Chapter 44 Flashcards
3 most clinically relevant spaces in the neck
submandibular (and sublingual) space
the lateral pharyngeal (or parapharyngeal) space,
the retropharyngeal space.
mortality rates of deep neck infection can be as high as
20–50%.
Infection of the submandibular and/or sublingual space typically originates from
an infected or recently extracted lower tooth
Life threatening infection of deep neck
serious, potentially life-threatening cellulitis or connective tissue infection, of the floor of the mouth, usually occurring in adults with concomitant dental infections and if left untreated, may obstruct the airways, necessitating tracheostomy.
Ludwig’s angina
Infection of the _____ is most often a complication of common infections of the oral cavity and upper respiratory tract, including tonsillitis, peritonsillar abscess, pharyngitis, mastoiditis, and periodontal infection.
lateral pharyngeal (or parapharyngeal) space
contains a number of sensitive structures, including the carotid artery, internal jugular vein, cervical sympathetic chain, and
portions of cranial nerves IX through XII
Lateral pharyngeal wall/space
Diagnosis of infection in the lateral pharyngeal space can be confirmed by
CT SCAN
Treatment consists of deep neck index consist of
airway management, operative drainage of fluid collections, and at least 10 days of IV therapy with an antibiotic active against streptococci and oral anaerobes (e.g., ampicillin/ sulbactam).
Infections in this space are more common among children <5 years old because of the presence of several small retropharyngeal lymph nodes that typically atrophy by age 4 years.
retropharyngeal space
are the most common pathogens of Retropharyngeal space infection
group A β-hemolytic streptococci and S. aureus
Patients with retropharyngeal abscess typically present with
sore throat, fever, dysphagia, and neck pain and are often drooling because of difficulty and pain with swallowing.
Upon PE of retropharyngeal abscess soft tissue mass is usually demonstrable by
lateral neck radiography or CT
Primary acute herpetic gingivostomatitis (HSV type 1; rarely type 2)
Heals spontaneously in 10–14 days; unless secondarily infected, lesions lasting >3 weeks are not due to primary HSV infection
occurs primarily in infants, children, and young adults
Primary acute herpetic gingivostomatitis (HSV type 1; rarely type 2)
The most common type of URTI
rhinovirus 30-40%
a well-established pathogen in pediatric populations, is also a recognized cause of significant disease in elderly and immu- nocompromised individuals.
Respiratory syncytial virus (RSV),
may suggest infection with adenovirus or enterovirus.
conjunctivitis
% of colds that are complicated by secondary bacterial infections
0.5% and 2%
rebound after initial clinical improvement
the “double-dip” sign
refers to an inflammatory condition involving the nasal sinuses.
Rhinosinusitis
is most commonly involved in rhinosinusitis
next, in order of frequency, are the ethmoid, frontal, and sphenoid sinuses.
maxillary sinus
Defined as sinusitis of <4 weeks’ duration
Acute rhinosinusitis
Among community- acquired cases of sinusitis, _______are the most common pathogens, accounting for 50–60% of cases.
s. pneumoniae and nontypable Haemophilus influenzae
patients with advanced frontal sinusitis with soft tissue swelling and pitting edema over the frontal bone from a communicating subperiosteal abscess.
Pott’s puffy tumor,
diagnosis for patients with “per- sistent” symptoms (i.e., symptoms lasting >10 days in adults or >10–14 days in children) accompanied by the three cardinal signs of purulent nasal discharge, nasal obstruction, and facial pain
Acute bacterial sinusitis
Acute sinusitis with Moderate symptoms (e.g., nasal purulence/ congestion or cough) for >10 d
Amoxicillin, 500 mg PO tid; or
Amoxicillin/clavulanate, 500/125 mg PO tid or 875/125 mg PO bidb
Acute sinusitis with Severe symptoms of any duration, including unilateral/focal facial swelling or tooth pain
Penicillin allergy:
Doxycycline, 100 mg PO bid; or Clindamycin, 300 mg PO tid
Exposure to antibiotics within 30 d or >30% prevalence of penicillin-resistant Streptococcus pneumoniae:
Amoxicillin/clavulanate (extended release), 2000/125 mg PO bid; or
An antipneumococcal fluoroquinolone (e.g., moxifloxacin, 400 mg PO daily)
Recent treatment failure:
Amoxicillin/clavulanate (extended release), 2000 mg PO bid; or
An antipneumococcal fluoroquinolone (e.g., moxifloxacin, 400 mg PO daily)
antibiotic therapy can be considered in acute rhinosinusitis
for adult patients whose condition does not improve after 10 days, and patients with more severe symptoms (regard- less of duration) should be treated with antibiotics
Chronic sinusitis is characterized by symptoms of sinus inflamma- tion lasting
> 12 weeks.
is seen in patients with a history of nasal polyposis and asthma, who often have had multiple sinus surgeries.
allergic fungal sinusitis
Is a disease of immunocompetent hosts and is usually noninvasive, although slowly progressive invasive disease is sometimes seen.
Chronic fungal sinusitis
is an infection of the skin overlying the external ear and typically follows minor local trauma.
Auricular cellulitis
an infection of the perichondrium of the auricular cartilage, typically follows local trauma (e.g., piercings, burns, or lacerations).
Perichondritis
Most common cause of perichondritis
P. Aeruginosa
And s. Aureus
refers to a collection of diseases involving primarily the auditory meatus.
otitis externa
usually results from a combination of heat and retained moisture, with desquamation and maceration of the epithelium of the outer ear canal.
Otitis externa
can develop in the outer third of the ear canal, where skin overlies cartilage and hair follicles are numerous.
Acute localized otitis externa (furunculosis)
As in furunculosis elsewhere on the body, _____ is the usual pathogen, and treatment typically consists of an oral antistaphy- lococcal penicillin (e.g., dicloxacillin or cephalexin), with incision and drainage in cases of abscess formation.
S. Aureus
is also known as swimmer’s ear,
Acute diffuse otitis externa
Predominant pathogen in Acute diffuse otitis externa
Pseudomonas aeruginosa
Acute diffuse Otitis externa
Treatment
consists of cleansing the canal to remove debris and enhance the activity of topical therapeutic agents—usually hypertonic saline or mixtures of alcohol and acetic acid.
aluminum acetate in water
Burow’s solution
is caused primarily by repeated local irrita- tion, most commonly arising from persistent drainage from a chronic middle-ear infection
Chronic otitis externa
Rarely can cause otitis externa
chronic infections such as syphilis, tuberculosis, and leprosy.
Predominant sx of Chronic otitis externa
PRURITUS
also known as malignant or necrotizing otitis externa, is an aggressive and potentially life-threatening disease that occurs predominantly in elderly diabetic patients and other immuno- compromised persons
Invasive otitis externa,
Begins in the EXTERNAL CANAL AND Severe, deep-seated otalgia, frequently out of proportion to findings on examination,
Invasive otitis externa
Most common affected CN in Internal otitis externa
Facial nerve or CN7
IV antibiotic therapy should be given for a prolonged course for internal otitis externa
6–8 weeks)
necrotizing otitis externa, recurrence is documented up to
20%
is an inflammatory condition of the middle ear that results from dysfunction of the eustachian tube in association with a number of illnesses, including URIs and chronic rhinosinusitis.
Otitis media
diagnosis of acute otitis media requires the
demonstration of fluid in the middle ear
Most common pathogens for otitis media
consistently found S. pneumoniae to be the most important bacterial cause, isolated in up to 35%
In OM, Viruses have been recovered either alone or with bacteria in
17–40% of cases.
Fluid in the middle ear is typically demonstrated or confirmed with
pneumatic otoscopy
In OM, Treatment is typically indicated for
for patients <6 months old;
for children 6 months to 2 years old who have mid- dle-ear effusion and signs/symptoms of middle-ear inflammation;
for all patients >2 years old who have bilateral disease, TM perfora- tion, immunocompromise, or emesis;
and for any patient who has severe symptoms, including a fever ≥39°C or moderate to severe otalgia
In OM, ____ is as successful as any other agent, and it remains the drug of first choice in recommendations from multiple sources
amoxicillin
Recurrent acute otitis media
more than three episodes within 6 months or four episodes within 12 months
In serous OM, Antibiotic therapy or myringotomy with insertion of tympanostomy tubes typically is reserved for patients in whom bilateral effusion
1) has persisted for at least 3 months and (2) is associated with significant bilateral hearing loss.
acute effusions are self-limited; most resolve in
2–4 weeks.
chronic effusions are often associated with significant hearing loss in the affected ear. The great majority of cases of otitis media with effusion resolve spontaneously within _____ without antibiotic therapy.
3 months
is characterized by persistent or recurrent purulent otorrhea in the setting of TM perforation.
Chronic suppurative otitis media
In chronic OM, squamous epithelium from the auditory canal may invade the middle ear through the perforation, forming a mass of keratinaceous debris called?
cholesteatoma
Treatment of chronic active otitis media is surgical; mastoidectomy, myringoplasty, and tympanoplasty can be performed as outpatient surgical procedures, with an overall success rate of ~
80%
Treatment of chronic active otitis media is surgical;
MTM
mastoidectomy, myringoplasty, and tympanoplasty
purulent exudate collects in the mastoid air cells , producing pressure that may result in erosion of the surrounding bone and formation of abscess-like cavities that are seen at ct scan
acute mastoiditis
Initial empirical therapy usually is directed against the typical organisms associated with acute otitis media, such as
S. pneumoniae, H. influenzae, and M. catarrhalis.
In acute pharyngitis, The most important source of concern is infection with _____ that is associated with acute glomerulonephritis and acute rheumatic fever.
group A β-hemolytic Streptococcus (S. pyogenes)
5-15%
respiratory viruses are the most common identifiable cause of acute pharyngitis,
with rhinoviruses and coronaviruses accounting
for large proportions of cases (~20% and at least 5%, respectively).
In acute pharyngitis, ______ has been increasingly recognized as a cause of pharyngitis in adolescents and young adults and is isolated nearly as often as group A streptococci. This organism is important because of the rare but life-threatening Lemierre’s disease
Fusobacterium necrophorum
FB NP
is distinguished by the presence of conjunctivitis in one-third to one- half of patients
adenoviral pharyngitis
This HSV syndrome is distinct from pharyngitis caused by _________ which is associated with small vesicles that develop on the soft palate and uvula and then rupture to form shallow white ulcers
coxsackievirus (herpangina)
Acute exudative pharyngitis coupled with fever, fatigue, generalized lymphadenopathy, and (on occasion) splenomegaly is characteristic of
infectious mononucleosis due to EBV or CMV
diagnosis of acute EBV infection depends primarily on the detection of antibodies to the virus with a:
heterophile agglutination assay (monospot slide test) or
enzyme-linked immunosorbent assay.
should be performed when acute primary HIV infection is suspected.
Testing for HIV RNA or antigen (p24)
Antibiotic therapy for acute phar- yngitis is therefore recommended in cases in which S. pyogenes is confirmed as the etiologic agent by
rapid antigen-detection test
(RAD test)
or throat swab culture.
Effective therapy for streptococcal pharyngitis consists of
either a single dose of IM benzathine penicillin
or a full 10-day course of oral penicillin
Treatment of acute pharyngitis
•Penicillin G 1.2 million units IM × 1
• Penicillin VK 250 mg orally QID, or 500 mg orally BID, or
• Amoxicillin 500 mg
orally BID
Treatment of acute pharyngitis with penicillin allergy
•Cephalexin 500 mg orally
BID or TID (only if non- anaphylactic penicillin allergy), or
• Azithromycin† 500 mg orally QD × 5 days, or
• Clindamycin 300 mg
orally TID
Treatment of viral pharyngitis is entirely symptom based except in infection with
influenza virus or HSV
______ and ____ are active against both influenza A and influenza B
oseltamivir and zanamivir
is the best-known complication of acute streptococcal pharyngitis
rheumatic fever
Aka Postanginal septicemia which is a rare anaerobic oropharyngeal infection caused predominantly by F. necrophorum.
Lemierre’s disease
is a rapidly progressive, potentially fulminant form of cellulitis that involves the bilateral sublingual and sub- mandibular spaces and that typically originates from an infected or recently extracted tooth, most commonly the lower second and third molars.
Ludwig’s angina
Fever, dysarthria, and drooling also may be noted, and patients may speak in a “hot potato” voice.
Ludwig’s angina
is the most common cause of death in ludwigs angina
asphyxiation
Recommended agents for ludwigs angina
include ampicillin/sulbactam, clindamycin, or high-dose penicillin plus metronidazole
also known as acute necrotizing ulcerative gingivitis or trench mouth, is a unique and dramatic form of gingivitis characterized by painful, inflamed gingiva with ulcerations of the interdental papillae that bleed easily
Vincent’s angina
Trench mouth Treatment consists of debridement and oral administration of
penicillin plus metronidazole, with clindamycin or doxycycline alone as an alternative.
Oropharyngeal candidiasis (thrush) is caused by a variety of Candida species, most often
C. albicans.
