GEMC- Oral and Facial Infections- Resident Training
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GEMC- Oral and Facial Infections- Resident Training

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This is a lecture by Dr. Shannon Langston from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about......

This is a lecture by Dr. Shannon Langston from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.

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  • 1. Project: Ghana Emergency Medicine Collaborative Document Title: Oral and Facial Infections Author(s): Shannon Langston (University), MD, 2011 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1
  • 2. Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt { Content the copyright holder, author, or law permits you to use, share and adapt. } Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Creative Commons – Zero Waiver Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Make Your Own Assessment { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ { Content Open.Michigan has used under a Fair Use determination. } Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. 2 To use this content you should do your own independent analysis to determine whether or not your use will be Fair.
  • 3. Oral  and  Facial  Infec.ons   12-­‐06-­‐2011   Shannon Langston, MD 3
  • 4. tracilawson, flickr 4
  • 5. Peritonsillar  Abscess   •  History   –  –  –  –  –    Sore  throat   Fever   Odynophagia   Dysphagia     Otalgia   •  Examina.on   –  –  –  –  –  Trismus   “hot  potato  voice”   Drooling   Effaced  anterior  pillar   Contralateral  devia.on  of   uvula   5
  • 6. •  History   –  Sore  throat   –  Fever   –  Odynophagia   –  Dysphagia     –  Otalgia   6
  • 7. •  Examina.on   –  Trismus   –  Vocal  Changes   –  Drooling   –  Effaced  anterior  pillar   –  Contralateral  devia.on  of  uvula   7
  • 8. •  Pathogens   –  Polymicrobial   –  Group  A  streptococcus     –  Staphylococcus  aureus   –  Respiratory  anaerobes     •  Fusobacteria,  Prevotella   8
  • 9. •  Management   –  Suppor.ve   –  Radiographs  +/-­‐   –  Labs  +/-­‐   –  An.bio.cs   –  Aspira.on   9
  • 10. •  Steroids   –  Controversial   –  Single  dose  effec.ve   –  No  evidence  of  harm   10
  • 11. Steroids  in  PTA   11
  • 12. Steroids  in  PTA   12
  • 13. James Heilman,MD, Wikimedia Commons 13
  • 14. Source Undetermined 14
  • 15. 15
  • 16. Source undetermined 16
  • 17. Source undetermined 17
  • 18. http://academiclifeinem.com/trick-of-the-tradeperitonsillar-abscess-aspiration-technique/ 18
  • 19. Dr. Hagod Afafum 19
  • 20. Differen.al?   Source Undetermined 20
  • 21. Source Undetermined 21
  • 22. Source Undetermined 22
  • 23. Ludwigs  Angina   •  Sublingual  space  infec.on   •  Bilateral   •  OUen  mul.ple  .ssue  planes   23
  • 24. Physical  Findings   •  •  •  •  •  Toxic  Appearance   Brawny  bilateral  woody  edema   Submandibular,  submental,  sublingual   Trismus   Tongue  eleva.on   24
  • 25. Gray’s Anatomy, Wikimedia Commons Tongue Sublingual gland Supramylohyoid portion of submandibular space Mylohyoid muscle Inframylohyoid portion of submandibular space Submandibular gland Digastric muscle (anterior belly) 25
  • 26. Geniohyoid muscle Submandibular space: Sublingual space Submaxillary space Mylohyoid muscle Superficial fascial layer Gray’s Anatomy, Wikimedia Commons 26
  • 27. Source undetermined 27
  • 28. Source undetermined 28
  • 29. History   •  •  •  •  •  •  Recent  dental  extrac.on  or  work   Dental  caries   Fever   Swelling  of  mouth,  face,  neck   Compromised  host   Co-­‐morbidi.es   29
  • 30. Pathogens   •  Streptococcus  viridans   •  Staphylococcus  species   •  Mixed  aerobic/anaerobic  infec.on   –  Peptostreptococcus  species,  Fusobacterium,   Bacteroides   30
  • 31. Treatment   •  Aggressive  airway  control   –  Fiberop.c   –  Cricothyrotomy  or  tracheostomy   •  Surgical  consulta.on  mandatory   –  Oral  maxillofacial  surgeon  or  ENT   •  An.bio.cs     •  Steroids?   •  ICU  admission   31
  • 32. •  Steroids   –  Controversial   –  Dosing:   •  10  mg  Dexamethasone  IV   •  4  mg  q  6  hours  for  48  hours   32
  • 33. Treatment   •  An.bio.c  Therapy   –  Ampicillin-­‐sulbactam  (3  g  IV  every  six  hours)  or   –  Clindamycin  (600  mg  IV  every  six  to  eight  hours)   PLUS   –  Vancomycin  (15  to  20  mg/kg  IV  every  12  hours)  or   –  Linezolid  (600  mg  orally  or  IV  every  12  hours).   33
  • 34. Ludwigs  Angina   •  Take  Home  Points   –  Aggressive  airway  management   –  An.bio.cs   –  CT  Scan   –  Surgical  Consulta.on  Early   34
  • 35. 35
  • 36. Source Undetermined 36
  • 37. Source Undetermined 37
  • 38. Diagnosis?   DentalLecNotes 38
  • 39. Modteque (Wikimedia Commons) 39
  • 40. ANUG   •  Acute  Necro.zing  Ulcera.ve  Gingivi.s   –  AKA  Trench  Mouth   –  Vincent’s  Disease   40
  • 41. Clinical  Features   •  •  •  •  •    Gingival  necrosis,  especially  .ps  of  papillae     Bleeding       Pain     Fe.d  breath   Pseudomembrane  forma.on   41
  • 42. •  Predisposing  Factors     –  Emo.onal  stress   –  Poor  oral  hygiene   –  Cigarede  smoking   –  Poor  nutri.on   –  Immunosuppression   42
  • 43. ANUG   •  •  •  •  Prevalence  0.6%   Young  adults  (mean  age  23  years)       More  common  in  Caucasians    Bacterial  flora  –     –  Spirochetes  (Treponema  sp.)   –  Prevotella  intermedia     –  Fusiform  bacteria   43
  • 44. •  Treatment   –  Amoxicillin     –  Clindamycin       –  Doxycycline   –  Chlorhexidine  Rinse   –  Hydrogen  Peroxide  3%   –  Oral  Hygiene     44
  • 45. 45
  • 46. Source Undetermined 46
  • 47. Ducts of sublingual glands Parotid glands Submandibular glands Submandibular duct Sublingual glands Arcadian, Wikimedia Commons 47
  • 48. Suppura.ve  Paro..s   •  Clinical  Findings   • Firm,  Erythematous  swelling     • Pain   • Fever   • Trismus   48
  • 49. E.ology   •  Staphylococcus*   –  Most  Common  Isolate   •  Aerobic:      34%   •  Anaerobes:    41%   •  Mixed:    25%   49
  • 50. Predisposing  Factors   •  •  •  •  •  •  Advanced  age     Dehydra.on     Diabetes     HIV   Alcoholism,   Poor  oral  hygiene   50
  • 51. •  Management   –  An.bio.cs   –  Hydra.on   –  Culture   –  Imaging   –  Surgical  Consulta.on   51
  • 52. An.bio.cs   Or Vancomycin 15-20 mg/kg IV Q 12 h Or Linezolid 600 mg orally or IV Q 12 h PLUS Either metronidazole 500 mg IV Q 6-8 h 52
  • 53. Case   •  65  year  old  farmer  presents  with  2  month   history  of  inflamma.on  and  pain  over  the   facial  region  and  nasal  mucosa.     •  Denies  fevers  or  systemic  symptom.   •  PMH:    Unremarkable.   •  Course  of  an.bio.cs  “the  white  one”   unsuccessful.   53
  • 54. Source Undetermined 54
  • 55. Source Undetermined 55
  • 56. Gorgas Courses 56
  • 57. •  Physical  Exam:   –  Nasal  mucosal  ulcera.ons  noted     –  No  drainage,  minimal  warmth   –  Oropharynx:    Ulcera.ve  lesion   –  General  exam  unrevealing,  no  LAD   57
  • 58. Differen.al?   58
  • 59. •  Fungal     –  Paracoccidioidomycosis,  sporotrichosis,   blastomycosis   •  Bacterial     –  Staphylococcal  and  streptococcal  infec.ons,   syphilis,  tuberculosis,  leprosy   59
  • 60. Differen.al   •  Inflammatory     –  Sarcoidosis,  lupus   •  Neoplas.c  –     –  Cutaneous  T-­‐cell  lymphoma,  basal  cell  carcinoma,   squamous  cell  carcinoma,  psoriasis   60
  • 61. Source Undetermined 61
  • 62. Mucocutaneous  Leishmaniasis   •  Leishmaniasis: vector-borne diseases caused by parasites of the genus Leishmania •  Multifaceted clinical manifestations: –  Mucocutaneous –  Cutaneous –  Visceral 62
  • 63. Leishmanaisis §  The global annual incidence is estimated at 1.5-2 million new cases per year: §  1-1.5 million cases of CL §  500,000 cases of VL. §  Overall prevalence of 12 million cases. §  500 US Soldiers in 18 month period 63
  • 64. Mucocutaneous  Leishmanisis   •  Distribu.on:   –  Present  in  88  countries  within  Central  America,   South  America,  Africa,  India,  the  Middle  East,  Asia,   southern  Europe,  and  the  Mediterranean.   64
  • 65. World Health Organization 65
  • 66. 66
  • 67. Vectors   •  Transmided  by  the  bite  of  female  sandflies       –  Genus  Lutzomyia  in  the  New  World   –  Genus  Phlebotumus  in  the  Old  World   •  Reservoir  host:     –  Domes.c  and/or  wild  animals     –  Humans.   67
  • 68. Leishmania  Species     •  Two  Groups  (15  species  cause  disease)   –  Those  restricted  to  the  skin  and  cause  dermal   leishmaniasis:     •  L.  mexicana,   •  L.  braziliensis   •  L.  tropica,  L.  major,  L.  aethiopica.   –  Visceral:     •  L.  donovani     68
  • 69. Extension of MCL §  Nose §  Nasopharynx §  Palate §  Epiglottis §  Larynx §  Vocal chords §  Trachea 69
  • 70. Diagnosis   •  Immunologic:  Skin  test  (80-­‐92%)   •  Visual  methods:   –   Impression  smear  (37.9%)   –   Dermal  scrapping  (32.7%)   –   Histopathology  (21.4%)   •  Isola.on  methods:   –   In  vitro  culture  (57%  -­‐  85%)   •  Demonstra.on  methods:     –  PCR  92-­‐94%   70
  • 71. Treatment   •  •  •  •  •  Pentavalent  an.monials   Amphotericin  B  (Liposomal  Preferred)   Pentamidine       Ketoconazole,  Itraconazole   Allopurinol   71
  • 72. Source Undetermined 72
  • 73. Source Undetermined 73
  • 74. Source Undetermined 74
  • 75. 75
  • 76. 76
  • 77. 77
  • 78. 78