ENT Part 3: a frog in your throat?

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Here is the third part in our three part ENT series looking at recognition and management of common paediatric ENT conditions. This series is based on a presentation by Rahul Santram, adapted by Tessa Davis, and checked by our resident ENT surgeon, Sinéad Davis.

Part 1 was on – the ear. Part 2 was on – the nose. Today, we look at the throat.

 


Pharygnitis/tonsillitis

This is a common presentation, and most are viral. Group A Strep is causative in 10-20% of cases (this is the most common bacterial cause).

The predominant age is 4-11 years, and it is rare in <3 year olds.

Due to concerns of potential non-suppurative complications of strep infection such as rheumatic fever and glomerulonephritis, many kids get unnecessary antibiotic prescriptions.

Symptoms

Symptoms include:

  • Sore throat
  • Decreased oral intake
  • Fever
  • Headache
  • Vomiting
  • Abdo pain

No set of symptoms are suggestive of either bacterial or viral aetiology.

Examination

It is difficult to distinguish between viral or bacterial causes.

You could calculate the strep score: fever; anterior cervical lymphadenopathy; tonsillar exudate and absence of cough. This gives a score out of 4. If 3-4/4 it suggests a strep throat.

Tonsillar exudates are also present in viral infections.

In ulcerative pharyngitis (herpangia), Coxsackie virus should be considered, but other causes might be aphthous ulcers or rarely autoimmune conditions.

In the presence of marked bilateral lymphadenopathy , especially in adolescence, consider glandular fever.

Investigations

Throat swab – but consider the utility of the results.

Monospot – this is usually requested first but there is a high false negative rate, so serology for EBV is suggested if concerned about this diagnosis but monospot negative.

Rapid antigen test – expensive and not sensitive.

Treatment

Analgesia and antipyretics.

Keep up fluids.

Antibiotics have only been shown to shorten the course of the illness by a few hours for patients with Strep. They can reduce the risk of non-suppurative complications e.g. rheumatic fever, so it may be worth considering a course of antibiotics in at-risk children.

Consider steroids for 24 hours in glandular fever cases.

Complications

  • Rheumatic fever, seen 2-6 weeks later (now rare)
  • Post-strep glomerulonephritis (not prevented by antibiotics)
  • Mastoiditis
  • Retropharyngeal abscess

Consider diptheria in non-immunised patients. You see a grey-green pseudomembranous pharyngitis, the child is febrile and appears toxic. These patients will need respiratory isolation, penicillin and anti-toxin. Complications include airway obstruction, myocarditis and polyneuritis.

Obviously if swabs detect gonococcus, sexual abuse is suspected. Treat with ceftriaxone and also cover for chlamydia with azithromycin.


Croup

Croup has a viral aetiology – parainfluenza is the most common, influenza A and B are also implicated.

Most commonly affects kids 3 months to 3 years of age.

It causes subglottic oedema and inflammation.

Symptoms

Croup begins with coryza and fever.

Patients are generally less toxic appearing than in those with epiglotitis.

They have a barking seal-like cough and can have inspiratory stridor.

X-ray if done (although usually not necessary) may show a “steeple sign” which indicates subglottic narrowing.

Treatment

Moderate to severe cases will need steroids and nebulised adrenaline which provide symptomatic relief but does not shorten course of illness.

Keep up fluids.

Analgesia and antipyretics for comfort.

Nebulised saline or humidified oxygen will improve humidification and help with expectoration.


Epiglottitis

This is most commonly bacterial etiology: H. influenzae in unvaccinated children; group A and C streptococci; staph aureus; moraxella; H. parainfluenzae.

Non-infectious cause includes fumes, gasoline ingestion, superheated steam, and angioedema.

Symptoms

The classic case is abrupt and rapid onset of fever, drooling and the child is in the tripod position.

  • Toxic appearance
  • Stridor
  • Respiratory distress

Often we see the “thumb print” sign on the lateral neck x-ray.

Even intra-oral examination can precipitate airway obstruction, so best to avoid this.

Treatment

  • Call for backup (ENT and Anaesthetics) to help secure the airway- you don’t want to be doing this alone
  • IV ceftriaxone and steroids, after the airway has been secured

Bacterial tracheitis

This usually occurs in <5 year olds but it can occur any where from 3 months to 13 years of age. Staph aureus is the most common pathogen.

Patients present with a fever, barky cough, sore throat, minimal voice change, and no dysphagia. It is often preceded by 2-7 days of upper respiratory symptoms.

Patients look toxic and have both inspiratory and expiratory stridor.

It is also known as membranous laryngotracheobronchitis, and there can be bacterial superinfection of the tracheal epithelium with copious mucopurulent secretions.

Treatment

  • Third generation cepahlosporin plus beta-lactamase resistant penicillin or clindamycin
  • Analgesia and antipyretics
  • Keep up hydration
  • May need ETT
  • Consider vancomycin for MRSA if suspected

Complications include airway obstruction.


Peritonsillar abscess/quinsy

This can occur at any age but it’s a disease of adolescence (rare in kids <12 years).

It is likely to be an extension of acute tonsillitis, but obstruction and infection of Weber’s glands are also touted as a possibility. Classically it is a complication of group A strep pharyngitis.

Only 20-30% have a prior history of tonsillitis, but 100% present with concomitant acute tonsillar infection.

Aetiology is polymicrobial, but most commonly is strep pyogenes.

Symptoms and examination

  • Severe sore throat and odynophagia
  • Drooling, fever, and trismus
  • “Cri du carnad”
  • Exudative tonsillitis
  • Unilateral peritonsillar erythema and swelling
  • Uvula and soft palate displaced medially
  • Cervical lymphadenopathy

Peritonsillar cellulitis will have minimal or no trismus.

Diagnosis

Diagnosis is usually clinical.

CT with contrast (1-3 mm cuts) to assess the presence of a deep space infection (parapharyngeal or retropharyngeal abscess) in hard to diagnose cases, or those who fail to improve despite appropriate treatment.

Treatment

  • Aspiration is effective in >90% of cases
  • Incision and drainage – if abscess reoccurs after aspiration
  • ‘Hot’ tonsillectomy – if unable to aspirate/drain or if abscess fails to settle
  • Penicillin, cephalosporin or clindamycin
  • Steroids, analgesia and antipyretics
  • Keep up hydration
  • Interval tonsillectomy, usually planned at 6 weeks, in recurrent cases

Complications

  • Airway compromise
  • Aspiration of pus resulting in pneumonia
  • Extension of infection laterally into the parapharyngeal or retropharyngeal spaces or superiorly intracranially or inferiorly into mediastinum
  • Lemierre’s syndrome
  • Recurrence of peritonsillar abscess – especially if patient has already had two episodes


Retropharyngeal abscess

This an emergent situation and the patients needs time-critical antibiotics.

There should be constant surveillance for airway compromise. Get specialists involved early (ENT, ICU and anaesthetics).

The age predominence is 6 months to 4 years. It is rare after age 4.

There is often insidious progression of upper respiratory tract symptoms.

Aetiology

This is polymicrobial. Group a beta-haemolytic strep is the most common. It can also be caused by staph and gram negative organisms.

Symptoms and examination

  • Fever, sore throat, neck pain
  • Odynophagia, trismus, inspiratory stridor
  • Muffled voice (cru du carnad), decreased oral intake
  • Lack of cough
  • Toxic appearance
  • Hyperextended neck
  • Nuchal rigidity
  • Lymphadenopathy
  • Intraoral exam reveals anterior displacement of the posterior pharyngeal wall

Investigations

CT scan is the radiological investigation of choice. US is handy but does not give anatomic detail.

Lateral neck x-ray may reveal pre-vertebral swelling, air-fluid level, gas, bony erosion or foreign body.

Usual blood workup.

Treatment

Secure the airway first and foremost if this is required (this may need to be done in OT with ENT and anaesthetics).

Give broad spectrum IV antibiotics: flucloxacillin; third genereation cepahlosporin; plus metronidazole. Clindamycin may also be used.

Fluid resus.

Correct any metabolic derangements.

Complications

 

  • Airway obstruction
  • Aspiration pneumonia
  • Mediastinitis
  • Septic shock
  • Vessel thrombosis
  • Neurological involvement
  • Septic emboli
  • Osteomyelitis

Post-tonsillectomy haemorrhage

This is the most common complication of tonsillectomy. Delayed or secondary haemorrhage (after 24hrs) occurs at a rate of 1.5-10%. The mean time to presentation is seven days.

Catastrophic bleeding is rare, but we should be prepared for this. Fever may indicate infection. Other vital signs could suggest shock.

Elicit a history of bleeding tendency which may necessitate investigating for bleeding disorder. Investigating for a bleeding disorder is warranted in massive bleeding.

Treatment

  • Immediate large bore IVC.
  • Hb level and crossmatch plus group and hold.
  • Fluid resus if indicated while waiting for blood to arrive.
  • Transfusions reqiured in 10-12% of secondary bleeds.
  • Recruit ENT help early, 4.3% have been shown to need surgical intervention.
  • Topical adrenaline on cotton wool and held on the bleeding point, if tolerated by the patient, may reduce rate of bleeding.
  • Silver nitrate cautery may be attempted.
  • Antibiotics if infection suspected (ENT use it regardless).

Complications

  • Hypovolaemic shock
  • Airway obstruction
  • Aspiration pneumonia
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About 

Tessa Davis is a paediatric emergency registrar from Glasgow and Sydney, but currently living in London. Tessa tries to spend time with her 3 kids in between shifts. @tessardavis | + Tessa Davis | Tessa's DFTB posts