GABHS Pharyngitis Quiz

ENT 3: Head and Neck Disorders

• Course taught by Professor Boucher
• Topics include Nose & sinus disorders, including chronic rhinosinusitis, invasive fungal rhinosinusitis, foreign bodies, and trauma.
• Nasopharyngeal & paranasal sinus neoplasms like polyps and inverted papillomas
• Oropharyngeal disorders
• Oral cancer
• Instructional objectives include describing epidemiology, etiology, clinical manifestations, diagnosis, and management of epistaxis, nasal polyps, rhinitis, rhinosinusitis, and nasal trauma.
• Identifying and describing etiology, clinical manifestations, diagnosis, and management of foreign bodies of the nose.
• Demonstrating the evaluation, diagnosis, and management of some common benign and malignant neoplasms of the nasopharyngeal and paranasal sinuses.
• Identifying and describing clinical manifestations, diagnosis, and treatment of diseases of the teeth/gums including necrotizing ulcerative gingivitis (NUG).
• Identifying and describing clinical manifestations, diagnosis, and treatment of infectious/inflammatory oropharyngeal disorders including aphthous stomatitis, candidiasis, deep neck infection, epiglottitis, herpes simplex, laryngitis, peritonsillar abscess, and pharyngitis.
• Identifying and describing the clinical manifestations, diagnosis, and treatment of salivary disorders including sialadenitis and parotitis.
• Identification and description of clinical manifestations, diagnosis, and treatment of oropharyngeal trauma, leukoplakia, oral squamous cell carcinoma (SCC), and foreign bodies of the larynx and pharynx.

Chronic Rhinosinusitis (CRS)

• Inflammatory condition involving paranasal sinuses and nasal passages lasting 12+ weeks
• Affects 5-12% of the general population, with a mean age at diagnosis of 39
• Onset can be abrupt or slow/insidious
• Diagnosis requires objective evidence of mucosal inflammation
• Risk factors/associated conditions include allergic rhinitis, asthma, aspirin-exacerbated respiratory disease (AERD), depression, smoking, irritants/pollutants, and immunodeficiency.
• Defects in mucociliary clearance (like cystic fibrosis), viral infections, systemic illnesses, dental infections, and anatomic abnormalities are also risk factors.
• Four cardinal signs/symptoms in adults include anterior/posterior nasal mucopurulent drainage, nasal obstruction, facial pain/pressure/fullness, and loss of smell.
• In children, cough is the 4th sign instead of loss of smell.
• Danger signs/complications include high fever, double/reduced vision, proptosis, dramatic periorbital edema, ophthalmoplegia, severe headache, meningeal signs, and significant or recurrent epistaxis.
• Evaluation involves a thorough clinical history, objective documentation of mucosal disease using anterior rhinoscopy, nasal endoscopy, CT (without contrast).
• Allergy evaluation and consideration of immunologic defects and infectious complications (recurrent purulent sinusitis, recurrent otitis media) can be done.
• Diagnosis is based on the presence of suggestive symptoms and objective evidence of mucosal inflammation and satisfying two of four cardinal signs/symptoms; also presence of one or more findings.
• Subtypes include CRS with nasal polyposis (20-33%), allergic fungal rhinosinusitis (AFRS) (<5%), and CRS without nasal polyposis (60-65%).

Invasive Fungal Rhinosinusitis

• Rare, aggressive fungal infection of sinuses
• Primarily seen in immunosuppressed individuals (e.g., diabetes, HIV, organ transplant recipients)
• Time course: from days to weeks
• Common causes are Aspergillus or Mucor species
• Symptoms resemble acute bacterial rhinosinusitis but there are more severe symptoms.
• Diagnosis requires CT and/or MRI, confirmed by biopsy.
• Treatment is a medical and surgical emergency involving hospital admission and referral to an ENT.
• Treatment includes IV antifungal therapy (voriconazole or amphotericin B) and prompt, wide surgical debridement.

Nasal Foreign Bodies

• Common in children and developmentally disabled patients
• Materials include inorganic materials (beads, pebbles) or organic materials (beans, peas)
• Removal difficulty increases with time due to swelling.
• Button batteries and magnets require immediate attention due to septal perforation risk.
• Symptoms include unilateral foul-smelling discharge, nasal obstruction.
• Management involves attempting to have patient blow their nose or nasal insufflation if that does not work, pretreating with nasal decongestant/topical anesthetic, conscious sedation if needed, and the use of instruments such as the Katz extractor, foley catheter, or forceps.
• Referral is needed for foreign bodies not successfully removed, those with localized reaction, young or developmentally delayed patients needing conscious sedation, significant trauma to the area, or sharp/hooked FBs.
• Instruments used in removal include Jobson-Horne probe, hook, and alligator forceps.

Nasal Trauma

• Nasal fracture is the most common fractured bone in the nasal pyramid.
• Symptoms include epistaxis, pain and soft tissue hematomas.
• Evaluation includes a full head and neck exam, intranasal exam, and assessment for septal hematoma; palpate for crepitus, mobile bony segments, step-off of infraorbital rim (zygomatic complex fractures); also x-rays for facial, spine, pulmonary, & intracranial injuries based on the mechanism of injury.
• Treatment for nasal fractures aims to maintain long-term nasal airway patency and cosmesis.
• Septal hematomas require urgent ENT referral, bilateral I&D, and fluid cultures.
• Nasal packing (3-5 days) is used to prevent further hematoma formation.
• Anti-Staph antibiotics (e.g., cephalexin, clindamycin) for 3-5 days can help reduce risk of toxic shock syndrome.
• Closed reduction, possibly with local or general anesthesia is performed when needed.

Malignant Nasopharyngeal & Paranasal Sinus Neoplasms

• Squamous cell carcinoma (SCC) is the most common neoplasm observed in sinuses and nasopharynx, and is typically diagnosed in the later stages.
• Adenocarcinoma, mucosal melanomas, sarcomas, and non-Hodgkin lymphomas are less common.
• Early symptoms often mimic rhinosinusitis.
• Common symptoms include unilateral nasal obstruction and discharge, otitis media, and pain with recurrent hemorrhage.
• Most cases are advanced when diagnosed and are often treated with chemoradiation therapy.
• Prognosis for advanced tumors is generally poor.

Benign Nasopharyngeal Neoplasms

• Nasal polyps: Pale, edematous, mucosal-covered masses, typically associated with allergic rhinitis.
• Possible chronic nasal obstruction and dysosmia.
• Topical intranasal steroids can improve quality of life for symptoms within 1-3 months for smaller polyps.
• Short course of oral steroids can also be considered.
• Massive polyps or failed medical therapy need surgical intervention.
• Inverted papillomas: Usually arise on lateral nasal walls; caused by HPV.
• Unilateral nasal obstruction and occasional hemorrhage; malignant potential (SCC in ~10% of cases).
• Complete excision is advisable

Oropharyngeal Disorders

• Diseases of the teeth and gums, infectious and inflammatory disorders, salivary disorders, and other disorders are included.

Diseases of the Teeth and Gums

• Necortizing Ulcerative Gingivitis (NUG), also known as Vincent's Angina or Trench Mouth, is an infection of the teeth and gums.
• It's commonly seen in young adults under stress, potentially exacerbated by underlying systemic diseases.
• Symptoms include painful, acute gingival inflammation, necrosis, and potential bleeding.
• Halitosis and fever with cervical lymphadenopathy are also potential symptoms.
• Treatment typically includes warm 1/2 strength peroxide rinses and metronidazole 500 mg PO q8h for 7 days (or until lesions heal), and dental gingival curettage as needed.

Infectious/Inflammatory Oropharyngeal Disorders

• Aphthous stomatitis, also known as canker sores, is a common condition (5–21%) characterized by recurring, painful, solitary, or multiple ulcers.
• The precise cause is unknown but sometimes associated with HHV-6.
• The condition involves the buccal and labial mucosa and not the palate or gingiva.
• Ulcers are typically covered in a white-to-yellow pseudomembrane and are surrounded by an erythematous halo.

Oral Candidiasis

• An infection of oral mucosa typically caused by Candida albicans.
• Patients may be immunocompetent, but denture use, xerostomia, antibiotic use or steroid use, or systemic illness (diabetes mellitus) may predispose some. Those who are immunocompromised (e.g., HIV/AIDS, hematological malignancies, transplant recipients, chemotherapy, steroids, head and neck radiation therapy) are especially at risk.
• Symptoms can be absent or include feelings of cotton mouth, loss of taste, painful eating/swallowing.
• Exam may show pseudomembranous (white plaques, buccal, palate, tongue); atrophic (erythema beneath dentures with the absence of plaques), erythematous macular lesions, and angular cheilitis (erythematous fissures).
• Diagnosis is clinical based on H&P, including Gram stain and KOH prep for yeast cells and pseudohyphae or true hyphae.
• Treatment involves antifungal medications (e.g., fluconazole, ketoconazole, clotrimazole) troches or rinses.
• Patients with HIV/AIDS may require longer treatment durations.

Deep Neck Infection

• Cellulitis of the submandibular space, often due to infection of the mandibular dentition; also known as Ludwig's angina.
• It is the most common encountered deep neck space infection
• Swelling and erythema of the upper neck and floor of mouth, including possible displacement of the tongue upward and backward (impeding airway).
• Pus may also be present in the floor of the mouth.
• Diagnosis is clinical but augmented with CT scan with contrast and potentially MRI to delineate extent of infection.
• Treatment involves hospital admission, IV antibiotics (like ceftriaxone or metronidazole), blood cultures, and potentially surgical intervention (I&D) and/or airway management (intubation or tracheotomy).

Epiglottitis

• Inflammation of epiglottis and supraglottic structures, typically due to viral or bacterial infection.
• Bacterial infection (most commonly by H. influenza type B (Hib)) is often rapid in progression, causing severe sore throat and odynophagia.
• This often out-weighs minimal oropharyngeal findings on exam, and usually seen in diabetics or others with non-routine vaccinations.
• Clinical features such as severe sore throats, dysphagia, odynophagia, drooling, muffled/hoarse voices, stridor, and dyspnea are commonly reported.
• Physical exam should reveal minimally abnormal external oral cavity. Airway management is critical and should not be delayed by imaging procedures.
• Treatment and management is prioritized by securing an airway. Hospitalization, hydration, and IV antibiotics (ceftriaxone or amoxicillin/clavulanate) are standard treatment.
• Supplemental oxygen, analgesics, and use of dexamethasone is often used.

Herpes Labialis

• Reactivation of HSV-1, causing oral vesicles along the vermilion border (and known as cold sores or fever blisters).
• Commonly seen in 15-45% of the US population via factors like immunodeficiency, stress, sunlight exposure, or dental procedures,
• Symptoms involve a prodrome phase of pain, burning, and pruritis, followed by clustered vesicles in 7-14 days.
• Topical anesthetics or antivirals (acyclovir, famciclovir, valacyclovir) may be considered in the treatment.
• Antivirals are most effective when started during the prodrome phase.
• Treatment choices vary depending on symptom severity: mild symptoms (no treatment or episodic therapy), severe disease (chronic suppressive therapy) and recurrence frequency (especially if symptomatic and no prodrome).

Acute Laryngitis

• A common cause of hoarseness, frequently following upper respiratory infections (viral or bacterial).
• Symptoms include hoarseness, sore throat, and congestion
• Treatment is primarily supportive (voice rest, hydration, humidified air).
• Antibiotics are usually unnecessary
• Complications may include vocal fold hemorrhage, polyps, or cysts (though these are less common)

Peritonsillar Abscess

• A polymicrobial deep neck infection, usually occurring in young adults (20-40).
• It's most commonly localized in the soft palate, immediately superior to the tonsil.
• Symptoms include severe sore throat, ill appearance, fever, malaise, and foul breath. Potential symptoms include odynophagia, drooling, and muffled voice ("hot potato" voice).
• Physical exam findings often include a tense swelling and erythema of the anterior pillar and soft palate. The tonsil is commonly inferior and medial. Uvula deviation is also a good identifying characteristic. Cervical lymphadenopathy can also develop.
• Diagnosis involves needle aspiration, intraoral or submandibular US, and/or CT or MRI (adjunct).
• Treatment involves observation with antibiotics (small abscesses, <1cm); however, abscesses larger than 1cm may require needle aspiration, I&D, and/or tonsillectomy.
• IV antibiotics (e.g., piperacillin-tazobactam, metronidazole + ceftriaxone, or clindamycin) are common, and often include hydration and analgesic measures.

Pharyngitis

• A condition characterized by a variety of causes (mostly viral or bacterial). It commonly occurs during late winter and early spring seasons.
• Additional causes can include: GERD, postnasal drip (rhinitis), persistent cough, thyroiditis, allergies, or foreign bodies
• Typical symptoms include a feeling of scratchiness in the throat, soreness, and difficulty swallowing.
• Viral causes are typical and most often resolved with rest, hydration, and humidified air, with supportive analgesics (like acetaminophen, NSAIDs, or ASA) and or throat lozenges, sprays, and beverages as needed.

Infectious Mononucleosis (IM)

• Typically a condition caused by the Epstein-Barr virus (EBV).
• It frequently affects 15–30-year-old individuals.
• Symptoms often involve fatigue, pharyngitis, and potentially exudates (white-purple).
• Common physical characteristics include pharyngeal injection with exudates (shaggy, white-purple), posterior cervical and auricular lymphadenopathy, palatal petechiae or hepatosplenomegaly.
• Diagnosis requires a heterophile antibody test (e.g., Monospot) and a confirmation test with specific antibody tests for EBV.
• Treatment is generally supportive and involves hydration, rest, non-steroidal anti-inflammatory drugs (NSAIDs) or use of acetaminophen; avoidance of contact sports for 3-4 weeks. Antibiotics do not treat EBV.

GABHS Pharyngitis

• A consequence of Group A beta-hemolytic streptococcus (GABHS) and often seen in children ages 5-15.
• Symptoms involve an acute onset of sore throat, fever, pharyngeal edema, and potentially exudates (patchy) or prominent, tender anterior cervical lymphadenopathy.
• Supportive physical characteristics may be seen, including palatal petechiae, scarlatiniform skin rash, or a strawberry tongue.
• Importance of accurate diagnosis revolves around the prevention of acute rheumatic fever (ARF) and other suppurative complications (peritonsillar abscess being one example), prevention of spread, and reduction in duration and severity.
• Adults with suspected GABHS often require rapid antigen detection (RADT) testing.

Oral Cancer

• Squamous cell carcinoma (SCC) of the oral cavity is a significant concern.
• Risk factors include increasing age, tobacco use, and alcohol use, with the lateral surface of the tongue being a common location.
• Physical examination typically shows a raised, firm, white lesion possibly with ulcers at the base.
• Diagnosis often involves a biopsy, and treatment may include surgery/radiation.

Upper Airway Foreign Bodies

• More common in young children, often due to inhaled objects.
• A 2022 study suggests 1068 cases and the foreign bodies most commonly observed were: larynx (3%), trachea (13%), right main bronchus (52%), right lower lobe bronchus (6%), left main bronchus (18%), and left lower lobe bronchus (5%).
• The typical symptoms involve a sudden onset of choking or coughing, and a development of wheezing, coughing or stridor.
• Airway management via 5 back blows and 5 chest thrusts may be required (children).

Esophageal Foreign Bodies

• Often caused by food bolus impedance, most (80%) spontaneously resolve.
• Peak incidence involves children (6-months to 6-years).
• Small batteries or other foreign bodies may necessitate medical intervention via instruments or medications. Complete obstruction can involve drooling, or inability to manage secretions.
• Treatment options include flexible endoscopy, or glucagon 1.0mg IV for esophageal relaxation.

Emergent Airway Management

• Cricothyroidotomy is a quick, stab incision through the cricothyroid membrane, used as an emergent access to the trachea.
• Formal tracheostomy may be necessary for more sustained intervention, and usually involves full anesthesia and the division of the thyroid isthmus. Posterior thyroid veins can be troublesome during procedures.

References

• CURRENT Medical Diagnosis & Treatment 2025, Papadakis
• Handbook of Otolaryngology: Head and Neck Surgery, 2nd Ed. Goldenberg
• Up To Date