This chapter reviews conditions that can obstruct the upper airway.
These disorders must be recognized quickly because early airway
management may be lifesaving. Infections of the neck and upper airway
include pharyngitis/tonsillitis, peritonsillar abscess,
epiglottitis, retropharyngeal abscess, and odontogenic abscess.
Cancers, congenital neck masses, ranulas, and mucoceles present
as masses in the neck and upper airway and may become infected.
Noninfectious causes of airway obstruction include posttonsillectomy
hemorrhage, airway and esophageal foreign bodies, laryngeal papillomatosis,
neck and facial trauma, and angioedema. If there is a possibility
of surgical intervention in the neck, the patient should remain
NPO after arrival at the ED.
Group A β-hemolytic Streptococcus (GABHS)
is the most common bacterial organism causing pharyngitis (Table 241-1). Acute viral pharyngitis is
most commonly caused by rhinovirus but can be caused by infectious
mononucleosis [Epstein-Barr virus, (EBV)], acute
retroviral syndrome [human immunodeficiency virus (HIV)],
and cytomegalovirus infection. Less commonly, Mycoplasma
pneumoniae and Chlamydia pneumonia have
been isolated from patients with symptomatic pharyngitis.
Table 241-1 Microbial Causes
of Acute Pharyngitis
| Save Table
Table 241-1 Microbial Causes
of Acute Pharyngitis
|Pathogen||Syndrome/Disease||Estimated Percentage of Cases*|
|Rhinovirus (100 types, 1 subtype)||Common cold||20|
|Coronavirus (3+ types)||Common cold||>5|
|Adenovirus (types 3, 4, 7, 14, 21)||Pharyngoconjunctival fever, acute respiratory disease||5|
|Herpes simplex virus (type 1, 2)||Gingivitis, stomatitis, pharyngitis||4|
|Parainfluenza virus (types 1–4)||Common cold, croup||2|
|Influenzavirus (types A, B)||Influenza||2|
|Coxsackievirus A (types 2, 4, 5, 6, 8, 10)||Herpangina||<1|
|Epstein-Barr virus||Infectious mononucleosis||<1|
|Human immunodeficiency virus type 1||Acute retroviral syndrome||<1|
|Streptococcus pyogenes (GABHS)||Pharyngitis, tonsillitis, scarlet fever||15–30|
|Group C β-hemolytic streptococci||Pharyngitis, tonsillitis||5|
|Chlamydia pneumonia||Pneumonia, bronchitis, pharyngitis||<1|
|Mycoplasma pneumonia||Pneumonia, bronchitis, pharyngitis||<1|
An important goal of treatment is to identify patients who require
specific antimicrobial agents and minimize the indiscriminate use
of these agents. Patients with nonbacterial causes of pharyngitis
only require symptomatic treatment, including gargling with warm
saltwater, maintenance of adequate oral intake, antipyretics, analgesics,
and rest. Patients unable to tolerate oral fluids or who become
dehydrated should be given IV fluids. Severe throat pain may be
temporarily relieved by over-the-counter lozenges with mild local
anesthetics. A single dose of 10 milligrams PO dexamethasone
reduces severe pharyngeal inflammatory pain, especially in patients
with an identified bacterial pathogen, but should not be
considered a routine treatment for pharyngitis.
Viral pharyngitis generally displays a vesicular and petechial
pattern on the soft palate and tonsils, is associated with rhinorrhea,
but is without tonsillar exudate or cervical adenopathy. Most cases of
viral pharyngitis require no specific diagnostic testing. There
are three notable exceptions: influenza, infectious mononucleosis,
and acute retroviral syndrome. Infectious mononucleosis refers
to the clinical triad of fever, pharyngitis, and lymphadenopathy
specifically caused by EBV. Up to 25% of patients in the
first week of symptoms may have a false negative heterophile antibody
(monospot) test; 10% of patients with EBV infection will
be persistently heterophile negative.2 Treatment
with amoxicillin or ampicillin causes a maculopapular rash in most.3 Cytomegalovirus
and human herpesvirus 6 are the most common causes of mononucleosis-like
illnesses. The acute retroviral syndrome of early HIV-1 can also
mimic mononucleosis. Up to 90% of primary infections with
HIV-1 are associated with acute retroviral syndrome.3 Symptoms of
pharyngitis develop 2 to 4 weeks after exposure and resolve within
2 weeks. Early treatment may decrease the viral load and lead to
enhanced immune response, making recognition of the syndrome important.3 Diagnosis
requires an HIV RNA viral load test, as an antibody titer will not be
positive until 4 to 6 months after exposure. A good history may
Group A β-Hemolytic Streptococcus Pharyngitis
S. pyogenes (GABHS) is responsible for 5% to
15% of pharyngitis in adults4 and 15% to
30% in children.5 Virulent strains of
GABHS are associated with acute rheumatic fever or acute glomerulonephritis.6 After
an incubation period of 2 to 5 days, patients develop the sudden
onset of sore throat, painful swallowing, chills, and fever. Headache,
nausea, and vomiting are common. Signs and symptoms of GABHS pharyngitis
include marked erythema of the tonsils and tonsillar pillars; tonsillar
exudate; enlarged, tender anterior cervical lymph nodes; and uvular
edema. Patients tend to have fever, myalgias, and malaise but not
rhinorrhea, cough, or conjunctivitis.
The original Centor criteria listed four indicators for
GABHS pharyngitis: (1) tonsillar exudates, (2) tender anterior cervical
adenopathy, (3) absence of cough, and (4) history of fever.7
The Centers for Disease Control and Prevention, the American
Academy of Family Physicians, and the American College of Physicans
recommend no antibiotic treatment for patients with none
or only one of these criteria (Figure 241-1).
For patients with two or more criteria, three strategies can be
1. Test patients with two, three, or four criteria using
a rapid antigen test, and limit antibiotic therapy to patients with
positive test results (this approach is recommended by the Infectious
Diseases Society of America)8;
2. Test patients with two or three criteria using a rapid antigen
test, and limit antibiotic therapy to patients with a positive test
result or with all four criteria; or
3. Do not use any diagnostic tests, and limit antibiotic therapy
to patients with three or four criteria (Figure 241-1). This approach is the least cost effective9 and
results in unnecessary antibiotics in 43.8% of patients [95% CI
(38.4% to 49.4%)].10
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