S19C241 - Infections and disorders of the neck and upper airway

Question 1

Pharyngitis etiology

Answer 1

bacterial: GABHS (group A strep), mycoplasma, chlamydia
viral: rhino, mono (EBV), HIV

Question 2

Mono triad

Answer 2

• pharyngitis
• fever
• lymphadenopathy
• up to 25% of pts will have a neg monospot in their first week of Sx, 10% will remain persistently negative
• tx with amoxicillin causes a rash

Question 3

GABHS - group A betahemolytic strep

Answer 3

• in up to 15% of adult pharyngitis and 30% of children
• incubation 2-5d, ten sore throat
• certain strains cause rheumatic fever and glomerulonephritis
• infxs during acute face and for one more week, if treated only infxs x24h
• tx reduces Sx by 1d and reduces complications

-group C and group B beta-hemolytic strep does NOT need tx

Question 4

Strep throat - Centor criteria

Answer 4

• tonsillar exudate
• tender anterior Cx adenopathy
• absence of cough
• hx of fever
• no Abx if only one
• if 2 present, swab and tx if positive
• if 3 or 4 present just treat

Question 5

Strep throat: tx

Answer 5

• PNC is first line
• PCN 500mg PO BID/TID x10d
• macrolide if pnc allergic or clindamycin
• dexamethasone if severe for sx relief

Question 6

Diphtheria

Answer 6

• immunizations exist
• slow onset of mild-moderate pharyngitis
• low, grade fever
• gray membrane firmly adherent to tonsillar or pharyngeal surface, may extend to soft palate/larynx

Question 7

PTA

Answer 7

• signs: fever, malaise, sore throat, trismus, muffled voice (hot potato), swollen tonsil
• ddx: cellulitis, mono, lymphoma, HSV, RPA, neoplasm, FB, internal artery aneurysm
• tx: needle aspiration, tonsillectomy (rare), 10d of amox-clav 875mg BID or PCN 500mg QID plus flagyl 500mg QID
• f/u 24h
• consider CT

Question 8

PTA: needle aspiration

Answer 8

• lidocaine inhaled or spray
• inject 1-2cc lidocain with epi into mucosa of tonsillar pillar
• then 18g needle lateral to tonsil 1/2 way b/w base of uvula and maxillary alveolar ridge NMT 1cm deep (consider palpating first to determine location of ICA)

Question 9

Epiglottitis

Answer 9

• b/of Haemophilus influenza b vaccine most cases are 46yo pts
• etiology: strep, staph, cirus, fungi, 25% are h flu still
• sx: 1-2d of dysphagia, odynophagia, dyspnea, pain with palpation of larynx and upper trachea, inspiratory stridor, tripod position
• 3D triad (drooling, dysphagia, distress)
• tx: protect airway (intubate if necessarY), O2, hydrate, monitor, IV Abx, heliox, intubate with bronchoscope if possible
• CTX 2g IV
• others: ampicillin-sulbactam, cefotaxime, pip-tazo, steroids

Question 10

Epiglottitis signs on xray

Answer 10

• obliteration of vallecula
• swelling of aryepiglottic folds
• edema of prevertebral and retropharyngeal soft tissues
• ballooning of hypopharynx
• epiglottis thumb shaped and enlarged

Question 11

RPA:

Answer 11

• anywhere from base of skull to corina
• adults with RPA are more likely to extend to mediastinum
• Sx: sore throat, fever, torticollis, dysphagia
• Dx: contrast-CT is gold standard
• Tx: clinda 600-900mg IV or cefoxitin 2g IV or pip-tazo, most require surgical intervention

Question 12

Odontogenic Abscess

Answer 12

-may occur

Question 13

Ludwig Angina

Answer 13

• infxn of submental, sublingual, submandibular spaces bilaterally
• Sx: poor dental hygience, dysphagia, odynophagia, trismus, edema upper neck and floor of mouth
• spreads quickly
• need immediate definite airway mgmt as it takes >1w for edema resolution with Abx

Question 14

Facial Necrotizing INfections

Answer 14

• Sx: critically ill, skin discoloration, crepitus, fever, tachy, HoTN, confusion
• CT: SC emphysema, deep tissue gas
• Tx: surgical fasciotomy, wide debridement, Abx
• Complications: mediastinal extension, great vessel erosion, retroperitoneal extension, pleural abscess, pericardial effusion, sepsis
• mortality 25-40%
• Dx: contrast CT
• Tx: Abx and drainage (pip-tazo, imipenem)

Question 15

Branchial Cleft Cysts

Answer 15

• occur at any age
• painless, fluctuant, anterior to border of anterior sternocleidomastoid muscle, may enlarge after URTI, may become infected
• if infected they need Abx and surgical excision once infection resolved

Question 16

Thyroglossal duct cysts

Answer 16

• from remnants of thyroid anlage
• anywhere midline from base of tongue to low neck, usually children, usually asymptomatic subhyoid midline neck mass
• may enlarge after URTI and become infected
• soft, mobile, bluish hue
• tx: surgical excision

Question 17

Most common cause of unilateral neck mass in >40yo?

Answer 17

• scc of upper aerodigestive tract

- metastatic to cervical lymph nodes

Question 18

Infectious lymphadenopathy

Answer 18

• empiric tx with Abx (keflex, amoxicillin or clinda)

- should resolve w/in 2w

Question 19

Posttonsillectomy bleeding

Answer 19

• common complication
• usually 5-10d post-op but can occur w/in 24h
• RF: ages 21-30yo
• Tx: NPO, monitor, IV, CBC/coags, pressure to tonsillar bed with gauze on a clamp, moisten gauze with thrombin or 1:10,000 epinephrine and lidocaine, intubate if necessary,cauterize with silver nitrate if bleeder identifiable, refer to ENT
• tip: suture through packing and tape to face so that no gauze is lost

Question 20

Recurrent Respiratory Papillomatosis

Answer 20

• bimodal: ages 2mo-4y and adults >30yo
• HPV infection
• Sx: chronic cough, hoarseness, stridor, dyspnea
• wart-like lesions w/o ulceration, can sometimes be seen on Soft tissue XR
• Tx: if severe give heliox, intubate only if absolutely needed

Question 21

Clothesline injury

Answer 21

• sudden blunt laryngeal trauma
• crush injury to thyroid cartilage, can cause laryngotracheal separation
• if unable to identify the tracheal lumen d/t antaomic disruption, edema or hemorrhage do not attempt intubation, do a tracheostomy (vertical skin incision, enter trachea b/w 4th/5th tracheal ring), avoid cricothyrotomy b/c may further injure the subglottis
• Dx: CT

Question 22

Angioedema of upper airway: etiologies

Answer 22

• congenital/acquired loss of C1 esterase inhibitor
• IgE mediated allergic rxn
• rxn to ACEi
• idiopathic

Question 23

Hereditary angioedema

Answer 23

• deficiency in C1 esterase inhibitor, results in unregulated vasoactive mediators
• pts have recurrent episodes and abdo pain
• usually occurs before 5yo, 75% will occur before 15yo
• autosomal dominant
• Dx: measure C1 and C4 levels
• Tx: epinephrine in acute attack, FFP contains the missing inhibitor protein but may worsen a life-threatening attack, if pt is in extremis then fiberoptic intubation
• long-term Tx: acetylated artificial androgens

Question 24

ACEi angioedema

Answer 24

• highest risk in first month of starting ACEi but can occura t any time
• occurs in 0.1-2.2% of pts on ACEi (blacks>whites)
• ACEi inactivate bradykinin, can result in increased bradykinin, vasodilation and increased permeability
• also documented in ARB
• Tx: IV, scope if possible (may have facial edema but no laryngeal edema), epi 1:1000 SC at 0.01mg/kg (NMT 0.3mg), or inhaled racemic epi or epi-pen
• repeat epi q15-20mins
• gravol 50mg/kg
• methylprednisolong 125mg IV

Question 25

Quincke edema

Answer 25

- isolated uvula edema - check for associated PTA or angioedema or epiglottitis - if isolated then give dex 4mg IV/PO