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PHARYNGITIS (TONSILLOPHARYNGITIS)

PRINCIPLES OF DISEASE Pathophysiology Inflammatory syndrom of the oropharnx primarily caused by infection Transmission usually through respiratory secretions, but fomite, food transmission also possible Infection localizes in lymphatic tissue: tonsils, cervical ln.s Rare significant complications of airway obstruction, decreased oral intake and dehydration Chronic pharyngitis: inflammation and infection of the tonsillar crypts rather than the tonsils themselves Beta-lactamase production is extremely common in bacteria responsible for chronic pahryngitis Microbiology Viral most common cause: 80 - 90%; rhinovirus, adenovirus, coronavirus, CMV, parainfluenza, rubella, influenza, HSV, coxsachie, EBV Bacterial (children): group A Beta-hemolytic Streptococcus (GAS) (Streptococcus pyogenes) Bacterial (adults): Beta-hemolytic strep (all groups), H.flu, Mycoplasma, Chlamydia Other causes: Actinomyces, Francissella tularenssi, Yersinia enterocolitica, Group B, C, G Streptococci Cultures: often mixed aerobes (staph aureus, Hflu, moraxella) and anaerobes (bactroides, anaerobic gram + cocci, fusobaclterium) CLINICAL FEATURES Hx:pharyngeal pain and odynophagia PE: pharyngeal erythema, pharyngeal or tonsillar exudate, tonsillar enlargement, tender cervical lymphadenopathy Strawberry tongue: petecheiae or hemorrhagic lesions suggesting scarlet fever Gingival lesions with ulcerating tonsillitis and pseudomembranous exudate: Vincents angina Bull neck: diptheria Vesicles: HSV, coxxachie Rash: sand-papery with scarlet fever, erythematous maculopapular with EBV Clinical differentiation of etiology is virtually impossible; some clues Viral: associated rhinitis, cough, myalgia, headache, stomatitis, conjunctivitis, exanhem, odynophagia, low-grade fever, white exudate; cervical lymphadenopathy less common Bacterial: rhinitis, conjuctivitis, exanthem, lymphadenopathy less common; exudate, high fever, cervical lymphadenompathy, abscence of cough more common VIRAL PATHOGENS Systemic viral infections: measles, CMV, rubella, HIV (mono-like illness) Influenza: fever, headache, myalgias; 50% with pharyngeal pain but minority with exudate and cervical lymphadenopathy Adenovirus: 30% associated with conjunctivitis

Mononucleosis: pharyngitis is common presentation, tonsillar exudate or membrane (creamy or cheesy whit), generalized lymphadenopathy in 90%, splenomegaly in 50%, periorbital edema and rash less common. Macular rash after amoxicillin is common (90% of those with mono given amoxil) HSV pharyngitis: young adults, painful superficial vesicles on erythematous base, ulcers may be present on lips/pharyng/tongue/gingiva/buccal mucosa, pharyngeal erythema and exudate + fever + ln.s for 1-2 weeks, can be primary or secondary, bacterial superinfection a complication

BACTERIAL PATHOGENS Group A Beta-Hemolytic Streptococcus primarily 5 - 15, winter and spring, incubation 12hr - 4 days < 15% of pharyngitis in > 15yo, rare < 3 yo, epidemics occur fever > 38.3, tonsillar exudates, palatal and uvular petechiae, uvular edema and erythema, tender anterior cervical ln.s, absence of cough/rhinitis. Rash: associated with diffuse erythematous fine sandpaper rash, first in flexor areas then generalized, concentrated in axilla, inguinal, popliteal fossa; characteristically FADES on pressure; lasts 7 days then desquamates (scarlet fever); not sensitive or specific; due to pyrogenic toxin; occurs in minority Pastias lines: petechiae in folds of the joints Strawberry tongue can occur with scarlet fever Toxic shock syndrome: sepsis and cardiovascular collapse, < 1%, pyrogenic exotoxin A, high mortality Diptheria uncommon b/c of vaccinations, potentially lethal, consider in immigrants sore throat, fever, dysphagia, gray or white exudate that coalesce to form a pseudomembrane which is a gray-green layer over the tonsils, pharyngeal mucosa, and occassionally the uvula and may extend to involve the larynx (hoarseness, cough, stridor) severe inflammation and edema can produce dysphonia and a bullneckappearance laryngeal, nasal, and cutaneous involvement possible (sharply demarcated ulcer with membranous base) must ask for special culture medium Corynebacterium diptheriae produces a systemic toxin ----> myocarditis, arrythmias, polyneuritis, vascular collapse, organ necrosis, death Arcanobacterium hemolyticum previously called Corynebacterium hemolyticum, 10 - 30 year old similar to GAS pharyngitis, most have rash scarlatiniform/urticarial/or erythema multiforme (may be only complaint) usually nontoxic and afebrile; can produce membrane similar to diptheria; associated with chronic pharyngitis Vincents angina anaerobic pharyngitis and acute necrotizing ulcerative gingivitis (ANUG) also called Trench Mouth etiology: Borellia vincenti superficial ulceration and necrosis that often results in the formation of a pseudomembrane and gingival lesions

food deposits in gingival crevice, gingivitis, frank ulceration and bleeding, pseudomembranous necrotic exudate in gingival margins, spread to tonsils and pharynx foul-smelling breath, odynophadia, submandibular lymphadenopathy, exudate often present, poor oral hygiene common Gonococcal pharyngitis STD, may be independent of genital infection, can be asymptomatic carrier, latent period common, important cause of gonococcemia Syphillitic pharyngitis primary or tertiary syphillus, painless mucosal lesions Tuberculosis pharyngitis hoarseness, dysphagia, pharyngeal ulcers in patient with advanced disease Candidal pharyngtitis dysphagia, odynophagia, adherent white plaques with focal bleeding points, immunocompromised Mycoplasma pneumoniae mild pharyngitis, epidemics occur, up to 10% of all adult pharyngitis, may have LRTI as well Chlamydia pneumoniae epidemics, severe, selling and pain of deep cervical lymph nodes, +/LRTI, hallmarks are recurrence and persistence Chlamydia trachomatis STD, urogenital and partner testing required, mild symptoms or asymptomatic

DIFFERENTIAL DIAGNOSIS Deep space infections, Tumors, Foreign bodies Pemphigus, Steven Johnson syndrome, Drug reaction Allergic reaction, Angioedema Chemical and thermal burns Esophagitis, GERD Epiglotitis, thyroiditis DIAGNOSTIC STRATEGIES Mononucleosis Monospot: 95% sensitive in adults, 90% sensitive in > 5yo, 75% sensitive in 2 - 4yo, 30% sensitive in 0 - 2yo; commonly negative in first week of illness; specificity can be a concern as test may remain positive for up to a year following the illness; POOR in young and early in dz EBV IgM antibodies can be measured EBV nuclear antigens develp w/i 3-6weeks and can be useful if initial testing is negative Peripheral blood smear reveals atypical mononuclear cells in 75% with peak incidence in 2nd to 3rd week of illness Group A Beta-Hemolytic Strep Important to diagnose and treat w/ abx to prevent rheumatic fever Antibiotic do NOT prevent post - strep glomerulonephritis Difficult to dx or r/o accurately with clinical assessment Serology: Anti-Streptolysin O (ASO) titers acute and convelescent are only

reliable way to diagnose; looks for grp A only; very specific but sensitivity is variable (60 - 90%) Throat swab cultures 90 - 95% sensitive for detection of Streptococcus pyogenes but specificity (50%) may be poor as asymptomatic carriage is common; lab only looks for GAS, must ask for diptheria etc Rapid diagnostic tests: latex agglutination, ELISA, optical immunoassay, chemiluminescent DNA probes; looks for streptococcal antigen in the throat swab (only grp A); sensitivities range from 30 - 100% and specificities range from 70 - 100% in trials but lower in practice; use is controversial considering significant false +ve and false -ves Clinical scoring system fever > 38.3 cervical lymphadenopathy tonsillar exudate absence of cough

Other testing Diptheria: requires specific culturet, toxigenicity testing must also be performed A. hemolyticum: suspect if rash present, including EM Vincents angina: clinical suspicion and a gram stain Gonococcus: requires a Thayer-Martin agar TB: requires acid-fast staining Syphilus: dark-field microscopy, direct immunofluorescence, serology Candida: yeast on KOH prep of throat swab or Sabourauds agar Mycoplasma: serology or culture Chlamydia: serology or antigen detection tests HSV: culture of vesicles

MANAGEMENT Group A Beta-hemolytic Strep Clinical judgement unreliable, poor diagnostic tests, vastly overtreated Benefit of antibiotics: shorten course of illness by < 1 day (2or3 vs 3or4), decreases transmission, prevention of complications, decrease incidence of rheumatic fever (or is a change in strain pattern, because rheumatic fever rarely seen today compared to 50 years ago, is it really the antibiotic use?) Disadvantage of antibiotics: increased bacterial resistance, increased recurrence, decreased immune response, patient expectation of abx Rheumatic Fever: treatment w/i 9 days will prevent RF, incidence dramatically decreased after antibiotic use, peak incidence in 5 - 15yo where Grp A Beta - hemolytic strep common, currently occurs in 0.3% of GAS pharyngitis and may increase to 3% with epidemics Tonsillectomy: > 5 episodes per year Antibiotics does NOT prevent post-strep glomerulonephritis Four ED strategies throat culture all and only treat positives: costly, poor specificity of positive culture b/c of carriage rate, delay in waiting for cultures, problems with f/u from ED, treat all, culture all, stop if culture negative: ineffective and costly perform rapid strep test and treat those who are positive:

false +ve lead to over treatment, negative test requires follow up cultures, treat all who have reasonable clinical probabililty of GAS: leads to over-treatment but avoids problems with testing COMBINATION: high clinical probability should be treated without testing, low clinical probability should be treated if testing is positive (culture or rapid strep testing) Group A Beta-hemolytic Strep antibiotic regimen Penicillin V 250 mg po qid X 10days Penicillin V 250 mg po qid X 2/7 then 500 mg bid X 8/7 Benzathine Penicillin 1.2 million units im X 1 dose Frequent dosing necessary, im dose has more reactions Erythromycin 500 mg bid X 10/7 for pen allergic Penicillin failure due to noncompliance, re-infection, or Beta - lactamase production; penicillin resistance growing, erythromycin resistance uncommon Alternatives: cephalosporins, macrolads, clindamycin (not shown to prevent RF although probably do) Amoxicillin, ampicillin, and penicillinase - resistant penicillins offer no advantage over uncomplicated GAS infections

GAS CLINICAL SCORING SYSTEM (i) fever > 38.3 (ii) cervical ln.s (iii) tonsillar exudate (iv) NO cough 0 - 1: no treatment or testing 2 - 3 : test, treat if positive 4: treat empirically

Other Bugs

Diptheria: concern for toxicity and airway compromise; treat immediately if suspecting, dont wait for tests; equine ANTITOXIN is indicated based on clinical grounds, dose varies, consultation required; antibiotics eradicate the bug but not the toxin, use erythromycin or rifampin; Td booster for immunized contacts and erythromycin + full vaccination course for unimmunized contacts A. hemolyticum: erythromycin d of c b/c of penicillin resistance Vincents angina: penicillin or clindamyucin and aoral oxidizing agent (hydrogen peroxide) Gonoccocus: ceftriazone 125 mg im or cipro/cifixime single dose; concomitant treatment with azithromycin or doxy to cover chlamydia TB: multiple drug regimen Syphillus: benzthine penicillin 2.4 million units or doxycycline X 14 days Candida: nystatin swish and swallow, versus oral

fluconazole/itraconazole/clotirmazole; chronic suppression with HIV Mycoplasma pneumonia: erythromycin, doxycycline, tetracycline Chlamydial: doxy or macrolide Recurrent tonsillitis: B-lactamase resistent antibiotics HSV: acyclovir X 1 week if primary infection Steroids? Mayshorten the duration of symptoms without increasing the complication rates

Symptomatic Tylenol, ibuprofen Warmed fluids, topical anesthetics (cepacol, etc) Mononucleosis Supportive, hydration, consider steroids Avoid sports or contact for 6-8 weeks (risk of splenic rupture) Acyclovir or famiciclovir if immunocompromized

DISPOSITION Complications may necessitate consultation and admission: Airway compromise, Local and distant spread of infection, Deep neck abscesses, Necrotizing fascitis, Sleep apnea, Bacteremia/sepsis Complications of mono: airway obstruction, tonsillar and peritonsillar abscess, lingual tonsillitis, necrotic epiglottitis, hepatic dysfunction, splenic rupture, neurologic disorders, pneumonitis, pericarditis, hematologic disorders GAS complications Suppurative: PTA, RPA, deep space abcessess, suppurative cervical lymphadenitis, OM, sinusitis, mastoidtits, bacteremia, sepsis, OM, meningitis, Nonsuppurative: RF, GN, pericarditis, myocarditis, erythema nodosum, streptococcal toxic shock syndrome Rheumatic Fever: rare, 18 days after infection is average, carditis and secondary valve disease, certain serotypes more of a problem (with M-protein), prevented with abx w/i 9 days Glomerulonephritis: uncommon, 10 days after infection is average, usually nephritic syndrome, uncommon progression to CRF, serotype M-type 12, NOT prevented by abx

ADULT EPIGLOTTIS
PRINICPLES OF DISEASE Potentially life-threatening condition from airway obstruction Increased incidence and recognition in adults; uncommon in peds after Hflu vaccine Localized cellulitis of upper airway Marked involvement of the supraglottic structuress: base of tongue, vallecular, aryepiglottic folds, arytenoid soft tissues, lingual tonsils, epiglotis Inflammation does NOT extend to the infraglottic rections b/c the submucosa is so densely adherent to the mucosa below the vocal cords Supraglossitis: reports of severe supraglottic involvement with normal epiglottis H. influenza type B is most common isolate

Majority have NO organisms identified by blood or supraglottic cultures ? viral (adenoviral) role

CLINICAL FEATURES No age, seasonal prevelance Males, smokers more commonly affected Prodrome variable: hours - days Rapid progression is predictor of airway compromise Sore throat, odynophagia, dysphagia (pain severe), STRIDOR Dysphonia and muffled voice common; usually NOT hoarse Fever in 50% and late Tacchycardia out of proportion to fever Tenderness over anterior neck in hyoid region and on moving larynx are reliable Imminent airway obstruction: stridor, drooling, respiratory distress, sniffing position Pharyngeal examination does not r/o epiglottis b/c of concominant pharyngitis, uvulitis, tonsillitis, Ludwigs angina, PTA, parotitis DIAGNOSIS Differential diagnosis Misdiagnosis common: strep pharyngitis is most common misdiagnosis Monon, deep space infections, lingual tonsillitis, diptheria, pertussis, croup, angioedema, allergy, FB, laryngospasm, tumor, toxic inhalant, aspiration, laryngeal trauma Laryngoscopy Direct, indirect, or fiberoptic visualization if not in respiratory distress Swollen epiglottis and surrounding structures, epiglottis may be cherry red but often is pale and edematous Respiratory distress, stridor, drooling, aphonia: indirect laryngoscopy contraindicated and direct laryngoscopy only if prepared for airway Lateral soft tissue of neck Sensitivity 80 - 90% (does NOT rule out) Xrays: obliteration of vallecula, swellin of arytenoids and aryepiglottic folds, edema of prevertebral and retropharyngeal soft tissues, ballooningof the hypopharynx and mesopharynx, edematous thumb shaped epiglottis (Epiglottis > 8mm or Aryepiglottic fold > 7mm) Direct laryngoscopy indicated if suspecting and Xrays normal MANAGEMENT Expect sudden, unpredictable airway obstruction Minimize stimulation, have airway equipment by the bed, have cric tray at bedside, notify OR and consult ENT emergently if airway compromise present or expected Hands off and transfer to OR for definitive airway management if at all possible If airway obstructs in ED: try orotracheal, could try LMA, be set up and ready for TTV or cricothyrotomy Safety and efficacy of Orotracheal and laryngoscopic guided nasotracheal intubation reported Blind nasotracheal intubation may lead to airway obstruction and is contraindicated Lateral neck Xray (portable) may be helpful but dont waste time to OR Start antibiotics ASAP: cefuroxime, ceftriaxone, cefotaxime ? role for steroids and racemic epinephrine Disposition

Mild cases: mild swelling on laryngoscopy without drooling, stridor, or respiratory distress --------> ICU for treatment and monitoring without intubation Moderate/Severe: to OR for intubation, to ICU So who needs intubation? Alert, stable, not tiring, no resp distress can be monitored

Complications Meningitis, RPA, pneumothorax, empyema, pneumonia, sepsis, ARDS, pulmonary edema

DEEP SPACE INFECTIONS OF THE LOWER FACE AND NECK


Deep space infection of neck are dangerous and require rapid treatment Much less common because of dental hygeine and antibiotics Distorted airway anatomy = difficult airway Paralytics may cause muscular laxity and worsen the degree of airway obstruction Fiberoptic intubation useful BNI can cause abscess rupture, airway damage, further compromise Submandibular space: conglomerate of the sublingual and submaxillary spaces which clinically function as a single space Sumandibular space is involved in Ludwigs angina Five clinically relevant potential spaces in neck (figure 70-4) Peritonsillar space Parapharyngeal space: carotid, jugular vein, CN IX > XII, sympathetics Retropharyngeal space: lies in the midline, medial to the parapharyngeal space and extends from the base of the skull to the superior mediastinum at the level of T2; superior constrictor muscle adheres to the prevertebral fascia and forms a raphe in the medial aspect ot the retropharyngeal space :. retropharyngeal abscesses tend to occur lateral to the midline Danger space: base of the skull to the diaphragm: abscesses will be midline Prevertebral space: base of the skull to the coccyx: abcesses will be midline Retropharyngeal, danger space, and prevertebral space infections have easy access to mediastinum, Danger space, Prevertebral space which all communicate Rapid spread of infection occurs easily through facial planes and spaces

PERITONSILLAR CELLULITIS (PTC)AND PERITONSILLAR ABSCESS (PTA)


PRINCIPLES OF DISEASE PTC and PTA are a continuum of peritonsillitis PTA (quinsy) is the most common deep infection of the adult head and neck Result of acute tonsillitis: infection of webers glands or tonsillar crypts invades the peritonsillar tissues leading to cellulitis that may progress to abscess formation Fibrous fascial septae divide the peritonsilar space into compartments and direct the

infection anteriorly and superiorly Risk factors: chronic tonsillitis, mono, smoking, CLL, tonsilloliths, dental infection All age groups, CAN occur with previous tonsillectomy, recurrence in up to 50% Polymicrobial aerobes (GAS, strep milleri, Hflu, strep viridans) and anaerobes (fusobacterium, bacteroides, peptostreptococcus, actinomyces)

CLINICAL FEATURES Odynophagia, dysphagia, drooling, trismus, referred otalgia, muffled hot potato voice, rancid breath, systemic symptoms of fever, dehydration, malaaise Recurrent tonsillitis hx common PE: trismus, inflammed and erythematous oral mucosa in peritonsillar area, purulent tonsillar exudates that may cover the tonsil, tender cervical lymph nodes PTC versus PTA can be difficult TRISMUS and UVULAR DEVIATION are the best predictors of abscess versus cellulitis DIAGNOSIS Clinical diagnosis for PTC Aspiration of pus for PTA Mono common (20%) and monospot testing may be relevant Xrays of limited utility Contrast CT, intraoral ultrasound, transcutaneous ultrasound useful when patients unable to co-operate with needle aspiration PTA needle aspiration Adv: diagnostic and therapeutic, easy and safe in ED, minimal pain compared to surgical incision and drainage Disadv: difficult if uncooperative or children, may miss abscess and lead to misdiagnosis of PTC, greater recurrence of PTA c/p to I&D, carotid artery puncture theoretical (NO case reports in literature) Differential diagnosis Hypertrophic tonsillitis, mono, diptheria, deep space infections of neck, cervica adenitis, congenital or traumatic internal carotid artery aneuryms, foreign bodies, neoplasms

MANAGEMENT No suspicious findings for abscess = suspect Peritonsillar Cellulitis Dont attempt ED aspiration IV antibiotics and f/u with HPTP Suspected Peritonsillar Abcess Needle aspiration in ED (except in peds) Start IV abx F/U with HPTP Arrange ENT follow up Controversies Aspiration equivalent to I&D in three small studies

Complications Airway obstruction is most important complication Other: abscess rupture with aspiration, pneumonia, empyema, pulmonary abcess, prapharyngeal and retropharyngeal spread of infection, Ludwigs angina, mediastinitis, myocarditis, carotid artery erosion, jugular vein thrombophlebitis, septic embolization, postanginal septicemia (Lemierres syndrome) and cervicothoracic necrotizing fascitis Intracranial: meningitis, venous sinus thrombosis, cerebral abscess Systemic: dehydration, sepsis, toxic shock Dispostion Admission: dehydration, inability to tolerate po intake, toxic, underlying diseases, severe pain, complications Discharge: generally iv abx through outpatient iv program

Indications for tonsillectomy: two PTAs, septic, etc Do all need to see ENT? recurrent, large, cant aspirate in ED Which antibiotic? Ancef + flagyl Ceftriaxone + flagyl Pencillin + flagyl Clindamycin alone (general choice in peds) IV antibiotics and observation before surgical intervention an option

RETROPHARYNGEAL (RPA) AND PREVERTEBRAL SPACE ABSCESSES


PRINCIPLES OF DISEASE Retropharyngeal swelling occurs from expansion of either the retropharyngeal space, danger space, or the prevertebral space (figure 70-4) -----------> collectively described as retropharyngeal abscesses (RPA) Previously a childhood disease, but increasing adult incidence Children < 4yo have prominent retropharyngeal lymph nodes that become infected, lead to retropharyngeal cellulitis and RPA formation Retropharyngeal nodes atrophy after 4 - 6 yo and thus decreasing incidence and different pathology in adults Adults: cellulitis in retropharyngeal area and abscess may form; nasopharyngitis, OM, parotitis, tonsillitis, PTA, dental infections and procedures, upper airway instrumentation, Ludwigs angina, lateral pharyngeal space infection, endoscopy are all implicated as causes Blunt and penetrating trauma also causes: FB, fish bones, cautic ingestion, vertebral fracture Hematologic spread less common Diabetes and immunocompromised states may be important Polymicrobial aerobes and anaerobes is most common Vertebral osteomyelitis leading to RPA is most commonly staph Tuberculosis was a common cause, but not now

CLINICAL FEATURES Sore throat, odynophagia, dysphagia, drooling, muffled voice, neck stiffness, neck pain, fever Dysphonia described as a duck quack (cri du canard) May be toxic, airway obstruction and respiratory distress possible Sniffing position to protect airway can occur May have posterior neck or shoulder pain with swallowing Physical Examination Tender cervical ln.s, tender cervical musculature, neck swelling, torticollis, high fever, trismus may be present Diffuse edema/erythema of posterior pharynx with retropharyngeal cellulitis Palpation of abscess: unreliable, risk of rupture Visualization of abscess: midline lump with prevertebral or danger space and unilateral if retropharyngeal space Tenderness on moving the larynx and trachea side to side (tracheal rock sign) DIAGNOSIS Lateral neck Xray Inspiratory film with widening of retropharyngeal space and forward displacement of esophagus and trachea Diffuse swelling with cellulitis, more localized with abcess Xrays are unreliable to distinguish RP cellulitis versus RP abscess Other: loss of cervical lordosis, air-fluid level in abcess, FB, vertebral body destruction (AIR in RP space is good predictor of abscess) Retropharyngeal space > 7mm at level of C2 is abnormal in kids and adults Retropharyngeal space > 14mm adults and 21mm kids at level of C6

Other CXR to evaluate mediastinal involvement CT or MR good for detection of complications CT with iv contrast is considered the gold standard for diagnosis but studies show sensitivity 90 - 100% and specificity 60 - 70 % (low) for RPA vs RPC U/S useful tod etect RPC from RPA

Differential Dx Cold abscesses: tuberculosis; insidious onset, chronic, constitutional symptoms, minimal fever, symptoms >> physical findings RP tumors, FB, hematoma, aneurysm, hemorrhage, lympadenopathy, edema, retropharyngeal thyroid tissue, tendinitis of longus colli muscle

MANAGEMENT RPC: iv antibiotics, choices as per Ludwigs angina, consider TB and fungal RPA: surgical incision and drainage, iv antibiotics (may try abx X 48hr before surgery) Cold abscesses: drained extraorally, unless in acute distres Vertebral body destruction: neck immobilization could be necessary with vertebra

osteomyelitis or atlantoaxial separation; external fixation possibly required Complications: abscess rupture and aspiration, pneumonia, empyema; extension to mediastinum, pericarditis, pleuritis, empyema; vascular erosion; atraumatic atlantoaxial separation due to damage of transverse ligament of atlas (wide predental space on Xray or CT); acute transverse myelitis, epidural abcess; esophageal erosion, necrotizing fascitis, ARDS, sepsis Disposition Admitted, consultation with ENT, surgical intervention

PARAPHARYNGEAL ABSCESS (PPA)


PRINICPLES OF DISEASE Parapharyngeal space (lateral pharyngeal space, pharyngomaxillary space) divided into two compartements by the styloid process Anterior compartment: muscle, lymph nodes, connective tissue Posterior compartment: carotid sheath (carotid artery, internal jugular vein, vagus nerve, CNIX/X/XI/XII, cervical sympathetic chain) Etiology: dental infections, pharyngotonsillary infections are most common causes Other causes: spread from surrounding deep spaces, parotits, sinusitis, neck tumors, infected branchial cleft cysts, mastoiditis, suppuration of local lymphadenitis, iatrogenic introduction by anesthetic blocks/tonsillectomy/nasal intubation/dental work Polymicrobial CLINICAL FEATURES Pain and swelling of the neck, odynophagia, dysphagia Classic: medial tonsillar displacement and posterolateral pharyngeal wall bulge Other findings: fever, trismus, edema, swelling at angle of jaw, erythematous/tender/and nonfluctuant mass at angle of mandible Diagnosis Clinically diagnosis Lateral neck Xray: upper prevertebral soft tissue swelling, otherwise not helpful U/S, CT, MR useful Ddx: as per RPA MANAGEMENT ENT consultation IV antibiotics as per Ludwigs angina Surgical drainage COMPLICATIONS AWO, rupture, aspiratoin, pneumonia, empyema, mediastinitis, necrotizing fascitis, bacteremia, sepsis, pericarditis, osteomyelitis of mandible, parotid abcess, cavernous sinus thrombosis, meningitis Unique complication of posterior pharyngeal infections Cervical sympathetic chain: horners Carotid artery erosion and aneurysms: oral, nasal, aural warning bleeding is common; unexplained bleeding with H/N infections is serious and

warrants aggressive investigation, persistent peritonsillar swelling and unilateral tender pulsatile masses may be clues CN IX > XII palsies

Lemierres syndrome (also called postanginal septicemia): IJ thrombophl Young, healthy patients, pharyngitis that improves then followed by severe sepsis, confused with right sided endocarditis or aspiration pneumonia Pharyngeal infection spreads to the paraphyngeal space and causes septic thrombophlebitis of the jugular vein Metastatic infectious spread to lungs cause bilateral nodular infiltrates, pleural effusion, pneumothoraces Septic arthritis, osteomyelitis, meningitis, vesiculopustular rash are also reported result of septic embolization Leukocytosis, incr bilirubin, incr LFTs, hematuria, renal failure, all reported Full septic picture with its complications reported Fusobacterium and Staph aureus are most common causes Antibiotics +/- jugular vein ligation and resection

LUDWIGS ANGINA
PRINCIPLES OF DISEASE Progressive cellulitis of the connective tissues of the floor of the mouth and neck that begins in the submandibular space Potentially fulminant, death within hours is possible Dental disease is the MCC: infected or recently extracted tooth in almost all cases Lower 2nd and 3rd molars are the MC teeth afftected Dentoalveolar abscesses may easily break through the relatively thin cortex of the mandible below the mylohyoid ridge and infect the submandibular spaace Other causes: mandible fracture, FB or laceration to floor of the mouth, tongue piercing, traumatic intubation/bronch, oral Ca that gets infected, OM, submandibular sialoadenitis, PTA, furuncle, infected thyroglossal cyst, sepsis Polymicrobial: aerobes/anaerobes (staph, strep, bactroides, pseudomonas, klebsiella, candida) CLINICAL FEATURES Sublingual and submaxillary space infections leads to edema and soft tissue displacement which may result in airway obstruction Symptoms: dysphagia, neck swelling, neck pain, dysphonia (hot-potato), odynophagia, dysarthria, drooling, tongue swelling, pain in floor of mouth, restricted neck movement, sore throat, history of dental extractions/dental pain, foul taste in mouth; air release, creptius, unilateral pharyngitis in any one with recent dental extraction is a clue PE: bilateral submandibular swelling and elevation or protrusion of the tongue, elevation of the floor of the mouth, posterior displacement of the tongue, woodyconsistency of the floor of the mouth, tense edema and brawny induration of the neck above the hyoid (bull neck), marked tenderness of neck, subQ emphysema of neck, trismus, fever, cervical LN, percussion tenderness over teeth

DIAGNOSIS Five diagnostic criteria Cellulitis with little or no pus present in the submandibular space Bilateral cellulitis Gangrene present with serosanguinous, putrid fluid Connnective tissue, fascia, muscle involvement but glandular tissue spared Cellulitis spread by continuity and not by lymphatic vessels Investigations Lab not very helpful Fluid for culture and gram stain Xrays: swelling of affected area, gas collections, panorex may demonstrate periodontal abscess and other dz Ultrasound: cellulitis versus abscess Differential Dx Deep cervical node suppuration, PTA, other deep neck abscesses, parotid abscess, submandibular gland abscess, oral cancer, angioedema, submandibular hematoma, laryngeal diptheria MANAGEMENT Airway

Airway obstruction and asphyxiation is the MCC of death Airway may obstruct rapidly Continuous monitoring essential Stridor, tachypnea, dyspnea, inability to handle secretions are indicators of impending airway obstruction Fiberoptic nasotracheal intubation is the preferred method of intubation Definitive therapy Antibiotics: high dose penicillin + flagyl or ptip-tazo or clinda Steroids: unknown role Surgery: incision and drainage if failure of antibiotics, crepitus and purulent collections Dental extraction Complications Spread of infection: deep spaces of neck, empyema, mediastinitis, mediastinal abscess, pericarditis, aspiration pneumonia, lung abscess IJ thrombosis, carotid artery erosion, bacteremia, sepsis, subphrenic abscess, necrotizing fascitis, spontaneous pneumothorax Disposition Admission, iv abx, ENT consult, +/- ICU monitoring

SINUSITIS
PRINCIPLES OF DISEASE Definition: inflammation of one or more of paranasal sinuses; acute < 4/52, chronic> 3/12 Common, viral URTIs complicated by sinusitis in 0.5 - 2.0% Viral sinusitis 200Xs more common than bacterial sinusitis Pranasal sinuses: frontal, maxillary, ethmoid, sphenoid based on which bone they are in Maxillary sinus: triangular, base being the lateral nasal wall and apex extending into the zygoma Ethmoid: anterior and posterior, 2 - 8 anterior air cells and 1 - 8 posterior air celss Ethmoid: blood supply connects tot eh opthalmic vessels and cavernous sinus; dangerous re spread tot eh orbit or CNS Frontal: variable pneumatization from aplastic to extensive; bony septum between left and right; Sphenoid: bony septum, optic nerve and carotied artery occupy the lateral walls of the sphenoid sinus Ethmoid and maxillary sinuses are present at birth Sphenoid sinuses start to develop at 2yrs and not well developed until 6 yrs - 12 yrs Frontal sinuses start to develop at 2 yrs, are small until 6 years, not full developed until teens Medial meatus: drainage for the maxillary, anterior ethmoid, frontal sinuses; located b/w the inferior and middle turbinates; this area is the ostiomeatal complex and is the focal point of sinus disease Superior meatus: drainage for the posterior ethmoid Sphenoid sinus drains just above th superior turbinate Healthy sinus depends on patent ostia with free air exchange and mucus drainage so that it does not accumulate mucus and remains sterile. URTI and allergic rhinits are the MCC of ostial obstuction with resultant sinusitis Ciliary abnormalities are also important: URTI, genetic syndromes Compromised drainage leads to resorption of air, lowers oxygen tension, increased metabolism, lowers the pH, bacterial introduction by coughing or blowing nose, inflammation and bacterial overgrowth Allergic sinusitis: sneezing, itchy eyes, allergen exposure, prior episodes Viral sinusitis up to 200Xs more common than bacterial Bacterial pathogens: pneumococcus, Hflu (50% together), Moraxella catarrhalis (10%) are primary bacteria; anaerobes, streptococcal species, staph aureus more important in chronic sinusitis (polymicrobial often associated with dental disease); pseudomonas (HIV and CF) Immunocompromised: aspergillus, candida, histoplasma, blastomyces, coccidioides, cryptococcus, rhizopus, etc (especially with DKA) Mucormyocosis Invasive, aggresive fungal sinusitis in the Immunocompromised Fever, localized nsal pain, cloudy rhinorrhea, grey/friable/anesthetic terbinates that do not bleed because of angioinvasion (may be necrotic and black tissue) Risk Factors Medical conditions: resp infections, allergic rhinitis, CF, immunodeficiency,

Wegeners syndrome, Kartageners syndrome Irritants: smoke, polution, chorine, cocaine Anatomy: deviated septum, adnoidal hypertrophy, immotile cilia, polpys, tumors, foreign bodies, NG tubes Trauma: facial fractures, dental procedures, diving

CLINICAL FEATURES Symptoms Worsening symptoms after 5 days or persistent after 10 days Double sickening: cold who improves initially only to have worsening sinus congestion and discomfort Nnasal congestion, nasal obstruction, mucopurulent discharge, post-nasal drip that may lead to cough, pressure/pain over the involved sinus, malaise, fever Pain over the affected sinus is the main symptom Sphenoid sinus: vague bitemporal h/a or various focal points anywhere in head Maxillary sinusitis: pain over the zygoma, canine or bicuspids, or periorbitally Ethmoid sinusitis: medial canthal pain and periorbital or temporal headache Chronic Sinusitis: slow onset, prolonged duration, recurrence; symptoms similar to acute but may also have cough, fetid breath, laryngitis, bronchitis, worsening asthma Pediatric sinusitis symptoms: more nonspecific; persitant URTI X 10 - 14 days with persistent nasal discharge and continued unwell state (+/- fever, irritabiliby, lethargy, cough, poor feeding) -----> consider foreign bodies, asthma, tumors, polyps, CF Physical Examination Periorbital edema or other facial swelling Tenderness by palpation or percussion over the maxillary or frontal sinus (no way to palpate the ethmoid or sphenoid sinuses) Maxillary teeth tenderness (10% related to dental infection) Malodorous breath in absence of other cause Anterior rhinoscopy (est performed after application of topical decongestant) Erythema and edema Mucopurulent discharge in nose Mucopurulent discharge from middle meatus or sinus ostia Anatomic anomalies (polyps, deviated septum) Transillumination How: dark room, light against infraorbital rim and look in pt mouth to see how much light is transmitted through maxilla (or can put light in mouth); place at supraorbital rim and aim toward frontal sinus Only 55% of patients with findings on CT have findings on transillumination and CT is nonspecific :. transillumination is not sensitive Interobserver reliability 60% Questionable role in adults No role in kids < 9 b/c thick bone and soft tissues, different rates of sinus development b/w kids and b/w sides, lack of aeration of sinuses

RADIOLOGY Plain films

What to look for: sinus opacification, air - fluid level (insensitive but more specifice), mucous membrane thickness > 5 - 6mm (sensitive but nonspecific) What views can be done: Waters view (maxillary sinusitis), Caldwell (ethmoid and frontal), Lateral (sphenoid), submentovertex (sphenoid and ethmoid) What views should be done: Waters view alone; add other views if Waters is inconclusive or specifically looking for non-maxillary sinusitis Overall 50% accurracy Xrays: false -ve in up to 40%, poor correlation with CT, sensitivities reported range from 40 - 90% and specificity 75 - 100% but CT or MRI is used as gold standard which is problematic Who should be Xrayed: if diagnosis uncertain but possible based on clinical criteria (2-3 out of 5 above criteria) Be more aggressive with Xrays in looking for frontal sinusitis b/c of important consequences of rupture into CNS Xrays in < 1yo not useful b/c of false opacification due to facial asymmetry and redundant mucosa Axial or coronal CT Considered the radiological gold standard (A/F levels, sinus opacification, sinus wall displacement, 4 mm or greater mucosal thickening) Need iv contrast to look for orbital or CNS complications CT is sensitive but lacks specificity thus CT findings need clinical correlation (CT findings suggestive of sinusitis as incidental findings and in 84% of early cold symptoms) Indications for CT: chronic sinusitis, suspected complication, failure of medical treatment

DIAGNOSIS Clinical diagnosis: definitive diagnosis is difficult No single symptom or sign is diagnostic Antral aspiration is gold standard: difficult, uncomfortable, maxillary only, not useful in ED Nasal and nasopharyngeal cultures correlate poorly with antrostomy cultures Culture and biopsy only for chronic and suspected fungal sinusitis Endoscopy of sinuses can be done Ultimately: clinical diagnosis; minimize testing as sensitivity and specificity are lacking Differential dx Rhinits: increased response to deongestants, clear nasal discharge, absence of pain, no ostial obstruction and thus no facial pain Tension headache, vascular headache, FB, dental disease, brain abscess, epidural abscess, meningitis, subdural empyema

Making the Diagnosis by History and Physical Examination: Williams 1992 Looked at various findings on hx and physical exam Note that sinusitis gold standard was defined radiographically (sinus opacification, air - fluid level, mucous membrane > 6 mm thick) Symptom Sensitivity Specificity - maxillary toothache 18 93 - nonresponse to decongestants 41 80 - hyposmia 56 64 - colored discharge 72 52 - myalgias 48 66 - cough 70 44 - preceeding URTI 50 61 - headache 68 30 - facial pain 52 43 - painful chewing 13 84 Signs - purulent secretion 51 76 - sinus tenderness 48 65 - abnormal transillumination 73 54 - temp > 38 16 83

CMAJ 1997: Likelihood of acute sinusitis as determined by number of signs and symptoms.... Symptom/Sign LR +ve Maxillary toothache 2.5 History of colored nasal secretion 1.5 Poor response to decongestant 2.1 Abnormal transillumination 1.6 Purulent nasal secretion visualized 2.1 Number of findings 0 1 2 3 4 0.1 0.5 1.1 2.6 6.4

Management based this 0 - 1: ruled out based on clinical features, no Xray 2 - 3: diagnosis unclear, sinus Xray recommended 4 - 5: actue bacterial sinusitis ruled in, no Xray

MANAGEMENT MOST will resolve spontaneously (60%), viral and bacterial Antibiotics Antibiotics should be started if suspecting bacterial etiology Treatment approach similar to otitis media Amoxicillin X 10/7 is drug of choice (may be ineffective if B-lactamase common): adequate coverage, best activity against penicillin intermediate B-lactam resistant pneumococcus, few side-effects, low resistance potential, no other antibiotic has been shown to be superior to amoxil in RCTs Consider high dose amoxil for high risk children b/c of abx use w/i 3 months or day care (90 mg/kg/day tid instead of 40 mg/kg/day tid) Penicillin allergic: trimethoprim - sulfamethoxazole, azithromicyin, cefuroxime Rx failure after 7days: amoxicillin-clavulanate, cefuroxime, clindamycin, ciprofloxacin, clarithromycin, +/- flagyl Chronic: cover B-lactamase and anaerobes Complications: iv abx, admission, ENT consultation Decongestants /Adjuncts Reduces tissue edema, facilitates drainage, maintains patency of ostia NO good scientific evidence of effectiveness Topical and systemic should be used inconjunction Topical: phenylephrine 0.5%, oxymetazolin 0.05%; use for 3 - 5 days only b/c extended use leads to rhinitis medicimentosa Oral: pseudoephrine, phenylpropanolamine (caution with TCA, MAO-I, nonselective Beta-blockers) Antihistamines contraindicated unless allergic sinusitis (impedes sinus drainage) Steroids for chronic and allergic sinusitis (controversial) Steam, humidifiers, nasal saline spray may help (indeterminate) Disposition Most discharged home with oral abx Immunocompromised, severe co-morbid illness, toxic, poor follow up, inability to tolerate po meds ----> admission for iv abx and observation Failure of definitive therapy means chronic sinusitis and ENT referral Frontal and sphenoid sinusitis with A/F levels may require hospitalization Fungal sinusitis requires admission, ENT consultation, iv antifungals, surgical debridement > watch for mucormyocosis which is aggressive and dangerous RTED for severe headache, neurologic symptoms, visual changes ENT referral: > 4 episodes of bacterial sinusitis per year, chronic sinusitis, anatomic abnormalities, complications COMPLICATIONS Facial cellulits, periorbitral cellulitis, periorbital abscess, optic neuritis, blindneess, orbital abscess Orbital complications: marked swelling, decreaed ocular motility, decreased visual acuity Intracranial: meningitis, cavernous sinus thrombosis, epidural or subdural empyema, brain abscess; suspect with neuro s/s,

MISCELLANEOUS
LINGULAR TONSILLITIS Rare cause of pharyngitis that usually occurs in patients who have had their palatine tonsils removed Lingual tonsils are a collection oof nonencapsulated lymphoid tissue most commonly located symmetrically on either side of the midline just below the inferior pole of the palatine tonsil and anterior to the vallecula at the base of the tongue This lymphoid tissue may enlarge after puberty, repeated infections, tonsillectomy Sore throat that worsens with movement of tongue and phonation May have classic hot potato voice and complain of feeling a swelling in the throat Dysphagia, fever, resp distress, stridor may be present PE: normal appearing pharynx with mild hyperemia Laryngoscopy: edematous lingual tonsil covered with a purulent exudate Lateral neck Xray: normal epiglottis and aryepiglottic folds with a scalloped appearance of the anterior surface of the vallecula caused by the enlarged tonsils Mx Airway, abx, supportive AWO possible but rare Humidified oxygen, hydration, corticosteroids Nebulized epi for AWO may help Antibiotics as per pharyngitis LARYNTITIS Hoarseness and aphonia Viral URTI Bacterial possible (strep, diptheria) TB, syphilis, leprosy, actinomyocosis, other fungal rare Consider epiglottitis Antibiotics only if suspecting bacterial VIRAL RHINITIS > 100 viruses: rhinovirus, parinfluenza, RSV, etc Winter peak incidence Transmission via resp secretions Incubation 3 - 7 days Duration 3 - 7 days Antipyretics, nasal saline drops, humidified air, decongestants

ORAL ANGIOEDEMA: UVULITIS IgE mediated reaction characterized by edema of dermis especially in face/neck Non-pruritic, well-demarcated, localized, nonpitting edema of deep subcutaneous tissue that primarily involves the periobital, perioral, intraoral regions CLUE: angioedema is NOT itchy Note: facial findings can be lateralized (one side only) Heriditary angioedema (HAE) Autosomal dominant condition lacking C1 esterase inhibitor or functional

deficiency Cardinal s/s: edema of face, airway, or extremities, agdominal pain associated with N/V/D Precipitated by trauma, stress Airway management is cornerstone of approach Acute management as per anaphylaxis although does not usually respond well to epinephrine, antihistamines, or steroids FFP contains some C1 inhibitor; case reports of effectiveness C1 esterase concentrate replacement is probably the most important treatment in a known HAE High dose epi may be effective Acquired Angioedema ACE-I, NSAIDS, sulpha drugs, others Idiopathic is common Angioedema occurs with ACE - Is in 0.2% and can be at any time (including years after onset); more common in blacks Mechanism: ? inhibition of bradykinin metabolism Management as above: consider FFP, d/c offending agent Management Severe: treat as per anaphylaxis, intubate ASAP Moderate: treat as per anaphylaxis, watch airway closely Mild Bendadryl Steroid X one dose Monitor 4-6hrs for progression