Specialist ENT oral cavity

FAUCIAL DIPHTHERIA

Synonym: Diphtheritic pharyngitis

Diphtheria is an infection caused by Corynebacterium diphtheria, a gram-positive bacillus.

The incidence of this disease has drastically reduced after the immunization programme.

Aetiology:

  1. Age: Young children from age 2 to 5 years.
  2. Spread: Air borne spread.
  3. Laryngeal diphtheria usually follows pharyngeal infection.

Causative organism:

Corynebacterium diphtheria.

This organism has 3 strains:

  1. Corynebacterium diphtheria gravis.
  2. Corynebacterium diphtheria intermedius.
  3. Corynebacterium diphtheria mitis.

Corynebacterium diphtheria gravis is the most fulminant pathogen causing epidemics with high mortality.

Clinical features:

I. General:

  1. Sore throat.
  2. Malaise.
  3. Pyrexia.

II. Oral cavity:

  1. Lesion is seen over the tonsil with necrosis.
  2. A characteristic greyish green membrane is formed on the tonsil, posterior pharyngeal wall and soft palate. This membrane contains rich fibrinous exudate and large number of bacteria.
  3. This membrane bleeds on touch and thickens with time.
  4. Bilateral tender cervical lymphadenopathy often present.
  5. Neck cellulitis may be present giving the appearance of “Bull Neck”.
Specialist ENT Screenshot 2020 12 02 ORAL CAVITY AND PHARYNX SEMIFINAL BS

III. Larynx:

  1. Infection from the pharynx easily spreads into the larynx causing rapid airway obstruction.
  2. Inspiratory stridor.
  3. Barking cough.
  4. Recession of anterior chest wall.

IV. Neurological symptoms:

They appear 3 to 6 weeks after the onset of diphtheria. The signs are:

  1. Paralysis of the

    a) Soft palate.

    b) Diaphragm.

    c) Ocular muscles.

  2. Occasionally, ‘Guillain- Barre Syndrome’.

Death is due to toxemia producing cardiac complications.

Complications

Exotoxin produced by Corynebacterium is toxic to the heart and nerves. 

It causes:

  1. Myocarditis.
  2. Cardiac arrhythmias. 
  3. Acute circulatory failure.
  4. Paralysis of soft palate, diaphragm and ocular muscles. 
  5. In the larynx, diphtheritic membrane may cause airway obstruction.

Treatment:

Diagnosis of diphtheria is made clinically. Isolation of the patient is necessary

  1. Neutralization of the exotoxin with equine antitoxin (20000-120000 units).             Dosage- 20,000–40,000 units for diphtheria in less than 48 h, or when the membrane is confined to the tonsils only; and 80,000–120,000 units, if disease has lasted longer than 48 hours, or the membrane is more extensive. Antitoxin is given by IV infusion in saline in about 60 min.
  2. Benzyl penicillin 600-1200 mg every 6 hourly is given along with the antitoxin for 7 days.
  3. Procaine penicillin Gis given intramuscularly for 14 days (300,000 U/d for patients weighing <10 kg and 600,000 U/d for those weighing >10 kg).
  4. Erythromycin is used in penicillin-sensitive individuals given (orally or by injection) for 14 days (40 mg/kg per day with a maximum of 2 g/d).
  5. Metronidazole is also given.
  6. Patients with allergies to penicillin G or erythromycin can use rifampin or clindamycin.
  7. Endotracheal intubation or tracheostomy may be necessary in severe cases of diphtheritic laryngitis.
  8. Immunization of all persons coming in contact with the patient.

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