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Viral URI

Etiology
Pathophysiology
Risk Factors
Symptoms (7)
Clinical Findings
Treatment (7)
Differentials
Etiology

  • Rhinovirus (25-30%)
  • Coronavirus (10% incl SARS and more severe illnesses)
  • Parainfluenza
  • Adenovirus (most common preschool)
  • Higher in fall and winter
Pathophysiology

  • Particles of respiratory secretions in air
  • Direct contact with secretions, skin and surfaces
  • incubates 2-3 days
  • PMNs to nasal mucosa
Risk Factors

winter months, colder climates, enclosed spaces (schools)


Symptoms

  • Nasal discharge (clear, yellow or green)
  • Nasal obstruction
  • Sneezing
  • Cough
  • HA
  • Malaise
  • Low grade fever (though more often assoc. with influenza or bacterial component)
Clinical Findings

Red nose, rinorrhea, pharyngeal erythema


Treatment

  • Prevent (handwashing and covering mouth with cough)
  • Decongestants (NOT for children <6)
  • Cough medicines
  • Medication for fever/discomfort
  • Saline nasal irrigation
  • Humidifier
  • Hydration

Differentials

Bacterial URI, etc.
Allergic Rhinitis

Etiology (6)
Pathophysiology
Risk Factors
Symptoms
Clinical Findings
Dx/Labs
Treatment
Differentials
Etiology

  • Immune-mediated
  • Infection
  • Overuse of decongestants/nasal sprays
  • Irritants
  • Nasal polys
  • Ciliary defects
  • >75% children with asthma
Pathophysiology

Type 1 hypersensitivity response by interaction of antigen with antigen-specific IgE bound to receptors on mast cells.


Risk Factors

seasonal allergy by pollen and spores, dust, household mites, air pollution & pet dander; chemical irritants, smoke


Symptoms

Bilateral nasal discharge, nasal congestion, watery/itchy/puffy eyes, sneezing, dark shadows under eyes


Clinical Findings

Nasal mucosa & turbinates pale, cyanotic and swollen with clear secretions


Dx/Labs

CBC, RAST, Nasal discharge, IgE, Sweat test (if suspect CF), other skin testing (referral)


Treatment

  • Environmental control
  • Antihistamines (Loratadine  (Claritin) or Fexofenadine (Allegra))
  • Nasal sprays (Fluticasone (Flonase) or Mometasone (Nasonex))

Differentials

Sinusitis, FB, Tumor/Nasal polyp, Congenital, Vasomotor rhinitis, Trauma
Sinusitis

Etiology
Pathophysiology
Risk Factors (6)
Symptoms (7)
Clinical Findings (4)
Dx/Labs
Treatment
Differentials
Etiology

An infection or inflammation of the mucous membranes that line the inside of the nose and facial sinuses. Usually viral (Thinovirus, parainfluenza, influenza) or can be same bacteria as OM


Pathophysiology

Mucous membrane inflamed, swells, blocking the drainage from sinuses into the nose and throat causing pressure and pain in the sinuses


Risk Factors

  • Allergic Thnosinusitis
  • Adenoid Hypertrophy
  • Immature Immune System
  • Barotrauma
  • Frequent URIs
  • Environmental
Symptoms

  • Facial pain, pressure
  • Congestion
  • Obstruction
  • Mucopurulent DC
  • Hypo or anosmia
  • Fever (with Thinosinusitis)
  • Toothache
Clinical Findings

  • Unilateral facial fullness
  • Tender cheeks
  • Pain refer to incisor/canine teeth
  • Green purulent secretion
Dx/Labs

Transillumination (not useful in children)


Treatment

Amoxicillin or erythromycin, decongestants, heat packs or steam


Differentials

Viral URI, Dental disease, Nasal FB, TMJ, HA, Wegener's granulomatosis
Streptococcal Pharyngitis

Etiology
Pathophysiology
Symptoms (8)
Clinical Findings (4)
Dx/Labs
Treatment (2)
Differentials
Etiology

group A beta-hemolytic streptococcal infection

Pathophysiology

Infection of the throat and associated inflammation

Symptoms

• Sudden onset of sore throat
• Painful swallowing
• Chills
• Fever
• Headache
• Nausea
• Vomiting
• w/o cough


Clinical Findings

a. Fever over 38 C
b. Tender anterior
cervical adenopathy c. Lack of a cough
d. Pharyngotonsillar exudates
These 4 features when present, strongly suggest GABHS

Dx/Labs

confirmation by throat culture or a rapid antigen detection test

Treatment

•penicillin
• alternative use Erythromycin (vs Mycoplasma & Chlamydia)

Differentials

a. Infectious mononucleosis
b. Diphtheria
c. Viruses
d. Corynebacterium diphtheria
e. Corynebacterium haemolyticum
Bacterial Pharyngitis

Etiology (4)
Pathophysiology
Symptoms (8)
Clinical Findings (7)
Dx/Labs
Treatment (2)
Differentials

Etiology

• Streptococcus pyogenes (most common)
• Group C beta hemolytic streptococcus (second most common)
• Mixed anaerobic infection
• Neisseria gonorrheae



Pathophysiology

Inflammatory process of the oropharynx caused by infections


Symptoms

• Sudden onset of sore throat
• Painful swallowing
• Chills
• Fever
• Headache
• Nausea
• Vomiting
• w/o cough



Clinical Findings

• Erythema of the tonsils and the tonsillar pillars
• Tonsillar exudates
• Enlarged, tender, lymph nodes
• Uvular edema
• Fever
• Myalgias
• Malais



Dx/Labs

throat culture or a rapid antigen detection test


Treatment

•penicillin
• alternative use Erythromycin (vs Mycoplasma & Chlamydia)


Differentials

a. Infectious mononucleosis
b. Diphtheria
c. Viruses
d.Corynebacterium diphtheria
e.Corynebacterium haemolyticum

Viral Pharyngitis

Etiology (9)
Symptoms (5)
Clinical Findings (4)
Dx/Labs
Treatment (3)
Etiology

• Rhinovirus & coronavirus
• Adenovirus
• Herpes simplex
• Parainfluenza
• Influenza virus
• Coxsackie virus
• Epstein-Barr virus
• Cytomegalovirus
• HIV-1


Symptoms

• Mild to moderate pharyngeal pain
• Fever
• Malaise
• Headache
• Dizziness


Clinical Findings

• Tonsillar enlargement
• Tonsillar exudates
• Rhinorrhea suggest viral etiology
• Vesicular and petechial pattern on soft palate and tonsils


Dx/Labs

Dx supported by (-) culture on rapid antigen test, serum monospot

Treatment

• warm salt water gargles
• Fluids
• Acetaminophen for fever control
Infective Mononucleosis

Etiology (2)
Pathophysiology
Risk Factors
Symptoms (7)
Clinical Findings (7)
Dx/Labs (4)
Treatment (4)
Differentials
Etiology

• Esptein-Barr Virus (EBV)
• Virus resides in the B lymphocytes

Pathophysiology

• Epstein Barr virus enters the B lymphocytes through the CD21 molecule on the surface of the B cells

Risk Factors

Kissing and other forms of saliva exchange ;)

Symptoms

• Fever
• Sore throat
• Lymphadenopathy
• Malaise
• Headache
• Anorexia
•myalgia


Clinical Findings

• Patients febrile
• Pharyngeal erythema
• Tonsillar enlargement
• Cervical adenopathy
• Mild periorbital edema
• Splenomegaly
• Hepatomegaly


Dx/Labs

• (+) heterophile antibodies
• EBV-specific
serologic studies • Elevated liver
transaminase level • Elevated
lymphocytes and monocytes

Treatment

• Rest
• Increase fluid intake
• No contact sports or strenuous activity for 4 weeks
• Aspirin or acetaminophen for mild pain


Differentials

Streptococcal pharyngitis, primary herpes stomatitis, CMV infection, toxoplasmosis, acute HIV infection, secondary syphilis, HHV-6, rubella, and drug hypersensitivity rxn
Lymphadenopathy of Head and Neck

Etiology (5)
Pathophysiology
Clinical Findings
Dx/Labs (6)
Etiology

• Infection
• Benign disorder of immune system
• Malignant disorders
• Storage diseases
• Endocrinopathies


Pathophysiology

Location of enlarged lymph nodes often reflect site of injury e.g cervical lymphadenopathy = pharyngitis

Clinical Findings

Lymph nodes larger than 1 to 2 cm in diameter (groin area excluded)

Dx/Labs

Careful physical exam
Lab tests
Sometime imaging
-CT
Needle Aspiration
Cutting needle biopsy
Tonsilitis

Etiology: 2 causes and groups affected
Pathophysiology (2)
Symptoms
Clinical Findings (5)
Dx/Labs
Treatment
Etiology

• Adenovirus most common in viral tonsillitis
• Group A beta hemolytic streptococcus pyogenes (bacterial) 15-30% Viral accounts for 90% of sore throats
Children <2 usually viral,
children >5 usually GAS

Pathophysiology

• Inflammation of the pharyngeal tonsils
• usually extends to the adenoids and lingual tonsils

Symptoms

Viral - Gradual onset, Rhinorrhea, Sore throat , Dysphagia, Mild cough, Low grade fever bacterial - Abrupt onset, Moderate to high fever, Malaise,

Clinical Findings

• Petechiae on soft palate and pharynx
• Swollen & red uvula
• Tonsillopharyngeal exudates
• Tender & enlarged cervical lymph nodes
• GAS - red sandpapery rash, exudates

Dx/Labs

Throat culture, rapid streptococcal antigen test

Treatment

viral: Fever and sore throat pain relief with acetaminophen or ibuprofen, ↑ fluid intake
bacterial:Penicillin, Benzathine penicillin G IM injection, fluid & rest

Epiglottitis

Etiology (4)
Pathophysiology
Risk Factors
Symptoms (5)
Clinical Findings (2)
Dx/Labs
Treatment
Etiology

H. influenzae type b is most common cause of acute epiglottitis.
• S.pneumoniae
• S. pyogenes
• S. aureus

Pathophysiology

Epiglottitis is inflammation of the cartilage that covers the trachea (windpipe).
Cellulitis of supraglottis which may cause airway compromise.

Risk Factors

More common in diabetics

Symptoms

• Rapid onset Fever
• sore throat
• drooling
• dysphagia (pain on swallow)
• Shortness of breath

Clinical Findings

• Cervical tenderness and lymphadenopathy.
• Pt w/ tripod position

Dx/Labs

Laryngoscopy-> reveals swollen, cherry red epiglottis.
Lateral radiograph of neck.

Treatment

Secure airway + supplemental oxygen or intubation, IV antibiotics (cefotaxime), corticosteroids (decrease swelling) -> admit ICU

Laryngitis

Etiology (8)
Pathophysiology (2)
Symptoms (3 + 4 when severe)
Clinical Findings (6)
Dx/Labs (2)
Treatment (3)
Etiology

• Rhinovirus
• Influenza virus
• Parainfluenza virus
•Cough induced from bronchitis or pneumonia
•Excessive use of voice
•Allergic reaction
•GERD, Bulimia
•inhale irritant

Pathophysiology

• Present after an upper respiratory tract infection has cleared
• Inflammatory process involving the larynx

Symptoms

•Change in voice
•Horseness
•Constant urge to clear voice Severe symptoms: fever, malaise, dysphagia and throat pain

Clinical Findings

• Hoarseness
• Decreased vocal pitch or aphonia
• Rhinorrhea
• Nasal congestion
• Cough
• Sore throat

Dx/Labs

• Laryngoscopy often reveals diffuse laryngeal erythema and edema
• Vascular engorgement of vocal folds

Treatment

• Humidification
• Voice rest
• Antibiotic treatment only when group A streptococcus is cultured

Peritonsillar Abscess

Etiology
Symptoms
Clinical Findings
Treatment
Etiology

Peritonsillar abscess is a complication of tonsillitis, caused by group A betahemolytic streptococcus. Generally a disease of older children, adolescents, and young adults.

Symptoms

Sore throat, tender glands of the jaw and throat, facial swelling, drooling, headache, fever, chills, difficulty & pain w/ opening the mouth, hoarseness

Clinical Findings

odynophagia, uvula or tonsil past midline, Unexplained severe sore throat and neck stiffness; stridor or noisy breathing

Treatment

penicillin or clindamyclin + pain killers. Surgery to remove abvscess.
Herpangina

Etiology
Symptoms
Clinical Findings
Treatment
Etiology

Children between 3-10 yrs old, disease begins after 3- 10 day incubation period. By coxsackievirus, outbreaks common in summer.

Symptoms

Sudden onset of fever, sore throat, pain on swallowing. Anorexia, vomiting, and abdominal pain. Headache, myalgia, Little blisters – around posterior pharynx

Clinical Findings

vesicular enanthem of the posterior pharynx. Fevers of 38-41*C. 1-2 mm vesicles & ulcers surrounded by 1-5mm zones of erythema on pharynx, soft palate, uvula. Small papule -> vesicle -> ulceration.

Treatment

Treat symptoms, drink fluid, last 4-6 days
Cellulitis (of face and neck)

Etiology
Pathophysiology
Risk Factors
Symptoms (6)
Clinical Findings
Dx/Labs
Treatment
Etiology

factors associated with this infection include a cut in the skin, skin ulcers, and problems with the drainage through the veins or lymph system. Most often caused by strep or staph.

Pathophysiology

Erysipelas is a type of cellulitis caused by group A strep. Starts at one point and spreads gradually over the surface.

Risk Factors

Break in the skin

Symptoms

•Pain
•Spreading erythema
•Edema
•Fever may occur
•lymph nodes may enlarge
•Skin is hot, red resembling a orange

Clinical Findings

Raised, red dimpled areas. Fever, chills, tachycardia, headache, hypotension, and delirium may precede cutaneous findings by several hours, but many patients do not appear ill.

Dx/Labs

tissue cultures for immunocompromised patients

Treatment

Penicillin oral or IV. Prevention can include maintaining intact skin, avoiding cuts/scrapes.

Laryngeal Cancer

Pathophysiology
Risk Factors
Symptoms
Clinical Findings
Treatment
Pathophysiology

Vocal fold nodules , smooth paired lesions that form at the junction of the anterior one-third and posterior two-thirds of the vocal folds

Risk Factors

associated w/ smoking

Symptoms

Hoarseness, lump in the neck, sore throat, persistent cough, stridor, bad breath, earache

Clinical Findings

Sputum may appear bloody, lump may appear on the outside of the neck, lesions on larynx hard nodule

Treatment

Referral: ENT surgeons and oncologist.

Epistaxis (also emergent)

Etiology
Risk Factors
Dx/Labs
Treatment
Etiology

• Kiesselbach’s venous plexus (90%) - little's area
• Inflammation-resp. inf., allergies, sinusitis
• Neoplasm
• Trauma (picking, rubbing and blowing)
• Foreign body

Risk Factors

Hemophillia, liver disease, polycythemia, digital trauma

Dx/Labs

If suggestive of more generalized bleeding
•Prothrombin time
•PTT
•CBC with Platelets
•Bleeding time

Treatment

•direct pressure x 10- 20 minutes
•Apply ice
•If continues to bleed cotton ball dampened with topical anesthetic
4% cocaine-pontocaine
•Nasal packing
Nasal Polyps

Etiology
Pathophysiology
Risk Factors
Symptoms
Clinical Findings
Dx/Labs
Treatment
Differentials
Etiology

Commonly seen in pt w/allergic rhinitis that may result into chronic nasal obstruction & diminished smell. May come from sinus infection. May suggest Cystic Fibrosis in children.

Pathophysiology

Develop in mucous lining of nose.

Risk Factors

CF

Symptoms

Stuffy and runny nose.

Clinical Findings

Pale, edematous mucosally covered masses

Dx/Labs

- HEENT exam (N in particular)
- Sweat test for children - test for CF

Treatment

Topical nasal corticosteroids 1-2 months, oral corticosteroids (prednisone 6 days)

Differentials

Neoplasm, congenital lesions, foreign body
URI ("common cold")

Etiology
Symptoms
Clinical Findings
Treatment
Differentials
Etiology

Rhinovirus (50%) coronavirus & RSV (10% each) Higher in Fall and Winter. Rhinovirus in September Parainfluenza in Oct/Nov

Symptoms

Rhinorrhea, nasal stuffiness, cough, mouth breathing, sneezing watery eyes, mylagias, headache, malaise

Clinical Findings

No fever, fever is usually sign of bacterial infection. Erythematous, engorged nasal mucosa.

Treatment

Prevention:AVOID STRESS, Hand washing. Symptoms disappear in 7 days w/o intervention. Rest and lots of H20. Nasal spray (oxymetazoline or phenylephrine).

Differentials

Allergic rhinitis, sinusitis, cocaine use
Retropharyngeal Abscess (emergency plan)

Etiology
Treatment
Etiology

a collection of pus in the tissues in the back of the throat. It is a potentially life-threatening medical condition.

Treatment

assuring a patent airway, receive consultation by Otolaryngology, admission to the hospital, and intravenous antibiotics. Incision + drainage by surgeon.

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