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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2

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

Jonathon Colman, Flickr

Healthy teeth Dozenist, Wikimedia Commons

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

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

Parulis = Fistula

Damdent, Wikimedia Commons

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

Gray’s Anatomy, Wikimedia Commons

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

Gums

Mohamed Hamze, Wikimedia Commons

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

Cheeks & Lips & Palate

2T, Wikimedia Commons

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

TheBlunderbuss, Wikimedia Commons

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

Kozlovsk, Wikimedia Commons

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

Uvulitis

1luckygamble, Wikimedia Commons

Uvular Angioedema

Source Undetermined

Uvulitis

Alexnevzorov, Wikimedia Commons

Bifid Uvula

Adam6611, Wikimedia Commons

Tongue & Mouth Floor

Jim Flanagan, Flickr

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

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