Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2866_Библиотеки_им_академика_М_И_Перельмана.pdf
272
S. Khasnavis
Diagnostic Tests
Since the diagnosis can often be made based on history and
physical examination, testing is done when the clinical diagnosis is uncertain.
• Nasal endoscopy or rhinoscopy allows detection of abnor-
malities of the nasal passage, polyps, and pus. Bacterial
culture can be taken from samples.
• Imaging techniques
– CT scan is the best method for viewing paranasal sinuses
and reveals the extent of inflammation and disease.
– X-ray is not as accurate as CT and is used when CT scan
and endoscopy are unavailable.
– MRI is not as effective as CT and is more expensive. It
may be used to differentiate between inflammatory
disease, malignant tumors, and complications within the
skull.
• Sinus puncture and bacterial culture is a standard reliable
method for making the diagnosis. Due to the invasive nature
of this process, it should be reserved for those patients that
have not responded to antibiotics or those at risk of having
an unusual infection or serious complications.
Treatment ofAcute Sinusitis
The primary objective for treatment of sinusitis is reduction
of swelling, eradication of infection, and drainage of sinuses.
The majority of cases will resolve with supportive care, and
few, 2–10%, of acute rhinosinusitis will require antimicrobials
[11, 12].
Treatment can be divided into the following categories:
• Immunocompetent patients with good follow-up:
Supportive treatment with saline irrigation, steam inhala-
tion, and hydration along with medications such as nasal or
oral decongestants, antihistamines, and mucolytics are
effective. Symptoms usually resolve in 7–10days.
Chapter 13. Sinusitis or Rhinosinusitis
273
The decision to use antibiotic therapy for acute bacterial
sinusitis is based on how symptoms present or progress.
Symptoms favoring treatment include the following:
• Duration of 7–10days
• High fever (>102)
• Purulent nasal discharge
• Worsening of symptoms after conservative management
– The choice of antibiotics should cover the following: S.
pneumonia, H. influenzae, M. catarrhalis [12, 13].
Antibiotic treatment of choice is amoxicillin 875mg/clavulanic acid 125mg BID or 500mg/125mg TID.If resistance is
suspected, then use a higher dosage of amoxicillin/clavulanic
acid 2000mg/125mg BID.
For patients with penicillin allergy, any of these medications can be used. Doxycycline, levofloxacin, moxifloxacin, or
clindamycin plus a third-generation oral cephalosporin. See
treatment algorithm.
• Antibiotics should be continued for at least 5–7days.
If there is no improvement in 72h with initial therapy or
there is worsening of symptoms, then the antibiotic should be
changed. Switch to a second line therapy (second-line agent will
depend on initial therapy), refer patients for imaging studies
and send cultures, and consider alternative diagnoses (Fig.13.3).
The risk factors for resistance to antibiotics are as follows:
• Age>65
• Hospitalization in the last 5days
• Antibiotic use in previous month
• Immunocompromised patients
• Comorbidities: diabetes, cardiac disease, renal failure,
hepatic disease.
– Severe infection, fever >102
– Threat of suppurative complications
Immunocompromised and severe symptoms may warrant
immediate antibiotics and specialist referral.
274
S. Khasnavis
Patients with uncomplicated
presentation
Treat with saline irrigation, nasal
decongestant, mucolytic and
antihistamine
Improved
No Penicillin allergy:
Treat with
amoxicillin-clavulanate (500
mg/125 mg tid) or (875 mg/125
mg bid)
Improved symptoms:
Treat for 5-7 days
Clindamycin 150 mg-300 mg every 6 hours plus third
No improvement or worsening symptoms
Treat with Doxycycline 100 mg twice, Levofloxacin
500 mg daily, Moxifloxacin 400 mg daily,
generation cephalosporin who can tolerate
No improvement or worsening symptoms:
Change antibiotic and treat for 7-10 days
Look for alternative diagnosis
Refer for imaging and culture
in 7 days:
Treat with antibiotic
Penicillin allergy:
cephalosporin
Refer to specialist
F . Treatment algorithm for acute sinusitis
Relapse Recurrence of symptoms after oral therapy within
2 weeks represents inadequate eradication of infection. If
symptoms are mild, treat with the same antibiotic for a longer
duration. If symptoms are severe, switch to an alternative
antibiotic.
Adjunct therapy Oxymetazoline and phenylephrine hydrochloride nasal spray may be used for 3–5days. Long-term use
may cause rhinitis medicamentosa, otherwise known as
rebound congestion. Intranasal corticosteroids may be beneficial.
Chapter 13. Sinusitis or Rhinosinusitis
275
Treatment ofChronic Sinusitis
Chronic sinusitis results from damage to the mucous membrane from past infection. The role of antibiotics is controversial unless there is a concomitant acute infection [8, 12].
• Antibiotics should be continued for 4–6weeks and should
cover organisms causing acute sinusitis and staphylococcus
species and anaerobes.
• These include amoxicillin-clavulanate, cefpodoxime prox-
etil, cefuroxime, gatifloxacin, moxifloxacin, and
levofloxacin.
• Nasal corticosteroid spray and saline irrigation may pro-
vide additional relief.
• A short course of oral steroids may be used for extensive
mucosal thickening and severe congestion. If no improve-
ment, surgery may be considered.
• Patients with allergies, sinusitis, and asthma should have
treatment targeting each condition. Treatment may include
nasal steroids, leukotriene antagonists, antihistamines, and
immunotherapy.
Additional Evaluation
Laboratory evaluation may be necessary to look for an
underlying disorder. Lab tests may include sweat chloride test
for cystic fibrosis, ciliary function test, HIV, and immunoglobulin testing. Any patient with recurrent sinusitis should
have an allergy consultation.
Emergency treatment Patients with fungal sinusitis or signs of
infection spreading beyond the paranasal sinuses (e.g., to the
brain or bone) need urgent treatment with parenteral
antibiotics and surgery.
276
S. Khasnavis
Prevention The best way to prevent sinusitis is to practice
good hand hygiene and obtain influenza and pneumococcal
vaccines as per recommendations.
Clinical Pearls [14]
Acute sinusitis is viral in nature in the vast majority of cases
and usually resolves in 7–10days without treatment.
• The presence of purulent secretions has the highest posi-
tive predictive value for clinically diagnosing sinusitis.
• The antibiotic of choice without penicillin allergy is amoxi-
cillin/clavulanate.
• CT of sinuses is the imaging procedure of choice.
Do Not Miss!
• Patients with immunocompromised conditions and severe
symptoms may need immediate attention, imaging studies,
and antibiotic treatment to prevent extension of
infection.
References
1. Meltzer EO, Hamilos DL, Hadley JA, etal. Rhinosinusitis: establishing definitions for clinical research and patient care. J Allergy
Clin Immunol. 2004;131:S1.
2. Tan T, Little P, Stokes T, Guideline Development Group.
Antibiotic prescribing for self limiting respiratory tract infection
in primary care: summary of NICE guidance. BMJ. 2008;337:a437.
3. Rosenfeld RM, Piccirillo JF, Chandrasekhar SS, et al. Clinical
practice guideline (update): adult sinusitis. Otolaryngol Head
Neck Surg. 2015;152:S1.
4. Chow AW, Benninger MS, Brook I, etal. IDSA, clinical practice
guideline for acute bacterial rhinosinusitis in children and adults.
Clin Infect Dis. 2012;54:e72–e112.
5. Spector SL, Bernstein IL, Li JT, etal. Parameters for the diagnosis and management of sinusitis. J Allergy Clin Immunol.
1998;102:s107–44.
6. King D, Mitchell B, Williams CP, Spurling GK. Saline nasal
irrigation for acute upper respiratory tract infection. Cochrane
Database Syst Rev. 2015;2015(4):CD006821.
Chapter 13. Sinusitis or Rhinosinusitis
7. Rosenfeld RM.Clinical practice. Acute sinusitis in adults. N Engl
J Med. 2016;375:962.
8. Hamilton DL. Chronic sinusitis. J Allergy Clin Immunol.
2000;106:213–27.
9. Winstead W.Rhinosinusitis. Prim Care. 2003;30:137–54.
10. Young J, De Sutter A, Merenstein D, etal. Antibiotic for adults
with clinically diagnosed acute rhinosinusitis a meta-analysis of
individual patient data. Lancet. 2008;371:908.
11. Anon JB, Jacobs MR, Poole MD, etal. Antimicrobial treatment
guidelines for acute bacterial rhinosinusitis. Otolaryngol Head
Neck Surg. 2004;130(1suppl):1–45.
12. de Bock GH, Dekker FW, Stolk J, etal. Antimicrobial treatment
in acute maxillary sinusitis. J Clin Epidemiol. 1997;50:881.
13. Osguthorpe JD, Hadley JA. Rhinosinusitis, current concept in
evaluation and management. Med Clin North Am. 1999;83:27.
14. Hwang PH.A 51-year woman with acute onset of facial pressure,
rhinorrhea and tooth pain, review of acute rhinosinusitis. JAMA.
2009;301:1798.
277
Chapter 14
Sore Throat
LoriCiuffo
Introduction
Acute pharyngitis is one of the most common conditions in
patients presenting with a sore throat.
Approximately 12 million ambulatory care visits in the
USA present with a sore throat [1]. It is characterized by
inflammation of the pharynx, nasopharynx, and tonsillar tissue. Incidence peaks between late winter and early spring.
Eighty percent of cases are caused by viral agents, and the
remaining are bacterial and rarely, fungal infections [2].
Among the many viruses, up to 20% of patients with
Covid-19 present with a sore throat [1, 3].
Strep throat and COVID-19 can produce many of the
same symptoms including fever, headache, body aches, and
vomiting. A few distinctions between them are strep throat
causes pain when swallowing, tonsillar exudates, petechiae,
and swollen lymph nodes.
Strep throat, caused by bacterial infection from
Streptococcus, requires antibiotics to prevent nonsuppurative
L. Ciuffo (*)
Department of Ambulatory Care, Jacob North Central Bronx
Hospital, Bronx, NY, USA
e-mail: lori.ciuffo@nbhn.net
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2022
E. Sydney et al. (eds.), Handbook of Outpatient Medicine,
https://doi.org/10.1007/978-3-031-15353-2_14
279
280
L. Ciuffo
complications including rheumatic fever and glomerulonephritis and suppurative complications including bacteremia,
cervical lymphadenitis, endocarditis, mastoiditis, meningitis,
otitis media, peritonsillar and retropharyngeal abscess, and
pneumonia [4, 5].
Decision-Making/Differential Diagnosis
All patients with acute pharyngitis should be tested for
severe acute respiratory syndrome coronavirus 2 (SARSCoV- 2) with a sensitive reverse-transcriptase polymerase
chain reaction (PCR) test. This is to identify patients who are
infectious and to isolate and perform contact tracing [2].
Viruses including adenovirus, influenza virus, parainfluenza virus, rhinovirus, and respiratory syncytial virus are frequent causes of acute pharyngitis. Other viral agents include
coxsackievirus, echovirus, coronavirus, enterovirus, cytomegalovirus (CMV), human immunodeficiency virus (HIV), and
herpes simplex virus. The Epstein-Barr virus is a frequent
cause of acute pharyngitis accompanied by other clinical features of infectious mononucleosis such as generalized fatigue,
lymphadenopathy, and splenomegaly. Systemic infections
with rubella virus or measles virus can be associated with
acute pharyngitis [6, 7]. Other bacterial causes of acute pharyngitis include groups C and G beta-hemolytic streptococci,
Corynebacterium diphtheria, Arcanobacterium haemolyticum, Neisseria gonorrhoeae, Chlamydia pneumoniae,
Francisella tularensis, Fusobacterium necrophorum, and
Mycoplasma pneumoniae.
Noninfectious causes include irritants such as cigarette
smoking or second-hand exposure, dry air, allergic rhinitis or
sinusitis, gastroesophageal reflux disease, trauma caused by
intubation or straining as with shouting, medications including angiotensin-converting enzyme inhibitors, and some chemotherapeutics, autoimmune disorders including Kawasaki
disease and Bechet syndrome [2].
Chapter 14. Sore Throat
It is important to distinguish between the two most common infectious etiologies of acute pharyngitis because management strategies differ [1].
1. Respiratory viruses
2. Group A streptococcus (GAS)
Red flags and the need for urgent care: Upper airway
obstruction can result from severe pharyngeal inflammation
but is more commonly associated with infectious mononucleosis and invasive infections involving the deep tissue of the
neck. Signs of upper airway obstruction include a muffled or
“hot potato” voice, hoarseness, drooling or pooling of saliva,
stridor, respiratory distress (tachypnea, dyspnea, retractions),
and “sniffing” or “tripod” positions which help maintain airway patency [5].
281
Key H&P
History of exposure to strep pharyngitis with exam findings
including pharyngeal erythema, fever, tonsillar exudates, tender, and enlarged anterior cervical lymph nodes, and palatal
petechiae is highly suspicious of GAS. Lymphadenopathy in
any area other than the anterior cervical chain is not typical
of GAS but is common in mononucleosis. The presence of a
rash should be noted, and signs and symptoms of conjunctivitis, coryza, cough, diarrhea, hoarseness, and stomatitis are
highly suggestive of viral infection as stated above [5, 6].
Viral pharyngitis clinical features include cough, nasal congestion, conjunctivitis, coryza, oral ulcer, and viral exanthem.
Antibiotic treatment is recommended for patients with
GAS pharyngitis, and supportive care is sufficient for patients
with viral pharyngitis.
Modified Centor score (Fig. 14.1) and FeverPAIN score
(Fig. 14.2) can be used to identify patients at low, moderate,
and high risk of group A strep pharyngitis.
282
Absence of cough 1
Swollen tender anterior cervical nodes
Temperature >100.4
Tonsillar exudates or swelling
3-14 years of ag
14-44 years of age
45 years or older
Total Score
Score =
Score=1
Score=2
Score=3
strep testing / culturetreat if rapid test positive
Score= > 4 51-53%No further testing, treat empirically
FeverPAIN Score for Pharyngitis Points
3 28 to 35% Rapid antigen detection testing
L. Ciuffo
1
F1
1
e1
0
-1
risk of GAS Recommendation (#7)
01-2.5% No further testing or antibiotic needed
5-10% Option to perform RADT or culture
11-17% strep testing / culturetreat if rapid test positive-
28-35%
-
F . Modified Centor score
Fever in past 24 hours 1
Intensely inflamed tonsils 1
Presentation within 3 days of symptom onset 1
Purulent tonsils1
___________________________________________________________________________
Points Risk Recommendation
0 or 11 to 10% No testing or treatment, consider backup throat
2 11 to 17% Rapid antigen detection testing
culture In children 3-15 years of age
F . FeverPAIN score for pharyngitis
Rapid Antigen Detection Tests
Because of improvements in the sensitivity of the rapid antigen detection test, a negative result no longer have to be
confirmed by a throat culture [8], sensitivity 91% and specificity 93% [9].