gemc- oral and facial infections- resident training

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/

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Oral and Facial Infec.ons

12-‐06-‐2011

Shannon Langston, MD

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tracilawson, flickr

Peritonsillar Abscess

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

•  Examina.on –  Trismus –  “hot potato voice” –  Drooling –  Effaced anterior pillar –  Contralateral devia.on of

uvula

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

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•  Examina.on – Trismus – Vocal Changes – Drooling – Effaced anterior pillar – Contralateral devia.on of uvula

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•  Pathogens – Polymicrobial – Group A streptococcus – Staphylococcus aureus – Respiratory anaerobes

•  Fusobacteria, Prevotella

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•  Management – Suppor.ve – Radiographs +/-‐ – Labs +/-‐ – An.bio.cs – Aspira.on

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

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Steroids in PTA

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Steroids in PTA

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James Heilman,MD, Wikimedia Commons

14 Source Undetermined

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Source undetermined

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Source undetermined

18 http://academiclifeinem.com/trick-of-the-trade-peritonsillar-abscess-aspiration-technique/

19 Dr. Hagod Afafum

Differen.al?

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Source Undetermined

Ludwigs Angina

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

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Physical Findings

•  Toxic Appearance •  Brawny bilateral woody edema •  Submandibular, submental, sublingual •  Trismus •  Tongue eleva.on

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Gray’s Anatomy, Wikimedia Commons

Tongue

Sublingual gland

Submandibular gland

Supramylohyoid portion of submandibular space

Mylohyoid muscle

Inframylohyoid portion of submandibular space

Digastric muscle (anterior belly)

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Submandibular space: Sublingual space

Submaxillary space

Geniohyoid muscle

Mylohyoid muscle

Superficial fascial layer Gray’s Anatomy, Wikimedia Commons

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Source undetermined

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Source undetermined

History

•  Recent dental extrac.on or work •  Dental caries •  Fever •  Swelling of mouth, face, neck •  Compromised host •  Co-‐morbidi.es

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Pathogens

•  Streptococcus viridans •  Staphylococcus species •  Mixed aerobic/anaerobic infec.on

– Peptostreptococcus species, Fusobacterium, Bacteroides

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Treatment

•  Aggressive airway control –  Fiberop.c –  Cricothyrotomy or tracheostomy

•  Surgical consulta.on mandatory –  Oral maxillofacial surgeon or ENT

•  An.bio.cs •  Steroids? •  ICU admission

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•  Steroids – Controversial – Dosing:

•  10 mg Dexamethasone IV •  4 mg q 6 hours for 48 hours

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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).

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Ludwigs Angina

•  Take Home Points – Aggressive airway management – An.bio.cs – CT Scan – Surgical Consulta.on Early

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Diagnosis?

38 DentalLecNotes

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Modteque (Wikimedia Commons)

ANUG

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

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Clinical Features

•  Gingival necrosis, especially .ps of papillae •  Bleeding •  Pain •  Fe.d breath •  Pseudomembrane forma.on

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•  Predisposing Factors – Emo.onal stress – Poor oral hygiene – Cigarede smoking – Poor nutri.on –  Immunosuppression

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ANUG

•  Prevalence 0.6% •  Young adults (mean age 23 years) •  More common in Caucasians •  Bacterial flora –

– Spirochetes (Treponema sp.) – Prevotella intermedia – Fusiform bacteria

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•  Treatment – Amoxicillin – Clindamycin – Doxycycline – Chlorhexidine Rinse – Hydrogen Peroxide 3% – Oral Hygiene

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Parotid glands

Submandibular glands

Ducts of sublingual glands

Submandibular duct

Sublingual glands

Arcadian, Wikimedia Commons

Suppura.ve Paro..s

•  Clinical Findings • Firm, Erythematous swelling • Pain • Fever • Trismus

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E.ology

•  Staphylococcus* – Most Common Isolate

•  Aerobic: 34% •  Anaerobes: 41% •  Mixed: 25%

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Predisposing Factors

•  Advanced age •  Dehydra.on •  Diabetes •  HIV •  Alcoholism, •  Poor oral hygiene

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•  Management – An.bio.cs – Hydra.on – Culture –  Imaging – Surgical Consulta.on

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An.bio.cs

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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

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.

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Source Undetermined

56 Gorgas Courses

•  Physical Exam: – Nasal mucosal ulcera.ons noted – No drainage, minimal warmth – Oropharynx: Ulcera.ve lesion – General exam unrevealing, no LAD

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Differen.al?

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•  Fungal – Paracoccidioidomycosis, sporotrichosis, blastomycosis

•  Bacterial – Staphylococcal and streptococcal infec.ons, syphilis, tuberculosis, leprosy

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Differen.al

•  Inflammatory – Sarcoidosis, lupus

•  Neoplas.c – – Cutaneous T-‐cell lymphoma, basal cell carcinoma, squamous cell carcinoma, psoriasis

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Source Undetermined

Mucocutaneous Leishmaniasis

•  Leishmaniasis: vector-borne diseases caused by parasites of the genus Leishmania

•  Multifaceted clinical manifestations: – Mucocutaneous – Cutaneous – Visceral

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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

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Mucocutaneous Leishmanisis

•  Distribu.on: – Present in 88 countries within Central America, South America, Africa, India, the Middle East, Asia, southern Europe, and the Mediterranean.

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65 World Health Organization

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.

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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

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Extension of MCL §  Nose §  Nasopharynx §  Palate §  Epiglottis §  Larynx §  Vocal chords §  Trachea

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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%

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Treatment

•  Pentavalent an.monials •  Amphotericin B (Liposomal Preferred) •  Pentamidine •  Ketoconazole, Itraconazole •  Allopurinol

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Source Undetermined

gemc- oral and facial infections- resident training

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