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PubMed1990

The sore throat. When to investigate and when to prescribe.

Sore throats are most commonly due to infections, many of which are viral and do not require specific treatment. Symptoms and signs of the common cold, influenza or croup, the occurrence of conjunctivitis in some adenoviral infections, generalised lymphadenopathy and splenomegaly in glandular fever or the presence of vesicles characteristic of herpangina (Coxsackie A virus) or of herpes simplex infection, occasionally enable a clinical diagnosis and avoid the need for antibiotic therapy. In the case of treatable conditions a typical membrane may suggest diphtheria, a scarlatiniform rash infection due to Streptococcus pyogenes or to Corynebacterium haemolyticum, and a cherry-red epiglottis Haemophilus influenzae type b. Associated atypical pneumonia suggests infection with Mycoplasma pneumoniae or Chlamydia pneumoniae. Pharyngitis due to Neisseria gonorrhoeae may be accompanied by infection at other sites or by other sexually transmitted diseases. Candidal infection, in the appropriate clinical circumstance, should suggest HIV infection. Surgical drainage is required in the case of peritonsillar or retropharyngeal abscess. Noninfectious cases of sore throat, e.g. thyroiditis, are relatively uncommon considerations in the differential diagnosis of acute febrile pharyngitis. The most common problem is to recognise streptococcal pharyngitis, which requires antibiotic treatment for 10 days to avoid the risk of rheumatic fever.

Humans↗
PubMed1992

[Carcinoma of the tonsils in pediatrics].

Tonsillar malignancies are frequently diagnosed as peritonsillar cellulitis or abscess until the tumor's growth is evident. The suspicion must arise when there is persistent and asymmetric tonsillar growth without fever. The presence of affected regional lymph nodes is of bad prognosis. A pediatric case is discussed, and recent reports are reviewed.

Biopsy↗
PubMed1984

Bacterial infections of the upper respiratory airways and beta-lactam antibiotics.

Infections of the upper respiratory tract, including the middle ear cleft, still create therapeutic problems. Although rhinitis is usually a virus infection, the infection of the paranasal sinuses are almost invariably of bacterial origin. Pneumococci, H. influenzae and anaerobes are the bacterial species most frequently isolated. In acute otitis media, pneumococci, H. influenzae and as demonstrated during the last few years, Branhamella catarrhalis constitutes the main pathogens. Anaerobes dominate the isolates in chronic otitis media, characterized by tissue destruction and sometimes intracranial complications. In acute tonsillitis and pharyngitis, Streptococcus pyogenes is the main bacterial pathogen whereas anaerobes are encountered in Vincent's angina, peritonsillar and parapharyngeal abscesses. The role of Branhamella in pharyngeal infections is still a subject of some dispute. In acute epiglottitis of children, H. influenzae is almost invariably isolated from the throat swabs and blood cultures. In adults, Streptococcus pyogenes and anaerobic bacteria also have to be considered as likely pathogens. The acute laryngitis has hitherto been regarded as a nonbacterial inflammation but there are reports indicating that Branhamella catarrhalis can be involved. Apparently the bacteriology of the upper respiratory tract infections have changed but little during the decades. The therapeutical problems of today are mainly due to decreased antibiotic susceptibility among the established pathogens, the presence of beta-lactamase production among bacterial species that establish the normal throat flora and lack of knowledge concerning the pathophysiology of infections of the mucous membranes.

Adult↗
PubMed2005

Tonsillopharyngitis: clinical highlights.

Tonsillopharyngitis is an extremely common infection seen in adults and children. Although the symptoms and signs of this disease are usually sufficient to make a diagnosis, it is often difficult to make a distinction between bacterial and viral etiology on clinical grounds alone. The complications of tonsillopharyngitis may be classified into suppurative and nonsuppurative complications. The nonsuppurative complications include scarlet fever, acute rheumatic fever, and post-streptococcal glomerulonephritis. Suppurative complications include peritonsillar, parapharyngeal, and retropharyngeal cellulites and/or abscess. Features suggestive of viral bacterial (GABHS) etiologies, the medical and surgical guidelines for managing tonsillopharyngitis, and its complications are highlighted in this article.

Algorithms↗
PubMed1999

Diagnosis of peritonsillar infections: a prospective study of ultrasound, computerized tomography and clinical diagnosis.

Peritonsillar infections include cellulitis and abscess (quinsy). Clinical diagnosis is often supplemented by diagnostic drainage (aspiration or incision) in an effort to distinguish abscess from cellulitis. In a prospective study of 14 patients we have shown that clinical impression alone is unreliable (sensitivity 78 per cent, specificity 50 per cent). Computerized tomography (CT) (sensitivity 100 per cent, specificity 75 per cent) and intraoral ultrasound (sensitivity 89 per cent, specificity 100 per cent) are much more reliable. We propose that intraoral ultrasound could play a useful role in the clinical assessment of peritonsillar infections helping to improve accuracy in distinguishing abscesses from cellulitis.

Adolescent↗
PubMed2006

[Peritonsillar infection. Out-patient management].

INTRODUCTION: Peritonsillar infections are the most frequent deep infections in head and neck. The estimated annual incidence is 30 cases per 100.000 inhabitants. PATIENTS AND METHODS: A retrospective study was undertaken in 132 patients with peritonsillar infection. A diagnostic and therapeutic protocol was used consisting on diagnostic needle aspiration, incision and drainage and intravenous antibiotic and steroids. RESULTS: 35,6% were peritonsillar phlegmons and 64,4% were abscesses. The median of hospital monitoring was 9,2 hours. Only 25,8% were admitted to the hospital. Six patients had recurrences of the symptoms during the study. DISCUSSION: The needle aspiration is useful in differential diagnosis between phlegmons and abscesses. Bacteriologic studies are not necessary in the routine management of peritonsillitis. Surgical treatment of these patients is controversial. Incision and drainage seems to be appropiated in the management of this pathology. Admission to the hospital is not always necessary if a correct outpatient control is possible.

Adolescent↗
PubMed2006

[Management of peritonsillar infections].

OBJECTIVE: To evaluate the clinical and epidemiologic characteristics in children with peritonsillar infections. PATIENTS AND METHODS: A longitudinal retrospective study was performed through a review of the clinical histories of patients attending the emergency unit in the previous 6 years. The variables gathered were age, sex, recurrent tonsillitis, previous upper airway infection, antibiotic administration, and therapeutic approach. RESULTS: Twenty-nine children were admitted, with a mean age of 7.4 +/- 1.6 years (boys 1.6:1). Twenty-seven percent had recurrent tonsillitis. At the visit, 57.8 % had an upper respiratory infection and 65 % were taking antibiotic treatment, especially macrolides. The treatment selected at our center consisted of the association of penicillin or amoxicillin-clavulanate acid with clindamycin, including corticosteroids. Ten children underwent computed tomography and nine underwent fine-needle aspiration. Drainage was performed in 20.6 % of confirmed abscesses. The mean length of hospital stay was 5.6 +/- 1.6 days. Delayed tonsillectomy was performed in 31 %, except in one patient who developed a parapharyngeal abscess. Currently, 18.9 % of all peritonsillar infections occur in the pediatric population. CONCLUSIONS: The increase in these infections is probably related to inappropriate use of antibiotics in respiratory diseases. Diagnosis is clinical, and infections are often resolved by intravenous administration of beta-lactams with clindamycin and an expectant attitude. When an abscess is suspected or there is no clinical improvement, fine-needle aspiration or computed tomography is warranted and drainage should be performed if an abscess is confirmed. Tonsillectomy, usually delayed, is only indicated in patients with recurrent tonsillitis.

Anti-Bacterial Agents↗
PubMed2006

Acute infectious upper airway obstructions in children.

There are numerous causes of acquired acute upper airway obstructions in children but most are secondary to infections, foreign bodies, and trauma. Recognizing impending airway obstructions is important because cardiopulmonary arrest rarely is a sudden event but rather follows a progressive deterioration in respiratory function. From an anatomic perspective, acute obstructions may present in the pharyngeal or laryngeal regions. In the pharynx, fascial layers create several potential peritonsillar, parapharyngeal, and retropharyngeal spaces that may accommodate abscess formation. Within the larynx and lower airways, small changes in radius dramatically affect the resistance to flow as described by Poiseuille's law, allowing for small amounts of inflammation to cause significant obstruction. The clinical presentation of acute upper airway obstruction will depend on the degree and location of the obstruction. Therapy is aimed primarily at maintaining a patent airway and prescribing appropriate antimicrobials.

Acute Disease↗
PubMed1996

[Clinical differential diagnosis of the mouth and oropharynx].

In the present paper, common disorders of the oral cavity and oropharynx are described with special emphasis on differential diagnostic aspects. The first part of this presentation covers different inflammatory diseases, mainly focusing on complications like peritonsillar, para- and retropharyngeal abscesses, and Ludwig's angina. These clinical entities can lead to further life-threatening complications, including deep neck infections and mediastinitis. The diagnostic value and necessity of modern imaging in these cases are emphasized. In the second part, the author reports on the incidence, etiology and clinical course of tumors of the oral cavity and oropharynx with special regard to malignancies. Tumors in these areas have been increasing in number over the past decades mainly due to changes in alcohol and nicotine consumption in the developed countries. Diagnostic management includes a thorough clinical evaluation as well as modern imaging for tumor delineation and possible bone infiltration, depending on the site of the original tumor. In addition, therapeutic considerations are discussed, focusing on surgical tumor removal and soft tissue replacement using different pedicled flaps and free flaps. It is also emphasized that postoperative radiotherapy is mandatory in most malignant tumors in this area.

Diagnosis, Differential↗
PubMed1985

An unusual otolaryngological problem--mucocutaneous lymph node syndrome (Kawasaki's syndrome) case report.

A case of Kawasaki's syndrome is reported, involving a 12 year old Caucasian male who presented with a sore throat, tonsillar hypertrophy, bilateral cervical swelling, and fever. A maculopapular rash present was attributed to a reaction to methicillin. An initial diagnosis of peritonsillar cellulitis with deep lateral neck space cellulitis and abscess was made. Negative surgical exploratory findings and subsequent development of specific signs and symptoms prompted the diagnosis of Kawasaki's disease. Treatment with salicylates proved effective and the patient was discharged home. Kawasaki's disease, a disorder of unknown origin with potentially fatal results, is not an uncommon condition. An awareness of this entity with its protein manifestations is warranted by the otolaryngologist who may well be the first doctor on the scene. Prompt and early treatment with salicylates may well decrease morbidity and potential mortality of this enigmatic disease.

Aspirin↗
PubMed1987

Peritonsillar infections.

The preferred antibiotic treatment for tonsillar and peritonsillar infections remains high dosages of penicillin. Peritonsillar swelling can be probed by needle aspiration. Where necessary, immediate incision and drainage of an abscess can be achieved. Quinsy tonsillectomy may be carried out for the best abscess exposure. Interval tonsillectomy is advised for those patients who give histories of previous tonsillar infections.

Anti-Bacterial Agents↗
PubMed2005

Spectrum and management of deep neck space infections: an 8-year experience of 234 cases.

OBJECTIVE: To study the clinical course and outcome of deep neck infections (DNI), with special emphasis on microbiology and histopathology. STUDY DESIGN: Two hundred thirty-four patients with DNIs were included in this study. Patients with peritonsillar or dental infections, infections arising from salivary glands, as well as subjects with abscesses caused by neck trauma were excluded. METHODS: Clinical analysis of all patients with DNIs who were treated between January 1, 1997 and May 31, 2005 in a single center. RESULTS: In 13 patients, the DNI was the first manifestation of a malignant tumor. In 17 cases, the DNI was associated with cat-scratch disease (CSD). Six patients suffered from tuberculosis, and in another 7, an infected lateral cleft cyst was found. In 176 patients, the origin of DNI remained unclear. CONCLUSIONS: Our results demonstrate that CSD, tuberculosis, and malignant tumors must be considered as possible causes of DNIs. The current study represents one of the largest series of DNIs in the modern medical literature. EBM RATING: C.

Adult↗
PubMed1997

Characterization and management of deep neck infections.

A retrospective review was conducted of 91 patients with deep neck infections to determine the pattern of clinical disease and formulate a management plan. The spaces involved, as determined by clinical, radiologic, and operative findings, were the peritonsillar space (72 patients), parapharyngeal space (eight patients) submandibular space (seven patients), retropharyngeal space (one patient) superficial space (one patient), anterior visceral space (one patient), and visceral vascular space (one patient). Of the 19 patients who did not have a peritonsillar space infection the origin of the infection was found in eight; four of these were odontogenic. Thirty-eight patients required surgical drainage of the abscess. Five patients underwent tracheotomy due to increasing dyspnea. One patient with diabetes mellitus and a past history of myocardial infarction died of unknown cause. All other patients had an uneventful recovery without major complications. The combination of early radiologic diagnosis, effective antimicrobial therapy, and intensive surgical management contributed to the good prognosis.

Abscess↗
PubMed1995

Deep neck space infections.

The incidence of deep neck space infections has dramatically decreased since the advent of antibiotics, but with delayed treatment they carry the potential for significant morbidity and mortality. Odontogenic infections with involvement of the submandibular space are the most common source of deep neck space infections in adults, whereas in the pediatric population the most common cause is acute tonsillitis with involvement of the peritonsillar space. The newest group of patients at risk for deep neck space infections are intravenous drug abusers who inject the major vessels of the neck. Knowledge of neck spaces and fascial relationships is important in understanding the presentation, treatment, and complications of deep neck space infections. The spaces, which are created by various fasciae of the head and neck, are only potential spaces in that under normal conditions they cannot be examined clinically or radiographically. As the spaces are invaded by bacteria, a cellulitis or abscess occurs, and this infection may travel through paths of least resistance from one space to another.

Adult↗
PubMed1986

Peritonsillar infection in Christchurch 1981-1984.

Retrospective review of the notes of 83 peritonsillar infection sufferers over three years at Christchurch Hospital reveals that the typical sufferer is a young adult male who is most likely to present in winter or summer. Only a quarter of the patients had a significant recent history of tonsillitis but four had had a previous quinsy and six had had a previous tonsillectomy in childhood. Length of symptoms does not appear helpful in differentiating an abscess from a cellulitis. Anaerobic organisms were found in 49% of aspirates and streptococci were the most important aerobic organism. Potential beta lactamase producing organisms, H influenzae, Staph aureus and Bacteroides sp were infrequent and penicillin remains the drug of choice. Appropriate antibiotics and drainage are the essentials of management and tonsillectomy may be indicated.

Adolescent↗
PubMed2005

Group C and G streptococcal disease among children.

Nine children with infections caused by group C and G streptococci were identified from 1995 through 2004. The children ranged in age from 12 to 18 years. The infections included 4 children with peritonsillar abscess/cellulitis and one child each with perirectal abscess, postoperative wound infection, ruptured appendix, septic arthritis and cellulitis/abscess. This study demonstrates the propensity of group C and G streptococci to cause disease in older children and at sites where the organisms reside normally.

Adolescent↗
PubMed2003

Craniocervical necrotizing fasciitis secondary to parotid gland abscess.

Necrotizing fasciitis is a potentially fatal soft-tissue infection that predominantly affects the abdominal wall, perineum and extremities. It is an uncommon clinical entity in the head and neck region and an exhaustive review of the English language literature disclosed reports on approximately 160 cases. Dental pathology, post-traumatic or iatrogenic skin or mucosa injuries and parapharyngeal or peritonsillar infections were the most frequently described origins. We describe herein the first case of craniocervical necrotizing fasciitis (CCNF) due to a parotid gland abscess. The patient was successfully treated with i.v. broad-spectrum antibiotic therapy and an aggressive surgical approach (drainage of the parotid abscess and exploration of the neck, with drainage and debridement of necrotic tissue). Effective management of CCNF depends on a prompt diagnosis. Intravenous broad-spectrum antibiotic therapy should be instituted immediately. Antibiotic coverage can be narrowed once the culture results are obtained. Aggressive surgical intervention is necessary, involving wide incision, adequate exploration of deep neck spaces and debridement of necrotic tissue until healthy bleeding tissue is encountered.

Abscess↗