1. No. 7173604 Age 3y2m 女 8/31 ER-management 報告人 R 盤明偉 指導者 吳孟書醫師

2. Cc: fever up to 38.5 degrees and chills since 8/20 morning Vital sign: –BP: –BT: 38.5°C –PR: 129/ min –RR: 26/ min Time

3. PI: She had repeated tonsillitis before. she suffered from fever, up to 38.5oC, with chills since the early morning of 96/08/20. Right face swelling, dysphagia, and drooling developed (96/08/20).There were dental carries (no dentist visited history), no fish/chicken bone mis-swallowing. Sorethroat and mild cough are noted. No travel or family-similar history in recent.Vaccine history:as schedule. Time

4. P/E: P.A.T--"good" HEENT-- right facial and upper neck swelling, no pain, no reddish, no open wound Right side tonsil swelling and reddish, no pus, no ulcer neck: no lympanopathy, no stridor CHEST: symmetrical expansion breathing sounds clear, no dyspnea, no wheezing HEART: sinus tachycardia, no murmur ABDOMEN: normal EXTREMITY and skin: normal

5. Impression –initial diagnosis? ---1.tonsilitis 2.Mumps 3.deep neck infection Time

6. ER course 8/20 18:2X - 入 ER -History taking, PE, order 8/20 19:3x - check CBC/DC, CRP, BUN, ALT, amylase, B/C, GAS Ag - On IV run D5W 80 ml/hr - arrange admission Time

7. ER course WBC 14.2 1000/cmm H 6.7~11.8(>1Y-4Y) RBC 4.70 milon/cmm 4.28~5.05(6M-6Y) HGB 12.4 g/dL 11.6~13.7(3M-6Y) HCT 36.5 % 34.2~39.8(6M-6Y) MCV 77.7 umm 74.9~ 84.6(6M-6Y) MCH 26.4 pg/Cell 25.2~29.1(6M-6Y) MCHC 34.0 g/dL 32.6~35.1(6M-6Y) RDW 11.9 % 11.5-14.5 PLATELET 277 1000/cmm 150-400 SEGMENT 69.0 % H 13.9~49.5(>1Y-4Y) LYMPHOCYTE 22.0 % L 44.7~81.6(>1Y-4Y) MONOCYTE 8.0 % H 1.3~ 7.2(>1Y-4Y) EOSINOPHIL 1.0 % 0.0~ 4.3(>1Y-4Y ) Time

8. ER course 檢驗組別 : 生化組 檢 體 別 :B 採檢日期 時間 :2007/08/20 19:3 BUN(B) 4 mg/dL L 5-20 (child) AMYLASE(B) 73 U/L 27-137 ALT 29 U/L 7-40 (1-18Y) CRP 57.07 mg/L H < 5 檢驗組別 : 鏡檢組 檢 體 別 :TH 採檢日期 時間 :2007/08/20 20:4 ---------------------------------------------------------------------------- 檢驗項目 檢驗值 單位 H/L 參考值 改 =================================================================== GAS Ag NEGATIVE NEGATIVE Time

10. 8/20 21:10 Admitted to ward, no progressive symptoms from the initial ER course to now.

11. Admission course 8/20 22:30 stridor, dyspnea were noted -> arranged emergency CT -> consult ENT( 建議請放射科作 guided-aspiration) retropharyngeal and parapharyngeal abscess were noted so arranged PICU for emergency condition. Use Augmentin 1pc stat and q8h Symptoms therapy( no bosmin)

13. Admission course 8/21 0:20 In PICU admission order- Rocephin 2pc q12h + stat Clindamycin 0.5PC q6h + stat bosmin 1pc stat + prn keep other symptoms therapy

14. Admission course 8/21~8/24 stay in PICU 8/21 radiologist said the abscess is too near carotid artery and jagular vein- >can not do echo-guided aspiration; lesion 後有 skull, 前有 mandible, proximal 有 carotid artery- >ca not do CT-guided aspiration. 8/21 & 8/22 ENT consultation- good response to antibiotics so do not need emergency operation (2006 pediatric review summary:48 hrs 內有 1/4~1/2 病人對 antibiotics 有 response).

15. Admission course 8/25 Transferred to ward for improved condition. arranged CT f/u in 8/28 afternoon.

16. WBC 12.0 1000/cmm H 6.7~11.8(>1Y-4Y) RBC 4.65 milon/cmm 4.28~5.05(6M-6Y) HGB 12.4 g/dL 11.6~13.7(3M-6Y) HCT 36.1 % 34.2~39.8(6M-6Y) MCV 77.6 umm 74.9~ 84.6(6M-6Y) MCH 26.7 pg/Cell 25.2~29.1(6M-6Y) MCHC 34.3 g/dL 32.6~35.1(6M-6Y) RDW 12.2 % 11.5-14.5 PLATELET 344 1000/cmm 150-400 SEGMENT 49.0 % 13.9~49.5(>1Y-4Y) LYMPHOCYTE 46.0 % 44.7~81.6(>1Y-4Y) MONOCYTE 4.0 % 1.3~ 7.2(>1Y-4Y) EOSINOPHIL 1.0 % 0.0~ 4.3(>1Y-4Y) CRP 48.05 mg/L H < 5

17. Retropharyngeal abscess Pathophysiology: The retropharyngeal space is posterior to the pharynx, bound by the buccopharyngeal fascia anteriorly, the prevertebral fascia posteriorly, and the carotid sheaths laterally. It extends superiorly to the base of the skull and inferiorly to the mediastinum.

18. Abscesses in this space can be caused by the following organisms: Aerobic organisms, such as beta-hemolytic streptococci and Staphylococcus aureus Anaerobic organisms, such as species of Bacteroides and Veillonella Gram-negative organisms, such as Haemophilus parainfluenzae

19. Cross-section of the neck at the level of the oropharynx shows the anatomic relations of the deep neck spaces. 1, pharyngomaxillary space; 2, visceral vascular space; 3, retropharyngeal space; 4, danger space; 5, prevertebral space; AD, alar division of deep layer; PD, prevertebral division of deep layer.

20. Mortality/Morbidity: Once mediastinitis occurs, mortality approaches 50%, even with antibiotic therapy. RPA can also cause internal jugular vein thrombosis, carotid artery erosion, pericarditis, and epidural abscess. In addition to invasion of contiguous structures, RPA can cause sepsis and airway compromise. Overall mortality was 1% in a recent review of deep cervical space infections in Taiwan.

21. CT scan of the neck –A CT scan of the neck with IV contrast is very useful in the diagnosis and management of RPA. RPA appears as a hypodense lesion in the retropharyngeal space with peripheral ring enhancement. Other findings on CT include soft-tissue swelling, obliterated fat planes, and mass effect. –Obtain a CT scan of the neck with IV contrast when the findings on the lateral neck x-ray are equivocal or if the clinical suspicion for RPA is high in patients with negative lateral neck x-ray findings. Lateral neck x-ray findings may be misleading, especially in young children. –A CT scan of the neck with IV contrast also may be useful if the x-ray findings are positive because the CT scan can differentiate between retropharyngeal abscess and cellulitis. The CT scan also shows the extent of the RPA and its relation to the great vessels, which is very helpful to the surgeon.

22. Emergency Department Care: ED management of RPA includes attention to the airway, fluid resuscitation if necessary, antibiotic treatment, and preparation for an emergency operation. Frequent vital sign checks and continuous oxygen saturation monitoring are essential. Airway management –Apply supplemental oxygen. In young children, this can be done in a nonthreatening way by letting the parent direct blow-by oxygen at the child's face. –Endotracheal intubation may be required if the patient has signs of upper airway obstruction. It may be difficult because of upper airway swelling. –Cricothyrotomy (surgical or needle) may be required in the patient with upper airway obstruction who cannot be intubated. Tracheostomy may be required for definitive airway management. Intravenous fluids are required if the patient is dehydrated because of fever and difficulty swallowing.

23. Prognosis: Prognosis generally is good if RPA is identified early, managed aggressively, and complications do not occur. The mortality rate may be as high as 40- 50% in patients in whom serious complications develop.

24. discussion 1. Abscess->OP? non-OP? Aspiration? Only medication?

25. HEAD and NECK SURGERY fig47.9 除非沒有 abscess, 否則至少都需要 aspiration of abscess, 並沒有純內科治療的 protocol

26. 2. Except lateral soft tissue view? Why CXR?  A chest x-ray is indicated to look for aspiration pneumonia and mediastinitis.