Rosen's Emergency Medicine Concepts and Clinical Practice

C H A P T E R 65
Upper Respiratory Tract Infections

Frantz R. Melio
PHARYNGITIS (TONSILLOPHARYNGITIS) 30% to 50% are associated with a follicular, usually unilateral,
conjunctivitis and preauricular lymphadenopathy. Coxsackievi-
Principles ruses are the most frequent causes of hand-foot-and-mouth
disease and herpangina.
Tonsillopharyngitis—pharyngitis—is an inflammatory syndrome Pharyngitis is a common manifestation of infectious mono-
of the oropharynx. Transmission is mainly through contact with nucleosis (caused by EBV) in young adults.2 Symptoms develop
respiratory secretions but can also occur through food and fomite after an incubation period of 4 to 7 weeks. Fever and a tonsillar
contact. Although most cases of pharyngitis are uncomplicated exudate or a cheesy or creamy white membrane is often present.
and self-limited, the associated swelling may threaten airway Cervical as well as generalized lymphadenopathy (90%–100%)
patency or preclude the ingestion of adequate liquids, leading to and splenomegaly (50%) are usually noted, and palatal petechiae
dehydration. Furthermore, a few causes of pharyngitis can also may be present. Hepatomegaly is present in 10% to 15% of cases.
lead to systemic complications. Periorbital edema and rash are rare findings. In up to 90% of
Viruses are responsible for most cases of pharyngitis in chil- patients with mononucleosis who are given ampicillin or amoxi-
dren and adults. Bacterial causes of pharyngitis include group A cillin, a diffuse macular rash develops that may be misdiagnosed
beta-hemolytic Streptococcus (GAS), non–group A streptococci, as an allergic reaction.
Mycoplasma pneumoniae, Chlamydia pneumoniae, and sexu- Patients with early (days to weeks) HIV infection can develop
ally transmitted diseases. Fusobacterium necrophorum has been an acute retroviral syndrome. This is manifested by fever, sore
increasing recognized as a cause of pharyngitis in adolescents throat, generalized nontender lymphadenopathy, diffuse maculo-
and young adults.1-3 Whereas immunization has led to a decline papular rash, arthralgias, mucocutaneous ulcerations and, com-
in diphtheria as a cause of pharyngitis, it can result in serious monly, diarrhea. Nonexudative pharyngitis is present in 50% to
complications and needs to remain in any differential diagnosis. 70% of patients. Oral thrush and ulcers may be present. Acute
Mixed aerobic and anaerobic bacteria often cause chronic or HIV infection can be differentiated from infectious mononucleo-
recurrent pharyngitis, especially those that produce β-lactamase. sis by a more acute presentation, absence of tonsillar hypertrophy
Epstein-Barr virus (EBV) and Actinomyces are also implicated in or exudates, frequent occurrence of rash, and presence of oral
chronic or recurrent pharyngitis. Rare causes of bacterial pharyn- ulcerations.
gitis include Francisella tularensis, Yersinia pestis, and Yersinia Herpes simplex pharyngitis, which typically affect young
enterocolitica.2 adults, manifests with the presence of painful vesicles with erythe-
matous bases. Ulcers may be present on the pharynx, lips, tongue,
Clinical Features gums, and buccal mucosa. Pharyngeal erythema and exudate,
fever, and tender lymphadenopathy are common for 1 to 2 weeks.
Table 65.1 outlines the various causes of pharyngitis and their In an immunocompromised host, large painful ulcers may be
associated signs, symptoms, and treatment. The most common present. Herpes pharyngitis can be caused by primary infection
symptom is pharyngeal pain aggravated by swallowing that may or reactivation. Concomitant bacterial superinfection may occur.
radiate to the ears. Examination usually reveals fever, pharyngeal GAS pharyngitis is primarily a disease of children 5 to 15 years
erythema, pharyngeal or tonsillar exudate, and tonsillar enlarge- old and, in temperate climates, occurs in winter and early spring.
ment (Fig. 65.1). The infection tends to localize to lymphatic It is responsible for 5% to 15% of cases of pharyngitis in patients
tissue and produces suppuration and swelling of the tonsils, along older than 15 years and is rare in patients younger than 3 years.
with tender cervical adenopathy. Occlusion of the eustachian In epidemics, amongst persons in semiclosed communities and
tubes may result in secondary otitis media. Clinical differentiation within families of index cases, the incidence may double. GAS
of the causative organisms is virtually impossible.2 pharyngitis is associated with sudden-onset sore throat, tempera-
Viral pharyngitis usually occurs in conjunction with cough, ture over 38.3° C (101° F), tonsillar erythema and exudates, palatal
rhinorrhea, myalgia, hoarseness, headache, stomatitis, conjuncti- and uvular petechiae (Fig. 65.2), uvular edema and erythema, and
vitis, exanthem, and odynophagia. Low-grade fever, diarrhea, oral tender anterior cervical lymphadenopathy. Headache, nausea,
ulcers, and pharyngeal edema, erythema and exudates may be vomiting, and abdominal pain may be present. GAS pharyngitis
present. Cervical lymphadenopathy is generally absent.2 Systemic associated with a fine sandpaper erythematous rash that subse-
viral infections, including measles, cytomegalovirus (CMV), quently desquamates is termed scarlet fever. These findings,
rubella, and human immunodeficiency virus (HIV), may initially however, cannot be used to diagnose or exclude streptococcal
manifest as mild pharyngitis.2 HIV and CMV pharyngitis may be pharyngitis reliably. Patients with recent exposure to others at risk
clinically indistinguishable from infectious mononucleosis. for GAS pharyngitis or in whom it has been diagnosed are more
Influenza occurs in epidemics and is associated with high fever, likely to become infected.2 Non-GAS species can cause pharyngitis
myalgia, and headache. Although 50% to 80% of patients with indistinguishable from GAS. Groups C and G streptococci can
influenza experience pharyngeal discomfort, pharyngeal exudate cause epidemic foodborne pharyngitis.
and cervical lymphadenopathy are rare. Adenovirus may cause Diphtheria is a potentially lethal cause of pharyngitis that is
severe exudative pharyngitis with cervical adenitis similar to that uncommon where adequate vaccinations are administered. US
in streptococcal pharyngitis. Of cases of adenoviral pharyngitis, serologic surveys have indicated that a large percentage of adults
857
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858 PART III Medicine and Surgery | SECTION Two Pulmonary System
TABLE 65.1
Clinical Signs and Treatment of Various Causes of Pharyngitis

ORGANISM OR CONDITION CHARACTERISTIC PRESENTATIONS AND FEATURES TREATMENT
Group A beta-hemolytic Fever, pain, pharyngeal erythema and exudate, tender anterior cervical Penicillin, steroids may be beneficial
Streptococcus (GAS) lymphadenopathy, nausea, vomiting, abdominal pain, fine sandpaper
rash = scarlet fever; systemic complications possible
Epstein-Barr virus Fever, exudate, lymphadenopathy, splenomegaly Steroids may be beneficial.
Influenza Fever, myalgia, headache; cervical lymphadenopathy rare Supportive treatment
Herpesvirus Gingivostomatitis, mucosal ulcers, lymphadenopathy Acyclovir, valacyclovir, or famciclovir
Human immunodeficiency virus Fever, generalized nontender lymphadenopathy, rash, arthralgia, diarrhea Antiretrovirals
Diphtheria Fever, malaise, dysphagia, grayish membrane on mucosal surfaces, Antitoxin plus penicillin G, followed by
respiratory distress; systemic toxin can lead to vascular collapse. penicillin VK once patient can tolerate
oral medication, for a total of 14 days
Arcanobacterium haemolyticum Rash, similar presentation as GAS; at times, membranous pharyngitis Erythromycin, 250 mg PO qid for 10 days
Anaerobic (Vincent’s angina) Superficial ulcerations and necrosis, foul breath, poor oral hygiene, Penicillin plus metronidazole
submandibular lymphadenopathy or
Clindamycin plus hydrogen peroxide rinses
Gonococcus (Neisseria Exudative or nonexudative Ceftriaxone, 250 mg IM, plus
gonorrhoeae) Azithromycin, 1 g PO
Chlamydia Lower respiratory tract infections, sinusitis, recurrent and persistent, Doxycycline, trimethoprim-
tender deep cervical lymph nodes sulfamethoxazole, or macrolide
Tuberculosis Hoarseness, dysphagia, ulcerations, late disease
Mycoplasma pneumoniae Mild symptoms, lower respiratory tract infections, hoarseness Macrolide or doxycycline, 7–14 days
Fig. 65.2. Palatal petechiae. (Courtesy Centers for Disease Control and
Prevention and Dr. Heinz F. Eichenwald.)
Fig. 65.1. Bilateral tonsillopharyngitis.
and adolescents lack immunity to diphtheria toxin. After a 2- to may cause myocarditis, polyneuritis (at first autonomic and then
4-day incubation period, patients develop malaise, sore throat, peripheral), vascular collapse, diffuse focal organ necrosis, and
fever, and dysphagia. Examination early in the disease process may death. Asymptomatic carriers may transmit the disease. Coryne-
reveal pharyngeal erythema and isolated spots of gray or white bacterium ulcerans is an animal pathogen transmitted by the
exudate that later coalesce to form a pseudomembrane. This gray- consumption of raw milk that can produce infection indistin-
green pseudomembrane is usually well demarcated and covers the guishable from that caused by C. diphtheriae.
nares, tonsils, soft palate, pharyngeal mucosa and, occasionally, Arcanobacterium haemolyticum typically affects the 10- to 30-
the uvula. The membrane may extend to involve the larynx and year-old age group and can be indistinguishable from streptococ-
tracheobronchial tree, leading to hoarseness, cough, stridor, and cal pharyngitis. Most patients have an associated rash that may be
airway obstruction. Painful cervical lymphadenopathy may be scarlatiniform, urticarial, or erythema multiforme; occasionally,
found. Severe inflammation and edema can produce dysphonia skin manifestations may be the only complaint. Patients report
and a characteristic so-called bull neck appearance. Some strains a moderately severe sore throat and are usually nontoxic and
of Corynebacterium diphtheriae produce a systemic toxin that afebrile. A. haemolyticum may cause a membranous pharyngitis
C H APTER 65 Upper Respiratory Tract Infections 859
that strongly mimics diphtheria; it is also associated with chronic Diagnostic Considerations
tonsillitis.2
Anaerobic pharyngitis, or Vincent’s angina, is characterized by Differential Diagnosis
superficial ulceration and necrosis that often results in the forma-
tion of a pseudomembrane. Foul-smelling breath, odynophagia, The differential diagnosis of pharyngitis includes epiglottitis,
submandibular lymphadenopathy, and exudate are often present. tracheitis, lingual tonsillitis, parapharyngeal abscess, retropharyn-
Patients typically have poor oral hygiene.2 geal and other deep space abscesses and cellulitis of the neck,
Gonococcal pharyngitis is a sexually transmitted disease that tumors, allergic reactions, Stevens-Johnson syndrome, drug reac-
may occur independently of genital infection. Those at highest tions, angioneuropathic edema, chemical and thermal burns,
risk are persons who practice receptive oral sex, especially men esophagitis, gastroesophageal reflux disease, thyroiditis, cricoary-
who have sex with men. Its severity is variable and may result in tenoid arthritis, and foreign bodies.
an exudative or nonexudative pharyngitis. These differing mani-
festations occur after a latent period of infection. Asymptomatic Diagnostic Testing
carriers are described, as is chronic and recurrent pharyngitis.
Gonococcal pharyngitis is an important source of gonococcemia.2 The Monospot test has a sensitivity of approximately 85% and a
Syphilitic pharyngitis is a manifestation of primary or tertiary specificity of almost 100%; however, results may be falsely nega-
syphilis and manifests with painless mucosal lesions. Chlamydia tive in up to 10% of patients with infectious mononucleosis in the
trachomatis pharyngitis is a sexually transmitted disease that early stages of the illness. Immunoglobulin M (IgM) antibodies
manifests similarly to gonococcal pharyngitis and is associated to EBV capsid antigen develop in 100% of cases. EBV nuclear
with orogenital sex. Urogenital culturing is necessary, along with antigens develop within 3 to 6 weeks and are useful if an initially
treatment of sexual contacts. Patients are usually asymptomatic negative test result becomes positive at a later date. Peripheral
or may have only mild symptoms. blood smears demonstrate atypical mononuclear cells in 75% of
Tuberculous pharyngitis usually occurs in patients with patients, with the peak incidence occurring in the second to third
advanced disease. Symptoms and signs include hoarseness and weeks of illness. The test may be ordered when the patient has
dysphagia with pharyngeal ulcerations. Candidal pharyngitis is failed treatment for GAS pharyngitis or when posterior cervical
usually found in immunocompromised adults. Patients have lymphadenopathy predominates.
dysphagia, odynophagia, and adherent white plaques with focal Herpes pharyngitis may be diagnosed by culture, cytopatho-
bleeding points. logic tests on scrapings of lesions, and serologic tests. Enzyme-
Mycoplasma pneumoniae infection usually causes a mild phar- linked immunosorbent assay testing for HIV can be falsely
yngitis. Mycoplasma infection occurs in epidemics and in crowded negative during the first 3 to 4 weeks of illness. During this period,
conditions and can be responsible for approximately 10% of cases quantitative assays for plasma RNA should be performed.2,4
of adult pharyngitis. Pharyngeal and tonsillar exudates, cervical Several authors have proposed scoring systems for diagnosing
lymphadenopathy, and hoarseness are common. Lower respira- GAS pharyngitis based on clinical findings. Clinical scoring is
tory tract infection may also be present.2 most accurate in identifying patients at low risk for GAS pharyn-
C. pneumoniae pharyngitis resembles M. pneumoniae pharyngitis.2,4 Antistreptolysin O titers are not recommended for the
gitis. It also occurs in epidemics or crowded conditions. Severe diagnosis of routine GAS pharyngitis. A single throat culture has
pharyngitis with laryngitis is suggestive of C. pneumoniae infec- a sensitivity of 90% to 95% in detecting Streptococcus pyogenes in
tion. Swelling and pain in the deep cervical lymph nodes may be the pharynx. Variables that affect the accuracy of throat cultures
prominent. Lower respiratory tract and concomitant sinusitis include collection and culturing techniques and the recent use of
occur. The hallmarks of chlamydial pharyngitis are recurrence antibiotics.2,4
and persistence.2 Fusobacterium pharyngitis presents in a manner Rapid diagnostic tests for GAS detect streptococcal antigens.
similar to GAS, primarily in patients aged 10 to 49 years.3 Rapid streptococcal tests (RSTs) have a reported specificity and
Although most cases of pharyngitis follow a benign course, sensitivity of up to 95%. Sensitivity and specificity in actual
life-threatening complications can occur. Airway compromise practice are lower than in controlled trials. Using RSTs in patients
from tonsillar enlargement, local and distant spread of infection, without clinical findings consistent with GAS increases false-
deep neck abscesses, necrotizing fasciitis, sleep apnea, bacteremia, positive results. A positive RST result seems to indicate the pres-
sepsis, and death have been reported but are very rare.2 ence of S. pyogenes in the pharynx reliably and does not require
Infectious mononucleosis may lead to hepatic dysfunction, backup culture. Patients with positive cultures or RSTs may actu-
splenic injury, neurologic disorders, pneumonitis, pericarditis, ally be carriers (5%–15% of cases) who may not need treatment
and hematologic disorders, including thrombocytopenia and and are at low risk for transmission and complications. In contrast,
hemolytic anemia. Complications of GAS pharyngitis are sup- RST results are often negative in the setting of pharyngitis with a
purative and nonsuppurative. Suppurative complications include low bacterial count. Although it is recommended that a negative
peritonsillar abscess, deep space abscesses, cervical lymphad- RST result in a child be followed by a confirmatory culture, adults
enitis, otitis media, sinusitis, mastoiditis, bacteremia, sepsis, with negative RST results do not require confirmatory cultures
osteomyelitis, empyema, meningitis, and soft tissue infections. because of the lower incidence of GAS infection and extremely
Nonsuppurative complications include scarlet fever, rheumatic low risk for complications. Neither testing nor antibiotic treat-
fever, poststreptococcal glomerulonephritis, nonrheumatic peri- ment should be used in adults who are clinically at low risk for
myocarditis, erythema nodosum, and streptococcal toxic shock GAS infection, especially patients who have symptoms associated
syndrome. In contrast to rheumatic fever, other complications of with a viral pharyngitis, including cough, rhinorrhea, hoarseness,
GAS pharyngitis have been increasing in incidence and severity. oral ulcers, stomatitis, and conjunctivitis.2,4
A chronic carrier state of streptococcal infection exists and can We recommend the use of clinical criteria in conjunction with
persist for several months, despite treatment. Affected patients are RSTs for the diagnosis of GAS pharyngitis. The Centor criteria
asymptomatic, at low risk for rheumatic fever, and not considered (Box 65.1) is a useful, validated clinical tool for adults but is not
highly contagious. Non–group A streptococcal pharyngitis may useful for diagnosing GAS pharyngitis in children. Adults who
be complicated by the same suppurative complications as group present with none or only one Centor criterion should not be
A infections. Scarlet fever and acute glomerulonephritis, but not tested or treated; patients with all four criteria should be treated
rheumatic fever, are linked to groups C and G pharyngitis.1,2 without testing. Patients with two or three criteria should undergo
BOX 65.1 to minimize the small risk of splenic rupture. Corticosteroids are
indicated for patients with tonsillar hypertrophy that threatens
Centor Criteria for Determining Group A airway patency, severe thrombocytopenia, or hemolytic anemia.
Steroids should be used cautiously in children and in only those
Beta-Hemolytic Streptococcal Pharyngitis with documented GAS infections. GAS pharyngitis is primarily
a disease of children 5 to 15 years of age. In adults, GAS is a
• Tonsillar exudates self-limited illness that lasts 3 to 4 days. The rationale for treating
• Tender anterior lymphadenopathy or lymphadenitis streptococcal pharyngitis is that antibiotics decrease suppura-
• Absence of cough tive and nonsuppurative complications, shorten the course of
• History of fever illness by about 1 day, and decrease transmission. Patients are
no longer infectious after 24 hours of antibiotic treatment, and
persistent symptoms lasting beyond a few days are suggestive of
suppurative complications.2,5 GAS pharyngitis should be treated
adequately (within 9 days) to prevent rheumatic fever, which is
TABLE 65.2
rare in the United States and complicates 0.3% of cases of GAS
Centor Criteria Scoring for Determining Testing pharyngitis but, in epidemics, the incidence increases to 3%. The
incidence and course of poststreptococcal glomerulonephritis
and Treatment for Group A Beta-Hemolytic caused by nephritogenic strains are unaffected by antibiotic
Streptococcal Pharyngitis therapy.2
CENTOR SCORE TESTING AND TREATMENT The antibiotic regimen of choice for adults with GAS pharyn-
gitis is a single intramuscular (IM) injection of 1.2 million units
0 or 1 None of benzathine penicillin or a 10-day course of penicillin V, 500 mg
2 or 3 Treatment based on results of rapid streptococcal orally bid.2 IM penicillin may be more effective than oral penicil-
test results lin and ensures compliance, but allergic reactions are more severe
as a result of procaine allergy, and treatment is more expensive.
4 Treat without testing
Penicillin failure usually reflects noncompliance, reinfection, or
the presence of β-lactamase–producing organisms. Clarithromy-
cin, cephalosporins, or clindamycin for 10 days, or a 5-day course
of azithromycin, is recommended for patients who are allergic to
RSTs and be treated only if they have positive results (Table 65.2). penicillin.2,6 Adjunctive therapy with corticosteroids has been
This approach may lead to some overtreatment with antibiotics.2,4 shown to shorten the duration and severity of symptoms some-
These recommendations apply only to immunocompetent what in patients with GAS. Single-dose dexamethasone has been
patients without comorbidities or a history of rheumatic fever. shown to be helpful in adults and children.
They do not apply in settings of outbreaks of GAS infection or Patients whose symptoms return within a few weeks of treat-
rheumatic fever, nor are they appropriate where the endemic rate ment may have been noncompliant, acquired a new infection (at
of rheumatic fever is higher than that in the United States. times from asymptomatic close contacts), or could be chronic
Pharyngitis caused by other treatable organisms should also be carriers of GAS who are experiencing repeat viral infections.
considered.4 Non–group A streptococcal pharyngitis should also With actual recurrent GAS infections, treatment should be with
be treated because the same suppurative complications occur as IM penicillin. Alternative antibiotics for recurrent infections
with group A streptococcal pharyngitis. Confirmation of diphthe- include cefdinir, cefpodoxime, amoxicillin-clavulanate, and
ria requires culturing on the proper media and immunologic clindamycin. Further recurrences require more extensive evalu-
testing (polymerase chain reaction assay), and toxigenicity testing ation, and pharyngeal cultures should be obtained and consid-
should also be performed.1 The diagnosis of A. haemolyticum eration given to evaluating and treating close contacts for GAS
infection should be considered if a rash, including erythema infection.2,6
multiforme, accompanies pharyngitis. The diagnosis of Vincent’s The successful treatment of diphtheria is inversely related to
angina is based on clinical findings and Gram staining. In cases disease duration. When diphtheria is strongly suspected based on
of possible gonococcal infection, a sample should be plated on clinical findings, patients should be placed in respiratory droplet
Thayer-Martin agar. Tuberculous pharyngitis is diagnosed by isolation and antitoxin (a horse serum product) treatment begun
acid-fast staining. Syphilitic pharyngitis is diagnosed with dark- empirically. The dose of antitoxin varies widely and depends on
field microscopy, direct immunofluorescence, and serologic the site of infection and duration of symptoms. Antibiotics have
testing. Candidal pharyngitis is diagnosed by noting yeast on little effect on the resolution of systemic toxicity but are useful in
potassium hydroxide preparations of throat swabs or Sabouraud’s eradicating C. diphtheriae infection and preventing transmission.
agar.2 The diagnosis of mycoplasmal pharyngitis can be confirmed The antibiotic of choice is penicillin G followed by penicillin VK,
serologically or by culture. Rapid antigen tests for Mycoplasma are when able to tolerate oral antibiotics, for a total of 14 days, or
available. Chlamydial pharyngitis can be diagnosed by serologic erythromycin 500 mg (IV or orally) qid for 14 days. A small
testing, culture, or antigen detection tests. percentage of patients require an additional 10-day course of
erythromycin for persistent infection. Rifampin, 600 mg/day for
Management 10 days, is also effective in eradicating the carrier state of C.
diphtheriae and treating erythromycin-resistant diphtheria. Close
Patients with pharyngitis should be treated symptomatically with contacts should be cultured and treated with penicillin G or
topical anesthetic rinses or lozenges and acetaminophen or ibu- erythromycin 500 mg qid a day for 7 to 10 days. Diphtheria toxoid
profen. Oral hydration and saltwater gargles are helpful. Most should be administered during convalescence and to unvaccinated
cases of pharyngitis are self-limited and follow a benign course.3-5 close contacts.6
Antibiotics are not indicated in the vast majority of cases of Candidal pharyngitis is treated with systemic fluconazole or
pharyngitis diagnosed in the United States. itraconazole. Alternative therapy includes nystatin (suspension or
Treatment of infectious mononucleosis is supportive (see tablets) or oral clotrimazole for 14 days. Chronic suppression
Chapter 130). Patients should avoid contact sports for 6 to 8 weeks therapy with fluconazole may be required for HIV pharyngitis.6
Treatment of recurrent or chronic tonsillitis should include

β-lactamase–resistant antibiotics active against aerobic and
anaerobic organisms. Choices include oral cephalosporins,
amoxicillin-clavulanic acid, penicillin with rifampin or metroni-
dazole, and clindamycin.2,6
Steroids given in conjunction with oral antibiotics in adults
with acute pharyngitis may significantly shorten the duration of
symptoms and provide a greater degree of pain relief without
increasing complications. Oral (40–60 mg of prednisone/day for
1–5 days) or IM (single dose of 10 mg of dexamethasone) admin-
istration is equally effective.7
Disposition
The vast majority cases of pharyngitis follow an uncomplicated
course, and patients can be treated on an outpatient basis. The
presence of local (airway) and systemic complications should
prompt consultation with an otolaryngologist, and possibly an Fig. 65.3. Lingual tonsillitis. Note the scalloped appearance of the
infectious disease specialist, and will often lead to hospital lingual tonsil on the anterior surface of the vallecula (arrows), with a
normal epiglottis and aryepiglottic fold.
admission.
LINGUAL TONSILLITIS
Principles Antibiotics are similar to those used for the treatment of

pharyngitis.
Lingual tonsillitis is a rarely diagnosed cause of pharyngitis that
predominantly occurs in patients who have had their palatine Disposition
tonsils removed. The lingual tonsils are usually (size and location
are highly variable) located symmetrically on either side of the Unless there is evidence of airway compromise, patients with
midline, just below the inferior pole of the palatine tonsils lingual tonsillitis can be safely discharged home.
and anterior to the vallecula at the base of the tongue. This lym-
phoid tissue may enlarge after puberty, repeated infection, and LARYNGITIS
tonsillectomy.
Principles
Clinical Features
Laryngitis is a common inflammatory condition which, when
Patients with lingual tonsillitis have a sore throat that worsens infectious, is almost always caused by a viral infection. There are
with movement of the tongue (including tongue depression) and numerous causes of noninfectious laryngitis, including acid reflux
phonation. The patient may have a classic so-called hot potato disease, trauma, chemical and thermal burns, overuse of the vocal
voice—the muffled voice one has when eating very hot food—and cords, and allergies.
report feeling a swelling in the throat. Dysphagia, fever, respira-
tory distress, and stridor may be present. Chronic or recurrent Clinical Features
lingual tonsillitis may also cause a chronic cough or sleep apnea.
Physical findings often include a normal-appearing pharynx with Laryngitis generally is a benign viral illness, with peak symptoms
mild hyperemia. lasting 3 to 4 days. Patients present with dysphonia. Fever, throat
pain, dysphagia, coughing, and myalgia may also be present.
Diagnostic Considerations Patients may develop chronic laryngitis.
Differential Diagnosis Diagnostic Considerations

The differential diagnosis is similar to that mentioned for adult Differential Diagnoses
pharyngitis.
The differential diagnosis is similar to that mentioned for
Diagnostic Testing pharyngitis.
Plain lateral radiographs of the neck are helpful in the diagnosis Management
of lingual tonsillitis (Fig. 65.3). Computed tomography (CT)
scanning and direct visualization with laryngoscopy may also help Although voice rest is recommended, there is no evidence that this
clarify the diagnosis. is of any benefit in terms of duration or severity of symptoms.
Proton pump inhibitors are useful in treating laryngitis and
Management chronic laryngitis due to esophageal reflux disease. Antibiotics are
not indicated unless signs of bacterial infection are present.8 Ste-
Management includes maintenance of airway patency, antibiotics, roids may hasten the resolution of symptoms.9
and supportive therapy. Rarely, acute lingual tonsillitis may be a
life-threatening condition. Airway management includes warmed Disposition
humidified oxygen, hydration, and corticosteroids. Nebulized
epinephrine can relieve the acute respiratory distress and stridor. Laryngitis is a self-limiting disease treated on an outpatient basis.
ADULT EPIGLOTTIS
Principles
Adult epiglottitis can lead to rapid, unpredictable airway obstruc-
tion. Although the incidence of pediatric epiglottitis has dimin-
ished since the introduction of Haemophilus influenzae vaccine,
there has been an increase in cases of adult epiglottitis.10,11 Adult
epiglottitis is a localized cellulitis involving the supraglottic struc-
tures, including the base of the tongue, vallecula, aryepiglottic
folds, arytenoid soft tissues, lingual tonsils, and epiglottis. Inflam-
mation does not extend to the infraglottic regions. Some adults
have a normal epiglottis in the setting of severe supraglottic
involvement; thus, the term supraglottitis may be a more accurate
description. Adults with epiglottic involvement are prone to epi-
glottic abscesses.10
Adult epiglottitis can be caused by many viral, bacterial or,
rarely, fungal pathogens, but the most commonly isolated bacte-
rial pathogen is H. influenzae type b, which is associated with a
more aggressive disease course. The predominant organisms iso-
lated from epiglottic abscesses are Streptococcus and Staphylococcus Fig. 65.4. Epiglottitis.
spp. Adult epiglottitis may also result from thermal injury.10
Clinical Features the glycopyrrolate has reduced secretions), and light sedation (eg,
midazolam in 1-mg increments, often with small doses [50-µg
Adult epiglottitis has no age or seasonal prevalence. Males and increments] of fentanyl). Laryngospasm and complete obstruc-
smokers are more commonly affected. Adults with epiglottitis tion can occur during instrumentation of the inflamed airway.
typically experience a prodrome resembling that of a benign Flexible laryngoscopy is the preferred approach because it pro-
upper respiratory tract infection. The duration of the prodrome vides direct, minimally invasive examination of the upper airway
is usually 1 to 2 days but may be as long as 7 days or as short as and intubation, if planned in advance, can be completed over the
several hours. Patients who have a rapid onset of the disease, as laryngosope. Laryngoscopy reveals a swollen epiglottis and sur-
well as those with comorbid conditions (especially diabetes), are rounding structures (Fig. 65.4). The epiglottis may appear cherry
more likely to require airway intervention.10 red but is often pale and edematous.
Patients typically have dysphagia, odynophagia, and a sore Although lateral cervical soft tissue radiographic films have a
throat. Pain may be severe, and the suspicion of epiglottitis is sensitivity of up to 90% when compared with the gold standard
raised when the patient reports severe symptoms of pharyngitis of laryngoscopy, radiographs are not a substitute for visualization
and has obvious odynophagia or dysphagia but examination of of the upper airway structures by flexible or rigid laryngoscopy.
the oral pharynx and tonsils shows only minimal or no signs of Patients with severe pain, altered voice, complaints of dyspnea, or
inflammation or exudate. Dysphonia and a muffled voice are inability to swallow secretions are at risk for sudden airway
common, whereas hoarseness is unusual. Fever is absent in up to obstruction; they should undergo prompt upper airway examina-
50% of cases and may develop only in the later stages of the tion and should not be sent to radiology for x-ray examination.
disease. Concomitant uvulitis, pharyngitis, tonsillitis, Ludwig’s Radiologic findings, when present, include obliteration of the
angina, peritonsillar abscess, and parotitis can occur. Tenderness vallecula, swelling of the arytenoids and aryepiglottic folds, edema
to palpation of the anterior aspect of the neck in the region of the of the prevertebral and retropharyngeal soft tissues, and balloon-
hyoid and when the larynx is moved side to side is a suggestive ing of the hypopharynx and mesopharynx. The edematous epi-
finding in epiglottitis. glottis appears enlarged and thumb-shaped (Fig. 65.5). An
epiglottic width greater than 8 mm or aryepiglottic fold width
Diagnostic Considerations greater than 7 mm is suggestive of epiglottitis. Adults with sus-
pected epiglottitis and normal soft tissue radiographic films
Differential Diagnosis should undergo laryngoscopy. Similarly, patients determined to
have epiglottitis by radiography also require upper airway exami-
The differential diagnostic considerations are similar to those nation by laryngoscopy to determine the extent of airway com-
listed for pharyngitis. promise and the need for intubation.
Diagnostic Testing Management

When epiglottitis is suspected, visualization of the epiglottis is Unlike in the pediatric population, most cases of adult epiglottitis
indicated. Necessary equipment to provide bag-mask ventilation, can be managed without intubation or tracheostomy. Antibiotic
intubation, or cricothyrotomy must be immediately available. In therapy and intensive care support until symptoms resolve is the
patients with respiratory distress, drooling, aphonia, or stridor, it cornerstone of therapy in these patients. Airway management is
is important that the patient be maintained in a position of indicated for less than 15% of patients and should be considered
comfort. Airway examination is undertaken as soon as equipment for those with symptoms and signs of imminent airway obstruc-
has been obtained and requires a double setup, with the ability to tion. Symptoms of severe disease that may require rapid airway
proceed immediately to cricothyrotomy.10 Depending on the intervention include tachycardia disproportionate to fever, tachy-
perceived urgency of the airway examination, preparations should pnea, stridor, shortness of breath, and rapid onset of symptoms.
include a drying agent, preferably glycopyrrolate, 0.2 mg intrave- Patients who are spiting, drooling, or unable to swallow their own
nously (IV), topical anesthesia (eg, 4% lidocaine by atomizer, after saliva, and patients who assume a classic sniffing position, should
have developed gradually over a longer period of time (ie, 24

hours), treatment with IV antibiotics, parenteral opioid analgesia,
and humidified oxygen in a monitored inpatient unit (often the
intensive care unit [ICU]) or an emergency department (ED)
observation unit is appropriate, providing the patient is without
dyspnea and can handle his or her secretions. Laryngoscopy is
repeated in 6 to 12 hours to ensure that the patient’s condition is
improving and to determine readiness for discharge.
PERITONSILLITIS (PERITONSILLAR CELLULITIS AND

PERITONSILLAR ABSCESS)
Principles
Peritonsillitis may occur as a result of acute tonsillitis. Infection
in Weber’s glands or the tonsillar crypts invades the peritonsillar
tissues and thereby leads to cellulitis and abscess formation.
Fibrous fascial septae divide the peritonsillar space into compart-
ments and direct the infection anteriorly and superiorly.
Dental infections, chronic tonsillitis, infectious mononucleosis,
smoking, chronic lymphocytic leukemia, and tonsilloliths are
predisposing factors. Peritonsillar abscess occurs in patients who
have undergone complete tonsillectomy and is seen in all age
groups. Peritonsillitis recurs in up to 50% of patients, with the
incidence of recurrent peritonsillar abscess approximately 10%.
The highest incidence of recurrence is seen in patients younger
than 40 years and in those with a history of chronic tonsillitis.
Most peritonsillar abscesses are polymicrobial. Fusobacterium
necrophorum is common. β-Lactamase–producing organisms are
isolated more commonly in patients who have received prior
Fig. 65.5. Radiograph of epiglottitis. antibiotics.12
be considered to be at imminent risk for rapid airway obstruction. Clinical Features

These patients should not be laid flat, and immediate preparations
should be made to secure the airway rapidly (see Chapter 1).10 In There is often a delay of 2 to 5 days between abscess formation
patients with a rapidly progressive course, such as those whose and local and systemic symptoms. Symptoms and signs include
symptoms have increased greatly in severity over 4 to 6 hours, odynophagia, dysphagia, drooling, trismus, and referred otalgia.
even with only moderate laryngoscopic findings, preventive Patients may have a characteristic muffled, hot potato voice, and
intubation is indicated because progression of swelling and airway rancid breath. Systemic manifestations include fever, malaise, and
compromise can occur rapidly and with little warning. Intubation dehydration. Patients may relate a history of recurrent tonsillitis.
also is undertaken, despite only moderate findings on laryngos- The examination of the pharynx can be limited by trismus.
copy, for patients who are immunocompromised or diabetic or Physical findings of peritonsillitis include inflamed and erythe-
have an epiglottic abscess.10 matous oral mucosa, purulent tonsillar exudates that obscure the
All patients with epiglottitis should be treated with extreme tonsil, and tender cervical lymphadenopathy. Peritonsillar celluli-
care because of the possibility of unpredictable sudden airway tis may be a precursor of and mimics peritonsillar abscess. Peri-
obstruction. Endotracheal intubation should be performed under tonsillar abscess is characterized by a greater frequency of drooling,
direct visualization. Awake flexible endoscopic intubation is the trismus, and dysphagia, whereas peritonsillar cellulitis is usually
optimal method, but awake orotracheal intubation by direct bilateral. The distinguishing feature of peritonsillar abscess is
laryngoscopy or videolaryngoscopy also can be done.10 Blind inferior medial displacement of the infected tonsil (at times
nasotracheal intubation can lead to airway obstruction and is involving the soft palate), with contralateral deviation of the uvula
contraindicated in the setting of epiglottitis. (Fig. 65.6). The abscess is generally unilateral and located in the
Antibiotics should be initiated against H. influenzae and other superior pole of the tonsil. Bilateral peritonsillar abscesses occur
likely bacterial pathogens. First-line agents pending culture and occasionally.
sensitivity results are cefotaxime and ceftriaxone plus vancomycin.
Alternative antibiotics include levofloxacin plus clindamycin.6 Diagnostic Considerations
The role of steroids is unresolved, but racemic epinephrine is used
only as a temporizing measure while preparations are made to Differential Diagnosis
secure the airway because short-term use can produce improve-
ment, only to be followed by a rebound effect, in which the The differential diagnosis of peritonsillitis includes hypertrophic
symptoms and signs revert to their pretreatment level of severity tonsillitis, infectious mononucleosis, tubercular granuloma, diph-
or become even worse.10 For patients admitted to the hospital, theria, other deep space infections of the neck, cervical adenitis,
consultation with an otolaryngologist should be arranged. carotid artery aneurysms, foreign bodies, and neoplasms.
Disposition Diagnostic Testing

If upper airway endoscopy shows mild or moderate disease, with Aspiration of pus establishes the diagnosis of peritonsillar abscess.
preservation of a widely patent airway, and the patient’s symptoms Because patients with peritonsillar abscess have a 20% incidence
LUDWIG’S ANGINA
Principles
Ludwig’s angina is a potentially fulminant disease process that can
lead to death within hours. This is a progressive cellulitis of the
connective tissues of the floor of the mouth and neck that begins
in the submandibular space, comprised of the sublingual and
submaxillary spaces. Dental disease is the most common cause of
Ludwig’s angina. An infected or recently extracted lower molar is
noted in most affected patients. Other causes of Ludwig’s angina
include a fractured mandible, foreign body or laceration in the
floor of the mouth, tongue piercing, traumatic intubation and
bronchoscopy, secondary infections of an oral malignancy, osteo-
myelitis, submandibular sialadenitis, peritonsillar abscess, furun-
cles, infected thyroglossal cysts, and sepsis.
Fig. 65.6. Peritonsillar abscess with uvular displacement to the right.
Clinical Features
of mononucleosis, laboratory testing for mononucleosis should
be considered when systemic symptoms or findings of mononu- Infection of the sublingual and submaxillary spaces leads to
cleosis are present (see Chapter 122.) edema and soft tissue displacement, which may result in airway
Radiographs are of no value when the clinical examination obstruction. The most common presentation in patients with
identifies peritonsillar abscess. Although contrast-enhanced CT Ludwig’s angina includes dysphagia, odynophagia, neck swelling,
and ultrasonography (intraoral and transcutaneous) aid in dif- and neck pain. Other symptoms and signs include dysphonia, hot
ferentiating peritonsillar abscess from cellulitis, especially when potato voice, dysarthria, drooling, tongue swelling, pain in the
patients are unable to cooperate with needle aspiration, these floor of the mouth, restricted neck movement, and sore throat.
rarely, if ever, are required.13 Patients should be questioned regarding recent dental extraction
and disease. The rapid development of crepitus and unilateral
Management pharyngitis in patients with a recent dental extraction should
suggest the diagnosis of Ludwig’s angina.
Needle aspiration is indicated when an abscess is present or sus- The most common physical findings in Ludwig’s angina are
pected. Antibiotics alone may suffice with peritonsillar cellulitis. bilateral submandibular swelling and elevation or protrusion of
Regimens include piperacillin-tazobactam or high-dose ceftriax- the tongue. Other findings include elevation of the floor of the
one plus metronidazole. Alternative antimicrobial agents include mouth, posterior displacement of the tongue, and a woody con-
clindamycin, cefoxitin, ampicillin-sulbactam, a carbapenem, high- sistency of the floor of the mouth. The combination of tense
dose penicillin and rifampin, or ticarcillin-clavulanate. The use of edema and brawny induration of the neck above the hyoid may
steroids are also beneficial.6 be present, described as a bull neck. Marked tenderness to palpa-
Drainage of an abscess is usually curative. Needle aspiration of tion of the neck and subcutaneous emphysema may be noted.
abscesses by emergency clinicians and otolaryngologists is diag- Usually, trismus and fever are present, but there is no palpable
nostic, although false-negative aspirations occur in approximately fluctuance or cervical lymphadenopathy. Tenderness to percus-
10% of cases, and another 10% may require repeated aspirations, sion may be elicited over the involved teeth.
and therapeutic. This immediately relieves symptoms and is more
cost-effective, less painful, and easier to perform than incision and Diagnostic Considerations
drainage. Intraoral ultrasound-guided needle aspiration is a useful
adjunct in the presence of trismus.13 Differential Diagnosis
Disposition The differential diagnosis includes deep cervical node suppura-

tion, peritonsillar and other deep neck space abscess, parotid and
Hospital admission rarely is indicated but is considered for submandibular gland abscess, oral carcinoma, angioedema, sub-
patients who have significant comorbidity, appear toxic, or are mandibular hematoma, and laryngeal diphtheria.
unable to tolerate oral fluids or whose pain is not managed by oral
analgesics. Most patients can be observed for 4 to 6 hours after Diagnostic Testing
aspiration in the ED observation unit or ED who are receiving
antibiotics, IV hydration, and analgesia. The most dangerous The diagnosis is made clinically. Soft tissue plain films of the neck
immediate complication of peritonsillitis is pharyngeal obstruc- may confirm the diagnosis by identifying swelling of the affected
tion with upper airway compromise. Other very rare complica- area and airway narrowing and gas collections but, in general, are
tions include sepsis, abscess rupture, and pulmonary aspiration not of value. CT and magnetic resonance imaging (MRI) can
leading to pneumonia, empyema, and pulmonary abscess forma- identify deep space neck infections and airway compromise.
tion. Infection can spread contiguously to the parapharyngeal and Ultrasonography is also useful in diagnosing abscesses and edema
retropharyngeal spaces. Ludwig’s angina, mediastinal involvement in the setting of Ludwig’s angina.
(including mediastinitis, pneumonia, empyema, and pericarditis),
myocarditis, carotid artery erosion, jugular vein thrombophlebitis, Management
septic embolization, abscess formation, Lemierre’s syndrome (see
later, “Parapharyngeal Abscess”), and cervicothoracic necrotizing Sudden asphyxiation is the most common cause of death in
fasciitis can complicate peritonsillitis. The intracranial extension patients with Ludwig’s angina. Stridor, tachypnea, dyspnea, inabil-
of peritonsillitis may result in meningitis, cavernous sinus throm- ity to handle secretions, and agitation all suggest impending
bosis, and cerebral abscess. airway compromise. Flexible endoscope–guided oral or nasal
intubation under sedation with topical anesthesia is the preferred another, and patients may present with concomitant deep space
method of airway control. Direct laryngoscopy can be particularly infections.15 Retropharyngeal swelling reflects expansion of the
difficult because of the inability to retract the tongue into the retropharyngeal, danger, or prevertebral space. This discussion
submandibular space and posterior and cephalad displacement of refers to infections in these spaces collectively as retropharyngeal
the tongue by the infection. There have been no reports reporting abscesses.
the use of videolaryngoscopes in this condition. Emergent trache- Retropharyngeal abscess is an uncommon condition that
ostomy may be necessary in patients with Ludwig’s angina if previously was a disease of childhood, with 96% of cases occur-
flexible endoscopic intubation cannot be accomplished. Cricothy- ring in patients younger than 6 years. In adult patients, who are
rotomy may be technically difficult due to anatomic distortion now increasingly affected, cellulitis develops in the retropharyn-
and opens tissue planes that increase the risk of spreading infec- geal area. Once the retropharyngeal space is involved, the infection
tion into the mediastinum.14 spreads rapidly and an abscess forms. Nasopharyngitis, otitis
Emergent high-dose IV antibiotic regimens include media, parotitis, tonsillitis, peritonsillar abscess, dental infections
piperacillin-tazobactam, ticarcillin-clavulanate, and high-dose and procedures, upper airway instrumentation, endoscopy, lateral
penicillin plus metronidazole. Clindamycin can be used in peni- pharyngeal space infection, and Ludwig’s angina are all implicated
cillin- allergic patients. Vancomycin should be added if the initial in the development of retropharyngeal abscess.6,15 Other causes
Gram stain reveals gram-positive cocci.6 With the exception of include blunt and penetrating trauma (usually from foreign
dental extractions, surgery is reserved for patients who do not bodies, commonly fish bones), ingestion of caustic substances,
respond to medical therapy and those with crepitus and purulent vertebral fractures, and hematologic spread from distant infec-
collections. tion. Vertebral osteomyelitis and diskitis may also lead to infection
of the prevertebral space.
Disposition Retropharyngeal abscesses are usually polymicrobial, with a
mixture of aerobes and anaerobes. β-Lactamase–producing
All patients with Ludwig’s angina require admission to the ICU organisms are present in two-thirds of the cases. Tuberculosis is
and parenteral antibiotics. The mortality rate associated with rarely reported in the United States as a cause of retropharyngeal
Ludwig’s angina is less than 10% with early aggressive antibiotic abscess. Staphylococcus is the most common cause of pyogenic
therapy and adequate protection of the airway. vertebral osteomyelitis, leading to the formation of retropharyn-
geal abscess. Disseminated coccidioidomycosis may also cause
RETROPHARYNGEAL ABSCESS retropharyngeal abscess.15
Principles Clinical Features

The retropharyngeal space lies in the midline and extends from the Patients typically have a sore throat, dysphagia, odynophagia,
base of the skull to the superior mediastinum (at about the level drooling, muffled voice, neck stiffness, pain, and fever. Dysphonia
of T2). Retropharyngeal abscesses tend to occur laterally to the is usually present and is described as a duck quack (cri du canard).
midline. Posterior to the retropharyngeal space lies the so-called Patients may report feeling a lump in the throat; those with a
danger space, which extends from the base of the skull to the retropharyngeal abscess may appear quite ill and generally prefer
diaphragm. The prevertebral space extends from the base of the to hold their necks extended and remain in the supine position.
skull to the coccyx. Danger space and prevertebral abscesses are This position keeps the swollen posterior pharynx from com-
located in the midline. Infections in the retropharyngeal, danger, pressing the upper airway. Forcing the patient to sit may lead to
and prevertebral spaces easily access the mediastinum, which increased dyspnea.15
allows the rapid spread of infection and life-threatening complica- Physical examination may reveal tender cervical lymphade-
tions (Fig. 65.7). Infection may spread from one deep space to nopathy and cervical musculature, neck swelling, torticollis, and
igh fever. Trismus may be present and makes visualization of the
pharynx difficult. With retropharyngeal cellulitis, diffuse edema
and erythema of the posterior pharynx are present. Once an
abscess has developed, palpation may demonstrate a unilateral
mass if the retropharyngeal space is affected and a midline mass
if the abscess is in the prevertebral or danger space. Palpation of
Prevertebral space
a fluctuant mass is unreliable and carries a risk of inadvertent
Prevertebral fascia rupture. Tenderness on moving the larynx and trachea side
to side (tracheal so-called rock sign) is commonly present. A
Danger space retropharyngeal abscess may also cause pain in the back of the
neck or shoulder, precipitated by swallowing. Cold abscesses
Alar fascia
(caused by tuberculosis) are characterized by insidious onset,
Retropharyngeal chronicity, constitutional symptoms, and a lower fever. Symp-
space toms disproportionate to the findings should prompt further
evaluation.
Visceral
fascia
Diagnostic Considerations
Esophagus
Trachea Differential Diagnosis
The differential diagnosis includes retropharyngeal tumors,
foreign bodies, inflammation, hematoma, aneurysms, hemor-
Fig. 65.7. Lateral view of the neck showing the relationship of fascia rhage, lymphadenopathy, and edema. Other considerations
to the prevertebral danger area and retropharyngeal and submandibular include tendinitis of the longus colli muscle and retropharyngeal
spaces. thyroid tissue.16
Diagnostic Testing Consultation with an infectious disease specialist and otolaryn-

gologist is advised when tuberculosis or a fungal infection is
Diagnosis rests on the clinical findings and particularly on lateral suspected as the causative agent.15,17
cervical radiographs and CT and MRI scans. The anteroposterior Neck immobilization may be necessary in patients with verte-
(AP) diameter of the soft tissue along the anterior bodies of C1-4 bral body destruction caused by osteomyelitis or atlantoaxial
should be less than 40% of the AP diameter of the vertebral body separation. Atraumatic atlantoaxial separation is caused by
just behind it; an increase in this tissue thickness suggests infec- damage to the transverse ligament of the atlas from the abscess.
tion or abscess. Soft tissue swelling may be diffuse in the case of These patients may have neurologic symptoms and a widened
cellulitis or more focal if an abscess cavity is present. A pathologic predental space on plain films or CT or MRI scans. These patients
process is suggested if the retropharyngeal space on lateral neck need neurosurgical or orthopedic evaluation and may require
films (measured from the anteroinferior aspect of the second fixation.
vertebral body to the posterior pharyngeal wall) is wider than
7 mm in children and adults or the retrotracheal space (measured Disposition
from the anteroinferior aspect of the sixth vertebral body to the
posterior pharyngeal wall) is more than 14 mm in children and Patients with retropharyngeal abscess are admitted to the ICU,
22 mm in adults. True lateral films with the neck fully extended and emergent consultation with an otolaryngologist is obtained.
during deep inspiration are the most reliable. Other radiographic
findings include reversal of the normal lordosis of the cervical PARAPHARYNGEAL ABSCESS
spine, air-fluid levels in the abscess cavity, foreign bodies, and
vertebral body destruction. Principles
Plain films may not be sufficiently sensitive to diagnose retro-
pharyngeal abscess. CT or MRI should be performed when doubt The parapharyngeal space is divided into two compartments by
persists after plain x-ray examination. These studies not only aid the styloid process. The anterior compartment contains connec-
in the diagnosis and differentiation between cellulitis and abscess tive tissue, muscle, and lymph nodes. The carotid sheath, which
but also determine the extent of the disease process and presence contains the carotid artery, internal jugular vein, vagus nerve,
of complications (Figs. 65.8 and 65.9). Ultrasonography is useful cranial nerves IX through XII, and the sympathetic chain, runs in
for differentiating retropharyngeal cellulitis from retropharyngeal the posterior compartment. Parapharyngeal abscesses are usually
abscess. polymicrobial, emanating from an odontogenic or pharyngoton-
sillar infections. Parapharyngeal space infections can also arise
Management from contiguous spread from deep neck space infections, parotitis,
sinusitis, infected neck tumors, infected branchial cleft cysts, sup-
Patients with retropharyngeal cellulitis are treated with high-dose purative lymphadenitis, chronic otitis with cholesteatoma, mas-
IV antibiotics. Appropriate regimens include clindamycin, high- toiditis, and iatrogenic introduction of organisms during a
dose penicillin plus metronidazole, piperacillin-tazobactam, and mandibular nerve block or anesthesia for tonsillectomy, nasal
ampicillin-sulbactam. The resolution of retropharyngeal cellulitis intubation, or dental extraction.
is possible without surgical intervention.6,15
In general, retropharyngeal abscesses are treated with antibiot- Clinical Features
ics in conjunction with operative incision and drainage by an
otolaryngologist. In select cases, retropharyngeal abscesses can be Odynophagia, pain, and swelling of the neck are the most common
treated successfully with antibiotics alone or in combination with complaints. A history of an antecedent sore throat may be elicited;
needle aspiration. Tuberculous (cold) abscesses should be drained torticollis caused by irritation of the sternocleidomastoid muscle
only extraorally unless the patient is in acute respiratory distress. is also reported.
Fig. 65.9. Sagittal CT scan demonstrating a right-sided retropharyngeal

Fig. 65.8. CT scan demonstrating a right-sided retropharyngeal abscess. abscess.
The classic physical findings of infection involving the anterior

compartment of the parapharyngeal space are medial tonsillar
displacement and posterolateral pharyngeal wall bulging. Other
findings include fever, trismus, caused by irritation of the muscles
of mastication, edema, and swelling at the angle of the mandible,
often seen in patients with an anterior parapharyngeal abscess.
Involvement of the posterior space is associated with many of
these same signs. If the anterior compartment is spared, however,
little or no trismus occurs. Instead, posterior displacement of the
tonsillar pillar and retropharyngeal swelling may be present.
Complications of a parapharyngeal abscess include airway
obstruction and abscess rupture, with subsequent aspiration,
pneumonia, and empyema. Infection can spread to surrounding
spaces and into the mediastinum and pericardium. This spread
may lead to mediastinitis, mediastinal abscess, pericarditis, myo-
cardial abscess, and/or empyema. Other complications include
osteomyelitis of the mandible, cervicothoracic necrotizing fasci-
itis, parotid abscess, cavernous sinus thrombosis, and meningitis.
Posterior parapharyngeal space infections are particularly
dangerous. These may affect the cervical sympathetic chain,
carotid artery, or internal jugular vein. Ipsilateral Horner’s syn-
drome and neuropathies of cranial nerves IX through XII may Fig. 65.10. CT scan demonstrating a left-sided parapharyngeal abscess.
occur. Carotid artery erosion may lead to hemorrhage and the
formation of aneurysms. Oral, nasal, and aural warning bleeding
is common with carotid artery erosion, with aural bleeding being
particularly ominous. Any unexplained bleeding associated with Diagnostic Strategies
parapharyngeal or other deep neck space infection should be
investigated thoroughly. Persistent peritonsillar swelling, despite Ultrasonography, CT, and MRI are more useful than lateral
resolution of the parapharyngeal abscess or a tender unilateral radiography in diagnosing parapharyngeal abscess and its com-
pulsatile mass, may indicate an arterial aneurysm. Aspiration or plications (Fig. 65.10). Angiography, Doppler flow studies, and
incision of a carotid artery aneurysm thought to be a parapharyn- magnetic resonance angiography may also be helpful in evaluating
geal abscess may have disastrous complications. vascular complications.
Involvement of the internal jugular vein may lead to septic
thrombosis and Lemierre’s syndrome.18 This entity, also termed Management
postanginal septicemia, affects primarily young healthy patients
and is easily confused with right-sided endocarditis or aspiration Treatment includes high-dose IV antibiotics and consultation
pneumonia. The manifestation is one of a pharyngitis that initially with an otolaryngologist for surgical drainage. Appropriate anti-
improves but is then followed by severe sepsis. It is thought that biotic regimens are those used for retropharyngeal abscess. IV
the pharyngeal infection spreads to the parapharyngeal space and antibiotics alone will cure parapharyngeal space infections in
causes septic thrombophlebitis of the jugular vein. Patients usually patients without abscess.6,15,17 The successful resolution of para-
appear ill and are febrile. Metastatic infections involve primarily pharyngeal abscesses with IV antibiotics and needle aspiration has
the lung and are manifested by bilateral nodular infiltrates, pleural been reported.15,17
effusion, and pneumothorax. Septic embolization may also lead
to arthritis, osteomyelitis, cellulitis and abscesses, meningitis, and Disposition
a vesiculopustular rash. Positive blood cultures, leukocytosis, and
elevated bilirubin levels and liver function tests, with and without Patients with parapharyngeal infections require emergent consul-
hepatomegaly and jaundice, are often present. Albuminuria, tation with an otolaryngologist and admission to the ICU. These
hematuria, and elevations in serum creatinine and blood urea patients may require emergent surgical intervention.
nitrogen levels are reported. Septic shock rarely develops, although
acute respiratory distress syndrome, transient coagulopathies, and RHINOSINUSITIS
hypotension commonly occur. The most frequent cause of this
entity is Fusobacterium (primarily Fusobacterium necrophorum), Principles
although Staphylococcus aureus is the most common pathogen in
IV drug users. Treatment consists of parenteral antibiotics and Because sinusitis usually involves the nasal cavity, the term rhino-
incision and drainage of abscesses. Antibiotic regimens include sinusitis is preferred. These terms will be used interchangeably in
piperacillin-tazobactam, imipenem-cilastatin, high-dose ceftriax- this section.19
one plus metronidazole, and clindamycin. Jugular vein ligation The paranasal sinuses—frontal, maxillary, ethmoid, and
and resection are necessary in patients with uncontrolled sepsis sphenoid—are named for the facial bones with which they are
and respiratory failure caused by repeated septic pulmonary associated. Pneumatization may involve other bones but repre-
emboli. The value of anticoagulation is unknown.18 sents extension from the main sinus. The maxillary, anterior
ethmoid, and frontal sinuses drain into the medial meatus, located
Diagnostic Considerations between the inferior and middle nasal turbinates. This area is
termed the ostiomeatal complex and is the focal point of sinus
Differential Diagnosis disease. The posterior ethmoid sinus drains into the superior
meatus and phenoid sinus just above the superior turbinate.19
The differential diagnosis includes infections of other deep spaces A healthy sinus is sterile, depends on a patent ostium with
of the neck, tumors and metastatic lymph nodes, thyroiditis, free air exchange, and is reliant on appropriate mucus drainage.
branchial cleft cyst, and carotid artery aneurysms. Many different processes can result in ostial obstruction and
rhinosinusitis, but the most common are viral upper respiratory without its symptoms or signs between episodes, occur annually.
tract infections and allergic rhinitis. Ciliary abnormality or immo- The presentation and treatment of recurrent acute disease is
bility also inhibits drainage, resulting in sinusitis. Bacteria are similar to that for acute bacterial sinusitis.19 Invasive fungal
introduced into the sinus by coughing and vigorous nose blowing, sinusitis (mucormycosis) is an aggressive opportunistic rhinocer-
leading to increased inflammation, decreased oxygen tension in ebral infection that affects immunocompromised hosts. Mucor-
the sinus, and bacterial overgrowth. Other factors predisposing to mycosis (Rhizopus) is generally associated with fever, localized
rhinosinusitis include immunocompromise, nasal septal devia- nasal pain, and cloudy rhinorrhea. On examination, the affected
tion and other structural abnormalities, nasal polyps, tumors, tissue (usually the turbinates) appears gray, friable, anesthetic, and
trauma and fractures, rhinitis medicamentosa, rhinitis secondary nonbleeding because of infarction caused by mucormycotic
to toxic mucosal exposure, barotrauma, foreign bodies, nasal angioinvasion. In advanced cases, the affected tissues are necrotic
cocaine abuse, and instrumentation, including nasogastric and and black, and the infection spreads beyond the sinus.19
nasotracheal intubation.19
Sinusitis can be classified into acute viral, acute bacterial, Diagnostic Considerations
chronic, and recurrent acute variations. Approximately 90% of
patients with colds have an element of the acute viral form. Acute Differential Diagnosis
viral sinusitis may lead to the development of the acute bacterial
variety. Streptococcus pneumoniae, nontypable H. influenzae, and Rhinitis can be differentiated from sinusitis by the increased
Moraxella catarrhalis are the primary pathogens responsible for response of nasal obstruction to treatment, clear nasal discharge,
acute bacterial and recurrent acute sinusitis. Pseudomonas aerugi- and absence of pain or fever. Rhinitis does not lead to ostial
nosa is associated with sinusitis in the setting of HIV infection and obstruction, and patients do not complain of facial pain. Malig-
cystic fibrosis. Anaerobic bacteria, streptococcal species, and S. nancy, tension headache, vascular headache, foreign body, dental
aureus are more prominent causes of chronic sinusitis. Fungi also disease, brain abscess, epidural abscess, meningitis, and subdural
have a role in chronic sinusitis. Rhizopus, Aspergillus, Candida, empyema may also manifest in a manner similar to that of
Histoplasma, Blastomyces, Coccidioides, and Cryptococcus spp., as sinusitis.
well as other fungi, may cause sinusitis, primarily in immunocom-
promised hosts. It is important to distinguish infectious from Diagnostic Testing
allergic sinusitis. Allergic sinusitis is associated with sneezing,
itchy eyes, allergen exposure, and previous episodes.19 Physical examination is best performed after the application of a
topical decongestant. Mucosal erythema and edema are usually
Clinical Features present. Purulent discharge from the nasal meatus may be
observed if the sinus ostia are not completely obstructed. In the
Frontal sinusitis can cause severe headache localized to the fore- setting of acute sinusitis, nasal and nasopharyngeal cultures do
head and orbit. Sphenoid sinusitis may cause vague headaches and not differentiate between acute viral and acute bacterial infections
focal pain almost anywhere in the head. Maxillary sinusitis may and are not indicated. Culture and biopsy are indicated in sug-
be seen with pain over the zygoma, in the canine or bicuspid teeth, gested chronic, recurrent acute, and fungal sinusitis.19
or periorbitally. Ethmoid sinusitis can cause medial canthal pain For suspected acute sinusitis, routine radiographic examina-
and periorbital or temporal headaches.19 tion is not recommended and should be limited to the diagnosis
The cardinal findings of acute rhinosinusitis are mucopurulent of chronic or recurrent acute sinusitis, cases of questionable
nasal discharge, nasal obstruction or congestion, and facial pain, diagnoses, patients with unresponsive disease, or investigation of
fullness, or pressure lasting less than 4 weeks. Other symptoms complications. Axial and coronal CT is the imaging modality of
and signs include postnasal drip (which may lead to coughing), choice. CT findings suggestive of sinusitis include air-fluid levels,
pressure over the involved sinus, malaise, hyposmia, anosmia, sinus opacification, sinus wall displacement, and mucosal thicken-
fever, maxillary dental pain, and ear fullness or pressure. Acute ing (Fig. 65.11). CT is sensitive, although not specific. Incidental
sinusitis typically progresses over a period of 7 to 10 days and sinus mucosal thickening is seen in 40% of asymptomatic patients,
resolves spontaneously. During the first 3 to 5 days of illness, it and abnormal CT findings can also be noted in just 50% of
may be difficult to differentiate acute viral from acute bacterial patients with seasonal allergies. CT with IV contrast or MRI may
sinusitis; antibiotics are not indicated in this phase because most be required to evaluate complications of rhinosinusitis and are
cases are viral and will resolve without treatment. Bacterial sinus- helpful in determining alternative diagnoses. In children, CT or
itis is more likely, and antibiotics are warranted when symptoms MRI with IV contrast should be performed if there is suspicion
persist beyond 10 days, or with severe onset of disease (fever > of orbital or central nervous system complications. Sinus endos-
39° C [102.2° F] with severe facial pain or purulent nasal discharge) copy is an optional diagnostic modality for the evaluation of
for at least 3 or 4 consecutive days. Bacterial origin also is sug- sinusitis.19,20
gested by so-called double sickening, which refers to patients who
improve initially, only to have worsening sinus congestion and Management
discomfort. In addition, the diagnosis of sinusitis is made in the
pediatric population when a child with an upper respiratory Most cases of acute sinusitis are self-limited and resolve spontane-
infection presents with persistent illness (daytime cough or nasal ously; therefore, management should focus on symptomatic
discharge) longer than 10 days without improvement, a worsening treatment and patient education. The goal of symptomatic treat-
course (worsening or new nasal discharge, daytime cough, or fever ment should be to reduce patient discomfort; it includes appropri-
after initial improvement), or severe onset of symptoms (concur- ate pain management and local decongestant therapy. When
rent fever and purulent nasal discharge for at least 3 days).19,20 allergic symptoms are prominent or the patient has a history of
Chronic sinusitis is slow in onset, prolonged in duration (>12 allergic rhinosinusitis, antihistamines, such as loratadine, 10 mg
weeks), and recurrent. Symptoms can be nonspecific but are daily, are helpful, but antihistamines otherwise are of no value.19
generally similar to those of acute disease. Symptoms of chronic Decongestant therapy, available in topical and systemic prepa-
disease may include chronic cough, fetid breath, laryngitis, bron- rations, can be used to reduce tissue edema, facilitate drainage,
chitis, and worsening asthma. Recurrent acute sinusitis is diag- and maintain patency of the sinus ostia.19 Topical agents provide
nosed when four or more episodes of acute bacterial infection, more relief than systemic decongestants. Longer acting agents,
actual or suspected complications of sinusitis; or (4) underlying

conditions (eg, asthma, cystic fibrosis, anatomic abnormalities of
the upper respiratory tract, immunodeficiency). Children with
persistent stable symptoms may be managed with antibiotics or
an additional short (usually up to 3-day) period of observation
because there is low risk for complications in these patients, and
the symptoms may resolve on their own. Patients who do not
improve within 72 hours should be treated with antibiotics. The
choice of antibiotics should consider β-lactamase production and
multidrug-resistant pneumococci. Amoxicillin-clavulanate for 5
to 7 days in adults and 10 days in children is the first-line agent
for uncomplicated bacterial sinusitis. High-dose amoxicillin-
clavulanate is recommended as empirical treatment for patients
from areas in which there are high endemic rates of invasive S.
pneumoniae, severe infections, and those at risk for suppurative
complications, such as patients who have recently been hospital-
ized, used antibiotics within the past 4 to 6 weeks, are older than
65 years, or are immunocompromised. Penicillin-allergic patients
may be treated with levofloxacin, or doxycycline may be used in
adults and, in children, a combination of clindamycin plus cefix-
ime or cefpodoxime may be used in those with non–type I penicil-
Fig. 65.11. CT scan demonstrating left maxillary sinus opacification in
lin allergy. Children who are vomiting, unable to tolerate oral
the setting of acute sinusitis. medications, or are at risk for nonadherence to oral therapy can
be treated with an initial dose of 50 mg/kg of ceftriaxone (IV or
IM) until they are able to tolerate oral antibiotics. Trimethoprim-
sulfamethoxazole, macrolides, and second- and third-generation
such as 0.05% oxymetazoline hydrochloride, are easy to use and cephalosporin antibiotics are no longer recommended as empiri-
highly effective. Topical agents should be used for up to 5 days cal therapy due to bacterial resistance.6,19,20
because extended use results in rebound vasodilation and nasal Failure of symptoms to resolve after 3 to 5 days of antibiotic
obstruction, a condition termed rhinitis medicamentosa. Systemic therapy, or patients who worsen after 48 to 72 hours of empirical
oral adrenergic agonists (eg, phenylpropanolamine, pseudo- antibiotics, necessitate reassessment to confirm the diagnosis
ephedrine) offer no advantage over topical agents and have sig- of acute bacterial sinusitis, a change to an alternate antibiotic
nificant systemic effects, so they should not be used unless the regimen for 5 to 10 days, and referral to an otolaryngologist.
patient is unwilling to use topical decongestants. They should not Appropriate management for patients with mild to moderate
be used in patients with poorly controlled hypertension or patients disease includes amoxicillin-clavulanate, cefpodoxime, and cef-
who are taking tricyclic antidepressants, monoamine oxidase dinir. Patients with severe disease should be treated with a respira-
inhibitors, or nonselective β-adrenergic blockers.19 Topical and tory fluoroquinolone. Treatment of life-threatening complications
systemic steroids offer modest benefit when used in conjunction requires consultation and high-dose IV antibiotics. Patients with
with antibiotics for the treatment of bacterial sinusitis. Topical but chronic sinusitis should be referred to an otolaryngologist. Anti-
not systemic steroids are indicated for chronic and allergic sinus- biotics may be helpful in the setting of chronic sinusitis and
itis. Systemic steroids may be indicated in allergic and chronic should be effective against anaerobic and β-lactamase–producing
sinusitis with nasal polyps.21,22 bacteria. Amoxicillin-clavulanate or clindamycin for 3 to 10 weeks
Sinus self-irrigation with a Neti pot or powered commercial may be used. Antifungals may be beneficial in the treatment of
irrigator can be helpful for patients with chronic low-grade chronic sinusitis.6,19
symptoms or frequently recurring acute episodes. Saline nasal
irrigation is beneficial for the treatment of acute bacterial, recur- Disposition
rent acute, and chronic sinusitis and even may be efficacious for
the prevention of sinusitis. Hypertonic saline preparations have Most patients with rhinosinusitis can be treated on an outpatient
superior antiinflammatory properties and may be more effective basis. Frontal or sphenoid sinusitis with air-fluid levels may
than normal saline.19 necessitate hospitalization. A previously healthy, nontoxic patient
Antibiotic therapy should be initiated when the diagnosis of with good home support can be treated as an outpatient but
acute bacterial sinusitis is established. In children, those with should return immediately for any symptoms or signs of compli-
severe onset or worsening symptoms should be treated with cations, including severe headache, neurologic changes, and visual
antibiotics. Children with persistent symptoms and one of the changes. Patients who appear toxic, are immunocompromised,
following should also be treated with antibiotics: (1) antibiotic or have poor home resources require hospital admission and IV
therapy in the last 4 weeks; (2) concurrent bacterial infections; (3) antibiotics.
KEY CONCEPTS
• Most cases of pharyngitis have a viral causes. CENTOR clinical position, whereas those with a retropharyngeal abscess prefer to lie
criteria in conjunction with RST can be used to determine the supine.
likelihood of GAS pharyngitis. • Posterior to the retropharyngeal space lies the danger space, which
• Rheumatic fever is rare in developed countries, where it may occur in extends from the base of the skull to the superior mediastinum at
epidemics. about the level of T2.
• Although rare, local (airway) and systemic life-threatening • Resolving pharyngitis followed by severe sepsis, right-sided
complications of bacterial pharyngitis do occur. endocarditis, or aspiration pneumonia should suggest septic
• A severe sore throat with surprisingly minimal findings on thrombosis of the internal jugular vein and Lemierre’s syndrome.
examination of the oropharynx suggests serious soft tissue infection, • Imaging is rarely indicated in the setting of sinusitis and should be
such as epiglottitis or retropharyngeal abscess. reserved for complex presentations or if there is a suspicion of
• Deep space cellulitis is difficult to differentiate from deep space complications.
abscess and may require needle aspiration after CT or MRI. • In children with persistent and stable sinusitis, a 3-day period of
• Patients with upper airway infections should be kept in a position observation prior to the initiation of antibiotics is effective.
of comfort. Patients with epiglottitis prefer the classic sniffing
The references for this chapter can be found online by accessing the accompanying Expert Consult website.
C H APTER 65 Upper Respiratory Tract Infections 870.e1
REFERENCES
1. Little P, et al: Incidence and clinical variables associated with streptococcal throat 12. Klug TE, et al: Significant pathogens in peritonsillar abscesses. Eur J Clin Microbiol
infections: a prospective diagnostic cohort study. Br J Gen Pract 62:787, 2012. Infect Dis 30:619, 2011.
2. Shulman ST, et al: Clinical practice guidelines for the diagnosis and management of 13. Costantino TG, et al: Randomized trial comparing intraoral ultrasound to landmark-
group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of based needle aspiration in patients with suspected peritonsillar abscess. Acad Emerg
America. Clin Infect Dis 55:86, 2012. Med 19:626, 2012.
3. Centor RM, et  al: The clinical presentation of fusobacterium-positive and 14. Wolfe MM, et al: Is surgical airway necessary for airway management in deep neck
streptococcal-positive pharyngitis in a university health clinic: a cross-sectional study. infections and Ludwig angina? J Crit Care 26:11, 2011.
Ann Intern Med 162:241, 2015. 15. Bakir S, et al: Deep neck space infections: a retrospective review of 173 cases. Am J
4. Aalbers J, et al: Predicting streptococcal pharyngitis in adults in primary care: a Otolaryngol 33:56, 2012.
systematic review of the diagnostic accuracy of symptoms and signs and validation 16. Roldan CJ, Carlson PJ: Longus colli tendonitis, clinical consequences of a misdiag-
of the Centor score. BMC Med 9:67, 2011. nosis. Am J Emerg Med 31:1538, 2013.
5. Del Mar CB, et al: Antibiotics for sore throat. Cochrane Database Syst Rev 17. Biron VL, et al: Surgical vs ultrasound-guided drainage of deep neck space abscesses:
(11):CD000023, 2013. a randomized controlled trial: surgical vs ultrasound drainage. J Otolaryngol Head
6. Gilbert DN, et al, editors: The Sanford guide to antimicrobial therapy 2014, ed 44, Neck Surg 42:18, 2013.
Sperryville, VA, 2014, Antimicrobial Therapy. 18. Kim BY, et al: Thrombophlebitis of the internal jugular vein (Lemierre syndrome):
7. Hayward G, et al: Corticosteroids as standalone or add-on treatment for sore throat. clinical and CT findings. Acta Radiol 54:622, 2013.
Cochrane Database Syst Rev (10):CD008268, 2012. 19. Chow AW, et al: IDSA clinical practice guideline for acute bacterial rhino sinusitis in
8. Reveiz L, Cardona AF: Antibiotics for acute laryngitis in adults. Cochrane Database children and adults. Clin Infect Dis 54:e72, 2012.
Syst Rev (28):CD004783, 2013. 20. Wald ER, et al: Clinical practice guideline for the diagnosis and management of acute
9. Souza AM, et al: Use of inhaled versus oral steroids for acute dysphonia. Braz J bacterial sinusitis in children aged 1 to 18 years. Pediatrics 132:e262, 2013.
Otorhinolaryngol 79:196, 2013. 21. Zalmanovici TA, Yaphe J: Intranasal steroids for acute sinusitis. Cochrane Database
10. Riffat F, et al: Acute supraglottitis in adults. Ann Otol Rhinol Laryntol 120:296, 2011. Syst Rev (12):CD005149, 2013.
11. Guardiani E, et al: Supraglottitis in the era following widespread immunization 22. Venekamp RP, et al: Systemic corticosteroids for acute sinusitis. Cochrane Database
against Haemophilus influenzae type B: evolving principles in diagnosis and manage- Syst Rev (3):CD008115, 2014.
ment. Laryngoscope 120:2183, 2010.
CHAPTER 65: QUESTIONS & ANSWERS

65.1. Which of the following associations regarding pharyngitis 65.3. A 10-year-old boy, who recently immigrated to the United
is true? States from Honduras, complains of 3 days of sore throat,
A. Appears clinically well—diphtheria fever, and trouble swallowing. Examination reveals a
B. Cervical adenopathy—influenza healthy boy in mild distress with a grayish membrane
C. Conjunctivitis—coxsackievirus covering the soft palate, pharynx, and uvula. The airway is
D. No pharyngeal exudates—infectious mononucleosis patent. The child is slightly hoarse. He has bilateral tender
C. Pharyngeal exudates—adenovirus anterior cervical adenopathy; his lungs are clear. Vital
signs are temperature, 102.5° F (39° C) oral, heart rate, 130
Answer: E. Adenovirus often mimics streptococcal pharyngitis
beats/min, blood pressure, 105/65 mm Hg, respiratory
regarding the appearance of the exudate. It is also associated with
rate, 28 breaths/min, and O2 saturationm 100%. Which of
conjunctivitis, rather than coxsackievirus, which is associated with
the following treatments is most appropriate?
hand-foot-and-mouth disease. Influenza rarely shows cervical
A. Antitoxin
adenopathy or pharyngeal exudates. Infectious mononucleosis
B. High-dose corticosteroids
typically exhibits a tonsillar exudate or membrane. Diphtheria
C. High-dose intravenous penicillin
cases are usually toxic-appearing.
D. Nebulized racemic epinephrine treatments
E. Urgent endotracheal intubation
65.2. A 9-year-old boy presents with fever, neck tenderness, and
painful swallowing. The physical examination reveals a Answer: A. This is diphtheria. Urgent antitoxin is necessary. The
well-developed boy in no distress with oral temperature, toxin may produce airway collapse, vocal cord necrosis, neuritis,
39.2° C (102.6° F), heart rate, 125 beats/min, respiratory and carditis. Antibiotics eradicate only the carrier state. Cortico-
rate, 22 breaths/min, blood pressure, 100/60 mm Hg, and steroids do not affect the toxin-induced damage. The status of the
O2 saturation, 99%. Examination reveals whitish bilateral child does not warrant emergent endotracheal intubation because
tonsillar exudates, tender bilateral cervical adenopathy, his hoarseness is only mild and he has a patent airway, although
clear lungs, and normal tympanic membranes. Appropriate he must be closely monitored.
treatment measures include which of the following?
A. Admission for intravenous antibiotics 65.4. A 14-year-old girl returns to the ED 1 week after
B. Amoxicillin daily for 10 days completing a 10-day course of penicillin for rapid strep
C. Discussion with the family that antibiotic treatment test–confirmed GAS pharyngitis. She reports identical
prevents rheumatic fever but does not shorten illness symptom return 1 week after completion of her
duration antibiotics. Examination is again consistent with an
D. Symptomatic treatment only exudative pharyngitis. Which of the following is
E. Symptomatic treatment, throat culture, and return visit indicated?
within 3 to 4 days for culture review and antibiotics as A. Admission for intravenous antibiotics
indicated B. Cephalosporin, 10-day course
C. Counseling the family that this is likely infectious
Answer: B. A 10-day course of penicillin or cephalosporin is the
mononucleosis and symptomatic treatment is
treatment of choice. The antibiotic regimen of choice for adults
warranted
with group A beta-hemolytic Streptococcus (GAS) pharyngitis is a
D. Intramuscular benzathine penicillin, 1.2 million units
single intramuscular injection of 1.2 million units of benzathine
E. Repeat rapid strep testing
penicillin. Culture and follow-up visits are acceptable practice but
time-consuming and expensive. Symptomatic treatment is only Answer: D. Such patients may have been noncompliant or rein-
indicated when GAS) has been ruled out. Antibiotic treatment fected by asymptomatic contacts. Throat culture, surveillance of
prevents rheumatic fever and modestly shortens illness duration. contacts, and intramuscular penicillin are indicated.

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C H A P T E R 65

Upper Respiratory Tract Infections

Clinical Signs and Treatment of Various Causes of Pharyngitis

Treatment of recurrent or chronic tonsillitis should include

Principles Antibiotics are similar to those used for the treatment of

Differential Diagnosis Diagnostic Considerations

Diagnostic Testing Management

have developed gradually over a longer period of time (ie, 24

PERITONSILLITIS (PERITONSILLAR CELLULITIS AND

be considered to be at imminent risk for rapid airway obstruction. Clinical Features

Disposition Diagnostic Testing

Disposition The differential diagnosis includes deep cervical node suppura-

Principles Clinical Features

Diagnostic Testing Consultation with an infectious disease specialist and otolaryn-

Fig. 65.9. Sagittal CT scan demonstrating a right-sided retropharyngeal

The classic physical findings of infection involving the anterior

actual or suspected complications of sinusitis; or (4) underlying

CHAPTER 65: QUESTIONS & ANSWERS

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Rosen&#39;s Emergency Medicine Concepts and Clinical Practice

Uploaded by

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Available Formats

Rosen&#39;s Emergency Medicine Concepts and Clinical Practice

Uploaded by

Copyright:

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C H A P T E R 65

Upper Respiratory Tract Infections

Clinical Signs and Treatment of Various Causes of Pharyngitis

Treatment of recurrent or chronic tonsillitis should include

Principles Antibiotics are similar to those used for the treatment of

Differential Diagnosis Diagnostic Considerations

Diagnostic Testing Management

have developed gradually over a longer period of time (ie, 24

PERITONSILLITIS (PERITONSILLAR CELLULITIS AND

be considered to be at imminent risk for rapid airway obstruction. Clinical Features

Disposition Diagnostic Testing

Disposition The differential diagnosis includes deep cervical node suppura-

Principles Clinical Features

Diagnostic Testing Consultation with an infectious disease specialist and otolaryn-

Fig. 65.9. Sagittal CT scan demonstrating a right-sided retropharyngeal

The classic physical findings of infection involving the anterior

actual or suspected complications of sinusitis; or (4) underlying

CHAPTER 65: QUESTIONS & ANSWERS

You might also like

Rosen's Emergency Medicine Concepts and Clinical Practice

Rosen's Emergency Medicine Concepts and Clinical Practice