18
Welcome Applicants!! Morning Report January 26, 2012

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

Embed Size (px)

Citation preview

Page 1: Welcome Applicants!! Welcome Applicants!! Morning Report January 26, 2012

Welcome Applicants!!Morning Report January 26, 2012

Page 2: Welcome Applicants!! Welcome Applicants!! Morning Report January 26, 2012

Retropharyngeal AbscessNot common, but definitely worth knowing about!!

Page 3: Welcome Applicants!! Welcome Applicants!! Morning Report January 26, 2012

Facial Spaces

Submandibular Parapharyngeal* Retropharyngeal*“Danger”PrevertebralPeritonsillar*ParotidMasticator

Page 4: Welcome Applicants!! Welcome Applicants!! Morning Report January 26, 2012

Peritonsillar and Parapharyngreal Spaces

Page 5: Welcome Applicants!! Welcome Applicants!! Morning Report January 26, 2012

Retropharyngeal Space

Page 6: Welcome Applicants!! Welcome Applicants!! Morning Report January 26, 2012

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

Page 7: Welcome Applicants!! Welcome Applicants!! Morning Report January 26, 2012

*Microbiology

POLYMICROBIAL!!◦Aerobes

Streptococcus viridans Group A Streptococcus Staphylococcus aureus Staphylococcus epidermidis

◦Anaerobes Bacteroides Fusobacterium Peptostreptococcus sp.

Page 8: Welcome Applicants!! Welcome Applicants!! Morning Report January 26, 2012

*Clinical Presentation

Neck pain (torticollis) or swellingFeverSore throatPainful or difficult swallowingFood refusalChange in vocal qualityRespiratory distressTrismusChest pain

Page 9: Welcome Applicants!! Welcome Applicants!! Morning Report January 26, 2012

*Clinical Manifestations

Page 10: Welcome Applicants!! Welcome Applicants!! Morning Report January 26, 2012

Laboratory Evaluation

CBCBlood culturesWound culture (if abscess drained)

**If any concern for the patient’s airway, NO labs or imaging until airway is secured**

Page 11: Welcome Applicants!! Welcome Applicants!! Morning Report January 26, 2012

*Imaging Studies

Page 12: Welcome Applicants!! Welcome Applicants!! Morning Report January 26, 2012

*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

Page 13: Welcome Applicants!! Welcome Applicants!! Morning Report January 26, 2012

*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

Page 14: Welcome Applicants!! Welcome Applicants!! Morning Report January 26, 2012

Complications

Airway obstructionSepticemiaAspiration PNAInternal jugular vein thrombosisJugular vein suppurative thrombophelbitisCarotid artery ruptureMediasteinitisAtlantoaxial dislocation

Page 15: Welcome Applicants!! Welcome Applicants!! Morning Report January 26, 2012

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. Cervical LN biopsy◦ B. CT scan of the neck◦ C. Laryngoscopic examination of the airway◦ D. LP◦ E. Sinus radiograph

Page 16: Welcome Applicants!! Welcome Applicants!! Morning Report January 26, 2012

Abscess Location

Peritonsillar Parapharyngeal Retropharyngeal

Patient Characteristics

Ages 15-30 Older children and adults

Adults and children (3-5 yo)

Causes Tonsillitis 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

High fever, rigors, dyspnea, dysphagia/ odynophagia

Page 17: Welcome Applicants!! Welcome Applicants!! Morning Report January 26, 2012

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 CT ABCs, CT ABCs, ?lateral neck XR, CT

Treatment Drainage;Clinda +/- Vanc

Drainage; Vanc/Clinda, (Metronidazole), Ceftriaxone

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

Page 18: Welcome Applicants!! Welcome Applicants!! Morning Report January 26, 2012

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