ThroatsThroats

October 2010October 2010

““Failure to examine the Failure to examine the throat is a glaring sin of throat is a glaring sin of omission, especially in omission, especially in

children. One finger in the children. One finger in the throat and one in the rectum throat and one in the rectum makes a good diagnostician.”makes a good diagnostician.”

-Sir William Osler-Sir William Osler

Areas to coverAreas to cover

Sore throatsSore throats ““Lumps in the throat”Lumps in the throat” Two week waitsTwo week waits HoarsenessHoarseness Lumps in neck – anterior and Lumps in neck – anterior and

posterior triangles.posterior triangles.

Sore ThroatsSore Throats

120 cases per year120 cases per year Mostly children and young adultsMostly children and young adults 90% of patients recover within one 90% of patients recover within one

weekweek 70% are viral, the rest bacterial70% are viral, the rest bacterial Most bacterial infections are Group Most bacterial infections are Group

A A ββ-haemolytic streptococcus-haemolytic streptococcus Complications are rare Complications are rare

Should I Swab?Should I Swab?

NO.NO. Positive culture makes strep sore throat Positive culture makes strep sore throat

likely but negative culture does not rule out likely but negative culture does not rule out diagnosis.diagnosis.

High asymptomatic carrier rate for GABHS High asymptomatic carrier rate for GABHS (up to 40%)(up to 40%)

Bacteria from the surface of tonsils correlate Bacteria from the surface of tonsils correlate poorly with those deep in the tonsillar poorly with those deep in the tonsillar crypts.crypts.

Poor correlation between culture results and Poor correlation between culture results and symptoms.symptoms.

Are Antibiotics Useful?Are Antibiotics Useful?

Reduce symptoms to half at day 3Reduce symptoms to half at day 3 90% better at one week whether 90% better at one week whether

treated or nottreated or not Rare complications are reducedRare complications are reduced

Rheumatic feverRheumatic fever Acute glomerulonephritisAcute glomerulonephritis Acute otitis mediaAcute otitis media Acute sinusitisAcute sinusitis QuinsyQuinsy

Antibiotics?Antibiotics? Centor criteria. Need 3 of the following:Centor criteria. Need 3 of the following:

Tonsillar exudateTonsillar exudate Tender anterior cervical lymph nodesTender anterior cervical lymph nodes History of fever History of fever Absence of coughAbsence of cough

Three or more gives 40-60% chance of Three or more gives 40-60% chance of GABHS infectionGABHS infection

Absence of 3 or 4 signs gives 80% chance Absence of 3 or 4 signs gives 80% chance of not having the infection.of not having the infection.

NICENICE

Indications for antibiotics include:Indications for antibiotics include: Features of marked systemic upset Features of marked systemic upset

secondary to acute sore throat.secondary to acute sore throat. Unilateral peritonsilitisUnilateral peritonsilitis History of rheumatic feverHistory of rheumatic fever A child at increased risk from acute A child at increased risk from acute

infection eg DM, immunodeficiency.infection eg DM, immunodeficiency.

ReferralReferral

Same day:Same day: Sustpected quinsy – usually adults. Sustpected quinsy – usually adults.

Unilateral peritonsillar swelling, Unilateral peritonsillar swelling, difficulty swallowing, trismus (difficulty difficulty swallowing, trismus (difficulty swallowing)swallowing)

Swelling causing airway obstruction, Swelling causing airway obstruction, swallowing difficulty with dehydration swallowing difficulty with dehydration and/or systemic upset.and/or systemic upset.

Referral NICE < 15yrsReferral NICE < 15yrs

Urgent – history of sleep apnoea Urgent – history of sleep apnoea (daytime sleepiness, FTT)(daytime sleepiness, FTT)

Routine – five or more episodes of Routine – five or more episodes of sore throat in the previous year, or sore throat in the previous year, or guttate psoriasis exacerbated by guttate psoriasis exacerbated by acute tonsillitis.acute tonsillitis.

Glandular FeverGlandular Fever Suspect in teenagers and young adults with Suspect in teenagers and young adults with

sore throat lasting more than a week.sore throat lasting more than a week. Signs: sore throat, malaise, fatigue, lymph Signs: sore throat, malaise, fatigue, lymph

noes, enlarged spleen, palatal petechiae, rashnoes, enlarged spleen, palatal petechiae, rash Send blood for FBC, glandular fever Send blood for FBC, glandular fever

antibodiesantibodies Complications: hepatitis, jaundice, Complications: hepatitis, jaundice,

pneumonitis.pneumonitis. Treatment: Simple analgesia, short course Treatment: Simple analgesia, short course

prednisolone if severeprednisolone if severe Do not prescribe amoxicillinDo not prescribe amoxicillin

Glandular FeverGlandular Fever

Counsel re duration of fatigue – 20% Counsel re duration of fatigue – 20% will last up to 6 monthswill last up to 6 months

Avoid contact sports for 1 monthAvoid contact sports for 1 month Contagious for at least 2 months Contagious for at least 2 months

after initial infection.after initial infection.

““Lump in the throat”Lump in the throat”

What is the exact problem?What is the exact problem? LumpLump FrogFrog TighteningTightening ClearingClearing ChokingChoking Phlegm (respiratory tract)Phlegm (respiratory tract) Cattarh (head)Cattarh (head)

GORD?GORD?

Symptoms inculdeSymptoms inculde AerophagiaAerophagia Buccal burningBuccal burning Cervical painCervical pain Choking sensationChoking sensation Chronic coughChronic cough Constant throat Constant throat

clearingclearing DysphagiaDysphagia Food sticking in Food sticking in

throatthroat

Globus sensationGlobus sensation HalitosisHalitosis HoarsenessHoarseness Unilateral otalgiaUnilateral otalgia Pharyngeal Pharyngeal

tightnesstightness Sore throatSore throat Water brashWater brash

Red flagsRed flags DysphagiaDysphagia Weight lossWeight loss HoarsenessHoarseness HaematemesisHaematemesis HaemoptysisHaemoptysis Unilateral earache Unilateral earache

with normal eardrumwith normal eardrum PainPain Neck swellingNeck swelling NeurologyNeurology

Others:Others: SmokersSmokers AgeAge HeartburnHeartburn RefluxReflux RegurgitationRegurgitation GurglingGurgling

What next?What next?

ExamineExamine Trial of PPITrial of PPI Barium swallowBarium swallow ENT opinionENT opinion Urgent referral?Urgent referral?

Two week waitTwo week wait

7 criteria in ENT/OMF7 criteria in ENT/OMF How many can you think of?How many can you think of?

Two Week WaitTwo Week Wait An unexplained persistent sore or painful An unexplained persistent sore or painful

throat.throat. Unilateral pain > 4 weeks assoc with otalgia Unilateral pain > 4 weeks assoc with otalgia

but normal otoscopy.but normal otoscopy. Unexplained oral mucosa/mass > 3 weeksUnexplained oral mucosa/mass > 3 weeks All red or red & white patches of oral mucosa All red or red & white patches of oral mucosa

that are painful and swollen/bleedingthat are painful and swollen/bleeding Unexplained neck lump of recent onset, or Unexplained neck lump of recent onset, or

previous lump changing over 3-6 weeksprevious lump changing over 3-6 weeks Unexplained persistent swelling in parotid or Unexplained persistent swelling in parotid or

submandibular gland.submandibular gland.

Two Week Wait IITwo Week Wait II

Thyroid swelling associated with: Thyroid swelling associated with: Solitary nodule increasing in sizeSolitary nodule increasing in size History of neck radiationHistory of neck radiation FH of endocrine tumourFH of endocrine tumour Unexplained hoarseness or voice Unexplained hoarseness or voice

changeschanges Cervical lymphadenopathyCervical lymphadenopathy Pre-pubertal patientPre-pubertal patient Age>=65 yearsAge>=65 years

HoarsenessHoarseness Unresolved for more than 3 weeksUnresolved for more than 3 weeks Pain not from cold or fluPain not from cold or flu Associated with:Associated with:

StridorStridor Heavy smokingHeavy smoking Age > 45Age > 45 HaemoptysisHaemoptysis Neck lumpNeck lump Pain on swallowingPain on swallowing EaracheEarache Weight lossWeight loss

CXR and urgent referral to ENTCXR and urgent referral to ENT

Lumps in NeckLumps in Neck

Superficial lumpsSuperficial lumps Sebaceous cystSebaceous cyst LipomaLipoma AbscessAbscess

Anterior triangleAnterior triangle How many can you remember?How many can you remember?

Lumps in NeckLumps in Neck Anterior triangleAnterior triangle

Lymph nodesLymph nodes Thyroglossal cyst (midline)Thyroglossal cyst (midline) Thyroid swellingThyroid swelling Dermoid cystDermoid cyst Submandibular (Salivary calculus, TB, Firm Submandibular (Salivary calculus, TB, Firm

implies ca)implies ca) Branchial cystBranchial cyst Cystic hygromaCystic hygroma Carotid aneurysmCarotid aneurysm Sternomastoid tumourSternomastoid tumour

Posterior triangle?Posterior triangle?

Lumps in NeckLumps in Neck

Posterior lumpsPosterior lumps Cervical ribCervical rib Subclavian artery aneurysmSubclavian artery aneurysm Pharyngeal pouchPharyngeal pouch Cystic hygromaCystic hygroma Brachial cystsBrachial cysts

Systemic lymphadenopathy – glandular Systemic lymphadenopathy – glandular fever, HIV, lymphoma.fever, HIV, lymphoma.

SummarySummary

Management of sore throatManagement of sore throat Glandular feverGlandular fever Lumps in throatLumps in throat Two week waits in ENT/OMFTwo week waits in ENT/OMF HoarsenessHoarseness Lumps in neckLumps in neck