and Disposition

1. Nonbacterial causes are treated with supportive care: antipyretics, analgesics, and IV fluids, if the patient is dehydrated.

2. Treat GABHS pharyngitis with a single dose of benzathine penicillin G 1.2 million units IM, penicillin VK 500 mg PO twice daily for 10 days, or amoxicillin 500 mg twice daily or 1000 mg per day. Treat penicillin-allergic patients with a first-generation cephalosporin or clindamycin.

PERITONSILLAR ABSCESS

Clinical Features

Patients appear ill and often complain of sore throat, fever, odynophagia, trismus, and dysphagia. A muffled voice may be noted. The infected tonsil is typically displaced medially, causing contralateral deflection of the uvula.

Diagnosis and Differential

Additional conditions to consider include peritonsillar cellulitis, infectious mononucleosis, retropharyngeal abscess, herpes simplex tonsillitis, neoplasm, and internal carotid artery aneurysm. Diagnosis is typically made through the history and physical exam. If diagnosis is in question, intraoral ultrasound is very sensitive and specific. CT scan with contrast can be employed if there is concern for extension of infection beyond the peritonsillar space.

Emergency Department Care and Disposition

1. Peritonsillar abscess is treated with needle aspiration with an 18-G needle or incision and drainage (I&D) after local anesthesia. Cut the plastic needle sheath at about 1 cm from its tip to deter from penetrating to the level of the internal carotid artery.

2. After adequate aspiration or drainage, patients able to tolerate PO may be discharged home on antibiotics. Give Penicillin VK PLUS metronidazole for 10 days. Choose clindamycin for penicillin-allergic patients. Toxic patients should receive piperacillin-tazobactam 3.375 g IV and admitted for observation.

ADULT EPIGLOTTITIS (SUPRAGLOTTITIS)

Clinical Features

Patients typically present with a 1- to 2-day history of worsening dysphagia, odynophagia, and dyspnea, worse ...