CMS150 Week 2 Sore Throat (Moodle Version) PDF

CMS150 CLINICAL MEDICINE WEEK 2 JANUARY 2023 LEARNING OUTCOMES 1. Differentiate between chronic and acute pharyngitis 2. Differentiate between infectious and non-infectious causes of pharyngitis 3. Follow a systematic approach to the diagnosis of acute pharyngitis 4. Identify alarm symp...

CMS150 CLINICAL MEDICINE WEEK 2 JANUARY 2023 LEARNING OUTCOMES 1. Differentiate between chronic and acute pharyngitis 2. Differentiate between infectious and non-infectious causes of pharyngitis 3. Follow a systematic approach to the diagnosis of acute pharyngitis 4. Identify alarm symptoms associated with acute pharyngitis 5. Identify alarm symptoms associated with cough 6. Apply the modified Centor score to patient cases 7. Know the relative frequencies of the causes of acute pharyngitis and how they vary based on patients’ epidemiological characteristics 8. Differentiate between clinical findings in common cold (upper respiratory tract infection) and influenza 9. Apply a clinical decision rule to the diagnosis of influenza 10. Apply the threshold model of decision-making to a case of acute cough with pharyngitis 11. Identify signs and symptoms that suggest acute otitis media 12. Differentiate between otitis externa and otitis media 13. Differentiate between conductive and sensorineural hearing loss based on clinical findings WEEK 2: THE CASE OF ALEX BEST Returns one year later 15-year-old adolescent CC: recent onset SORE THROAT SORE THROAT = PHARYNGITIS Inflammation of the pharynx DURATION OF SORE THROAT Acute pharyngitis – less than 2 weeks duration Chronic pharyngitis – more than 2 weeks duration IN OUR CASE, RECENT ONSET We have another case of acute pharyngitis GENERAL APPROACH TO ACUTE PHARYNGITIS Rule out serious diagnoses and red flags/alarm symptoms that prompt emergent/urgent management Most cases of acute pharyngitis are due to infectious cause – determine the specific infectious cause (i.e., viral or bacterial) Identify acute sore throat caused by group A beta- hemolytic streptococcal (GABHS) pharyngitis Antibiotic treatment may be indicated - Rhinovirus - Persistent cough - Coronavirus - Upper airway cough syndrome - Adenovirus (postnasal drip) - Herpes simplex virus - Gastroesophageal reflux (HSV) Causes of Pharyngitis disease - Influenza A and B - Acute thyroiditis - Parainfluenza virus - Neoplasm - Epstein-Barr virus - Allergies - Cytomegalovirus Non- - Smoking - Human herpesvirus Infectious infectious (HHV) 6 Causes Causes - Group A beta-hemolytic - HIV streptococci (GABHS) - Fusobacterium necrophorum - Group C beta-hemolytic Viral Bacterial streptococci - Neisseria gonorrhoeae - Corynebacterium diphtheriae - Mycoplasma pneumoniae - Chlamydophila pneumoniae WHAT’S DIFFERENT THIS TIME? Associated symptoms: Productive cough Sneezing, runny nose Ear fullness Slight fatigue, muscle aches, headache WHAT’S DIFFERENT THIS TIME? Physical exam findings: Posterior oropharynx mildly inflamed and erythematous; no exudate present Posterior cervical nodes are enlarged and tender to palpation Nasal turbinates are red and swollen Left ear: cloudy, bulging TM with displaced cone of light Hearing tests of left ear: unable to repeat words whispered, sound lateralizes to left; BC>AC HOW DO WE PROCEED? First, rule out alarm symptoms and signs as we did last week NONE ARE SEEN HERE  Symptoms Serious Diagnoses Potential Complications Sore throat, dysphagia, or Acute epiglottitis or Airway obstruction; sepsis; odynophagia with any of the supraglottitis spread to parapharyngeal or following: Peritonsillar abscess retropharyngeal spaces, with ALARM Drooling Parapharyngeal space infection subsequent spread to pleura, SYMPTOMS Respiratory distress Retropharyngeal space mediastinum, carotid sheath, or A S S O C I AT E D Inability to open mouth fully infection jugular vein WITH SORE (trismus) Submandibular space infection T H R O AT Muffled voice (Ludwig's angina) Stiff neck Superficial jugular Erythema of neck thrombophlebitis (Lemierre syndrome). History of recent foreign body Retropharyngeal abscess Airway obstruction; sepsis; impaction or oropharyngeal spread to mediastinum, pleural procedure (trauma) space, or pericardium Fever, rash, diffuse adenopathy, Primary HIV infection Transmission of disease sore throat Recent cocaine smoking Mucosal burn injury to pharynx Respiratory obstruction and larynx Weight loss, fevers, night sweats Lymphoma, head and neck Advanced malignancy cancers Source: The Patient History, 2e  ALARM SYMPTOMS ASSOCIATED WITH COUGH HOW DO WE PROCEED? Most acute pharyngitis is infectious Viral > bacterial But we must determine the probability of streptococcal pharyngitis HOW DO WE DO THIS? Apply the modified Centor (McIsaac) score APPLYING THE SCORE TO ALEX BEST Online calculator available via https://www.mdcalc.c om/calc/104/centor- score-modified- mcisaac-strep- pharyngitis IF NOT STREP THROAT, WHAT COULD THIS BE? Class Infection Frequency1 Clinical Syndrome Viruses Rhinovirus 20% Common cold Coronavirus 5% Common cold Adenovirus 5% Acute respiratory disease Herpes Simplex Virus (HSV) 1 and 2 4% Stomatitis, pharyngitis Influenza A and B 2% Influenza Parainfluenza virus 2% Common cold, croup Epstein-Barr virus (EBV) < 1% Infectious mononucleosis Cytomegalovirus (CMV) < 1% Infectious mononucleosis HIV < 1% Primary HIV infection Bacteria Group A beta-hemolytic streptococci 15–30% Pharyngitis, tonsillitis Fusobacterium necrophorum 10% Pharyngitis, peritonsillar abscess, Lemierre syndrome (rare) Group C beta-hemolytic streptococci 5% Pharyngitis, tonsillitis Neisseria gonorrhoeae < 1% Pharyngitis Corynebacterium diphtheriae < 1% Diphtheria Mycoplasma pneumoniae < 1% Pneumonia, bronchitis Chlamydophila pneumoniae Unknown Pneumonia, bronchitis Table 30-1.Frequency and clinical syndrome for infectious causes of sore throat. 1Estimated percentage of cases in all ages, prevalence estimates are sensitive to the population studied. Source: Symptom to Diagnosis: An Evidence-Based Guide, 4e WHAT TYPE OF INFECTION COULD IT BE? Source: Canadian Family Physician Jul 2011, 57 (7) 791-794 VIRAL PHARYNGITIS Most pharyngitis cases are viral in origin Associated symptoms that are more likely to present with viral illness: cough, nasal congestion, conjunctivitis, hoarseness, diarrhea, oropharyngeal lesions (ulcers or vesicles) Viruses that are most likely to cause pharyngitis in children (aged 5-15): Common cold (50%) – caused by rhinovirus, coronavirus, adenovirus, parainfluenza virus, respiratory syncytial virus Influenza (5%) – caused by Influenza virus (type A and B) most commonly Mononucleosis (5%) – caused by Epstein-Barr Virus (EBV), cytomegalovirus (CMV) Viral causes of pharyngitis do not require antibiotic therapy unless there is a secondary bacterial infection COMMON COLD VS. INFLUENZA Common cold is a viral infection of the upper respiratory tract  Rhinitis Upper (infection of the nose) Respiratory Tract Lower Respiratory Tract COMMON COLD Viral infection of upper respiratory tract with inflammation Peaks in winter months Symptoms usually worst 2-3 days then resolve in 7-10 days Cough may last 2-3 weeks Can by caused by many viruses Rhinoviruses are the most common cause Grows optimally at temperatures near 32.8°C – the temperature inside the human nose Other viruses: coronavirus, adenovirus, parainfluenza virus, respiratory syncytial virus COMMON COLD Clinical Presentation Nasal congestion, rhinorrhea, sneezing Sore throat, cough Slight body aches Mild headache Afebrile or low-grade fever Malaise May have conjunctivitis, sinus symptoms Chest exam is normal – no signs of lower respiratory tract infection COMMON COLD Complications Asthma/COPD exacerbation Secondary infection Acute otitis media Acute sinusitis Other infections – pneumonia, streptococcal pharyngitis, croup, bronchiolitis, bronchitis COMMON COLD Treatment/Management Self-limiting. No antibiotics unless secondary bacterial infection. Analgesics/antipyretics Ensure hydration Steam inhalation Soothing, warm fluids Lozenges Saline nasal rinse Other supportive therapies (see https://www.aafp.org/afp/2019/0901/p281.html) COMMON COLD For children 1 year old. Cool-mist humidifiers may help with breathing, and saline nasal drops and bulb suctioning can help with nasal congestion. Amdur, Rachel L., and Jeffrey A. Linder. "Upper Respiratory Symptoms, Including Earache, Sinus Symptoms, and Sore Throat." Harrison's Principles of Internal Medicine, 21e Eds. Joseph Loscalzo, et al. McGraw Hill, 2022, https://accessmedicine-mhmedical- Prevention com.ccnm.idm.oclc.org/content.aspx?bookid=3095&sectionid=262791875. Avoid sick contacts Respiratory etiquette – cough/sneeze into tissues Proper hygiene – hand washing BACK TO THE CASE OF ALEX BEST: Returns one year later 15-year-old adolescent CC: recent onset SORE THROAT Do we see any other symptoms and signs of viral URTI? YES! Associated symptoms: Productive cough Sneezing, runny nose Slight fatigue, muscle aches, headache Physical exam findings: Posterior oropharynx mildly inflamed and erythematous; no exudate present Posterior cervical nodes are enlarged and tender to palpation Nasal turbinates are red and swollen This presentation is consistent with the common cold WHAT ABOUT INFLUENZA? INFLUENZA Infection by Influenza A or B Peaks in winter months Symptoms appear 1-4 days after exposure to virus Contagious period: 1 day before symptoms to 5 days after symptom onset Clinical Presentation: Acute onset Fever Cough Myalgia Other common symptoms: headache, chills, fatigue, loss of appetite, sore throat, nasal congestion, rhinnorhea, diarrhea, nausea, vomiting Incze M, Grady D, Gupta A. I Have a Cold—What Do I Need to Know? JAMA Intern Med. 2018;178(9):1288. doi:10.1001/jamainternmed.2018.2621  Symptom Allergy URI Influenza Itchy, watery eyes common rare; conjunctivitis may occur soreness behind eyes, with adenovirus sometimes conjunctivitis Nasal discharge common common common Nasal congestion common common sometimes Sneezing very common very common sometimes Sore throat sometimes (postnasal drip) very common sometimes Cough sometimes common, mild to moderate, common, dry cough, can be hacking cough severe Headache uncommon rare common Fever never rare in adults, possible in very common, 37.8-38.9°C children (100-102°F) or higher (in young children), lasting 3-4 days; may have chills Malaise sometimes sometimes very common Fatigue, weakness sometimes sometimes very common, can last for weeks, extreme exhaustion early in course Myalgias never slight very common, often severe Duration weeks 3-14 days 7 days, followed by additional days of cough and fatigue  Likelihood Ratio for Influenza Clinical Finding Positive Negative Rigors 7.2 0.9 Sweating 2.9 0.6 Being confined to bed 2.5 0.5 Inability to cope with 2.3 0.4 daily activities Fever (subjective) 1.7 0.5 Absence of systemic 1.5 0.4 symptoms Headache 1.3 0.6 Cough 1.3 0.4 Myalgia 1.3 0.6 Nasal congestion 1.2 0.7 Chills 1.1 0.7 Sore throat 1.1 0.9 Sputum 1.1 0.9 Data from Ebell et al. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3022049/  INFLUENZA CLINICAL DECISION RULE Fever plus cough 2 points Myalgias 2 points Duration < 48 hours 1 point Chills or sweats 1 point Total Points Risk of Influenza Ebell MH, Afonso AM, Gonzales R, Stein J, Genton B, Senn N. Development and validation of a 0 to 2 points 8% clinical decision rule for the diagnosis of influenza. J Am Board Fam Med. 2012 Jan- 3 points 30% Feb;25(1):55-62. doi: 10.3122/jabfm.2012.01.110161. PubMed PMID: 22218625. 4 to 6 points 59%  APPLYING THE SCORE TO ALEX BEST Fever plus cough 2 points Cough without fever Myalgias 2 points Slight muscle aches Duration < 48 hours 1 point None of these Chills or sweats 1 point apply Total Points Risk of Influenza Ebell MH, Afonso AM, Gonzales R, Stein J, Genton B, Senn N. Development and validation of a 0 to 2 points 8% clinical decision rule for the diagnosis of influenza. J Am Board Fam Med. 2012 Jan- 3 points 30% Feb;25(1):55-62. doi: 10.3122/jabfm.2012.01.110161. PubMed PMID: 22218625. 4 to 6 points 59% Threshold Model for Diagnosis of Influenza Risk of influenza is low for Alex Best We are below the test threshold https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3022049/ IF IT WAS THE FLU…WHAT YOU SHOULD DO Watch for complications Pneumonia – watch for signs of LRTI Most common complication? (tachypnea or tachycardia along with fever, signs of consolidation on chest exam) Watch for susceptible populations Which would include? Young children, elderly > 65 yoa, people residing in long term care facilities, diabetes or heart/lung conditions, weakened immune systems And then, rest and fluids! If high fever, also watch for signs of dehydration BACK TO THE CASE OF ALEX BEST: WHAT ABOUT THESE FINDINGS? Ear fullness Left ear: cloudy, bulging TM with displaced cone of light Hearing tests of left ear: unable to repeat words whispered, sound lateralizes to left; BC>AC What could this be? INTERPRETING THE FINDINGS Whisper test is a screening test for hearing loss Alex is unable to repeat the words whispered to the left ear Left ear is the affected ear Now we determine what type of hearing loss this might be TYPES OF HEARING LOSS Conductive Hearing Loss Hearing loss due to dysfunction in one or more parts of auditory pathway from the external ear to the middle ear For example, can result from dysfunction of external ear canal, tympanic membrane, and/or ossicles Sensorineural Hearing Loss Hearing loss due to dysfunction in one or more parts of the auditory pathway between the inner ear and auditory cortex For example, can result from dysfunction of cochlea, auditory nerve, and/or auditory processing pathway in the central nervous system The ear can be divided into three parts: the outer, middle and inner ear. The outer ear comprises the auricle (or pinna) and the ear canal. The tympanic membrane (eardrum), a thin cone- shaped membrane, separates the outer ear from the middle ear. The middle ear comprises the middle ear cavity and the ossicles (the malleus, incus and stapes), which are attached to the tympanic membrane. The oval window connects the middle ear with the inner ear, which includes the semicircular ducts and the cochlea. The middle ear cavity is connected to the nasopharynx by the Eustachian tube. Figure 1 Anatomy of the human ear Schilder, A. G. M. et al. (2016) Otitis media Nat. Rev. Dis. Primers doi:10.1038/nrdp.2016.63 WEBER AND RINNE TEST FINDINGS Weber Test Hearing Loss Rinne Test Findings Findings Midline (no Air conduction > None lateralization) Bone conduction Conductive Hearing Lateralization to Bone conduction > Loss affected ear Air conduction Sensorineural Lateralization to Air conduction > hearing loss unaffected ear Bone conduction BACK TO THE CASE OF ALEX BEST: Ear fullness Hearing tests of left ear: unable to repeat words whispered, sound lateralizes to left; BC>AC Suggests left sided conductive hearing loss What could this be? ALEX IS A SWIMMER COULD THIS BE SWIMMER’S EAR? OTITIS EXTERNA aka “swimmer’s ear” Inflammation or infection of the external ear canal Most commonly a bacterial infection – Pseudomonas species or Staphylococcus aureus Can be a fungal infection (39°C (102.2°F) Amdur, Rachel L., and Jeffrey A. Linder. "Upper Respiratory Symptoms, Including Earache, Sinus Symptoms, and Sore Throat." Harrison's Principles of Internal Medicine, 21e Eds. Joseph Loscalzo, et al. McGraw Hill, 2022, https://accessmedicine-mhmedical- com.ccnm.idm.oclc.org/content.aspx?bookid=3095&sectionid=262791875. ANTIBIOTICS FOR AOM Benefits are modest and offset by adverse effects Do not result in early resolution of pain but decrease pain by day 2 to 3 (NNT = 20) Side effects of antibiotic therapy: vomiting, diarrhea, rash (NNH = 14) Severe complications like mastoiditis are rare (NNT = 5000) Amoxicillin is the antibiotic therapy of choice 10-day duration for children