Chapter 44

Question 1

3 most clinically relevant spaces in the neck

Answer 1

submandibular (and sublingual) space

the lateral pharyngeal (or parapharyngeal) space,

the retropharyngeal space.

Question 2

mortality rates of deep neck infection can be as high as

Answer 2

20–50%.

Question 3

Infection of the submandibular and/or sublingual space typically originates from

Answer 3

an infected or recently extracted lower tooth

Question 4

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.

Answer 4

Ludwig’s angina

Question 5

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.

Answer 5

lateral pharyngeal (or parapharyngeal) space

Question 6

contains a number of sensitive structures, including the carotid artery, internal jugular vein, cervical sympathetic chain, and
portions of cranial nerves IX through XII

Answer 6

Lateral pharyngeal wall/space

Question 7

Diagnosis of infection in the lateral pharyngeal space can be confirmed by

Answer 7

CT SCAN

Question 8

Treatment consists of deep neck index consist of

Answer 8

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).

Question 9

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.

Answer 9

retropharyngeal space

Question 10

are the most common pathogens of Retropharyngeal space infection

Answer 10

group A β-hemolytic streptococci and S. aureus

Question 11

Patients with retropharyngeal abscess typically present with

Answer 11

sore throat, fever, dysphagia, and neck pain and are often drooling because of difficulty and pain with swallowing.

Question 12

Upon PE of retropharyngeal abscess soft tissue mass is usually demonstrable by

Answer 12

lateral neck radiography or CT

Question 13

Primary acute herpetic gingivostomatitis (HSV type 1; rarely type 2)

Answer 13

Heals spontaneously in 10–14 days; unless secondarily infected, lesions lasting >3 weeks are not due to primary HSV infection

Question 14

occurs primarily in infants, children, and young adults

Answer 14

Primary acute herpetic gingivostomatitis (HSV type 1; rarely type 2)

Question 15

The most common type of URTI

Answer 15

rhinovirus 30-40%

Question 16

a well-established pathogen in pediatric populations, is also a recognized cause of significant disease in elderly and immu- nocompromised individuals.

Answer 16

Respiratory syncytial virus (RSV),

Question 17

may suggest infection with adenovirus or enterovirus.

Answer 17

conjunctivitis

Question 18

% of colds that are complicated by secondary bacterial infections

Answer 18

0.5% and 2%

Question 19

rebound after initial clinical improvement

Answer 19

the “double-dip” sign

Question 20

refers to an inflammatory condition involving the nasal sinuses.

Answer 20

Rhinosinusitis

Question 21

is most commonly involved in rhinosinusitis

next, in order of frequency, are the ethmoid, frontal, and sphenoid sinuses.

Answer 21

maxillary sinus

Question 22

Defined as sinusitis of <4 weeks’ duration

Answer 22

Acute rhinosinusitis

Question 23

Among community- acquired cases of sinusitis, _______are the most common pathogens, accounting for 50–60% of cases.

Answer 23

s. pneumoniae and nontypable Haemophilus influenzae

Question 24

patients with advanced frontal sinusitis with soft tissue swelling and pitting edema over the frontal bone from a communicating subperiosteal abscess.

Answer 24

Pott’s puffy tumor,

Question 25

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

Answer 25

Acute bacterial sinusitis

Question 26

Acute sinusitis with Moderate symptoms (e.g., nasal purulence/ congestion or cough) for >10 d

Answer 26

Amoxicillin, 500 mg PO tid; or Amoxicillin/clavulanate, 500/125 mg PO tid or 875/125 mg PO bidb

Question 27

Acute sinusitis with Severe symptoms of any duration, including unilateral/focal facial swelling or tooth pain

Answer 27

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)

Question 28

antibiotic therapy can be considered in acute rhinosinusitis

Answer 28

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

Question 29

Chronic sinusitis is characterized by symptoms of sinus inflamma- tion lasting

Answer 29

>12 weeks.

Question 30

is seen in patients with a history of nasal polyposis and asthma, who often have had multiple sinus surgeries.

Answer 30

allergic fungal sinusitis

Question 31

Is a disease of immunocompetent hosts and is usually noninvasive, although slowly progressive invasive disease is sometimes seen.

Answer 31

Chronic fungal sinusitis

Question 32

is an infection of the skin overlying the external ear and typically follows minor local trauma.

Answer 32

Auricular cellulitis

Question 33

an infection of the perichondrium of the auricular cartilage, typically follows local trauma (e.g., piercings, burns, or lacerations).

Answer 33

Perichondritis

Question 34

Most common cause of perichondritis

Answer 34

P. Aeruginosa | And s. Aureus

Question 35

refers to a collection of diseases involving primarily the auditory meatus.

Answer 35

otitis externa

Question 36

usually results from a combination of heat and retained moisture, with desquamation and maceration of the epithelium of the outer ear canal.

Answer 36

Otitis externa

Question 37

can develop in the outer third of the ear canal, where skin overlies cartilage and hair follicles are numerous.

Answer 37

Acute localized otitis externa (furunculosis)

Question 38

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.

Answer 38

S. Aureus

Question 39

is also known as swimmer’s ear,

Answer 39

Acute diffuse otitis externa

Question 40

Predominant pathogen in Acute diffuse otitis externa

Answer 40

Pseudomonas aeruginosa

Question 41

Acute diffuse Otitis externa | Treatment

Answer 41

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.

Question 42

aluminum acetate in water

Answer 42

Burow’s solution

Question 43

is caused primarily by repeated local irrita- tion, most commonly arising from persistent drainage from a chronic middle-ear infection

Answer 43

Chronic otitis externa

Question 44

Rarely can cause otitis externa

Answer 44

chronic infections such as syphilis, tuberculosis, and leprosy.

Question 45

Predominant sx of Chronic otitis externa

Answer 45

PRURITUS

Question 46

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

Answer 46

Invasive otitis externa,

Question 47

Begins in the EXTERNAL CANAL AND Severe, deep-seated otalgia, frequently out of proportion to findings on examination,

Answer 47

Invasive otitis externa

Question 48

Most common affected CN in Internal otitis externa

Answer 48

Facial nerve or CN7

Question 49

IV antibiotic therapy should be given for a prolonged course for internal otitis externa

Answer 49

6–8 weeks)

Question 50

necrotizing otitis externa, recurrence is documented up to

Answer 50

20%

Question 51

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.

Answer 51

Otitis media

Question 52

diagnosis of acute otitis media requires the

Answer 52

demonstration of fluid in the middle ear

Question 53

Most common pathogens for otitis media

Answer 53

consistently found S. pneumoniae to be the most important bacterial cause, isolated in up to 35%

Question 54

In OM, Viruses have been recovered either alone or with bacteria in

Answer 54

17–40% of cases.

Question 55

Fluid in the middle ear is typically demonstrated or confirmed with

Answer 55

pneumatic otoscopy

Question 56

In OM, Treatment is typically indicated for

Answer 56

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

Question 57

In OM, ____ is as successful as any other agent, and it remains the drug of first choice in recommendations from multiple sources

Answer 57

amoxicillin

Question 58

Recurrent acute otitis media

Answer 58

more than three episodes within 6 months or four episodes within 12 months

Question 59

In serous OM, Antibiotic therapy or myringotomy with insertion of tympanostomy tubes typically is reserved for patients in whom bilateral effusion

Answer 59

1) has persisted for at least 3 months and (2) is associated with significant bilateral hearing loss.

Question 60

acute effusions are self-limited; most resolve in

Answer 60

2–4 weeks.

Question 61

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.

Answer 61

3 months

Question 62

is characterized by persistent or recurrent purulent otorrhea in the setting of TM perforation.

Answer 62

Chronic suppurative otitis media

Question 63

In chronic OM, squamous epithelium from the auditory canal may invade the middle ear through the perforation, forming a mass of keratinaceous debris called?

Answer 63

cholesteatoma

Question 64

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 ~

Answer 64

80%

Question 65

Treatment of chronic active otitis media is surgical;

Answer 65

MTM mastoidectomy, myringoplasty, and tympanoplasty

Question 66

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

Answer 66

acute mastoiditis

Question 67

Initial empirical therapy usually is directed against the typical organisms associated with acute otitis media, such as

Answer 67

S. pneumoniae, H. influenzae, and M. catarrhalis.

Question 68

In acute pharyngitis, The most important source of concern is infection with _____ that is associated with acute glomerulonephritis and acute rheumatic fever.

Answer 68

group A β-hemolytic Streptococcus (S. pyogenes) 5-15%

Question 69

respiratory viruses are the most common identifiable cause of acute pharyngitis,

Answer 69

with rhinoviruses and coronaviruses accounting for large proportions of cases (~20% and at least 5%, respectively).

Question 70

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

Answer 70

Fusobacterium necrophorum FB NP

Question 71

is distinguished by the presence of conjunctivitis in one-third to one- half of patients

Answer 71

adenoviral pharyngitis

Question 72

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

Answer 72

coxsackievirus (herpangina)

Question 73

Acute exudative pharyngitis coupled with fever, fatigue, generalized lymphadenopathy, and (on occasion) splenomegaly is characteristic of

Answer 73

infectious mononucleosis due to EBV or CMV

Question 74

diagnosis of acute EBV infection depends primarily on the detection of antibodies to the virus with a:

Answer 74

heterophile agglutination assay (monospot slide test) or enzyme-linked immunosorbent assay.

Question 75

should be performed when acute primary HIV infection is suspected.

Answer 75

Testing for HIV RNA or antigen (p24)

Question 76

Antibiotic therapy for acute phar- yngitis is therefore recommended in cases in which S. pyogenes is confirmed as the etiologic agent by

Answer 76

rapid antigen-detection test (RAD test) or throat swab culture.

Question 77

Effective therapy for streptococcal pharyngitis consists of

Answer 77

either a single dose of IM benzathine penicillin or a full 10-day course of oral penicillin

Question 78

Treatment of acute pharyngitis

Answer 78

•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

Question 79

Treatment of acute pharyngitis with penicillin allergy

Answer 79

•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

Question 80

Treatment of viral pharyngitis is entirely symptom based except in infection with

Answer 80

influenza virus or HSV

Question 81

______ and ____ are active against both influenza A and influenza B

Answer 81

oseltamivir and zanamivir

Question 82

is the best-known complication of acute streptococcal pharyngitis

Answer 82

rheumatic fever

Question 83

Aka Postanginal septicemia which is a rare anaerobic oropharyngeal infection caused predominantly by F. necrophorum.

Answer 83

Lemierre’s disease

Question 84

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.

Answer 84

Ludwig’s angina

Question 85

Fever, dysarthria, and drooling also may be noted, and patients may speak in a “hot potato” voice.

Answer 85

Ludwig’s angina

Question 86

is the most common cause of death in ludwigs angina

Answer 86

asphyxiation

Question 87

Recommended agents for ludwigs angina

Answer 87

include ampicillin/sulbactam, clindamycin, or high-dose penicillin plus metronidazole

Question 88

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

Answer 88

Vincent’s angina

Question 89

Trench mouth Treatment consists of debridement and oral administration of

Answer 89

penicillin plus metronidazole, with clindamycin or doxycycline alone as an alternative.

Question 90

Oropharyngeal candidiasis (thrush) is caused by a variety of Candida species, most often

Answer 90

C. albicans.