Throats October 2010

“Failure to examine the throat is a glaring sin of omission, especially in children. One finger in the throat and one in the rectum makes a good diagnostician.” -Sir William Osler

Areas to cover Sore throats Sore throats “Lumps in the throat” “Lumps in the throat” Two week waits Two week waits Hoarseness Hoarseness Lumps in neck – anterior and posterior triangles. Lumps in neck – anterior and posterior triangles.

Sore Throats 120 cases per year 120 cases per year Mostly children and young adults Mostly children and young adults 90% of patients recover within one week 90% of patients recover within one week 70% are viral, the rest bacterial 70% are viral, the rest bacterial Most bacterial infections are Group A β- haemolytic streptococcus Most bacterial infections are Group A β- haemolytic streptococcus Complications are rare Complications are rare

Should I Swab? NO. NO. Positive culture makes strep sore throat likely but negative culture does not rule out diagnosis. Positive culture makes strep sore throat likely but negative culture does not rule out diagnosis. High asymptomatic carrier rate for GABHS (up to 40%) High asymptomatic carrier rate for GABHS (up to 40%) Bacteria from the surface of tonsils correlate poorly with those deep in the tonsillar crypts. Bacteria from the surface of tonsils correlate poorly with those deep in the tonsillar crypts. Poor correlation between culture results and symptoms. Poor correlation between culture results and symptoms.

Are Antibiotics Useful? Reduce symptoms to half at day 3 Reduce symptoms to half at day 3 90% better at one week whether treated or not 90% better at one week whether treated or not Rare complications are reduced Rare complications are reduced Rheumatic fever Rheumatic fever Acute glomerulonephritis Acute glomerulonephritis Acute otitis media Acute otitis media Acute sinusitis Acute sinusitis Quinsy Quinsy

Antibiotics? Centor criteria. Need 3 of the following: Centor criteria. Need 3 of the following: Tonsillar exudate Tonsillar exudate Tender anterior cervical lymph nodes Tender anterior cervical lymph nodes History of fever History of fever Absence of cough Absence of cough Three or more gives 40-60% chance of GABHS infection Three or more gives 40-60% chance of GABHS infection Absence of 3 or 4 signs gives 80% chance of not having the infection. Absence of 3 or 4 signs gives 80% chance of not having the infection.

NICE Indications for antibiotics include: Indications for antibiotics include: Features of marked systemic upset secondary to acute sore throat. Features of marked systemic upset secondary to acute sore throat. Unilateral peritonsilitis Unilateral peritonsilitis History of rheumatic fever History of rheumatic fever A child at increased risk from acute infection eg DM, immunodeficiency. A child at increased risk from acute infection eg DM, immunodeficiency.

Referral Same day: Same day: Sustpected quinsy – usually adults. Unilateral peritonsillar swelling, difficulty swallowing, trismus (difficulty swallowing) Sustpected quinsy – usually adults. Unilateral peritonsillar swelling, difficulty swallowing, trismus (difficulty swallowing) Swelling causing airway obstruction, swallowing difficulty with dehydration and/or systemic upset. Swelling causing airway obstruction, swallowing difficulty with dehydration and/or systemic upset.

Referral NICE < 15yrs Urgent – history of sleep apnoea (daytime sleepiness, FTT) Urgent – history of sleep apnoea (daytime sleepiness, FTT) Routine – five or more episodes of sore throat in the previous year, or guttate psoriasis exacerbated by acute tonsillitis. Routine – five or more episodes of sore throat in the previous year, or guttate psoriasis exacerbated by acute tonsillitis.

Glandular Fever Suspect in teenagers and young adults with sore throat lasting more than a week. Suspect in teenagers and young adults with sore throat lasting more than a week. Signs: sore throat, malaise, fatigue, lymph noes, enlarged spleen, palatal petechiae, rash Signs: sore throat, malaise, fatigue, lymph noes, enlarged spleen, palatal petechiae, rash Send blood for FBC, glandular fever antibodies Send blood for FBC, glandular fever antibodies Complications: hepatitis, jaundice, pneumonitis. Complications: hepatitis, jaundice, pneumonitis. Treatment: Simple analgesia, short course prednisolone if severe Treatment: Simple analgesia, short course prednisolone if severe Do not prescribe amoxicillin Do not prescribe amoxicillin

Glandular Fever Counsel re duration of fatigue – 20% will last up to 6 months Counsel re duration of fatigue – 20% will last up to 6 months Avoid contact sports for 1 month Avoid contact sports for 1 month Contagious for at least 2 months after initial infection. Contagious for at least 2 months after initial infection.

“Lump in the throat” What is the exact problem? What is the exact problem? Lump Lump Frog Frog Tightening Tightening Clearing Clearing Choking Choking Phlegm (respiratory tract) Phlegm (respiratory tract) Cattarh (head) Cattarh (head)

GORD? Symptoms inculde Symptoms inculde Aerophagia Aerophagia Buccal burning Buccal burning Cervical pain Cervical pain Choking sensation Choking sensation Chronic cough Chronic cough Constant throat clearing Constant throat clearing Dysphagia Dysphagia Food sticking in throat Food sticking in throat Globus sensation Halitosis Hoarseness Unilateral otalgia Pharyngeal tightness Sore throat Water brash

Red flags Dysphagia Dysphagia Weight loss Weight loss Hoarseness Hoarseness Haematemesis Haematemesis Haemoptysis Haemoptysis Unilateral earache with normal eardrum Unilateral earache with normal eardrum Pain Pain Neck swelling Neck swelling Neurology Neurology Others: Smokers Age Heartburn Reflux Regurgitation Gurgling

What next? Examine Examine Trial of PPI Trial of PPI Barium swallow Barium swallow ENT opinion ENT opinion Urgent referral? Urgent referral?

Two week wait 7 criteria in ENT/OMF 7 criteria in ENT/OMF How many can you think of? How many can you think of?

Two Week Wait An unexplained persistent sore or painful throat. An unexplained persistent sore or painful throat. Unilateral pain > 4 weeks assoc with otalgia but normal otoscopy. Unilateral pain > 4 weeks assoc with otalgia but normal otoscopy. Unexplained oral mucosa/mass > 3 weeks Unexplained oral mucosa/mass > 3 weeks All red or red & white patches of oral mucosa that are painful and swollen/bleeding All red or red & white patches of oral mucosa that are painful and swollen/bleeding Unexplained neck lump of recent onset, or previous lump changing over 3-6 weeks Unexplained neck lump of recent onset, or previous lump changing over 3-6 weeks Unexplained persistent swelling in parotid or submandibular gland. Unexplained persistent swelling in parotid or submandibular gland.

Two Week Wait II Thyroid swelling associated with: Thyroid swelling associated with: Solitary nodule increasing in size Solitary nodule increasing in size History of neck radiation History of neck radiation FH of endocrine tumour FH of endocrine tumour Unexplained hoarseness or voice changes Unexplained hoarseness or voice changes Cervical lymphadenopathy Cervical lymphadenopathy Pre-pubertal patient Pre-pubertal patient Age>=65 years Age>=65 years

Hoarseness Unresolved for more than 3 weeks Unresolved for more than 3 weeks Pain not from cold or flu Pain not from cold or flu Associated with: Associated with: Stridor Stridor Heavy smoking Heavy smoking Age > 45 Age > 45 Haemoptysis Haemoptysis Neck lump Neck lump Pain on swallowing Pain on swallowing Earache Earache Weight loss Weight loss CXR and urgent referral to ENT CXR and urgent referral to ENT

Lumps in Neck Superficial lumps Superficial lumps Sebaceous cyst Sebaceous cyst Lipoma Lipoma Abscess Abscess Anterior triangle Anterior triangle How many can you remember? How many can you remember?

Lumps in Neck Anterior triangle Anterior triangle Lymph nodes Lymph nodes Thyroglossal cyst (midline) Thyroglossal cyst (midline) Thyroid swelling Thyroid swelling Dermoid cyst Dermoid cyst Submandibular (Salivary calculus, TB, Firm implies ca) Submandibular (Salivary calculus, TB, Firm implies ca) Branchial cyst Branchial cyst Cystic hygroma Cystic hygroma Carotid aneurysm Carotid aneurysm Sternomastoid tumour Sternomastoid tumour Posterior triangle? Posterior triangle?

Lumps in Neck Posterior lumps Posterior lumps Cervical rib Cervical rib Subclavian artery aneurysm Subclavian artery aneurysm Pharyngeal pouch Pharyngeal pouch Cystic hygroma Cystic hygroma Brachial cysts Brachial cysts Systemic lymphadenopathy – glandular fever, HIV, lymphoma. Systemic lymphadenopathy – glandular fever, HIV, lymphoma.

Summary Management of sore throat Management of sore throat Glandular fever Glandular fever Lumps in throat Lumps in throat Two week waits in ENT/OMF Two week waits in ENT/OMF Hoarseness Hoarseness Lumps in neck Lumps in neck