welcome applicants!! welcome applicants!! morning report january 26, 2012
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Welcome Applicants!!Morning Report January 26, 2012
Retropharyngeal AbscessNot common, but definitely worth knowing about!!
Facial Spaces
Submandibular Parapharyngeal* Retropharyngeal*“Danger”PrevertebralPeritonsillar*ParotidMasticator
Peritonsillar and Parapharyngreal Spaces
Retropharyngeal Space
Epidemiology
Commonly follows URI infection◦Tonsillitis◦Pharyngitis◦Lymphadenitis◦Sinusitis◦OM
Peak incidence in 3-5 year olds◦Also peak age group for numerous viral URIs◦Increased number of LN in the retropharyngeal
space
*Microbiology
POLYMICROBIAL!!◦Aerobes
Streptococcus viridans Group A Streptococcus Staphylococcus aureus Staphylococcus epidermidis
◦Anaerobes Bacteroides Fusobacterium Peptostreptococcus sp.
*Clinical Presentation
Neck pain (torticollis) or swellingFeverSore throatPainful or difficult swallowingFood refusalChange in vocal qualityRespiratory distressTrismusChest pain
*Clinical Manifestations
Laboratory Evaluation
CBCBlood culturesWound culture (if abscess drained)
**If any concern for the patient’s airway, NO labs or imaging until airway is secured**
*Imaging Studies
*Management
Airway, Airway, Airway!!
Antimicrobial therapy◦Empiric coverage for GAS, S.aureus (MRSA),
and respiratory anaerobes Ampicillin-sulbactam or Clindamycin* +/- Vancomycin or Linezolid +/- Third-generation cephalosporin
◦Transition to oral ABx can be considered when the patient is afebrile and clinically improved
◦Total length of treatment: 14 days
*Mangement
Surgical drainage◦Indications
Airway compromise* A large (>2cm) hypodense area on CT scan (?) Failure to respond to parentral ABx therapy*
◦Debate on how to manage retropharyngeal abscess in patients without airway compromise Only 25-50% patients require surgery May be appropriate to wait 24-48h on broad-
spectrum ABx to assess need for surgery
Complications
Airway obstructionSepticemiaAspiration PNAInternal jugular vein thrombosisJugular vein suppurative thrombophelbitisCarotid artery ruptureMediasteinitisAtlantoaxial dislocation
A Question…
A 3 yo boy presents to your office with a 3 day h/o a severe sore throat, decreased PO intake (especially with solid foods), and pain with swallowing. Nothing in his PMHx is noteworthy, and his immunizations are UTD. On PE, the boy in uncomfortable but alert and does not appear toxic. He is sitting upright holding his neck stiffly, and refusing to open his mouth. His temp is 38.6C. He has no LAD, lungs are CTA, there is no heart murmur and no abdominal organomegaly. Of the following, the test MOST likely to confirm this child’s diagnosis is:◦ A. Cervical LN biopsy◦ B. CT scan of the neck◦ C. Laryngoscopic examination of the airway◦ D. LP◦ E. Sinus radiograph
Abscess Location
Peritonsillar Parapharyngeal Retropharyngeal
Patient Characteristics
Ages 15-30 Older children and adults
Adults and children (3-5 yo)
Causes Tonsillitis Dental infxns, peritonsillar abscess (parotitis, otitis, mastoiditis)
URI, FB/trauma, pharyngitis
Microbiology Polymicrobial; Group A Strep, oral anaerobes
Polymicrobial; Group A Strep, Strep viridans, S. epidermidis, oral anaerobes
Polymicrobial; Group A Strep, Strep viridans, S. aureus, resp. anaerobes
Symptoms High fever, odynophagia, unilateral sore throat, otalgia
High fever, rigors, dyspnea, dysphagia/ odynophagia
High fever, rigors, dyspnea, dysphagia/ odynophagia
Abscess Location
Peritonsillar Parapharyngeal Retropharyngeal
Signs/PE Unilateral deviation of uvula (unaffected side)
Swelling/induration below angle of mandible, medial bulging of pharyngeal wall, resp. distress, neuro signs#
Anterior bulging of the pharyngeal wall neck swelling or torticollis, stridor, tachypnea
Evaluation CT ABCs, CT ABCs, ?lateral neck XR, CT
Treatment Drainage;Clinda +/- Vanc
Drainage; Vanc/Clinda, (Metronidazole), Ceftriaxone
Drainage; Vanc/Clinda, (Metronidazole), Ceftriaxone
Complications ~Extension into the parapharyngeal space
~Carotid sheath involvement~Supurrative jugular thrombophlebitis~Airway compromise
~Acute necrotizing mediastinitis abscess in pleural cavity, pleural/ pericardial effusion~Airway compromise
Have a great day!Noon Conference: HTN, Dr. Iorember
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