Section 10.3: Nose, Sinus, and Throat Complaints (Sinusitis, Pharyngitis, Epiglottitis)

Section 10.3: Nose, Sinus, and Throat Complaints (Sinusitis, Pharyngitis, Epiglottitis)

Why This Topic Matters for PANCE

Upper respiratory tract and throat complaints are common on the PANCE. Focus on differentiating self-limiting viral infections from bacterial processes requiring antibiotics or emergent airway interventions. High-yield topics include clinical criteria separating viral from bacterial sinusitis, the Modified Centor criteria for managing streptococcal pharyngitis to prevent rheumatic fever, and the urgent recognition and management of epiglottitis.

Acute Rhinosinusitis

Pathophysiology & Pathogens

Acute rhinosinusitis involves inflammation of the mucosal lining of the nasal cavity and paranasal sinuses (most commonly the maxillary sinuses). Mucosal edema (from viral infections or allergens) obstructs sinus ostia, trapping secretions that undergo bacterial colonization. Pathogens:

1. Streptococcus pneumoniae
2. Haemophilus influenzae
3. Moraxella catarrhalis

Diagnostic Criteria (Bacterial vs. Viral)

Most cases are viral. Clinicians must apply strict criteria to identify Acute Bacterial Rhinosinusitis (ABRS) for antibiotic therapy. ABRS is diagnosed when a patient meets at least one of the following:

1. Persistent Symptoms: Nasal discharge or facial pain lasting 10 days or longer without clinical improvement.
2. "Double Sickening" (Worsening Symptoms): Initial improvement from a viral upper respiratory infection followed by sudden worsening (new fever, increased discharge, or facial pain).
3. Severe Symptoms at Onset: High fever (temp >=39°C or 102.2°F) and purulent nasal discharge/facial pain lasting at least 3 to 4 consecutive days at onset.

Clinical Management

• Viral: Supportive care (nasal saline, oral decongestants, intranasal corticosteroids).
• Bacterial: First-line is Amoxicillin-Clavulanate (Augmentin). Amoxicillin monotherapy is no longer preferred due to beta-lactamase resistance in H. influenzae. Use Doxycycline or Levofloxacin for penicillin-allergic patients.

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Pharyngitis and Tonsillitis

Pharyngitis is pharyngeal tissue inflammation. Identifying Group A beta-hemolytic Streptococcus (GAS) is essential to prevent systemic sequelae.

Modified Centor Criteria

Use the Modified Centor Criteria to guide diagnostic testing and antibiotic use:

• Tonsillar exudates or swelling (+1 point)
• Tender anterior cervical lymphadenopathy (+1 point)
• Fever >38°C (100.4°F) (+1 point)
• Absence of cough (+1 point)
• Age modifier: 3–14 years (+1 point), 15–44 years (0 points), >=45 years (-1 point)

Testing and Treatment Protocol

• Score 0–1: Low risk; no testing or antibiotics.
• Score 2–3: Perform a Rapid Antigen Detection Test (RADT). If positive, treat.
• Score 4+: High risk; perform RADT and treat if positive. Confirm negative RADT in children with a throat culture; not required in adults.
• First-line Treatment: Penicillin V oral (10 days) or Amoxicillin. Prevents acute rheumatic fever (must initiate within 9 days of symptom onset). Note that antibiotics do not prevent post-streptococcal glomerulonephritis (PSGN).
• Penicillin Allergy: Cephalexin (mild allergy) or Clindamycin/Azithromycin (severe allergy).

Practical EBV Distinction

Consider Epstein-Barr Virus (EBV) in patients with exudative pharyngitis.

• Presentation: Severe sore throat, shaggy exudates, posterior cervical lymphadenopathy, and splenomegaly.
• Amoxicillin Rash: Prescribing amoxicillin in EBV causes a classic, non-allergic diffuse maculopapular rash.
• Management: Supportive. Avoid contact sports for 3–4 weeks to prevent splenic rupture.

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Epiglottitis

Pathophysiology & Etiology

Epiglottitis is a rapidly progressive, life-threatening bacterial cellulitis of the epiglottis and supraglottic structures that can cause sudden airway obstruction. Historically caused by Haemophilus influenzae type b (Hib), it has decreased dramatically in children due to vaccination. Pathogens in adults and vaccinated children include S. pneumoniae, S. pyogenes, and S. aureus (including MRSA).

Clinical Presentation

Patients present with high fever, severe sore throat, and the "3 Ds":

1. Dysphagia (difficulty swallowing)
2. Drooling (due to inability to swallow secretions)
3. Distress (respiratory distress, stridor, tachypnea) Patients sit in the "tripod" or "sniffing" position (leaning forward, neck hyperextended, chin jutting forward).

Diagnostic Workup

• Contraindication: Do NOT examine the throat with a tongue depressor or perform direct oral examination in a child outside a controlled environment, as this can trigger fatal laryngospasm.
• Lateral Neck X-ray: Shows the classic "thumbprint sign".
• Gold Standard: Laryngoscopy showing a cherry-red, swollen epiglottis in the operating room.

Clinical Management

1. Airway Protection: Immediate endotracheal intubation in the operating room with anesthesia and ENT teams present.
2. Antibiotics: After the airway is secured, administer IV Ceftriaxone plus Vancomycin.

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Classic PANCE Traps & Clinical Pearls

• Tongue Depressor Trap: In a child with drooling, stridor, and tripod posture, never use a tongue depressor; perform a lateral neck X-ray or prepare for immediate controlled intubation.
• Strep Prevention Target: Antibiotics for GAS pharyngitis prevent acute rheumatic fever, not post-streptococcal glomerulonephritis.
• Mono Contact Sports: Patients with EBV mononucleosis must avoid contact sports for 3–4 weeks to prevent splenic rupture, even if splenomegaly is not palpable.
• Double Sickening: Suspect bacterial sinusitis when a patient's viral cold symptoms initially improve but then suddenly worsen with a new fever.

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Sinus, Pharyngeal, and Airway Disease Comparison

Peritonsillar Abscess

A peritonsillar abscess (quinsy) is a collection of pus between the tonsillar capsule and the pharyngeal constrictor muscle, typically a complication of untreated tonsillitis.

• Causative Organisms: Group A Streptococcus (most common), anaerobes, and oral flora.
• Clinical Presentation: Severe unilateral sore throat, trismus (inability to open the mouth due to pterygoid muscle irritation), muffled "hot potato" voice, drooling, and uvular deviation away from the abscess. The tonsil is displaced medially and anteriorly.
• Diagnosis: Clinical. Needle aspiration with pus confirms. CT with contrast if extension to the retropharyngeal or parapharyngeal space is suspected.
• Management: Needle aspiration or incision and drainage of the abscess, plus antibiotics (penicillin + metronidazole, or clindamycin). Tonsillectomy may be required for recurrent abscesses ("Quinsy tonsillectomy").