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Questions and Answers
What is the likelihood ratio for reported fever in diagnosing GAS infection?
What is the sensitivity of any exudates in diagnosing strep throat?
What is the likelihood ratio for absence of cough in diagnosing GAS infection?
What is the specificity of measured temperature >37.8°C in diagnosing strep throat?
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What is the likelihood ratio for tonsillar exudates in diagnosing strep throat?
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What is the sensitivity of anterior cervical nodes swollen/enlarged in diagnosing strep throat?
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What is the likelihood ratio for duration of symptoms < 3 days in diagnosing GAS infection?
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What is the specificity of tonsillar or pharyngeal exudates in diagnosing strep throat?
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What is the likelihood ratio for streptococcal exposure in previous 2 weeks in diagnosing GAS infection?
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What is the sensitivity of pharyngeal exudates in diagnosing strep throat?
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Study Notes
Red Flags and Serious Diagnoses
- Red flags are signs and symptoms that indicate possible serious underlying pathology
- Red flags prompt further investigation and/or referral
Symptoms and Serious Diagnoses
- Sore throat, dysphagia, or odynophagia with respiratory distress, inability to open mouth fully, or stiff neck may indicate serious diagnoses such as acute epiglottitis, peritonsillar abscess, or retropharyngeal space infection
- Erythema of neck, muffled voice, or fever, rash, diffuse adenopathy, and sore throat may indicate primary HIV infection
- Weight loss, fevers, night sweats, and sore throat may indicate lymphoma or head and neck cancers
- Recent cocaine smoking may indicate mucosal burn injury to pharynx and larynx
- Recent foreign body impaction or oropharyngeal procedure may indicate retropharyngeal abscess
Acute Epiglottitis
- Rare but potentially fatal condition
- Inflammation of epiglottis and adjacent tissues
- Bacterial infection primarily caused by Haemophilus influenzae
- Most commonly seen in children aged 2-6, but incidence decreased with HiB vaccination
- Positive thumb sign on lateral radiograph of the neck is diagnostic
- Medical emergency requiring airway management and antibiotic therapy
Acute Epiglottitis Clinical Presentation
- Acute onset fever, severe sore throat, and toxic appearance
- The 4 Ds: dysphagia, drooling, dysphonia, and distress
Peritonsillar Abscess
- Also known as quinsy
- Most common deep infection of head and neck
- Most common in young adults, with increased risk in immunocompromised and diabetics
- Polymicrobial infection, with common organisms including Group A streptococci, Staphylococcus aureus, and Haemophilus influenzae
- Diagnosis can be made clinically without lab work or imaging in patients with typical presentation
Peritonsillar Abscess Clinical Presentation
- Severe unilateral sore throat
- Dysphagia and odynophagia, leading to pooling of saliva or drooling
- Fever and malaise
- Dysphonia: muffled "hot potato" voice
- Rancid or fetor breath
- Otalgia
- Trismus and oropharyngeal exam: erythematous enlarged tonsil and bulging soft palate on affected side
Complications
- Non-suppurative complications:
- Acute rheumatic fever (ARF)
- Poststreptococcal glomerulonephritis
- Pediatric autoimmune neuropsychiatric disorder associated with group A streptococcal (PANDAS) infection
- Suppurative complications:
- Peritonsillar abscess
- Retropharyngeal abscess
- Otitis media
- Sinusitis
- Mastoiditis
- Cervical lymphadenitis
- Meningitis
- Bacteremia
Diagnosing Strep Throat
- Best history questions to ask:
- Reported fever
- Absence of cough
- Absence of runny nose
- Presence of myalgias
- Presence of headache
- Presence of nausea
- Duration of symptoms < 3 days
- Streptococcal exposure in previous 2 weeks
- Best physical exams to perform:
- Any exudates
- Reported fever
- Measured temperature >37.8°C
- Anterior cervical nodes swollen/enlarged
- Pharyngeal exudates
- Tonsillar swelling/enlargement
- Tonsillar or pharyngeal exudates
- Anterior cervical nodes tender
- Tonsillar exudates
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