gemc- oral and dental emergencies: the patient with a sore throat- resident training
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Project: Ghana Emergency Medicine Collaborative
Document Title: Oral and Dental Emergencies: The Patient With A Sore
Throat
Author(s): Joe Lex, MD, FAAEM, FACEP (Temple University) 2013
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Oral and Dental Emergencies
The Patient with a Sore Throat
Joe Lex, MD, FACEP, FAAEM
Associate Professor, Department of
Emergency Medicine
Temple University School of Medicine
Philadelphia, PA
Objectives
1. Understand that teething does
not cause fever
2. Define, recognize, and treat
pericoronitis, periapical abscess,
and alveolar osteitis
3. Describe treatment for ANUG
4. State three ways to treat bleeding
gums
Objectives
5. Identify and differentiate among
these mouth lesions: aphthous,
HSV, herpangina, perlèche
6. Describe the demographics of
GABHS
7. Memorize the Centor criteria
8. Know the rationale behind using
antibiotics to treat a sore throat
Teeth
David Shankbone, Wikimedia Commons
How Many Teeth?
32 permanent
• 8 incisors
• 4 canines
(cuspids)
• 8 premolars
(bicuspids)
• 12 molars
(tricuspids)
20 primary or
deciduous
• 8 incisors
• 4 canines
• 8 molars
How to Name the Teeth
Gray’s Anatomy, Wikimedia Commons
Source Undetermined
Source Undetermined
Definitions
• Interproximal: the surfaces
between two adjacent teeth
• Mesial: interproximal surface
facing toward midline
• Distal: interproximal surface facing
away from midline
• Occlusal: chewing surface
Definitions
• Labial: toward the lips, specific to
anterior teeth
• Buccal: toward the cheek, specific
to posterior teeth
• Palatal: toward the palate, specific
to maxillary teeth
• Lingual: toward the tongue,
specific to mandibular teeth
Definitions
• Apical: toward the tip of the root of
the tooth
• Radicular: associated with the
root, especially the apical region
• Coronal: toward the crown of the
tooth
• Incisal: toward the biting edge of
incisors
Basic Anatomy
• Dentin surrounds pulp, which is
neurovascular supply
• Crown: enamel on dentin, visible
portion of tooth
• Root: cementum on dentin,
extends into the alveolar bone
Sam Fentress, Wikimedia
Commons
Basic Anatomy
• Periodontium = attachment
apparatus
• Periodontal ligament = collagen
fibers that extend from alveolar
bone to root of tooth
• Gingivitis and periodontal disease
destroy peridontium tooth
mobility and loss
Basic Anatomy
• Gingiva = keratinized stratified squamous epithelium
– Free gingiva: 2- to 3- mm-deep gingival sulcus in disease-free state
– Attached gingiva: adheres to alveolar bone and extends to oral vestibule, floor of mouth
• Nonkeratinized alveolar mucosa covers cheeks, lips, floor of mouth
Teething
Daniel Schwen, Wikimedia Commons Vmg13, Wikimedia Commons
About ye seveth moneth, sometime more,
sometime lesse, after ye byrth, it is natural
for a child to breed teeth, in which time
many one is sore vexed with sondry
diseases and pains, as swelling of ye
gummes and jaws, unquiet crying fevers,
cramps, palsies, fluxes, reumes and other
infirmities, specially when it is long or ye
teeth come forth, for the sooner they appear
the better and the more ease it is to the childe.
Thomas Phayre – 1530
The Boke of Children, London
Death by Teething!!
• Common “Cause of Death” in
Middle Ages
• Usually weaned at same time
• Frequently lance erupting tooth
• Malnutrition from watered-down
milk
• Typhus from infected milk
Teething
• No data support association of
teething, fever, and diarrhea
• Possible mild dehydration from
excessive salivary production or
decreased intake
• Must seek other source
for fever, diarrhea
Pain from Wisdom Teeth
• Erupting third molars
• Pericoronitis: inflammation of
gingival tissue overlying occlusal
surface of erupting tooth
(operculum)
• Masseter irritation trismus
• Rx irrigate debris, antibiotic,
analgesia, dental referral
Pericoronitis
Coronation Dental Specialty Group, Wikimedia Commons
Dental Caries
• Loss of tooth enamel integrity due
to exposure to acidic metabolic
byproducts of plaque bacteria
• Early: sensitive to cold or sweet
• Later: direct communication with
dental pulp “pulpitis”
• Irreversible pulpitis: protracted
pain
Dental Caries
Dozenist, Wikimedia Commons
Antibiotics for Toothache??
• Undifferentiated dental pain
without overt infection
• Penicillin vs. placebo
• Evaluation at enrollment, again at
5- to 7-day follow-up
• Outcome measure: overt dental
infection at follow-up
Acad Emerg Med. 2004 Dec;11(12):1268-71.
Antibiotics for Toothache??
• 13 / 134 patients (9%) developed
infection
– 6/64 (9%) in penicillin group
– 7/70 (10%) in placebo group
• No significant difference in
baseline characteristics,
compliance, VAS pain scores
Acad Emerg Med. 2004 Dec;11(12):1268-71.
Antibiotics for Toothache??
• CONCLUSIONS: “These data
support the hypothesis that
penicillin is neither necessary nor
beneficial in the treatment of
undifferentiated dental pain in the
absence of overt infection.”
Acad Emerg Med. 2004 Dec;11(12):1268-71.
Periapical Abscess
• Most common source of severe
odontogenic pain: periapical
• Most common lesion: periapical
granuloma = periradicular
periodontitis, results from pulpitis
• X-ray widened periodontal
ligament space (radiolucent stripe)
Widened periodontal
ligament space
Source Undetermined
Periapical lucency Source Undetermined
Periapical abscess Source Undetermined
Periapical Abscess
• Exquisite pain with percussion
• Suppurative periodontitis = parulis
• X-rays rarely indicated
• Rx antibiotic (penicillin still best),
analgesia, referral
• Definitive treatment: extraction or
root canal
Parulis = Fistula = Gum Boil
Source Undetermined
Postextraction Pain
• Periosteitis: 24 to 48 hours,
common, easily treated
• Alveolar osteitis = dry socket:
second or third post-op day
exquisite oral pain due to bone
exposed to oral environment
Dry Socket
• Up to 35% after impacted 3rd molar removal
• X-ray for retained root tip
• Irrigate socket with sterile saline
• Pack socket with gauze soaked in oil of cloves or eugenol
• Relief is immediate
• Antibiotic if severe
Dry Socket
Source Undetermined
Infraorbital Nerve Block
Source Undetermined
Infraorbital Nerve Block
Source Undetermined
Infraorbital Nerve Block
Source Undeternined
Mental Nerve Block
Source Undetermined
Mental Nerve Block
Source Undetermined
Mental Nerve Block
Source Undetermined
Palatal Nerve Block
Source Undetermined
Palatal Nerve Block
Source Undetermined
Palatal Nerve Block
Adapted from: Alan, Flickr
Inferior Alveolar Nerve Block
Gray’s Anatomy, Wikimedia Commons
Inferior Alveolar Nerve Block
Source Undetermined
Inferior Alveolar Nerve Block
Adapted from: Lusb, Wikimedia Commons
Inferior Alveolar Nerve Block
Source Undetermined
Inferior Alveolar Nerve Block
Mikael Häggström, Wikipedia
Frenum Diastema
i.e., gap-toothed
Bryon Viechnicki, Wikimedia
Commons
Tetracycline Staining
Source Undetermined
Periodontal Disease
• Gingivitis: accumulation of plaque
along gum margins
• Causes: bad hygiene, hormonal
variations (puberty, pregnancy),
medications (phenytoin), etc.
• Sulcus deepens pockets
periodontitis mineralization
bone loss tooth loss
Periodontal Disease
Source Undetermined
Periodontal Disease
Source Undetermined
ANUG
• Acute Necrotizing Ulcerative
Gingivitis = Vincent ´s disease =
trench mouth
• Diagnostic triad: pain + ulcerated
or “punched out” interdental
papillae + gingival bleeding
• Etiology unclear, but opportunistic
• Anaerobes always present
ANUG
• Invades otherwise healthy tissue
• Treatment:
– Identify, treat predisposing factors
– Chlorhexidine oral rinses twice daily
– Debridement and scaling by dentist
– Metronidazole 250 mg tid
– Supportive therapy: soft diet rich in
protein and vitamins
ANUG
Source Undetermined
ANUG
Source Undetermined
Gingival Hyperplasia
• Associated with many commonly
used medications
• 50% of patients on chronic
phenytoin
• Also calcium channel blockers
(especially nifedipine) and
cyclosporine.
• Treatment: fastidious oral hygiene
Gingival Hyperplasia
Lesion, Wikimedia Commons
Bleeding Gums
• Hemorrhage after scaling easily
controlled with peroxide mouth
rinses or direct gingival pressure
• Clotting factor deficiencies,
leukemia, and end- stage liver
disease may first present as
spontaneous gingival hemorrhage
• Treatment: based on cause
Bleeding Gums
Source Undetermined
Bleeding Gums
Source Undetermined
Post-Extraction Bleeding
Usually a dislodged clot
1. Firm pressure usually adequate:
folded 2 × 2 gauze pad placed over
extraction site, then firm pressure by
clenching teeth for 20 minutes
2. Tea bag: tannic acid is hemostatic
3. Gel-Foam, Avitene, or Instat sutured
snugly into socket
4. Infiltrate lidocaine with epinephrine
Pyogenic Granuloma
• “Pregnancy tumor”
• Benign proliferation of connective
tissue, primarily on gingiva
• Not pyogenic, not a granuloma
• Usually recurs if removed during
pregnancy
• If not regressed 2 to 3 months
postpartum, definitive removal
Pyogenic Granuloma
Source Undetermined
Pyogenic Granuloma
Kuebi, Wikimedia Commons
Before We Leave the Gums…
Intentional pain
And the taste of gums bleeding
Prevent toothlessness
Morsels sit between my teeth
Minty, waxy nylon thread
Saves my smile
Two Flossing Haiku
Oral Candidiasis
• Present in 60% of healthy adults
• Opportunistic pathogen: many risk
factors
• Adherent white plaque
• Perioral = angular cheilitis
• Rx topical oral (nystatin) or
systemic (fluconazole) antifungal
agent
Oral Candidiasis
James Heilman, MD, Wikimedia Commons
Oral Candidiasis
Centers for Disease Control and Prevention, Wikimedia Commons
Angular Cheilitis = Perlèche
• Breakdown at labial commissures
• Candida albicans implicated
• Radiation therapy
• HIV
• Dietary deficiencies
• Antifungal with steroid may help
Angular Cheilitis = Perlèche
James Heilman, MD, Wikimedia Commons
Angular Cheilitis = Perlèche
Lesion, Wikimedia Commons
Angular Cheilitis = Perlèche
Source Undetermined
Aphthous Stomatitis
• Canker sores: common
• Probable cell-mediated response
• Nonkeratinized epithelium
• Superficial painful ulcers
• Resolve in 10 – 14 days
• Rx topical steroid: betamethasone syrup or 0.01% dexamethasone elixir mouth rinse
Aphthous Stomatitis
Noorus, Wikimedia Commons
HSV = Cold Sores
• Type 1 most common
• Gingivostomatitis: painful
ulcerations on mucosal surfaces
• Fever, lymphadenitis common
• Prodrome: tingling 1 – 2 days
before outbreak
• Rx palliative: antivirals started
during prodrome severity
HSV = Cold Sores
Centers for Disease Control and Prevention, Wikimedia
Commons
WarXboT, Wikimedia Commons
Herpangina
• Coxsackieviruses
• Summer and autumn
• Sudden high fever, sore throat,
headache, malaise then vesicles
• Soft palate, uvula, posterior
pharynx, tonsillar pillars
• Buccal mucosa, tongue, gums
spared
Herpangina
• Lasts 7 to 10 days
• Distinguished from herpetic
gingivostomatitis by lack of gingival
involvement
United Kingdom Royal Navy,
Wikimedia Commons
Herpangina
Shawn C, Wikimedia Commons
Aphilosophicalmind, Wikimedia Commons
Hand, Foot, and Mouth
• Coxsackievirus
• Vesicles on tongue, gums, soft palate, buccal mucosa
• Rupture painful, shallow ulcers with red halo
• Lateral & dorsal fingers & toes
• Fever day or two, rash 5 to 8 days
• Treatment: palliative
Hand, Foot, and Mouth
MidgleyDJ, Wikimedia Commons
James Heilman, MD, Wikimedia Commons
Ngufra, Wikimedia Commons
Lichen Planus
• Chronic cutaneous
vesiculoerosive disease
• T- lymphocytes on basal cell layer
• Scattered white papules
interconnected with white lines
(Wickham’s striae)
• Symptomatic: topical steroids
Lichen Planus
Source Undetermined
Cheek Chewing
Source Undetermined
Aspirin Burn (ASAcid!)
Source Undetermined
Aspirin Burn (ASAcid!)
Source Undetermined
Torus Palatinus
• Hard, firm isolated mass on hard
palate.
• May be several centimeters
• Appears in adulthood
• Don’t confuse with neoplasm
• May interfere with dentures
Torus Palatinus
Dozenist, Wikimedia Commons
Torus Mandibularis
Source Undetermined
Denture Stomatitis
Source Undetermined Source Undetermined
Nicotine Stomatitis
Source Undetermined
Uvulitis
• Quincke’s disease
• Patient complains “something
hanging down my throat”
• Bacteria, virus, angioedema
• Treatment symptomatic: antibiotic,
antihistamine, nebulized steroid or
epinephrine
Uvular Angioedema
Source Undetermined
Ludwig’s Angina
• Cellulitis of submandibular and
lingual spaces
• Potentially life threatening.
• Rapidly spreading cellulitis
• Brawny induration of suprahyoid
region and elevation of tongue
Ludwig’s Angina
• Epiglottis can be involved
• Airway compromise is immediate
concern
• Treatment: high- dose penicillin
and metronidazole or cefoxitin,
immediate oral and maxillofacial
consultation
Ludwig’s Angina
Stevenfruitsmaak, Wikimedia Commons
Ludwig’s Angina
Source Undetermined
Geographic Tongue
• Erythema migrans = geographic
tongue = benign migratory
glossitis
• Multiple, well-demarcated zones
of erythema due to atrophy of
filiform papillae
• Usually asymptomatic
• Reassurance sufficient
Geographic Tongue
Bin im Garten, Wikimedia Commons
Geographic Tongue
Martanopue, Wikimedia Commons
Fissured Tongue
Kozlovsk, Wikimedia Commons
Scrotal Tongue
Source Undetermined
Median Rhomboid Glossitis
• Believed to be developmental
defect of the dorsal surface of the
tongue
• 1 x 2 cm ovoid erythematous area
just anterior to circumvallate
papillae
• Devoid of papillae, asymptomatic
• No treatment necessary
Median Rhomboid Glossitis
Klaus D. Peter, Wikimedia Commons
Black Hairy Tongue
• Discoloration of elongated filiform
papillae
• Can grow up to 18 mm
• Usually asymptomatic
• Treatment: frequent tongue
brushing, avoid tobacco, strong
mouthwashes, antibiotics
• Resolution usually spontaneous
White Hairy Tongue
Source Undetermined Source Undetermined
Black Hairy Tongue
Source Undetermined
Source Undetermined
Pepto-Bismol® Tongue
• Bismuth + sulfur (in saliva) =
bismuth sulfide = black tongue
(and sometimes black stool)
• Harmless, self limited
Source Undetermined
Strawberry Tongue
• Associated with erythrogenic
toxin-producing Streptococcus
pyogenes or Kawasaki disease
• Prominent red spots on white-
coated background.
• Treatment: antibiotics directed at
group A streptococci
Strawberry Tongue
Source Undetermined
Strawberry Tongue
Source Undetermined
Leukoplakia (Precancerous)
Source Undetermined
Leukoplakia (Precancerous)
Source Undetermined
Frenulum
Jean-Rene Vauzelle, Wikimedia Commons Zabbed, Wikimedia Commons
Salivary Glands
BruceBlaus, Wikimedia Commons
Salivary Glands
• Parotid and submandibular
• Parotid (Stenson) duct opens
opposite upper second molar
• Submandibular ducts open into
mouth at either side of frenulum
• Multiple sublingual ducts open into
sublingual fold or submandibular
duct
Viral Parotiditis
• Mumps: paramyxovirus
• Incubation period: 12 to 21 days.
• Infective from 3 days prior to 7
days after salivary gland swelling
• Repeat episodes possible
• Others: influenza, enteroviruses,
cytomegalovirus, human
immunodeficiency virus (HIV).
Viral Parotiditis
• Swelling bilateral ~70%
• May be surrounding edema
• No discharge from Stenson duct
• Benign in kids
• 25% of men suffer orchitis
• Diagnosis: clinical
• Treatment: supportive
Viral Parotiditis
Source Undetermined
Viral Parotiditis
Source Undetermined
Suppurative Parotiditis
• Debilitated, dehydrated patients
• Tender, red, swollen parotid
• Bilateral in ~25%
• Fever and trismus common
• Pus from Stenson duct
• Staphylococcus aureus mixed with anaerobes.
• Diagnosis is clinical
Suppurative Parotiditis
Source Undetermined
Sialolithiasis
• Any age, peak from 30 to 60
• >80% are submandibular
• Mostly calcium phosphate
• Pain, swelling, tenderness
• Similar to parotitis, ductal
obstructive symptoms (pain and
swelling) exacerbated by meals
Sialolithiasis
• Diagnosis clinical; extraoral x-rays
~50% sensitive
• Therapy initiated on clinical
findings: analgesics, massage,
and sialogogues, like lemon drops
Sialolithiasis
Source Undetermined Source Undetermined
Ranula – “little frog”
• Sublingual mucocele
• Benign, usually asymptomatic
• No special treatment
Ranula
Ph0t0happy, Wikimedia Commons Klaus D. Peter, Wikimedia Commons
Piercings
Tommy T, Wikimedia Commons Sara Marx, Wikimedia Commons
Doct Blake, Wikimedia Commons
The Patient with a Sore Throat
U.S. Navy, Wikimedia Commons
ParentingPatch, Wikimedia Commons
Sore Throat
• Dysphagia = difficulty
swallowing
• Odynophagia = painful
swallowing
• Pharyngitis = infection or
irritation of pharynx
Pharyngitis
• Rare under 1 year
• Uncommon under 2 years
• Peak incidence: 4 to 7 years
• Higher incidence in winter
• Viruses, bacteria, fungi, parasites
• Most common causes: rhinovirus
and adenovirus
Principles of appropriate antibiotic
use for acute pharyngitis in adults
•Large majority of adults with acute
pharyngitis have self-limited illness
•Antibiotic treatment benefits only
patients with GABHS infection
•Adults with sore throat: “Strep
throat” prevalence 5 –15%
Cooper et al. Ann Emerg Med. June 2001;37:711-719
• Offer all appropriate analgesics,
antipyretics, other supportive care
• Clinically screen adults with
pharyngitis for Centor criteria
• Do not test or treat patients with
zero or one; they are unlikely to
have GABHS
Cooper et al. Ann Emerg Med. June 2001;37:711-719
Principles of appropriate antibiotic
use for acute pharyngitis in adults
Centor Score
1. history of fever
2. tonsillar exudates
3. no cough
4. anterior cervical lymphadenitis
Score 0-1 = <5% GABHS
Score 2-3 = 5 – 30% GABHS
Score 4 = 30 – 60% GABHS
Cooper et al. Ann Emerg Med. June 2001;37:711-719
Centor
Points
Pretest probability of GABHS (%)
5 10 15 20 25 40 50
0 1 2 2 3 5 10 14
1 2 3 5 7 9 17 23
2 4 8 12 16 20 33 43
3 10 19 27 34 41 58 68
4 25 41 53 61 68 81 86
Post-test probability of GABHS
Principles of appropriate antibiotic
use for acute pharyngitis in adults
1. Rapid antigen if 2, 3, or 4
criteria; antibiotic only if test + 2. Rapid antigen if 2 or 3 criteria;
antibiotic if test + or 4 criteria
3. Antibiotic if 3 or 4 criteria; no
rapid antigen testing
Cooper et al. Ann Emerg Med. June 2001;37:711-719
• Throat culture not recommended
for routine primary evaluation of
adult with sore throat or to confirm
negative rapid antigen
• Preferred antibiotic for GABHS
pharyngitis: penicillin or
erythromycin if penicillin-allergic
Cooper et al. Ann Emerg Med. June 2001;37:711-719
Principles of appropriate antibiotic
use for acute pharyngitis in adults
“We Prevent Rheumatic Disease”
• 1/3000 untreated GABHS leads to
acute rheumatic fever
• 1000 kids / 20% prevalence = 200
• Strep screen 80% sensitive, 95%
specific
• Treat 160, send cultures on other
840 TP = 160 FP = 40
TN = 760 FN = 40
“We Prevent Rheumatic Disease”
• Prevalence now 40/840 ~5%
• Culture 95% sensitive, 95%
specific
• NNT = 798/38 = 21 cultures to find
one positive
• 3000 x 21 = 63,000 prevent one
case ARF
• NNH = 15
TP = 38 FP = 2
TN = 798 FN = 2
Pharyngitis – GABHS
James Heilman, MD, Wikimedia Commons
Pharyngitis – GABHS
Source Undetermined
Pharyngitis – GABHS
Real exudates Source Undetermined
Epiglottitis
• Potentially life-threatening - rapid,
unpredictable airway obstruction
• Epiglottis plus aryepiglottic folds
and pre-epiglottic and paraglottic
loose connective tissue
• Traditional: children 2 – 8 years
• Contemporary: adults increasing
Epiglottitis
• Most common: Haemophilus
influenzae type b (Hib)
• 1- to 2-day prodrome resembles
benign URI
• Exam: apprehensive, drooling,
difficulty lying flat, stridor, tongue
protruding
• Fever initially absent in 30 – 50%
Epiglottitis
• Movement of upper trachea or
thyroid cartilage painful
• Diagnosis by history, examination,
radiographs, and laryngoscopy
• Use extreme care – unpredictable
sudden airway obstruction
Epiglottitis
• Lateral soft tissue neck x-ray:
vallecula obliterated, aryepiglottic,
prevertebral and retropharyngeal
soft tissues swollen, hypopharynx
ballooned
• Find hyoid bone to find epiglottis
• Epiglottis: large, thumb-shaped
Epiglottitis
• >1/3 moderate cases initially
misdiagnosed
• Immediate otolaryngologic consult
• Never leave patient unattended
• Initial treatment: IV hydration,
oxygen, monitor, IV antibiotics.
• Be prepared for difficult intubation
Epiglottitis
藤澤孝志, Wikimedia Commons
Epiglottitis
Insert tube here
Source Undetermined
Epiglottitis
Epiglottitis
Normal epiglottis
Source Undetermined
Epiglottitis
Source Undetermined
Epiglottitis
Source Undetermined
Mononucleosis
• Classic: fever, lymphadenopathy,
exudative pharyngitis, atypical
lymphocytosis, splenomegaly
• Severe sore throat is common
complaint
• Physical: severe bilateral
exudative tonsillitis / pharyngitis –
“wet white leather”
Mononucleosis
• Treatment: supportive
• Ampicillin rash (transient EBV-
induced antibodies against drug)
• Acyclovir has in vitro effects on
EBV replication, but in vivo clinical
studies have failed to show any
clinically significant effect
Mononucleosis
Source Undetermined
Mononucleosis
Note petechiae!
Wet white leather
Source Undetermined
Mononucleosis
Cervical adenopathy
James Heilman, MD, Wikimedia Commons
Mononucleosis
Atypical lymphocytes
Ed Uthman, MD, Wikimedia Commons
PTA
• Peritonsillar abscess = quinsy:
most common deep-space
infection of head and neck
• Young adults
• Predominant bugs: Streptococcus
pyogenes, peptostreptococcus,
bacteroides, Staphylococcus
aureus
PTA
• Symptoms: fever, malaise, “hot-
potato voice,” odynophagia,
dysphagia, otalgia
• Signs: tonsil hypertrophy, swollen
deviated uvula, inferior and medial
displacement of infected tonsil,
tender cervical nodes, drooling,
bad breath, trismus
PTA
• Diagnostic gold standard:
aspiration of pus through needle
• Majority treated with outpatient
needle aspiration, antibiotics, pain
medication
• High-dose penicillin is drug of
choice
PTA
• Anesthetize mucosa using
lidocaine with epinephrine
• Insert 18-gauge needle medially
and superiorly within abscess
cavity no more than 1 cm (use
needle guard)
• Carotid artery lies laterally and
inferiorly
PTA
Large but
normal tonsils
Scurik 19, Wikimedia Commons
PTA
“Kissing” tonsils
Source Undetermined
PTA
Deviated uvula
Source Undetermined
PTA
Source Undetermined
Post-Tonsillectomy Bleed
• Classically 5 – 10 days postop
• Management: ensure airway,
control bleeding, consult ENT
• Direct pressure to tonsillar bed
• Silver nitrate, electric cautery,
oxidized cellulose, thrombin
packs, gauze moistened with
lidocaine / epinephrine
Tonsillitis – GABHS
Pbeck, Wikimedia Commons
Tonsillectomy
~3 Days
Post-op
James Heilman, MD, Wikimedia Commons
Diphtheria
Adherent exudate
Frederick Magee Rossiter,
Wikimedia Commons
Source Undetermined
Steroids for Sore Throat?
Pain improve in 24 hours (VAS)
• 1.8 ± 0.8 w/ dexamethasone
• 1.2 ± 0.9 w/ placebo (P<.05)
Time to onset of pain relief
• 6.3 ± 5.3 hrs w/ dexamethasone
• 12.4 ± 8 .5 hrs w/ placebo
(P<.01)
O'Brien et al. Ann Emerg Med 1993;22(2):212-5
Steroids for Sore Throat?
CONCLUSION: In patients with
severe, acute exudative pharyngitis,
single-injection dexamethasone
compared with placebo resulted in
statistically and clinically significant
more rapid onset and greater
degree of pain relief
O'Brien et al. Ann Emerg Med 1993;22(2):212-5
Steroids for Sore Throat?
12 and 24 hour pain relief (VAS)
• IM dexamethasone 4.2 ± 2.3
• Oral dexamethasone 3.8 ± 2.3
• Placebo 2.1 ± 2.0
Onset of pain relief average 4 hours
earlier in IM dexamethasone
group
Wei JL, et al. Laryngoscope 2002;112(1):87-93
Steroids for Sore Throat?
CONCLUSIONS: Patients treated
with IM or oral dexamethasone had
significant relief of pain (relative to
baseline) compared with patients
given placebo.
Wei JL, et al. Laryngoscope 2002;112(1):87-93
Steroids for Sore Throat?
35 IM steroid plus oral placebo
35 IM placebo plus oral steroid
No difference in pain scores at 24
(p=0.13) or 48 hours (p=0.82)
No difference in hours to relief of
pain (p=0.06)
Marvez-Valls EG, et al. Acad Emerg Med 2002;9:9-14
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