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Question: HEENT

A 17yo boy presents with severe sore throat for two days, and fever to 39. He has difficulty swallowing due to pain. He has no cough, congestion, nor ill contacts. His immunizations are up to date. On examination, he is alert, has no respiratory distress or stridor. His oropharynx has 2+ tonsils which are somewhat red, no exudate, no vesicles, no peritonsillar swelling. He has tender cervical lymphadenopathy and is very tender on palpation of his anterior neck at the level of the hyoid bone. The most appropriate management is:

A. Obtain lateral neck X-ray in the ED and consult ENT specialist

B. Consult ENT specialist to intubate the patient in the O.R.

C. Give dexamethasone and penicillin-benzathine and discharge home

D. Recommend supportive care for a viral URI

E. Obtain a CT scan to evaluate for deep neck infection


pemsou5_wp • November 22, 2016

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  1. Kelly November 27, 2016 - 2:31 am Reply

    A. This is a case of epiglottitis, which is currently more common in adolescents and young adults due to widespread H. influenza vaccination. Presentation tends to be more indolent than classic epiglottitis that occurred in young children in the past. Suspect if severe sore throat out of proportion to oropharyngeal exam, exquisite tenderness to the anterior neck at the level of the hyoid, dysphagia and muffled or hot potato voice. Plain films may show the “thumbprint” sign. Unlike young children in the past, stable adolescent and adult patients do not need to be emergently intubated, but should be evaluated by ENT and admitted for close observation and antibiotic therapy. However, drooling, stridor, tripod positioning, dyspnea, are all signs of impending airway obstruction, which should be managed expediently.

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