UPPER RESPIRATORY TRACT

INFECTIONS.
DR ABDELMONIEM SAEED MOHAMMED
 INTRODUCTION
 The vast majority of cases are caused by viruses

 15-30% of children and 5-10% of adults will have

pharyngitis caused by group A β-hemolytic streptococci
(GABHS), the single most common etiology.

 Judicious antibiotic use is warranted to prevent over

treatment

 over 70% of adults receive antibiotic treatment despite

the low prevalence of GABHS in this age group.
PHARYNGITIS / TONSILLITIS
 ESSENTIALS OF DIAGNOSIS

 Sore throat

 Fever

 Erythematous pharynx or tonsil

 Odynophagia
GENERAL CONSIDERATIONS

 Acute pharyngitis is a common presenting complaint,

winter months,

 is caused by a multitude of organisms :

CAUSES
 Group A -hemolytic Streptococcus (GABHS) is the
most common bacterial organism causing pharyngitis

 Acute viral pharyngitis is most commonly caused by

rhinovirus but can be caused by
 infectious mononucleosis [Epstein-Barr virus, (EBV)],
 acute retroviral syndrome [human immunodeficiency
virus (HIV)],
 and cytomegalovirus infection.
 Less commonly, Mycoplasma pneumoniae and Chlamydia
pneumonia have been isolated from patients with
symptomatic pharyngitis.
CLINICAL FINDINGS
 A. Symptoms and Signs:
 fever, sore throat, anterior cervical lymphadenopathy, a
"beefy red" uvula and pharynx, and tonsillar exudates.

 Children more commonly present with headache,

vomiting, and abdominal pain with a nontender
abdomen.

 A scarlatiniform rash and palatal petechiae may also be

present.

 Absence of cough, diarrhea

GROUP A -HEMOLYTIC STREPTOCOCCUS PHARYNGITIS

 four indicators for GABHS pharyngitis:

 (1) tonsillar exudates

 (2) tender anterior cervical adenopathy

 (3) absence of cough

 (4) history of fever.

INFECTIOUS MONONUCLEOSIS
 refers to the clinical triad of fever, pharyngitis, and
lymphadenopathy specifically caused by EBV

 Clinical findings may be identical to those in GABHS,

although the onset and course are usually more indolent.

 and hepatosplenomegaly are common and resolve over 3-6

weeks.

 Laboratory testing for specific antibodies to Epstein-Barr

virus, heterophile antibody,

 CBC to document atypical lymphocytosis support the

diagnosis.
DIPHTHERIA
 Diphtheria is rare but should be considered in
patient for whom immunization status is
uncertain in the face of a membranous or
exudative pharyngitis.

 A "bull neck" appearance due to prominent

anterior and posterior cervical lymphadenopathy

 tachycardia out of proportion to fever, and a

grayish-brown pseudomembrane that may
extend down the pharynx to include the
tracheobronchial tree are classic findings.
VINCENT ANGINA
 Vincent angina is a polymicrobial infection,
typically limited to the gingiva,
 characterized by
 foul breath,
 cervical lymphadenopathy, and fever In
immunocompromised individuals,

 it may extend to include a necrotic gray

pseudomembrane on the pharynx.
LABORATORY FINDINGS
 CBC
 An elevated white cell count (>12,000) suggests bacterial
pharyngitis.
 may also reveal a lymphocytosis with atypical lymphocytes

 Rapid streptococcal antigen tests are highly specific but not as

sensitive as culture.

 diagnosis of group A streptococcal pharyngitis by culture of

exudates from the throat.

 Obtain a heterophil agglutination test or mononucleosis spot test

for patients thought to have infectious mononucleosis
TREATMENT
 GABHS
 According to criteria for diagnosis
 no antibiotic treatment for patients with none or only one of
these criteria

 two or more criteria, three strategies can be used:

 1.Test patients with two, three, or four criteria using a rapid
antigen test, and limit antibiotic therapy to patients with
positive test results

 2. Test patients with two or three criteria using a rapid antigen

test, and limit antibiotic therapy to patients with a positive test
result or with all four criteria

 3. Do not use any diagnostic tests, and limit antibiotic therapy to

patients with three or four criteria
 ALGORITHM FOR TREATING STREP THROAT

Does not apply to patients with a history of rheumatic fever, valvular heart disease,
immunosuppression, or recurrent or chronic pharyngitis
TREATMENT

 GABHS is rarely resistant to penicillin, which

remains the recommended first-line drug for this
disease

 Macrolide antibiotic or clindamycin may be used for

penicillin-allergic patients

 Viral pharyngitis
 Supportive treatment is adequate
 Antiviral may be used
 Dexamethasone is beneficial in acute pharyngitis but
multiple doses may be required in infectious
mononucleosis.
DISPOSITION
 Patients with uncomplicated pharyngitis may be
discharged home with appropriate supportive
therapy and antibiotics, if indicated.

 Hospitalization with appropriate consultation is

indicated for diphtheria, Vincent angina, and
epiglottis.

 Patients with infectious mononucleosis should follow

up with their primary-care physician before
returning to sports because of the risk of splenic
rupture
PERITONSILLAR ABSCESS
PERITONSILLAR ABSCESS
 is a polymicrobial collection of purulent material between
the tonsillar capsule and the superior constrictor and
palatopharyngeus muscles.
 Peritonsillar abscess develops primarily in young adults
during winter and early spring, coinciding with the
incidence of streptococcal pharyngitis
 Risk factors include
 periodontal disease
 Smoking
 chronic tonsillitis
 multiple trials of oral antibiotics
 previous peritonsillar abscess
CLINICAL FEATURES
 Patients looks ill and present with
 fever
 malaise,
 sorethroat
 odynophagia, dysphagia, and/or otalgia

 Physical signs include

 trismus
 muffled voice ("hot potato voice")
 inferior and medial displacement of the infected
tonsil(s)
 contralateral deflection of the swollen uvula
 palatal edema
 tender cervical lymphadenopathy
 drooling, and dehydration
RIGHT PERITONSILLAR ABSCESS (PTA)
DIAGNOSIS OF A PERITONSILLAR ABSCESS
 is often made by history and physical examination
alone.
 When the diagnosis is in question
 needle aspiration of purulent material
 CT scan with contrast
 transcutaneous or intraoral US may help confirm diagnosis.

 CT scan or MRI is indicated if

 there is concern for spread beyond the peritonsillar space
 lateral neck space complications.

 Bilateral peritonsillar abscesses are rare and difficult to

diagnose clinically, so contrasted CT is needed for
diagnosis.
TREATMENT
 Treatment options are
 drainage of the abscess by needle aspiration,

 incision and drainage (I & D)

 rarely, immediate tonsillectomy

EPIGLOTTITIS
EPIGLOTTITIS, OR SUPRAGLOTTITIS

 is an acute inflammatory condition of the

epiglottis that may progress rapidly to life-
threatening airway obstruction.

 The epiglottis is a leaf-shaped cartilaginous

structure with a thin epithelial layer.

 It arises from the base of the posterior tongue

and covers the larynx during swallowing.
EPIGLOTTITIS
 Widespread implementation of an effective Haemophilus
influenzae type B vaccine has significantly reduced the
number of cases of childhood epiglottitis.

 In the postvaccine era, most cases of infectious epiglottitis

are caused by streptococcal and staphylococcal species.

 Candida species can cause epiglottitis in the

immunocompromised patient.

 Noninfectious causes, such as thermal injury, caustic burns,

and direct trauma, may cause swelling and inflammation of
the epiglottis with a clinical picture identical to that of
infectious epiglottitis in the absence of fever.
CLINICAL FEATURES
 Infection typically presents with
 the abrupt onset of fever, drooling, and sore throat.

 Symptoms may progress rapidly, such that the pt may be

unable to handle oral secretions and develops stridor and
respiratory distress.

 Cough is often absent, but the voice may be muffled.

 Most pts appear toxic and anxious and may assume a

tripod or sniffing position with the neck hyper-
extended and the chin forward to maintain the airway
CLINICAL FEATURES
 Examination
 general
 gentledirect visualization of the epiglottis may
be attempted.

 Investigation
 Routine
 Radiological
 Lateral neck soft tissue x-ray
EPIGLOTTITIS AT LARYNGOSCOPY
LATERAL NECK VIEW OF A CHILD WITH EPIGLOTTITIS
TREATMENT
 Triage pt resuscitation area

 ABC

 Antibiotic admmisteration

 Early referral of the pt paeds and ENT

specialist
AIRWAY AND BREATING
 Keep the pt seated and upright in a position of comfort.

 Provide oxygen.

 Administer nebulized racemic or L-epinephrine to decrease airway edema.

 For a pt who is able to maintain an airway, the decision to administer

paralytics must be accompanied by absolute certainty that intubation will
be successful

 Intubation should be done by the most skilled individual available as soon

as the diagnosis is made.

 Sedation, paralytics, and vagolytics are used as indicated.

 Have multiple endotracheal tube sizes immediately available.

 If endotracheal intubation is unsuccessful, an emergent surgical airway is

required
CIRCULATION
 Inser iv line and with draw blood for investigation

 Iv fluid for hydration and maintain line open

 Atibiotic
 second-or third-generation cephalosporin, such as cefuroxime or
ceftriaxone administeration, to ensure adequate coverage of the
most common infectious pathogens.

 Vancomycin empirically may add to the antibiotic regimen with

the increasing incidence of Staphylococcus aureus and highly
resistant Streptococcus pneumoniae as a cause of epiglottitis,.

 Antibiotics are typically continued for 7 to 10 days.

 Steroidsare often employed to decrease mucosal edema of the

epiglottis.
RETROPHARYNGEAL ABSCESS
RETROPHARYNGEAL ABSCESSQ
22222222222223
 The retropharyngeal space is a potential space anterior
to the prevertebral fascia that extends from the base of
the skull to the tracheal bifurcation.

 The space is fused in the midline and contains two

paramedian chains of lymph nodes (nodes of Rouviere),
which drain the nasopharynx, adenoids, and posterior
nasal sinuses.
RETROPHARYNGEAL ABSCESS
 In children, retropharyngeal abscesses usually are suppurative
changes within a lymph node, with the primary infection
elsewhere in the head and neck.

 In adults, however, a retropharyngeal abscess is generally the

direct extension of purulent debris from an adjacent site, such
as Ludwig angina. Therefore, retropharyngeal abscess in an
adult is more likely to extend into the mediastinum.

 Cultures from retropharyngeal abscesses are usually

polymicrobial and include anaerobes.

 The most common aerobic species isolated are S. viridans and S.

pyogenes. Most of the staphylococcal species isolated are
-lactamase-producing. Bacteroides and Peptostreptococcus are
the most commonly isolated anaerobes
CLINICAL FEATURES AND DIAGNOSIS
 The most common symptoms are
 sore throat (76%)
 fever (65%)
 torticollis (37%),
 and dysphagia (35%).

 In addition, patients may also have complaints of
 neck pain,
 cervical lymphadenopathy,
 poor oral intake,
 muffled voice,
 and respiratory distress.
 Stridor and neck edema are likely in children but not
adults
 INVESTIGATON

 contrast-enhanced CT scan of the neck is the

gold standard for diagnosis of a retropharyngeal
abscess
CONTRASTED CT OF A LEFT RETROPHARYNGEAL ABSCESS
TREATMENT
 All patients need immediate ENT consultation.

 IV hydration and antibiotic treatment should be started in the

ED using either
 clindamycin 600 to 900 milligrams IV,
 or cefoxitin 2 grams IV;
 alternatively,
 piperacillin-tazobactam or ampicillin-sulbactam may be used.21

 Although a few patients with small abscess cavities may be

managed with IV antibiotics alone, most patients will require
surgical intervention via transoral or transcervical I & D.

 Catastrophic complications from retropharyngeal abscess

include
 extensionof the infection into the mediastinum
 and upper airway asphyxia from direct pressure or aspiration after
sudden rupture of the abscess.
LUDWIG ANGINA
LUDWIG ANGINA
 is infection of the submental, sublingual, and
submandibular spaces bilaterally.

 Infection progresses rapidly and can

posteriorly displace the tongue, causing
airway compromise.
CILINICAL PRESENTATION
 Patients usually present with
 poor dental hygiene,
 Dysphagia or odynophagia,
 trismus,

 Clinical examination reveals

 edema of the upper midline neck and the floor of
mouth.
 edema of the entire upper neck and floor of mouth.

 Stridor, difficulty managing secretions, and cyanosis

are late signs and require emergent airway
management
TREATMENT
 Airway management is provided by awake
fiberoptic intubation or awake tracheostomy.

 Systemic antibiotics are usually not a

substitute for definitive airway
management as it may take >1 week for
edema resolution with antibiotic therapy
NECROTIZING INFECTIONS
 Patients are
 critically ill,
 with overlying skin discoloration
 crepitus of the subcutaneous tissue

 systemic signs, including

 fever,
 tachycardia,hypotension,
 and confusion.
INVESTIGATION
 Routine lab test

 Imaging
 CT
 reveals subcutaneous emphysema,
 deep tissue gas,
 and pockets of suppuration (Aerobic and anaerobic
cultures are necessary for identification of causative
organisms
CT-SCAN DEMONSTRATING NECROTIZING FASCIITIS WITH
GAS IN THE DEEP TISSUE OF THE ANTERIOR NECK
TREATMENT
 ABC
 Tracheostomy should be performed if airway obstruction develops

 immediate surgery with fasciotomy with wide local debridement

 Surgery can be lifesaving, and immediate surgical consultation is
required for this rapidly progressing disease.

 broad-spectrum IV antibiotics.

 Mediastinal extension places the patient at risk

 for great vessel erosion,

 retroperitoneal extension,

 pleural abscess,

 pericardial effusion,
 and sepsis

 mortality ranges from 25% to 40%..

THANK YOU