Transcript Document 7246864
INFECTIONS OF THE HEAD AND NECK
Brenda Beckett, PA-C Clinical Medicine II UNE PA Program
Topics
Rhinitis Sinusitis Stomatitis Otitis/Mastoiditis Pharyngitis – Viral – Group A strep – EBV Tonsilitis Soft tissue infections Etiology/Epidemiology Clinical Presentation Clinical Course Diagnostic Studies Clinical Intervention HPDP
Causes: Allergic Viral URI Influenza Others
Rhinorrhea
RHINITIS: “The Common Cold”
Epidemiology/Etiology Most common infection: 3-8/yr in school age, more in preschool.
Viral etiology: rhinoviruses, adenoviruses, coronaviruses. Many serotypes Virus in nasal secretions, symptoms 2-3 days post exposure
Rhinitis
Clinical – Nasal congestion, watery rhinorrhea, sneezing, cough, post nasal drip, conjunctival injection, sore throat, +/ malaise.
– Exam: edematous, erythematous nasal mucosa with watery discharge. Purulent discharge suggests bacterial infection.
Rhinitis
Course Self limiting Resolves in 7-10 days (can take up to 3 weeks) Risk of secondary bacterial infections
Rhinitis
Treatment – Symptomatic – Oral decongestants (pseudophedrine), mucolytics (guaifenasen) – Nasal sprays such as phenylephrine are effective short term, although chronic use can cause rebound congestion ( Rhinitis Medicamentosa ).
Rhinitis
HPDP Huge misconception by patients that antibiotics are helpful antibiotic resistance Hand washing
Sinusitis
Result of impaired mucociliary clearance and obstruction of the osteomeatal complex Maxillary sinus is most commonly affected Pathogens: –
S pneumoniae
–
H influenza
–
S aureus
–
M catarrhalis
Sinusitis
Clinical presentation: Pain and pressure over forehead &/or cheeks Pain to upper incisors Pain worsens with forward bending Purulent nasal discharge Fever URI lasting greater than 10-14 days
Sinusitis
Pain on palpation Failure to transilluminate suggestive CT more sensitive than x-ray (for recurrent)
Sinusitis
Sinusitis
TREATMENT – Amoxicillin, TMP-SMZ, Augmentin, decongestants, nasal saline, NSAIDS – Treatment should last 10-14 days minimum – Recurrent sinusitis requires referral to ENT – Complications – bacterial meningitis, brain abscess, subdural empyema
Stomatitis
Inflammation of the mucous membranes of mouth, multiple possible causes – Thrush – Aphthous ulcers or “canker sores” – HSV – Vincent’s stomatitis – Herpangina – Systemic disease, others (Syphilis)
Stomatitis
Thrush: Oral candidiasis – Chessy white exudate – Underlying mucosa inflamed – Caused by: Candidia albicans – At risk: diabetes, dentures, anemia, chemotherapy, on abx or steroids – Treat with clotrimazole (or other azoles)
Stomatitis
Aphthous ulcers – Common, cause uncertain – On labial or buccal mucosa – Discrete shallow painful ulcers on erythematous base, last days to weeks – Symptomatic treatment with saline mouthwash, topical anesthetics – ? Topical steroids
Stomatitis
Herpes Simplex Virus: – Burning, tingling, vesicles that rupture and form scabs – On vermillion border – Treat with acyclovir to shorten course
Stomatitis
Vincent’s disease: Trench mouth, necrotizing ulcerative gingivitis – d/t anaerobic fusobacteria and spirochetes – Ulcerative – Foul breath, ulcer covered with gray exudate – Treat with penicillin – Can cause peritonsilar and neck infections
Stomatitis
Herpangina – Caused by coxsackie A virus – Childhood disease – Discrete ulcerations on soft palate – Children <6 yrs – Symptomatic treatment – What else does coxsackie cause?
Name that Stomatitis
Otitis externa Otitis media Referred pain
Otalgia
Otitis
EXTERNA – Pseudomonas due to Swimmer’s Ear – Staph or strep (normal flora of the skin) due to trauma – Pain and/or pruritis, +/- d/c – Pain w/manipulation of pinna, inflamed, red canal – Tx w/topical neomycin (otic drops) with corticosteroid
Otitis Externa
Otitis
MEDIA – URI and obstruction to drainage due to edematous, congested eustachian tube – Common in kids d/t anatomy – Strep pneumo, H. influenza, M. catarrhalis, S. pyogenes, viral – Fever, pain, pressure, diminished hearing – Can lead to TM rupture (otorrhea) – Red TM NOT diagnostic!
– Fluid or decreased mobility of TM
Otitis Media
Otitis media treatment: – ? Treat with abx?
– <2 yrs, yes – >2 yrs, can treat with analgesics x24 hrs, then abx if no Tx: amoxicillin 1 st line, then cephalosporin, augmentin PE tubes for recurrent
Otitis Media
TM perforation
Tubes (Sometimes they’re blue)
Otitis
Serous Otitis Media – Blocked eustachian tube with negative pressure leads to transudative fluid – More common in children – URI, barotrauma, allergies – Hypomobile, air bubbles, conductive hearing loss – Treatment controversial
Serous Otitis
Mastoiditis
Serious complication of inadequately treated OM —occurs mostly in peds group H/O OM, abx use, persistent otalgia and/or otorrhea Suspect with mastoid tenderness, erythema, and loss of postauricular crease, + fluctuance
Mastoiditis
CT scan is essential for Dx Call ENT emergently and start on IV abx (cefuroxime, ceftriaxone, etc)
Mastoiditis
PHARYNGITIS
Caused by viral, Group A strep, others Thorough history and exam is critical Seven Danger Signs – Persistent symptoms >1 week w/o improvement – Respiratory difficulty, especially stridor – Difficulty swallowing – Difficulty handling secretions – Severe pain w/o erythema – Palpable mass – Blood (even small amount) in pharynx or ear
Pharyngitis
VIRAL – Influenza – rhinorrhea, cough, fever, myalgias – Rhinovirus or adenovirus – rhinorrhea, conjunctival injection, cough – EBV – malaise and fever, prominent cervical nodes GROUP A STREP – Fever, exudate, tender cervical nodes, NO cough. Later – “sandpaper” rash
Other sx of strep
Headache Stomach ache, N/V Palatal petichiae – see up on palate Always look at their skin for rash
Exudate
Palatal Petichiae
Diagnosing Strep Pharyngitis
Criteria for suspicion (Centor criteria) – Lack of cough – Swollen anterior cervical nodes – Marked exudate – Fever >38.3 C (100.9 F) – Age <15 yrs Group A strep screen or Throat culture +
Pharyngitis
TREATMENT – VIRAL • Symptomatic, decongestants, OTC pain relievers – GROUP A STREP • Self-limiting, but treat with Pcn, e-mycin if pcn allergy • Treatment shortens duration and decreases frequency of sequlae such as scarlet fever, glomerulonephritis, rheumatic myocarditis, and local abscess
EBV Pharyngitis
Symptoms: – Pain, difficulty swallowing – Marked lymphadenopathy – Tonsillar exudate – Lymphocytosis – Heptosplenomegaly 1/3 have strep concurrently
EBV
Diagnosis: Heterophile antibody and/or EBV antibodies Treatment: Supportive. No contact sports
EBV
Soft Tissue Infections
EPIGLOTTITIS – Aggressive disease of children, but can affect adults – Early recognition is critical – H. influenza – Consider in any pt w/ST and any of the following • Difficulty swallowing • Copious oral secretions • Severe pain w/o erythema • Respiratory difficulty, especially stridor
Epiglottitis
Diagnosis: Lateral plain film (thumb sign) Treat with IV abx (cefuroxime) and dexamethasone Possible intubation HPDP: Hib vaccine has decreased incidence
Epiglottitis
Soft Tissue Infections
Peritonsillar abscess – Pain, difficulty swallowing, trismus, “hot potato” voice – Swollen peritonsillar tissue & laterally displaced uvula – CT for dx, Surgical drainage and antibiotics for tx (or tonsillectomy) – Untreated can progress to invade vascular structures
Peritonsillar Abscess
Soft Tissue Infections
Ludwig’s Angina – Extension of infection from tooth – Floor of mouth inflamed, tongue pushed upwards – Firm induration of submandibular space and neck – Laryngeal edema and respiratory compromise – PCN + metronidazole – Protect airway, drain
EXTRA RESPIRATORY PHARYNGITIS
Onset w/activity Abrupt onset of tearing pain Tenderness in anterior neck, enlarged thyroid Sore mouth with beefy red tongue – Angina – Dissecting aorta – Thyroiditis – Vitamin B deficiency