12.3.1 FOREIGN BODY (FB) in the AIRWAY

Mostly occurs in children <5 years

Cause

• Types of FBs include seeds (especially groundnuts) beans, maize, plastics, rubber, metal wires, ball bearings

• Usually inhaled from the mouth - child is chewing, laughing or crying or there is a sudden disturbance, which opens the vocal cords so the object is inhaled

Clinical features

• History of inhalation (usually reported as swallowing) or choking

• Stridor

• Cough

• Difficulty in breathing, wheezing

• Hoarseness of voice if FB stuck at the vocal cords

• Symptoms start suddenly, fever is initially absent and some of the symptoms may be transient (may disappear after a short period)

• Upper airway obstruction as shown by:

- flaring of the nostrils
- recession of the chest inlet and/or below the ribs
- rapid chest movements
- air entry may be reduced (usually on the right side)

Investigations

Once the history and examination are suggestive, investigations can be omitted to save time
Chest x-ray may show lung collapse, hyperinflation, mediastinal shift, shift of heart shadow

Management

Child:

Prop the child up
Give oxygen
Refer to an ENT specialist

Adult:

Dislodge large FB, eg. chunk of meat, from the pharynx by standing behind the patient with both arms around the upper abdomen and giving 6-10 thrusts (Heimlich manoeuvre)

- such circumstances are very rare
- If patient pregnant or very obese: perform 6-10 chest thrusts with patient lying on the back

Prevention

• Do not give groundnuts or other small hard food items to children <2 years

• If a child is found with objects in the mouth, leave the child alone to chew and swallow or gently persuade the child to spit out the object

- do not struggle with/force the child

12.3.2 FOREIGN BODY in the FOOD PASSAGE

Causes

• Types of FBs commonly involved include fish or chicken bones (in the pharynx and oesophagus), cedar tree (Xmas tree) leaves which get stuck in the pharynx or even behind the soft palate in the nasopharynx, coins

• Children: tend to insert objects in their orifices - coins are particularly likely to be ingested

• Adults: eating fish or chicken while drunk or not paying attention (eg. watching television) or both are risky - sharp objects lodge in the tonsils, behind the tongue or in the pharynx and some may get stuck in the oesophagus

Clinical features

• Difficulty and pain in swallowing - patient winces as attempts to swallow
• Drooling of saliva
• Patient may point to the area with a finger
• FB may be seen, eg. in tonsil, pharynx

Differential diagnosis

• Infection in pharynx
• Trauma by foreign body

Investigations

X-ray may reveal radio-opaque FB - coins may appear on x-rays done for other reasons
Many FBs are radiolucent - look for a gas shadow if in the oesophagus

Management

Initial:

Allow only clear fluids

Do not try to dislodge/move the FB with solid food - this may push it into the wall of the oesophagus causing infection and sometimes death

Give IV infusion (p354) if unable to swallow liquids or if oral fluid intake intake is poor

If FB is invisible on X-ray or symptoms persist >24 hours from time of ingestion:

Refer to Regional Centre with ENT facility

If FB is visible in the pharynx, tonsil, etc:

Grasp and remove it with long forceps

If patient tried to push FB with solid food:

Give broad-spectrum antibiotic cover with amoxicillin 500mg every 8 hours for 5 days

Prevention

• Children: keep potential FBs out of the way as far as is possible

• Advise on care in eating, ie. not taking in too large pieces of food, chewing thoroughly before swallowing - advise once a FB is stuck to avoid trying to ‘push’ it down with solid food as this may sometimes be fatal

12.3.3 PHARYNGITIS (Sore throat)

Inflammation of the throat

Causes

• Viral: most cases

• Infection with various bacterial organisms of which Group A haemolytic Streptococci is the commonest

• Diphtheria in non-immunized children

• Gonorrhoea (usually from oral sex)

• Viral upper respiratory tract infections

• May also follow ingestion of undiluted spirits

• Candida albicans in the immunosuppressed

Clinical features

• Abrupt onset
• Pain on swallowing
• Fever
• Loss of appetite, general malaise
• In children: nausea, vomiting and diarrhoea
• Inflamed tonsils and throat
• Tender neck glands
• Exudates on tonsils

Differential diagnosis

• Tonsillitis
• Epiglottitis
• Laryngitis
• Otitis media, if there is referred pain

Investigations

Throat examination with torch and tongue depressor
Throat swab for microscopy, C&S
Blood: haemogram
Serological test for haemolytic streptococci (ASOT)

Management
HC2

Keep the patient warm
Give plenty of (warm) oral fluids
Give analgesics for 3 days (see p343)
Review the patient for progress

If streptococcal pharyngitis suspected:

benzathine penicillin 1.2 MU IM single dose

child: <30kg: 30,000 IU/kg
or PPF 20,000 IU/kg IM daily for 10 days
or phenoxymethylpenicillin 500mg every 6 hours for 10 days child: 12.5mg/kg per dose

HC2

If allergic to penicillin:

erythromycin 500mg every 6 hours for 10 days child: 12.5mg/kg per dose

Note

♦ If not properly treated, streptococcal pharyngitis may lead to acute rheumatic fever and retropharyngeal or peritonsillar abscess - therefore ensure that the full 10-day courses of antibiotics are completed where applicable

♦ Cotrimoxazole is not effective for the treatment of streptococcal pharyngitis and it should not be used

♦ For candidiasis use ketoconazole (see p3)

12.3.4 TONSILLITIS

Inflammation of the tonsils

Cause

• Streptococcal infection (most common)
• Viral infection (less common)

Clinical features

• Sudden onset, most common in children

• Sore throat

• Fever, shivering

• Headache

• Vomiting

• Enlarged inflamed tonsils and cervical lymph nodes

• Complications include: sinusitis, endocarditis, nephritis, LRTI, peritonsillar abscess (quinsy), otitis media

Differential diagnosis

• Pharyngitis
• Submandibular lymphadenitis

Investigations

Throat swab: for C&S

Management
HC2

If bacterial:

phenoxymethylpenicillin 500mg every 6 hours for 10 days child: 10-20mg/kg per dose

If viral:

Treat symptomatically with analgesics (see p343) and increased oral fluids

12.3.5 PERITONSILLAR ABSCESS (QUINSY)

An abscess between the tonsil capsule and the lateral wall

Cause

• Follows (often mild) tonsillitis attack

Clinical features

• Severe throat pain
• Fever
• Headache, malaise
• Rigors may occur
• Inability to open the mouth; salivation and dribbling
• Bad mouth odour
• Thickened muffled (unclear) speech
• Ear pain
• Enlarged cervical lymph nodes
• Tonsil and soft palate reddish and oedematous
• Swelling pushing the uvula to opposite side - may be pointing (bulging collection of pus)

Differential diagnosis

• Tumour
• Tonsillitis
• Abscess in the pharynx

Investigations

Carry out C&S on pus if present or after drainage

Treatment

Adult (early stages):

Conservative management

Bed rest

benzylpenicillin adults 2MU IV or IM every 6 hours for 48 hours then switch to amoxicillin 500mg every 8 hours to complete a total of 7 days

If unable to take oral fluids: set up an IV drip (p354)

When swelling is marked:

Surgery (which should be done by a trained person)

- suction facility will be needed

- carry out incision & drainage at the most pointing area with the protected tip of No.11 surgical blade

6 weeks later: refer for tonsillectomy as this condition might recur

Prevention

Prompt and adequate treatment of tonsillitis