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