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怖い咽頭痛を見極めるTips_新撰医チバ 第5回ミニセミナー

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怖い咽頭痛を見極めるTips_新撰医チバ 第5回ミニセミナー

  1. 1. 怖い咽頭痛を見極める Tips 新撰医チバ 第5回ミニセミナー 千葉大学医学部附属病院 総合診療科 鋪野 紀好 国際医療福祉大学医学部 救急医学講座 志賀 隆 Copyright by Shinsenichiba
  2. 2. 咽頭痛の鑑別疾患 •感染症 – ウイルス, 細菌, カンジダ •アレルギー – アレルギー性鼻炎 •GERD •外傷 – 魚骨, 異物誤飲 •化学物質, 熱傷 •急性喉頭蓋炎 •甲状腺炎 •咽後膿瘍 Copyright by Shinsenichiba
  3. 3. Thumb-sign 急性喉頭蓋炎 Copyright by Shinsenichiba
  4. 4. 三脚位 • 手を膝について, 三脚のような姿勢 • 顎を前に出して苦しそうに 息をする • のどが一番広がる姿勢 Copyright by Shinsenichiba
  5. 5. 咽後膿瘍  頸部後屈で痛みが悪化  縦隔炎に移行するリスクが高い Copyright by Shinsenichiba
  6. 6. 5日前から咽頭痛 開口制限(+) 嚥下困難(+) 流涎(+) 体温38.0℃ 16歳女性 咽頭痛 Copyright by Shinsenichiba
  7. 7. • 咽頭炎、扁桃炎の合併症 • 強い咽頭痛、開口制限 • 扁桃腫大 • 口蓋垂の健側への偏位 • 咽頭切開排膿が必要 扁桃周囲膿瘍 扁桃とその周囲の炎症と浮腫 口蓋垂の肥大・偏位 Copyright by Shinsenichiba
  8. 8. Lemierre's syndrome ・咽頭炎に続発して(3〜5日)血栓性内頸静脈炎 ・患側頸部の腫脹, 発赤, 疼痛 ・多発性閉塞肺炎を起こして膿胸に至る ・咀嚼筋群への炎症の波及による開口障害 ・下顎角及び胸鎖乳突筋に沿った圧痛と腫脹 N Engl J Med. 2004;350(16):e14. Copyright by Shinsenichiba
  9. 9. 開口障害…3横指開くか? 顎関節または咀嚼筋の関与 Sniffing position…鼻を突き出し, やや前傾 流涎…喉頭蓋の浮腫 Muffled voice…熱いジャガイモを口の中に入れた声 Stridor…気道閉塞 舌骨部圧痛…急性喉頭蓋炎 頸部後屈で悪化…咽後膿瘍 口腔底の腫脹… Ludwig's angina(口腔底蜂窩織炎) 咽頭正常…疼痛と咽頭所見の解離 Red Flags Copyright by Shinsenichiba
  10. 10.  頸動脈解離  亜急性甲状腺炎  破傷風  壊死性リンパ節炎  急性心筋梗塞(関連痛)  髄膜炎  偽痛風 Differential Diagnosis 咽頭以外も見落とさない! Copyright by Shinsenichiba
  11. 11. 急性喉頭蓋炎 喉頭蓋が腫大し、気管入口部の狭窄、閉塞をきたす(下咽頭) 扁桃周囲膿瘍 扁桃周辺に炎症が波及し、咽頭の開口部が狭窄(中咽頭) 咽後膿瘍 咽頭後壁に炎症が波及し、後方から気道を圧迫(中〜下咽頭) 口腔底蜂窩織炎(Ludwig angina) 舌下の口腔底から軟部組織に感染し、顎下部の腫大(中〜下咽頭) 化膿性血栓性内頸静脈炎(Lemierre’s syndrome) 内頸静脈に血栓性静脈炎をきたし、肺を中心に敗血症性肺塞栓を起こす アナフィラキシー 気道浮腫による窒息、血圧低下に伴う循環不全 Dr.井村のクリニカルパールズより改変 Six killer sore throat Copyright by Shinsenichiba
  12. 12. ホームページ https://shinsenichiba.jimdo.com/ Facebookページ https://www.facebook.com/shinsenichiba1/ Twitter @shinsen_ichiba Copyright by Shinsenichiba

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