1. Welcome Applicants!! Welcome Applicants!! Morning Report January 26, 2012

2. Retropharyngeal Abscess Not common, but definitely worth knowing about!!

3. Facial Spaces Submandibular Parapharyngeal* Retropharyngeal* “Danger” Prevertebral Peritonsillar* Parotid Masticator

4. Peritonsillar and Parapharyngreal Spaces

5. Retropharyngeal Space

6. Epidemiology Commonly follows URI infection ◦Tonsillitis ◦Pharyngitis ◦Lymphadenitis ◦Sinusitis ◦OM Peak incidence in 3-5 year olds ◦Also peak age group for numerous viral URIs ◦Increased number of LN in the retropharyngeal space

7. *Microbiology POLYMICROBIAL!! ◦Aerobes  Streptococcus viridans  Group A Streptococcus  Staphylococcus aureus  Staphylococcus epidermidis ◦Anaerobes  Bacteroides  Fusobacterium  Peptostreptococcus sp.

8. *Clinical Presentation Neck pain (torticollis) or swelling Fever Sore throat Painful or difficult swallowing Food refusal Change in vocal quality Respiratory distress Trismus Chest pain

9. *Clinical Manifestations

10. Laboratory Evaluation CBC Blood cultures Wound culture (if abscess drained) **If any concern for the patient’s airway, NO labs or imaging until airway is secured**

11. *Imaging Studies

12. *Management Airway, Airway, Airway!! Antimicrobial therapy ◦Empiric coverage for GAS, S.aureus (MRSA), and respiratory anaerobes  Ampicillin-sulbactam or Clindamycin*  +/- Vancomycin or Linezolid  +/- Third-generation cephalosporin ◦Transition to oral ABx can be considered when the patient is afebrile and clinically improved ◦Total length of treatment: 14 days

13. *Mangement Surgical drainage ◦Indications  Airway compromise*  A large (>2cm) hypodense area on CT scan (?)  Failure to respond to parentral ABx therapy* ◦Debate on how to manage retropharyngeal abscess in patients without airway compromise  Only 25-50% patients require surgery  May be appropriate to wait 24-48h on broad- spectrum ABx to assess need for surgery

14. Complications Airway obstruction Septicemia Aspiration PNA Internal jugular vein thrombosis Jugular vein suppurative thrombophelbitis Carotid artery rupture Mediasteinitis Atlantoaxial dislocation

15. A Question… A 3 yo boy presents to your office with a 3 day h/o a severe sore throat, decreased PO intake (especially with solid foods), and pain with swallowing. Nothing in his PMHx is noteworthy, and his immunizations are UTD. On PE, the boy in uncomfortable but alert and does not appear toxic. He is sitting upright holding his neck stiffly, and refusing to open his mouth. His temp is 38.6C. He has no LAD, lungs are CTA, there is no heart murmur and no abdominal organomegaly. Of the following, the test MOST likely to confirm this child’s diagnosis is: ◦A◦A. Cervical LN biopsy ◦B◦B. CT scan of the neck ◦C◦C. Laryngoscopic examination of the airway ◦D◦D. LP ◦E◦E. Sinus radiograph

16. Abscess Location Peritonsillar Parapharyngeal Retropharyngeal Patient Characteristics Ages 15-30Older children and adults Adults and children (3-5 yo) CausesTonsillitis Dental infxns, peritonsillar abscess (parotitis, otitis, mastoiditis) URI, FB/trauma, pharyngitis Microbiology Polymicrobial; Group A Strep, oral anaerobes Polymicrobial; Group A Strep, Strep viridans, S. epidermidis, oral anaerobes Polymicrobial; Group A Strep, Strep viridans, S. aureus, resp. anaerobes Symptoms High fever, odynophagia, unilateral sore throat, otalgia High fever, rigors, dyspnea, dysphagia/ odynophagia

17. Abscess Location Peritonsillar Parapharyngeal Retropharyngeal Signs/PE Unilateral deviation of uvula (unaffected side) Swelling/induration below angle of mandible, medial bulging of pharyngeal wall, resp. distress, neuro signs# Anterior bulging of the pharyngeal wall neck swelling or torticollis, stridor, tachypnea Evaluation CTABCs, CTABCs, ?lateral neck XR, CT Treatment Drainage; Clinda +/- Vanc Drainage; Vanc/Clinda, (Metronidazole), Ceftriaxone Complications ~Extension into the parapharyngeal space ~Carotid sheath involvement ~Supurrative jugular thrombophlebitis ~Airway compromise ~Acute necrotizing mediastinitis  abscess in pleural cavity, pleural/ pericardial effusion ~Airway compromise

18. Have a great day! Noon Conference: HTN, Dr. Iorember