Infectious Emergencies Elisabeth Ference, PGY4 August 7, 2014

(some of these are from the last 2 weeks!) Topics Whitney covered airway David covered otologic infections 8 cases will cover other infectious emergencies (some of these are from the last 2 weeks!)

Case 1: What’s your diagnosis? --2 weeks ago: 86 you F s/p recent dental extractions --Pain with palpation , trismus

Case 1: Infected Spaces Sublingual: between FOM and mylohyoid, contains sublingual gland, CNXII, wharton’s duct, commmunicates with contralateral side and submental space Submandibular: between body of mandible and mylohyoid/hyoglossus/styloglossus; contains submandibular gland, lingual nerve and facial artery, communicates with sublingual and pharyngeal spaces

Case 1: Ludwig Angina Rapid bilateral cellulitis/inflammation of the submandibular and sublingual spaces with possible abscess formatin “wooden” floor of mouth, neck swelling/induration, drooling, swollen tongue, dysphagia, trismus, Usually in elderly debilitated patients and precipitated by dental procedures Massive swelling with impending airway obstruction Tx: airway management, oral or external drainage, antibiotics

Case 2: What’s your diagnosis? --Common call: 24 yo with 4 days of sore throat

Case 2: Infected Spaces Boundaries: palatal tonsil medial border, superior constrictor is lateral border, palatoglossus and palatopharyngeus

Case 2: PTA Spread of infection outside tonsillar capsule into the peritonsillar space (typically begins at superior pole) vs Weber’s glands Associated w/ unilateral otalgia, odynophagia, uvular deviation, assymetry, trismus, drooling Tx: I&D (consider needle first if uncomfortable), antibiotics, elective tonsillectomy after resolution, Quinsy if extenuating circumstances

Quick Research Point National Trends in the Treatment of PTA’s In US Children, 2000-2009 (Qureshi, Ference, Pritchett, Novis, Smith and Schroeder)

Case 3: Now what? And spiked fevers, rigors, cervical lymphadenopathy, shortness of breath

Case 3: Infected Spaces

Case 3: Lemierre’s Syndrome Thrombophlebitis of IJV and bacteremia caused by anaerobic bacterium (Fusobacterium species vs polymicrobial) following an oropharyngeal infection Suspect in young, healthy patients with pharyngitis followed by septicemia or pneumonia, or atypical lateral neck pain Dx: CT with clot in IJ, blood cultures Tx: Abx, surgical drainage prn, anticoagulation controversial PTAs can lead to complications (spread into adjacent spaces)!!!

Case 4: What’s your diagnosis? 6 year old w/ odynophagia, stiff neck, fever, drooling

Case 4: Infected Spaces Parapharyngeal space: cone shaped with base at base of skull and apex at lesser cornu of hyoid bone, bound by pharynx, parotid, mandible and pterygoid, has pre and post styloid compartments

Case 4: Infected Spaces Continued Visceral space: between constrictors and alar fascia, extends from hyoid and mediastinum Retropharyngeal space: between pharyngeal constrictors and alar fascia, extends from skull base to mediastinum Danger Space: betetween alar and prevertebral fascia, extends from skull; base to diaphragm

Case 4: Deep Space Neck Infection Retropharyngeal/parapharyngeal infections more common in kids, but we see visceral space/retropharyngeal infections in adults s/p TEE/esophagoscopy Large infections/perfs: require drainage (external versus internal approach), aggressive abx Small infections in children: < 1 cm2 not require surgery, > 3 cm2 require surgery, 1-3cm2 debated

Case 5: What do you do? 10 MO who is febrile and fussy

Case 5b: Do you I&D this one? 10 MO who is afebrile and not bothered by you touching the area

Case 5: Soft Tissue Abscess Peds: To OR for I&D If violacious, painless and no signs of systemic illness, consider atypical Mycobacterium and don’t I&D Adult: I&D at bedside Ativan/dilaudid prn in addition to local Check imaging to ensure that no evidence of brachial cleft cyst, thyroglossal cyst, lymphatic malformation, ranula, etc and don’t I&D Pearls: If will not be able to change packing on daily basis, pack w/ knotted iodoform strip Send cultures (aerobic/anaerobic/mycobacterium/possibly fungal) in blood culture bottles to increase yields

Case 6: What’s your diagnosis? 36 yo F type II DM with pain out of proportion to exam, rice krispies under the skin Sumi Y, Ogura H, Nakamori Y, et al. Nonoperative Catheter Management for Cervical Necrotizing Fasciitis With and Without Descending Necrotizing Mediastinitis. Arch Otolaryngol Head Neck Surg. 2008;134(7):750-756. doi:10.1001/archotol.134.7.750.

Case 6: Necrotizing Fascitis Aggressive polymicrobial infection which invades subcutaneous tissue and fascia causing local ischemia and anesthesia Risk factors: immunocompromised, IVDU Management: surgical debridement and irrigation, antibiotics, SICU w/ strict glucose control, Thoracic Surgery Consult; consider immunoglobulin, hyperbaric oxygen

Case 7: What’s your diagnosis? OR or no OR?

Case 7: Infected Spaces I: preseptal II: orbital cellulitis 3: subperiosteal abscess 4: orbital abscess 5: cavernous sinus thrombosis

Case 7: Periorbital Cellulitis Need an urgent Ophtho eval Pathway: direct extension (esp through lamina), thrombophlebitis (valveless veins), congenital dehiscence, trauma, lymphatics Urgent surgical intervention for orbital abscess or cavernous sinus thrombosis, changes in vision, progression despite antibiotics, bilateral Antibiotics if none of the above and subperiosteal or preseptal Don’t forget decongestants and saline irrigations Other complications of acute sinusitis: epidural/subdural/brain abscess, meningitis, superior orbital fissure syndrome, orbital apex syndrome, osteitis, Pott Puffy Tumor, sinocutaneous fistula

Case 8: What should you do next? 32 yo BMT patient in Prentice

Case 8: Invasive Fungal Fungus invades soft tissue, mucor invades vessel walls, causing infarction and tissue necrosis plus anesthesia Exam: scope, especially MT, and check sensation of mucosa examine soft palate CN exam/mental status exam Biopsy and take it to 5th Floor yourself to look for invasion Take the patient for a sinus CT (or skip this step) MRI (enhancement in T2 of fungal elements) if time or post-op OR for surgical debridement Amphotericin B IV, saline irrigations (poor data for amphotericin irrigations), glucose control, address immunospupression if possible