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GEMC: Selected E.N.T. Emergencies Related to Sepsis


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

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GEMC: Selected E.N.T. Emergencies Related to Sepsis

  1. 1. Project: Ghana Emergency Medicine Collaborative Document Title: Selected E.N.T. Emergencies Related to Sepsis Author(s): Jim Holliman (Uniformed Services University), MD, FACEP, 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: 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 with any questions, corrections, or clarification regarding the use of content. For more information about how txo cite these materials visit 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: 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. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. 2
  3. 3. Selected E.N.T. Emergencies Related to Sepsis ©  ©  ©  ©  ©  ©  ©  Jim Holliman, M.D., F.A.C.E.P. Program Manager, Afghanistan Health Care Sector Reconstruction Project Center for Disaster and Humanitarian Assistance Medicine Uniformed Services University Bethesda, Maryland, U.S.A. 3
  4. 4. Selected E.N.T. Emergencies Lecture Outline ©  ©  ©  ©  ©  ©  ©  ©  ©  Complications of acute sinusitis ©  Frontal and orbital abscesses Acute mastoiditis Acute chondritis Mucormycosis Peritonsillar abscess Retropharyngeal and parapharyngeal abscesses Ludwig’s angina Vincent’s Angina Acute epiglottitis 4
  5. 5. Acute Sinusitis Complications ©  ©  ©  Frontal or orbital abscess Need facial CT scan for Dx Need IV antibiotics, hospital admission, and surgical drainage 5
  6. 6. Signs of Potentially Dangerous Complications of Acute Sinusitis ƒ  Periorbital, frontal, or cheek edema ƒ  Proptosis ƒ Manifestation of orbital abscess ƒ  Ophthalmoplegia ƒ  Ptosis ƒ  Diplopia ƒ  Meningeal signs ƒ  Neuro deficits of cranial nerves II to VI 6
  7. 7. Source undetermined CT scan showing fluid with pockets of air in frontal air cells from frontal sinusitis in a six year old male 7
  8. 8. Source undetermined CT scan showing orbital & brain abscesses from ethmoid sinusitis 8
  9. 9. Source undetermined CT scan showing epidural abscess from frontal sinusitis (six 9 year old male with headache, emesis, and fever)
  10. 10. Subdural abscess from frontal sinusitis 10 Source undetermined
  11. 11. Source undetermined Surgical drainage for same patient in prior slide 11
  12. 12. Source undetermined Patient with bony destruction from frontal sinus abscess 12
  13. 13. Source undetermined Coronal CT scan showing left ethmoid opacification and displacement of globe by intraorbital mass (patient was a 2 year old male presenting with fever, proptosis, and left orbital 13 cellulitis)
  14. 14. Source undetermined Patient with left orbital abscess 14
  15. 15. Source undetermined CT scan of same patient with left orbital abscess 15
  16. 16. Source undetermined Another patient with right retro-orbital abscess16
  17. 17. Preseptal cellulitis (important to differentiate from orbital abscess ; Use facial CT to do this) -tripp-, flickr These patients should be admitted and receive IV and topical antibiotics 17 Source Undetermined
  18. 18. Antibiotics to Consider for Rx of Sinusitis Complications ƒ  Ceftriaxone 1 gm IV q 12h ƒ  Cefotaxime 2 gm IV q 4h ƒ  Ceftizoxime 4 gm IV q 8h + metronidazole 30 mg/Kg/d ƒ  Ampicillin / sulbactam 3 gm IV q 6h ƒ  Vancomycin 500 mg q 6h + aztreonam 1 gm q 8h or chloramphenicol ( for PCN - allergic patients) 18
  19. 19. Acute Mastoiditis ƒ  Uncommon now due to antibiotic use for otitis media ƒ  Most common causative bug is Strep pneumoniae ƒ  Rx is IV antibiotics, myringotomy, & drainage ƒ  Mastoidectomy for resistant or complicated cases ƒ  Related serious problem is Necrotizing External Otitis (or “Malignant External Otitis”) ƒ Usually caused by Pseudomonas ƒ Requires IV antibiotics for 4 weeks and radical surgical debridement 19
  20. 20. Source Undetermined Source Undetermined Child with acute mastoiditis from concurrent otitis media 20
  21. 21. Acute Chondritis ƒ  Can be complication of ear piercing ƒ  Most commonly caused by Pseudomonas but can be due to Strep or Staph ƒ  Requires IV antibiotics ƒ  Also needs incision, drainage, and pressure dressing if abscess present 21
  22. 22. Patients with acute chondritis Source undetermined 22
  23. 23. Mucormycosis ƒ  An aggressive opportunistic fungal infection usually with Mucor or Rhizopus ƒ  Occurs in immunocompromised and poorly controlled diabetic patients ƒ  Mortality 30 to 70 % ƒ  Requires IV and topical amphotericin B and aggressive surgical debridement 23
  24. 24. Source Undetermined Source Undetermined 24
  25. 25. Source undetermined 25
  26. 26. Source undetermined 32 year old diabetic presented with coma and DKA ; the hard palate was necrotic with mucormycosis 26
  27. 27. Peritonsillar Abscess ƒ  Complication of acute tonsillitis ƒ  Unilateral peritonsillar and soft palate swelling with uvular deviation ƒ  Most commonly caused by Strep species but can be polymicrobial ƒ  Usually have trismus, drooling, muffled “hot potato” voice ƒ  May need CT to r/o parapharyngeal abscess ƒ  Requires antibiotics, needle aspiration, and later interval tonsillectomy 27
  28. 28. Appearance of peritonsillar abscess Image sources undetermined 28
  29. 29. Axial CT scan of peritonsillar abscess in a child 29 Source undetermined
  30. 30. Retropharyngeal and Parapharyngeal Abscesses ƒ  Sx are neck swelling, fever, dysphagia, muffled voice, neck hyperextension ƒ  Due to suppuration of retro- or parapharyngeal lymph nodes, or direct trauma ƒ  Requires CT scan to delineate extent of abscess, IV antibiotics, surgical drainage, and sometimes airway protection with intubation 30
  31. 31. Plain film of retropharyngeal abscess Source undetermined 31
  32. 32. Another plain film of retropharyngeal abscess Source undetermined 32
  33. 33. Source undetermined Parapharyngeal abscess on CT 33
  34. 34. Parapharyngeal abscess (note endotracheal tube in place) 34 Source undetermined
  35. 35. Ludwig’s Angina ƒ The most common neck space infection ƒ Is a rapidly swelling cellulitis (+/- abscess) of the sublingual and submaxillary spaces, usually arising from molar and premolar tooth root infections ; usually polymicrobial infection including anerobes ƒ Most patients are toxic, severely ill, dehydrated ƒ Risk of airway obstruction due to upward tongue swelling ƒ Need CT to delineate any abscess present ƒ Rx: tracheostomy, IV antibiotics, incision and drainage of the neck, excision of source teeth 35
  36. 36. Kulkarni et. al., Wikimedia Commons Patient with Ludwig’s angina (note typical brawny swelling of the submandibular area) 36
  37. 37. Vincent’s Angina ƒ An acute necrotizing infection of the pharynx and/or tonsils caused by a combination of fusiform bacilli and spirochetes (the same organisms that cause acute gingivostomatitis or “trench mouth” ƒ May have fever, lymphadenopathy, and metallic taste ƒ Need CT to look for gas and if any associated abscess in the soft tissues ƒ Rx : IV penicillin and/or clindamycin, surgical debridement of necrotic tissue 37
  38. 38. Source undetermined Acute necrotizing ulcerative gingivitis 38
  39. 39. Acute Epiglottitis ƒ  Due to HiB vaccine, is now rare (I’ve never seen a case in my entire career) ƒ  Most cases now are in men age 40 to 60 ƒ  Usually caused by Hemophilus sp. and Strep pneumoniae ƒ  Adult mortality reportedly 7 % ƒ  Most patients febrile, toxic, drooling, muffled voice ƒ  Need CT to r/o parapharyngeal abscess ƒ  Rx : IV ceftriaxone, +/- airway control 39
  40. 40. Plain film showing enlarged epiglottis from epiglottitis in an adult Source undetermined 40
  41. 41. Acute epiglottitis in a 66 year old male Source undetermined 41
  42. 42. Source undetermined CT scan of same patient as on prior slide ; note column of air around the epiglottis (E) ; the right side of the epiglottis is more swollen than the left ; hypoattenuation at “A” is suggestive of 42 early abscess
  43. 43. E.N.T. Emergencies Related to Sepsis : Lecture Summary ƒ Maintain low threshold for workup with facial CT, particularly in immunocompromised patients ƒ Start IV antibiotics early ƒ Don’t forget routine resuscitative measures (such as IV fluid bolus) and blood cultures in febrile or toxic patients ƒ Early consultation with your friendly otolaryngologist ƒ May require additional consults to neurosurgery or ophthalmology ƒ Use consultant to decide if pre-operative needle aspirates for culture 43