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Project: Ghana Emergency Medicine Collaborative
Document Title: Oral and Facial Infections
Author(s): Shannon Langston (Un...
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Oral	
  and	
  Facial	
  Infec.ons	
  
12-­‐06-­‐2011	
  

Shannon Langston, MD

3
tracilawson, flickr
4
Peritonsillar	
  Abscess	
  
•  History	
  
– 
– 
– 
– 
– 

	
  

Sore	
  throat	
  
Fever	
  
Odynophagia	
  
Dysphagia	
...
•  History	
  
–  Sore	
  throat	
  
–  Fever	
  
–  Odynophagia	
  
–  Dysphagia	
  	
  
–  Otalgia	
  

6
•  Examina.on	
  
–  Trismus	
  
–  Vocal	
  Changes	
  
–  Drooling	
  
–  Effaced	
  anterior	
  pillar	
  
–  Contralate...
•  Pathogens	
  
–  Polymicrobial	
  
–  Group	
  A	
  streptococcus	
  	
  
–  Staphylococcus	
  aureus	
  
–  Respirator...
•  Management	
  
–  Suppor.ve	
  
–  Radiographs	
  +/-­‐	
  
–  Labs	
  +/-­‐	
  
–  An.bio.cs	
  
–  Aspira.on	
  

9
•  Steroids	
  
–  Controversial	
  
–  Single	
  dose	
  effec.ve	
  
–  No	
  evidence	
  of	
  harm	
  

10
Steroids	
  in	
  PTA	
  

11
Steroids	
  in	
  PTA	
  

12
James Heilman,MD,
Wikimedia Commons
13
Source Undetermined
14
15
Source undetermined

16
Source undetermined

17
http://academiclifeinem.com/trick-of-the-tradeperitonsillar-abscess-aspiration-technique/

18
Dr. Hagod Afafum
19
Differen.al?	
  

Source Undetermined

20
Source Undetermined
21
Source Undetermined

22
Ludwigs	
  Angina	
  
•  Sublingual	
  space	
  infec.on	
  
•  Bilateral	
  
•  OUen	
  mul.ple	
  .ssue	
  planes	
  

2...
Physical	
  Findings	
  
• 
• 
• 
• 
• 

Toxic	
  Appearance	
  
Brawny	
  bilateral	
  woody	
  edema	
  
Submandibular,	...
Gray’s Anatomy,
Wikimedia Commons

Tongue

Sublingual
gland
Supramylohyoid
portion of
submandibular space

Mylohyoid muscl...
Geniohyoid muscle

Submandibular space:
Sublingual space
Submaxillary space

Mylohyoid muscle

Superficial fascial layer
G...
Source undetermined

27
Source undetermined

28
History	
  
• 
• 
• 
• 
• 
• 

Recent	
  dental	
  extrac.on	
  or	
  work	
  
Dental	
  caries	
  
Fever	
  
Swelling	
  ...
Pathogens	
  
•  Streptococcus	
  viridans	
  
•  Staphylococcus	
  species	
  
•  Mixed	
  aerobic/anaerobic	
  infec.on	...
Treatment	
  
•  Aggressive	
  airway	
  control	
  
–  Fiberop.c	
  
–  Cricothyrotomy	
  or	
  tracheostomy	
  

•  Surg...
•  Steroids	
  
–  Controversial	
  
–  Dosing:	
  
•  10	
  mg	
  Dexamethasone	
  IV	
  
•  4	
  mg	
  q	
  6	
  hours	
...
Treatment	
  
•  An.bio.c	
  Therapy	
  
–  Ampicillin-­‐sulbactam	
  (3	
  g	
  IV	
  every	
  six	
  hours)	
  or	
  
– ...
Ludwigs	
  Angina	
  
•  Take	
  Home	
  Points	
  
–  Aggressive	
  airway	
  management	
  
–  An.bio.cs	
  
–  CT	
  Sc...
35
Source Undetermined

36
Source Undetermined

37
Diagnosis?	
  

DentalLecNotes
38
Modteque (Wikimedia Commons)

39
ANUG	
  
•  Acute	
  Necro.zing	
  Ulcera.ve	
  Gingivi.s	
  
–  AKA	
  Trench	
  Mouth	
  
–  Vincent’s	
  Disease	
  

4...
Clinical	
  Features	
  
• 
• 
• 
• 
• 
	
  

Gingival	
  necrosis,	
  especially	
  .ps	
  of	
  papillae	
  	
  
Bleedin...
•  Predisposing	
  Factors	
  	
  
–  Emo.onal	
  stress	
  
–  Poor	
  oral	
  hygiene	
  
–  Cigarede	
  smoking	
  
–  ...
ANUG	
  
• 
• 
• 
• 

Prevalence	
  0.6%	
  
Young	
  adults	
  (mean	
  age	
  23	
  years)	
  	
  	
  
More	
  common	
 ...
•  Treatment	
  
–  Amoxicillin 	
  	
  
–  Clindamycin	
   	
  	
  
–  Doxycycline	
  
–  Chlorhexidine	
  Rinse	
  
–  H...
45
Source Undetermined
46
Ducts of
sublingual
glands

Parotid
glands

Submandibular
glands
Submandibular
duct

Sublingual
glands

Arcadian, Wikimedi...
Suppura.ve	
  Paro..s	
  
•  Clinical	
  Findings	
  
• Firm,	
  Erythematous	
  swelling	
  	
  
• Pain	
  
• Fever	
  
•...
E.ology	
  
•  Staphylococcus*	
  
–  Most	
  Common	
  Isolate	
  

•  Aerobic:	
  	
  	
  34%	
  
•  Anaerobes:	
  	
  4...
Predisposing	
  Factors	
  
• 
• 
• 
• 
• 
• 

Advanced	
  age	
  	
  
Dehydra.on	
  	
  
Diabetes	
  	
  
HIV	
  
Alcohol...
•  Management	
  
–  An.bio.cs	
  
–  Hydra.on	
  
–  Culture	
  
–  Imaging	
  
–  Surgical	
  Consulta.on	
  

51
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...
Case	
  
•  65	
  year	
  old	
  farmer	
  presents	
  with	
  2	
  month	
  
history	
  of	
  inflamma.on	
  and	
  pain	
...
Source Undetermined

54
Source Undetermined

55
Gorgas Courses

56
•  Physical	
  Exam:	
  
–  Nasal	
  mucosal	
  ulcera.ons	
  noted	
  	
  
–  No	
  drainage,	
  minimal	
  warmth	
  
– ...
Differen.al?	
  

58
•  Fungal	
  	
  
–  Paracoccidioidomycosis,	
  sporotrichosis,	
  
blastomycosis	
  

•  Bacterial	
  	
  
–  Staphylococ...
Differen.al	
  
•  Inflammatory	
  	
  
–  Sarcoidosis,	
  lupus	
  

•  Neoplas.c	
  –	
  	
  
–  Cutaneous	
  T-­‐cell	
  ...
Source Undetermined

61
Mucocutaneous	
  Leishmaniasis	
  
•  Leishmaniasis: vector-borne diseases
caused by parasites of the genus
Leishmania
•  ...
Leishmanaisis
§  The global annual incidence is estimated at
1.5-2 million new cases per year:
§  1-1.5 million cases of...
Mucocutaneous	
  Leishmanisis	
  
•  Distribu.on:	
  
–  Present	
  in	
  88	
  countries	
  within	
  Central	
  America,...
World Health Organization

65
66
Vectors	
  
•  Transmided	
  by	
  the	
  bite	
  of	
  female	
  sandflies	
   	
  	
  
–  Genus	
  Lutzomyia	
  in	
  the...
Leishmania	
  Species	
  
	
  
•  Two	
  Groups	
  (15	
  species	
  cause	
  disease)	
  
–  Those	
  restricted	
  to	
 ...
Extension of MCL
§ 

Nose

§ 

Nasopharynx

§ 

Palate

§ 

Epiglottis

§ 

Larynx

§ 

Vocal chords

§ 

Trachea

...
Diagnosis	
  
•  Immunologic:	
  Skin	
  test	
  (80-­‐92%)	
  
•  Visual	
  methods:	
  
–  	
  Impression	
  smear	
  (3...
Treatment	
  
• 
• 
• 
• 
• 

Pentavalent	
  an.monials	
  
Amphotericin	
  B	
  (Liposomal	
  Preferred)	
  
Pentamidine	...
Source Undetermined

72
Source Undetermined

73
Source Undetermined
74
75
76
77
78
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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 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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Transcript of "GEMC- Oral and Facial Infections- Resident Training"

  1. 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. 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. 3. Oral  and  Facial  Infec.ons   12-­‐06-­‐2011   Shannon Langston, MD 3
  4. 4. tracilawson, flickr 4
  5. 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. 6. •  History   –  Sore  throat   –  Fever   –  Odynophagia   –  Dysphagia     –  Otalgia   6
  7. 7. •  Examina.on   –  Trismus   –  Vocal  Changes   –  Drooling   –  Effaced  anterior  pillar   –  Contralateral  devia.on  of  uvula   7
  8. 8. •  Pathogens   –  Polymicrobial   –  Group  A  streptococcus     –  Staphylococcus  aureus   –  Respiratory  anaerobes     •  Fusobacteria,  Prevotella   8
  9. 9. •  Management   –  Suppor.ve   –  Radiographs  +/-­‐   –  Labs  +/-­‐   –  An.bio.cs   –  Aspira.on   9
  10. 10. •  Steroids   –  Controversial   –  Single  dose  effec.ve   –  No  evidence  of  harm   10
  11. 11. Steroids  in  PTA   11
  12. 12. Steroids  in  PTA   12
  13. 13. James Heilman,MD, Wikimedia Commons 13
  14. 14. Source Undetermined 14
  15. 15. 15
  16. 16. Source undetermined 16
  17. 17. Source undetermined 17
  18. 18. http://academiclifeinem.com/trick-of-the-tradeperitonsillar-abscess-aspiration-technique/ 18
  19. 19. Dr. Hagod Afafum 19
  20. 20. Differen.al?   Source Undetermined 20
  21. 21. Source Undetermined 21
  22. 22. Source Undetermined 22
  23. 23. Ludwigs  Angina   •  Sublingual  space  infec.on   •  Bilateral   •  OUen  mul.ple  .ssue  planes   23
  24. 24. Physical  Findings   •  •  •  •  •  Toxic  Appearance   Brawny  bilateral  woody  edema   Submandibular,  submental,  sublingual   Trismus   Tongue  eleva.on   24
  25. 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. 26. Geniohyoid muscle Submandibular space: Sublingual space Submaxillary space Mylohyoid muscle Superficial fascial layer Gray’s Anatomy, Wikimedia Commons 26
  27. 27. Source undetermined 27
  28. 28. Source undetermined 28
  29. 29. History   •  •  •  •  •  •  Recent  dental  extrac.on  or  work   Dental  caries   Fever   Swelling  of  mouth,  face,  neck   Compromised  host   Co-­‐morbidi.es   29
  30. 30. Pathogens   •  Streptococcus  viridans   •  Staphylococcus  species   •  Mixed  aerobic/anaerobic  infec.on   –  Peptostreptococcus  species,  Fusobacterium,   Bacteroides   30
  31. 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. 32. •  Steroids   –  Controversial   –  Dosing:   •  10  mg  Dexamethasone  IV   •  4  mg  q  6  hours  for  48  hours   32
  33. 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. 34. Ludwigs  Angina   •  Take  Home  Points   –  Aggressive  airway  management   –  An.bio.cs   –  CT  Scan   –  Surgical  Consulta.on  Early   34
  35. 35. 35
  36. 36. Source Undetermined 36
  37. 37. Source Undetermined 37
  38. 38. Diagnosis?   DentalLecNotes 38
  39. 39. Modteque (Wikimedia Commons) 39
  40. 40. ANUG   •  Acute  Necro.zing  Ulcera.ve  Gingivi.s   –  AKA  Trench  Mouth   –  Vincent’s  Disease   40
  41. 41. Clinical  Features   •  •  •  •  •    Gingival  necrosis,  especially  .ps  of  papillae     Bleeding       Pain     Fe.d  breath   Pseudomembrane  forma.on   41
  42. 42. •  Predisposing  Factors     –  Emo.onal  stress   –  Poor  oral  hygiene   –  Cigarede  smoking   –  Poor  nutri.on   –  Immunosuppression   42
  43. 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. 44. •  Treatment   –  Amoxicillin     –  Clindamycin       –  Doxycycline   –  Chlorhexidine  Rinse   –  Hydrogen  Peroxide  3%   –  Oral  Hygiene     44
  45. 45. 45
  46. 46. Source Undetermined 46
  47. 47. Ducts of sublingual glands Parotid glands Submandibular glands Submandibular duct Sublingual glands Arcadian, Wikimedia Commons 47
  48. 48. Suppura.ve  Paro..s   •  Clinical  Findings   • Firm,  Erythematous  swelling     • Pain   • Fever   • Trismus   48
  49. 49. E.ology   •  Staphylococcus*   –  Most  Common  Isolate   •  Aerobic:      34%   •  Anaerobes:    41%   •  Mixed:    25%   49
  50. 50. Predisposing  Factors   •  •  •  •  •  •  Advanced  age     Dehydra.on     Diabetes     HIV   Alcoholism,   Poor  oral  hygiene   50
  51. 51. •  Management   –  An.bio.cs   –  Hydra.on   –  Culture   –  Imaging   –  Surgical  Consulta.on   51
  52. 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. 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. 54. Source Undetermined 54
  55. 55. Source Undetermined 55
  56. 56. Gorgas Courses 56
  57. 57. •  Physical  Exam:   –  Nasal  mucosal  ulcera.ons  noted     –  No  drainage,  minimal  warmth   –  Oropharynx:    Ulcera.ve  lesion   –  General  exam  unrevealing,  no  LAD   57
  58. 58. Differen.al?   58
  59. 59. •  Fungal     –  Paracoccidioidomycosis,  sporotrichosis,   blastomycosis   •  Bacterial     –  Staphylococcal  and  streptococcal  infec.ons,   syphilis,  tuberculosis,  leprosy   59
  60. 60. Differen.al   •  Inflammatory     –  Sarcoidosis,  lupus   •  Neoplas.c  –     –  Cutaneous  T-­‐cell  lymphoma,  basal  cell  carcinoma,   squamous  cell  carcinoma,  psoriasis   60
  61. 61. Source Undetermined 61
  62. 62. Mucocutaneous  Leishmaniasis   •  Leishmaniasis: vector-borne diseases caused by parasites of the genus Leishmania •  Multifaceted clinical manifestations: –  Mucocutaneous –  Cutaneous –  Visceral 62
  63. 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. 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. 65. World Health Organization 65
  66. 66. 66
  67. 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. 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. 69. Extension of MCL §  Nose §  Nasopharynx §  Palate §  Epiglottis §  Larynx §  Vocal chords §  Trachea 69
  70. 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. 71. Treatment   •  •  •  •  •  Pentavalent  an.monials   Amphotericin  B  (Liposomal  Preferred)   Pentamidine       Ketoconazole,  Itraconazole   Allopurinol   71
  72. 72. Source Undetermined 72
  73. 73. Source Undetermined 73
  74. 74. Source Undetermined 74
  75. 75. 75
  76. 76. 76
  77. 77. 77
  78. 78. 78
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