Elisabeth Ference, PGY5

August 6, 2015
 David covered airway
 John covered otologic infections
 8 cases will cover other infectious
emergencies
(some of these are from 3rd year!)
 Rapid bilateral cellulitis/inflammation of the
submandibular and sublingual spaces with
possible abscess formation
 “wooden” floor of mouth, neck swelling/induration,
drooling, swollen tongue, dysphagia, trismus,
 Usually in elderly debilitated patients and
precipitated by dental procedures
 Massive swelling with impending airway
obstruction
 Tx: airway management, oral or external
drainage, antibiotics
 Spread of infection outside tonsillar capsule
into the peritonsillar space (typically begins
at superior pole) vs Weber’s glands
 Associated w/ unilateral otalgia,
odynophagia, uvular deviation, asymetry,
trismus, drooling
 Tx: I&D (consider needle first if
uncomfortable), antibiotics, elective
tonsillectomy after resolution, Quinsy if
extenuating circumstances
National Trends in the Treatment of PTA’s In US Children, 2000-2009
Qureshi et al
And spiked fevers, rigors, cervical lymphadenopathy, shortness of breath
 Thrombophlebitis of IJV and bacteremia caused
by anaerobic bacterium (Fusobacterium species
vs polymicrobial) following an oropharyngeal
infection
 Suspect in young, healthy patients with
pharyngitis followed by septicemia or
pneumonia, or atypical lateral neck pain
 Dx: CT with clot in IJ, blood cultures
 Tx: Abx, surgical drainage prn, anticoagulation
controversial
PTAs can lead to complications
(spread into adjacent spaces)!!!
 Retropharyngeal/parapharyngeal infections
more common in kids, but we see visceral
space/retropharyngeal infections in adults s/p
TEE/esophagoscopy
 Large infections/perfs: require drainage
(external versus internal approach),
aggressive abx
 Small infections in children: < 1 cm2 not
require surgery, > 3 cm2 require surgery, 1-
3cm2 debated
 Peds:
 To OR for I&D
 If violacious, painless and no signs of systemic illness, consider
atypical Mycobacterium and don’t I&D
 Adult: I&D at bedside
 Ativan/dilaudid prn in addition to local
 Check imaging to ensure that no evidence of brachial cleft cyst,
thyroglossal cyst, lymphatic malformation, ranula, etc and don’t
I&D
 Pearls:
 If will not be able to change packing on daily basis, pack w/ knotted
iodoform strip
 Send cultures (aerobic/anaerobic/mycobacterium/possibly fungal)
in blood culture bottles to increase yields
SumiY, Ogura H, Nakamori Y, et al. Nonoperative Catheter Management for Cervical Necrotizing Fasciitis With and
Without Descending Necrotizing Mediastinitis. Arch Otolaryngol Head Neck Surg. 2008;134(7):750-756.
doi:10.1001/archotol.134.7.750.
 Aggressive polymicrobial infection which
invades subcutaneous tissue and fascia
causing local ischemia and anesthesia
 Risk factors: immunocompromised, IVDU
 Management: surgical debridement and
irrigation, antibiotics, SICU w/ strict glucose
control, Thoracic Surgery Consult; consider
immunoglobulin, hyperbaric oxygen
 Need an urgent Ophtho eval
 Pathway: direct extension (esp through lamina),
thrombophlebitis (valveless veins), congenital dehiscence,
trauma, lymphatics
 Urgent surgical intervention for orbital abscess or
cavernous sinus thrombosis, changes in vision,
progression despite antibiotics, bilateral
 Antibiotics if none of the above and subperiosteal or
preseptal
 Don’t forget decongestants and saline irrigations
 Other complications of acute sinusitis:
epidural/subdural/brain abscess, meningitis, superior orbital
fissure syndrome, orbital apex syndrome, osteitis, Pott Puffy
Tumor, sinocutaneous fistula
 Fungus invades soft tissue, mucor invades vessel walls, causing
infarction and tissue necrosis plus anesthesia
 Exam:
 scope, especially MT, and check sensation of mucosa
 examine hard palate
 CN exam/mental status exam
 Biopsy and take it to 5th Floor yourself to look for invasion (or the
basement at County) needs to be done as frozen pathology
 Take the patient for a sinus CT (or skip this step)
 MRI (enhancement in T2 of fungal elements) if time or post-op
 OR for surgical debridement
 Amphotericin B IV, saline irrigations (poor data for amphotericin
irrigations), glucose control, address immunospupression if possible