* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download neck infection File - Ain Shams University
Hepatitis C wikipedia , lookup
Middle East respiratory syndrome wikipedia , lookup
Trichinosis wikipedia , lookup
Neonatal infection wikipedia , lookup
Herpes simplex wikipedia , lookup
Onchocerciasis wikipedia , lookup
Human cytomegalovirus wikipedia , lookup
Herpes simplex virus wikipedia , lookup
Marburg virus disease wikipedia , lookup
African trypanosomiasis wikipedia , lookup
Typhoid fever wikipedia , lookup
Gastroenteritis wikipedia , lookup
Clostridium difficile infection wikipedia , lookup
Hospital-acquired infection wikipedia , lookup
Oesophagostomum wikipedia , lookup
Visceral leishmaniasis wikipedia , lookup
Antibiotics wikipedia , lookup
Hepatitis B wikipedia , lookup
Rocky Mountain spotted fever wikipedia , lookup
Traveler's diarrhea wikipedia , lookup
Schistosomiasis wikipedia , lookup
Leptospirosis wikipedia , lookup
Neck Infections Magdy Amin Riad Professor of Otolaryngology . Ain Shams University Senior Lecturer in Otolaryngology. University of Dundee Etiology • Infectious – Viral:Adenovirus, Epstein Barr virus, Coxsackie A, Herpes simplex – Bacterial: Group A Strep, other Streptococci, Mycoplasma, Fungal: Candida • • • • • • • Peritonsillar abscess ,Parapharyngeal abscess,Retropharyngeal abscess Neoplasm Gastric Reflux Mouth-breathing Smoking Sinusitis Foreign Body Sore throats Pharyngitis infective viral : herpetic, influenza, HIV fungal : candida non-infective fumes, smoking nasal obstruction reflux leukaemia foreign body Sore throats • Tonsillitis • bacterial : strep (gonococcus, diphtheria) • viral : EBV • Epiglottitis • Neoplasm • Post tonsillectomy Tonsillitis • Acute • Recurrent acute • Chronic (?) Pharyngitis and Tonsillitis. • Most sore throats are caused by viruses and thus don't require antibiotics. • Acute tonsillitis and pharyngitis present with throat pain that may radiate to the ears and dysphagia. • Fever is more commonly associated with group A beta-hemolytic streptococci (Streptococcus pyogenes), which accounts for about 15% of all cases. Pharyngitis and Tonsillitis. • The proportion of pharyngitis and tonsillitis that is cause by group A streptococci is related to the patient's age. • In children 6 to 15 years of age, approximately 50% of the pharyngitis that presents for care is caused by streptococci. Classic streptococcal symptoms • include sore throat, dysphagia, fever, malaise, and headache in the absence of other URI symptoms. • Occasional patients will have abdominal pain and vomiting. • Signs include exudative erythema, palatal petechiae, and tender anterior cervical adenopathy. Other causes of exudative pharyngitis • include Mycoplasma, Epstein-Barr virus, adenovirus, influenza virus, Arcanobacterium hemolyt-icum, gonococcal pharyngitis, Noninfectious causes of Sore throat • include mouth-breathing secondary to nasal obstruction (as with a URI). • Mouth breathing classically presents as a sore throat that is worst in the morning and abates as the day progresses. • carotidynia, an ill-defined entity characterized by tenderness over the carotid artery, painful swallowing, and pain radiating to the ears. • Carotidynia will respond to NSAIDs; antibiotic treatment is not indicated. • Consider adult epiglottitis in the febrile adult with severe sore throat, trouble in swallowing and anterior neck tenderness. • Also consider peritonsillar abscess. Acute tonsillitis - investigations • FBC – WCC : lymphocytes, neutrophils • Glandular fever screening test – eg Monospot • Microbiology (?) – swab, pus aspirate • CT (?) • Tonsil biopsy (??) Testing for streptococci. • Rapid streptococcal tests demonstrate a sensitivity of approximately 95%. • Avoid false negatives with proper sampling technique (i.e., vigorous samples of both tonsils and posterior pharynx while avoiding the uvula and soft palate as they dilute the sample). Who to treat. • The central question in pharyngitis is deciding which patients require antibiotics and doing so in a cost-effective manner keeping in mind antibiotic resistance. Adults. • A reasonable approach in adults is to treat all patients with fever, systemic symptoms, and tonsillar exudate with antibiotics because they are likely to have streptococcal pharyngitis. Adults. • Patients exhibiting little or no evidence suggestive of bacterial pharyngitis (those with concurrent URI symptoms, obvious cause such as mouth breathing, little or no visual evidence of pharyngitis, absent adenopathy) may be reassured and treated symptomatically with lozenges or addressing the underlying problem (humidity, nasal congestion, etc.). Adults. • Streptococcal cultures or quick streptococcal tests can be reserved for those patients in whom the diagnosis is not clear or has an intermediate probability. • Testing for mononucleosis can be reserved for those with appropriate adenopathy and those who do not respond to conservative treatment Children. • Antibiotics should NOT be given in the absence of a definite diagnosis. This selects for resistance, carries a risk of allergy, and creates unnecessary cost. • Antibiotics started within 9 days of onset are effective in preventing renal failure and rheumatic fever. Children. • Many clinicians advocate empiric therapy with antibiotics and systemic analgesia while awaiting culture results. • quick streptococcal test followed by a pharyngeal culture for group A betahemolytic streptococci if the quick streptococcal test is negative. Complications of tonsillitis • • • • • Peritonsillar cellulitis Peritonsillar abscess (quinsy) Parapharyngeal abscess Cervical node abscess Airway obstruction • Recurrent / chronic tonsillitis • Tonsillolith formation Acute tonsillitis - treatment • Antibiotics – eg penicillin (NB not amoxycillin/augmentin) • • • • Analgesia Fluids Steroids (?) Surgery – drainage of pus – tonsillectomy Treatment. • Treat for entire 10-day course. • Clinical/bacteriologic cure >90% (shorter courses less effective). • There are no isolates of group A beta-hemolytic streptococci that are penicillin resistant. However, there are some isolates resistant to macrolides • Some resistance to treatment may be noted if the patient is simultaneously colonized with H. influenzae that is beta-lactamase producing. Treatment. • The first drugs of choice are penicillin (that is, Pen-VK 500 mg PO BID or TID or Penicillin G Benzathine 1.2 million U IM in adults, 600,000 U IM in children) • Erythromycin 250 to 500 mg PO Q6h for 10 days. • Consider amoxicillin for young children since it is more palatable. • If these fail, a first-generation cephalosporin (such as cephalexin 250 mg PO QID or 500 mg PO BID) may be used. • Alternatives include amoxicillin/clavulanate, azithromycin, clarithromycin, cefixime, cefuroxime and clindamycin Indications for tonsillectomy • Recurrent acute tonsillitis – 6 in 1 year – 4 per year for 2 years (depending on age and severity) • Obstruction – OSA, airway obstruction (acute) – Dysphagia, speech difficulty • Recurrent quinsy • Biopsy Supportive measure 1. Supportive measure: rest, fluids, analgesics, Tantum oral rinse 2. Return for reassessment in 48 hrs if no better 3. Children may return to school after 72 hours of therapy. 4. Suggest that patients obtain a new toothbrush since strep can be harbored on toothbrushes and lead to recurrent disease. 5.Treating other family members empirically is controversial. When to treat with antibiotics? • Tonsillar exudate • Enlarged anterior cervical nodes • Fever > 38oC Infectious Mononucleosis Etiology • Epstein Barr virus Clinical course • • • • Incubation period: 4-8 weeks Prodrome: Malaise, anorexia, fever Few days later: Pharyngitis and lymphadenopathy Signs: – – – – Fever up to 40oC in 90% Cervical lymphadenopathy in 90% Pharyngitis in most, exudative commonly Maculopapular eruption with ampicillin in 90% of those to whom it's given – Splenomegaly in 50% – Others: hepatomegaly, palatal petechiae, rash, periorbital edema (not common) • Course: Pharyngitis lasts 7-10 days, Lymphadenopathy 7-14 days, Malaise 4 weeks or more Diagnosis. • Diagnosis is by CBC revealing a lymphocytosis with atypical lymphocytes. • This will be present in most of the mono syndromes. • A positive heterophil antibody (monospot test) may or may not be present in the early stages of the disease (only 60% by 2 weeks) but will eventually become positive in 90% of young adults. • The heterophil test rarely becomes positive in those <5 years of age. • If there is any doubt, an EBV antibody titer can be performed. • Liver enzymes are almost uniformly elevated. Heterophil negative mononucleosis • the same symptoms may be caused by other organisms including CMV, Toxoplasma, acute HIV infection, or leptospirosis. • Mononucleosis is most common in young adults, and most of the adult population has had clinically inapparent EBV disease as evidenced by antibody titers. • If patients with mononucleosis are treated with ampicillin or similar drug, they will almost uniformly develop a morbilliform rash. • Rarely EBV may cause genital ulcerations Lab investigations • Heterophile antibodies (Paul Bunnell or Monospot tests) • Atypical lymphocytosis • Elevated hepatic transaminases Complications • Hematologic: autoimmune hemolytic anemia, thrombocytopenia • Hepatitis • Splenic rupture (no contact sports for 8 weeks after onset of illness) • Neurological: Cranial nerve palsies, encephalitis • Airway obstruction Treatment • Treatment is symptomatic, and the illness generally resolves within 2 weeks. • Supportive (rest, analgesics, antipyretics, fluids, etc.) • Steroids for: airway obstruction, autoimmune hemolytic anemia/thrombocytopenia . prednisone has been shown to reduce the length of the illness. Treatment • A steroid burst of 30 to 60 mg of prednisone PO per day for 3 days or 4 mg of methylprednisolone PO TID for a week may be used but should be reserved for treating the complications of mononucleosis, including respiratory obstruction, myocarditis-pericarditis, aseptic meningitis, and hemolysis-thrombocytopenia. • Contact sports or activities producing other forms of trauma should be avoided because of the risk of splenic rupture. • Spontaneous rupture can occur in 0.1%-0.5% of documented mononucleosis Peritonsillar Abscess (Quinsy) • Unilateral peritonsillar suppuration, predominantly between tonsillar capsule and muscular wall of pharynx (superior constrictor) • Pushes the uvula across the midline. • Trismus (masseter spasm so they can't open their mouth). Clinical Features Typical picture: • Unilateral throat pain, dysphagia, drooling, muffled voice ("hot potato" voice), and fever • sore throat not resolving despite antibiotics • Not necessarily associated with recurrent tonsillitis (only 30% have history) Diagnosis • Pus can be aspirated with a needle • Pus can be visualized with CT scan or intraoral ultrasound (neither is used routinely, except in excluding other conditions or assessing spread of suppuration ) What causes it? • Typically a mixed bacterial infection, most common species are Bacteroides (anaerobe) and Streptococci (aerobe). Management The 3 main methods are: • 1. Needle aspiration of pus • 2. Incision and drainage • 3. Abscess Tonsillectomy (either unilateral or bilateral) • 4. Antibiotics (penicillin + flagyl ) or Clindamycin since anaerobes are so common). • 1. and 2. are often combined with tonsillectomy several weeks later (once acute infection is resolved). 1. Needle aspiration • Pro: Easy to do, safe and Inexpensive; Requires only local anesthesia; >90% resolution rate • Con: Up to 15% require 2nd aspiration to resolve; Requires patient cooperation 2. Incision & drainage • Pro: Requires only local anesthesia; Get wider drainage than needle aspiration • Con: Increased morbidity over needle aspiration; 3. Abscess Tonsillectomy • Pro: Get complete drainage; Prevents recurrence; Fewer days of morbidity than if tonsils are removed after resolution of acute infection; Literature shows no increased morbidity over elective tonsillectomy (ie: blood loss, complications are comparable) • Con: require experienced surgeons; difficulty intubating Prognosis • 15% recur, and these are typically young (age 16-30) and have a history of recurrent tonsillitis For recurrent disease streptococcal disease • Attempt to identify carrier in family with throat and nasal cultures. • Treat any identified carriers. • Consider IM treatment to rule out noncompliance as a reason for treatment failure. • Change all toothbrushes. Scarlet fever. • Scarlet fever is a self-limited systemic manifestation of streptococcal pharyngitis. • Symptoms include "strawberry tongue" (a red tongue with red or whitish papillae), a fine "sandpaper" rash that appears as a diffuse erythema beginning and concentrating in the skin folds (especially axillary) but spares the palms and soles. • Frequently, there is circumoral pallor. • A fine desquamation that begins on the fingers and toes may occur. • The differential diagnosis includes Kawasaki's disease. Tonsillectomy Indications 1. Obstructive tonsils: associated with sleep apnea, dysphagia, speech defects, failure to thrive 2. Recurrent sore throats – – – 6 sore throats in 1 year 4 in each of 2 years 3 in each of 3 years Associated with: – – – – Fever > 38oC Swollen anterior cervical nodes Tonsillar exudate or Positive Strep culture Key feature: recurrent sore throats which have significant impact on patient's life: lots of missed time from work or school, association with febrile seizures, development of multiple antibiotic allergies, development of Strep complications etc. 3. Suspicion of tonsillar cancer Tonsillectomy • Patient is laid supine and operator sits at head of bed • Inserts mouth gag • Grasps tonsil with a tenaculum, retracts it medially, and dissects it from tonsil bed (constrictor muscles) • Hemostasis in tonsil bed (various methods: cautery, pressure, ligatures, etc.) • Suctions clear oropharynx Complications 1. Hemorrhage (most common complication; estimated at 23%) – – – – Intra-op Primary (within first 24 hrs) Secondary (between 24 hrs and usually at most 10 days) Treatment of bleeds: 1. Local pressure with towel holder and gauze (can use epinenephrine on gauze) -Hold for 10-20 minutes 2. Chemical or electric cautery 3. Cold water rinses 4. Start IV fluid and antibiotics Complications 2. Dehydration (common in kids who won't eat due to pain) 3. Weight loss (also common in kids who won't eat due to pain) 4. Fever (not common: usually related to local infection) Complications 5. Post-op airway obstruction (due to edema, hematoma, aspirated material) 6. Local trauma to oral tissues 7. Tonsillar remnants 8. Death (uncommon; usually related to bleeding or anesthetic complications) Post-op Care 1. Pain control 2. Hydration 3. Adequate diet There's no evidence that a special diet is required; obviously soft foods will go down easier 4. No smoking (delays healing) 5. No heavy lifting/ exertion for 10 days (associated with late hemorrhage) 6. Warn patients that pain will first abate over 5 days or so, then will increase for a day or 2 before completely disappearing (related to eschar separation) Bacterial Cervical Adenitis • Tender, enlarged nodes • Organisms- Staphylococcus, Group A Streptococcus • Treatment- Beta-lactamase resistant antibiotic • Fine Needle Aspiration Infectious and Inflammatory Lesions • 40% of infants have palpable LAD • 55% of pediatric patients. • Most commonly involving the submandibular and deep cervical nodes. Branchial Cleft Cysts Branchial Cleft Cysts • Branchial cleft anomalies • 2nd cleft most common (95%) – tract medial to cnXII between internal and external carotids • 1st cleft less common – close association with facial nerve possible • 3rd and 4th clefts rarely reported • Present in older children or young adults often following URI Branchial Cleft Cysts • Most common as smooth, fluctuant mass underlying the SCM • Skin erythema and tenderness if infected • Treatment – Initial control of infection – Surgical excision, including tract • May necessitate a total parotidectomy (1st cleft) Thyroglossal Duct Cyst Thyroglossal Duct Cyst • • • • • Most common congenital neck mass (70%) 50% present before age 20 Midline (75%) or near midline (25%) Usually just inferior to hyoid bone (65%) Elevates on swallowing/protrusion of tongue • Treatment is surgical removal (Sis trunk) after resolution of any infection Aphthous Ulcers • Aphthous ulcers are recurrent painful lesions of non-keratinized mucosa that vary in size and may appear as solitary lesions or in clusters (herpetiform ulcerations). • The typical appearance is of an erythematous periphery with a white or yellow depressed center. • Healing within 10 to 14 days is the rule. Aphthous Ulcers Causes. • Viral (coxsackievirus, herpesvirus), • systemic illness (Crohn's disease, lupus, Behçet's disease, erythema multiforme), • toothpaste (sodium lauryl sulfate), • stress, and smoking. • Dental trauma, • vitamin B12, folate, and iron deficiency have also been implicated in some cases. Treatment. • Symptomatic relief can be obtained by the use of diphenhydramine elixir as a mouth rinse that is not swallowed. • Alternatively, viscous lidocaine 2% can be used in the adult. • This may suppress the gag reflex, however, and may result in systemic toxicity in children. • The application of a topical steroid (triamcinolone as 0.1% in Orabase) or steroid mouth rinse (betamethasone syrup) may accelerate recovery. Treatment. • Herpetiform ulcerations may respond to tetracycline syrup, which is used as a mouth rinse and then swallowed. • oral prednisone may be required in some cases. • A mixture of nystatin 12,500 U, diphenhydramine 1.25 mg, and hydrocortisone 0.25 mg/ml has been used as a "shotgun" solution. Some also include tetracycline syrup in the mixture. Herpes simplex virus • infrequently causes recurrent intraoral herpes. • The lesions occur as a cluster of vesicles that rupture leaving superficial ulcerations that remain for 3 to 10 days. • Keratinized tissues, attached gingiva, and the hard palate are often involved, and such features distinguish herpes from aphthous ulcers. • Treatment with acyclovir may decrease healing time.