2. David covered airway
John covered otologic infections
8 cases will cover other infectious
emergencies
(some of these are from 3rd year!)
3.
4.
5. 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
6.
7.
8. Spread of infection outside tonsillar capsule
into the peritonsillar space (typically begins
at superior pole) vsWeber’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
10. And spiked fevers, rigors, cervical lymphadenopathy, shortness of breath
11.
12. 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)!!!
13.
14.
15.
16. 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
17.
18.
19. 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
20. SumiY, Ogura H, NakamoriY, et al. Nonoperative Catheter Management for Cervical Necrotizing FasciitisWith and
Without Descending Necrotizing Mediastinitis. ArchOtolaryngol Head NeckSurg. 2008;134(7):750-756.
doi:10.1001/archotol.134.7.750.
21. 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
22.
23.
24. 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
25.
26. 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 inT2 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
Editor's Notes
--2 weeks ago: 86 you F s/p recent dental extractions
--Pain with palpation , trismus
Sublingual: between FOM and mylohyoid, contains sublingual gland, CNXII, wharton’s duct, commmunicates with contralateral side and submental space
Submandibular: between body of mandible and mylohyoid/hyoglossus/styloglossus; contains submandibular gland, lingual nerve and facial artery, communicates with sublingual and pharyngeal spaces
--Common call: 24 yo with 4 days of sore throat
Boundaries: palatal tonsil medial border, superior constrictor is lateral border, palatoglossus and palatopharyngeus
6 year old w/ odynophagia, stiff neck, fever, drooling
Parapharyngeal space: cone shaped with base at base of skull and apex at lesser cornu of hyoid bone, bound by pharynx, parotid, mandible and pterygoid, has pre and post styloid compartments
Retropharyngeal space: between pharyngeal constrictors/visceral fascia and alar fascia, extends from skull base to mediastinum
Danger Space: betetween alar and prevertebral fascia, extends from skull; base to diaphragm
10 MO who is febrile and fussy
10 MO who is afebrile and not bothered by you touching the area
36 yo F type II DM with pain out of proportion to exam, rice krispies under the skin
Chandler Classification
I: preseptal
II: orbital cellulitis
3: subperiosteal abscess
4: orbital abscess
5: cavernous sinus thrombosis