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CASE: HPI  BV. 14 year old F  Remote tonsillectomy and ESS x 2  In the ED with 9 d h/o sore throat and odynophagia. Antecedent ‘head cold’ 4 d prior,

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Presentation on theme: "CASE: HPI  BV. 14 year old F  Remote tonsillectomy and ESS x 2  In the ED with 9 d h/o sore throat and odynophagia. Antecedent ‘head cold’ 4 d prior,"— Presentation transcript:


2 CASE: HPI  BV. 14 year old F  Remote tonsillectomy and ESS x 2  In the ED with 9 d h/o sore throat and odynophagia. Antecedent ‘head cold’ 4 d prior, has since resolved with conservative measures.  Developed intense L otalgia 2 d ago. Treated with amoxicillin for putative AOM → no improvement.  Last night, spiked fevers to F. Had emesis. Not tolerating PO. Courtesy of BCM Dept. OTO-HNS. Grand Rounds Archives. 16 Sept 2010

3 CASE: PHYSICAL  VITALS: T | BP 138/66 | HR 116 | R 24 | SpO2 97% RA  GEN: Sitting comfortably. Phonation is normal. No drooling.  EARS: L pre-auricular tenderness. External ears normal. TMs quiet bilaterally.  NOSE: Normal nares, septum, and turbinates.  MOUTH: Mandible centered. Moderate trismus. Tonsils surgically absent. Posterior pharynx with L > R fullness, no erythema or exudates.  NECK: No meningismus. Mildly restricted active ROM to L. Tenderness at Level II on L > R.  PULM:Respirations relaxed. No stridor. Lung fields clear throughout.  NEURO: Mental status is clear. No lateralizing deficits.

4 CASE: LABS and STUDIES  CBC: WBC 21,000 with 85% PMNs, 15% band forms  BMP: Na 149, K 5.1, Cr 1.4, BUN: 30  Rapid Strep: Non-reactive  AP Neck Film: Unremarkable  CXR:Unremarkable

5 Victor Tseng, MS-3 OTO-HNS Subrotation

6  DEEP NECK SPACES: Eleven anatomic or potential compartments created by interfascial planes within the neck  DEEP NECK INFECTION: A supperative (usually bacterial) infection within the deep neck spaces of the deep cervical fascia DEFINITIONS





11 A MENU OF SPACES: PEARLS  SUPRAHYOID  PARAPHARYNGEAL (PP): A major nexus of contiguous spread. Transmits the carotid sheath. Isolated involvement is uncommon.  SUBMANDIBULAR (SM): Infection may lead to upper airway obstruction  MASTICATOR: Most closely associated with trismus. Almost exclusively secondary to odontogenic causes.  PAROTID: Most likely seen in dehydrated and decrepit patients with poor dentition  TEMPORAL: Between temporalis fascia and temporal bone periostium  PERITONSILLAR (PTS): Most common site overall, but not aknowledged as a true DNI, since it is not defined by fascial apposition  INFRAHYOID  RETROPHARYNGEAL (RPA): Extends from skull base to level of carina (T2). Does not communicate with the pleural space.  DANGER: Infection easily escapes into the mediastinum and pleural space  PREVERTEBRAL (PV): Extends to coccyx and may develop into psoas absess.  CAROTID: Associated with IVDA and septic thromboembolism  PRETRACHEAL (PT): Associated with anterior perforation of the esophageal wall

12 HOOFBEATS: COMMONS  PERITONSILLAR (49%)  RETROPHARYNGEAL (22%, 43% non-PTS)  Most common DNI across all age groups  But it is predominantly a pediatric infection  SUBMANDIBULAR (14%, 27% non-PTS)  PAROTID (11%)

13 RETROPHARYNGEAL ABSCESS (RPA)  EPIDEMIOLOGY  > 75% of cases occur 75% of cases occur < 6 years old. 50% of cases occur by 12 mos.  Overall (treated) mortality approximately 1%  ETIOLOGY  Children (< 18 years): 60% related to supperative LAD due to URI, AOM, acute sinusitis  Adults: Mostly due to trauma, foreign body, instrumentation, or contiguous extension from primary DNI  MICROBIOLOGY  >90% are polymicrobial. Average n = 5 microbes isolated from culture.  >50% of isolates grow anerobes  S. pyogenes > S. aureus > oropharyngeal anaerobes > H. influenzae  PATHOPHYSIOLOGY  supperative lymphadenitis → organized phlegmon → mature abscess  Morbidty and mortality is due to development of complications

14 RETROPHARYNGEAL ABSCESS (RPA)  CLINICAL PRESENTATION  Adults: Sore Throat > Fever > Dysphagia > Odynophagia > Nuchal Pain > Dyspnea > Hoarseness  Children: Sore Throa (84%) > Fever (64%) > Odynophagia (55%) > Cough  Infants: Neck Fullness (97%) > Fever (85%) > Poor PO (55%)  DIFFERENTIAL DIAGNOSIS  Epiglottitis, PTA, Croup, Diphtheria  Angioedema  Respiratory lymphagiomas or hemangiomas  Traumatic esophagus or airway, foreign body impaction  COMPLICATIONS  Acute Mediastinitis: very high (>50%) mortality  Empyema  Pericardial effusion with tamponade physiology  Mass effect: supraglottic airway obstruction (anterior) or epidural abscess (posterior)

15 RETROPHARYNGEAL ABSCESS (RPA)  PHYSICAL FINDINGS  Adults: pharyngeal edema > cervical LAD > nuchal rigidity > drooling > stridor  Children: fever and nuchal rigidity (64%) > retropharyngeal bulge and neck mass (55%) > agitation or lethargy > drooling (22%) > respiratory distress or stridor  Other: dystonic reactions (torticollis), dysphonia (‘hot potato’ voice), trismus  In a drooling or stridorous patient, be minimally invasive when examining the pharynx  LABORATORY  CBC: 20% of cases may not show leukocytosis or relative left shift  Standard GAS rapid throat swab and culture  Blood cultures: rarely return positive growth  Wound culture: 91% sensitivity for polymicrobial infection  CRP and ESR to follow baseline. CRP is actually prognostic of hospitalization legnth.  Pre-operative labs in anticipation of surgical intervention (coagulation panel, metabolic panel, type and cross)

16 RETROPHARYNGEAL ABSCESS (RPA)  IMAGING  Lateral Neck Film: look for widened AP diameter of retropharyngeal tissue. Maximal reported sensitivity of 88%.  CT Neck with Contrast  Most important imaging test to consider  Hypodense lesion of retropharyngeal space with rim enhancement  Absolute Indications: equivocal LNF, negative LNF with high clinical suspicion  Sensitivity 77 – 100%, Specificity 95%  High-Resolution U/S  Maybe used to track abscess during hospitalization. Some anatomic insight into surrounding vascular structures.  Proof of concept. No data to support routine use.  MRI: Not recommended for initial evaluation due to untimeliness  Flexible Endoscopy: not recommended


18  MEDICAL MANAGEMENT PARENTERAL ANTIBIOTIC THERAPY is guided by suspected source of infection!  Must have MRSA coverage if strain is endemic, poor clinical response to clindamycin, or in patients with very severe disease SUSPECTED SOURCEFIRST-LINE THERAPYALTERNATIVE OdontogenicAmpicillin-Sulbactam 3 g IV q6h Penicillin G 2-4 MU IV q4-6h + Metronidazole 500 mg IV q6-8h Clindamycin 600 mg IV q6-8h Imipenem 500 mg IV q6h Meropenem 1 g IV q8h Rhinogenic and OtogenicAmpicillin-sulbactam 3 g IV q6h Ceftriaxone 1 g IV q24h + Metronidazole 500 mg IV q6-8h Ciprofloxacin 400 mg q12h + Clindamycin 600 mg IV q6-8h As above ImmuncompromisedCefipime 2 g IV q12h + Metronidazoole 500 g IV q6h Piperacillin-Tazobactam 4.5 g IV q6h As above

19 RETROPHARYNGEAL ABSCESS (RPA)  SURGICAL INDICATIONS Important: > 50% of patients with uncomplicated RPA achieve spontaneous resolution with medical therapy alone  Respiratory distress  Urgent complication of RPA (e.g. mediastinitis, empeyema, septic thrombophlebitis)  Diameter of abscess > 2 cm on CT Neck  No response to ABx therapy at 48 hrs  SURGICAL APPROACH  U/S guided FNA: preferred in hemodynamically unstable patients, or those with small and accessible loculations  I/D: Usually requires trans-cervical entry. Small abscesses may be drained via trans-oral aspiration.


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