It s Monday! July 28, 2014

Transcription

1 It s Monday! July 28, 2014

2 Prep Question The mother of a 6-year-old girl reports during a health supervision visit that her daughter has nighttime wetting and occasional daytime accidents with urgency. She has no history of constipation, and no one else in the family has suffered enuresis. Her urinalysis reveals: Spec Gravity 1.020, ph 7, 2+blood, Trace Protein, Positive for nitrites, 3+ leukocyte esterase, 5-10 RBCs, WBCs Of the following, the BEST next diagnostic test to perform for this patient is: A. Cystoscopy B. DMSA (technetium dimercaptosuccinic acid) renal scan C. Magnetic resonance imaging of lumbosacral spine D. Renal/bladder ultrasonography E. Spiral CT scan of the abdomen

3 Gastroesophageal Reflux Postnasal drip Allergic Rhinitis Peritonsillar Abscess Chronic Cough Foreign Body My throat hurts!! What could it be? Retropharyngeal Abscess Inhaled irritants (tobacco) Caustic ingestions Bacterial Tracheitis Malignancy Rheumatologic syndromes Viruses: Rhino Corona Influenza Parainfluenza RSV Adeno Entero EBV Herpes

4 Let s hear from our patient

5 On exam Vitals: 75.9kg T100.1 P96 R28 BP 136/73 General: awake, alert, muffled voice Eyes: EOMI, PERRLA ENT: TMs visualized, normal; Nasal mucosa normal; Oropharynx clear, no erythema, left tonsil enlarged (3+), no exudates, soft palate swelling CV: regular, no murmur Resp: clear bilaterally, no retractions or increased WOB Abd: BSx4, soft, NTND Lymphatic: Left cervical LAD Neuro: normal, grossly intact

6 Gastroesophageal Reflux Postnasal drip Allergic Rhinitis Peritonsillar Abscess Chronic Cough Foreign Body My throat hurts!! Is it just a sore throat?? Retropharyngeal Abscess Inhaled irritants (tobacco) Caustic ingestions Bacterial Tracheitis Malignancy Rheumatologic syndromes Viruses: Rhino Corona Influenza Parainfluenza RSV Adeno Entero EBV Herpes

7 Time for another battle of the infections! This week it s: Retropharyngeal vs Peritonsillar Abscesses (When it s not just a sore throat!)

8 Definitions and Anatomy Retropharyngeal Abscessdeep neck abscess involving the potential space between the posterior pharyngeal wall and the alar division of the deep cervical fascia Peritonsillar Abscesspurulent collection in the tonsillar fossa

9 Retropharyngeal Space

10 Patient Characteristics Retropharyngeal Abscess Patients are <6 years old (3-5 years typically) In younger children: it complicates pharyngitis In older children: it complicates penetrating injury to the posterior pharynx Peritonsillar Abscess Older Children (mean age 11 years) OR year olds

11 History Retropharyngeal Abscess High fever (may be gradual onset) URI symptoms Sore throat Onset is insidious or sudden Dysphagia Odynophagia +/- Stridor Decreased PO intake Peritonsillar Abscess High Fever Sore throat, unilateral Often biphasic with sudden worsening Dysphagia Drooling Ipsilateral otalgia voice sounds funny

12 Exam Findings Retropharyngeal Abscess +/- Tachypnea +/- Retractions +/- Stridor Neck pain or stiffness Drooling Cervical LAD Retropharyngeal mass Peritonsillar Abscess Trismus Muffled hot potato voice No stridor Ipsilateral cervical LAD Ipsilateral palatal edema Contralateral uvular deviation

13 Causes and Bugs Retropharyngeal Abscess Infection of the nasopharynx spreads to the RP space by lymphatic route. Lymph node inflammation and necrosis leads to abscess URI, Trauma, Pharyngitis Usually Polymicrobial** Strep pyogenes* Strep viridans* Staph aureus* Less common: anaerobes (fusobacterium, peptostreptococcus, bacteroides), Eikenella Peritonsillar Abscess Begins with pharyngitis or cellulitis Seen in chronic tonsillitis Smoking Strep pyogenes** Staph aureus Haemophilus influenza, Neisseria species, Anaerobes (Fusobacterium Prevotella, Bacteroides)

14 Diagnosis Retropharyngeal Abscess Rapid Strep Leukocytosis with neutrophil predominance Inspiratory lateral neck radiograph Contrast-enhanced CT Peritonsillar Abscess Rapid Strep Leukocytosis with neutrophil predominance Usually no imaging needed to make actual diagnosis Contrast-enhanced CT used to determine extent of infection

15 Our patient s evaluation S/13L/3M/1E CRP: 12.1/ESR: 51 Rapid Strep: positive Blood Cx: Pending

16 Treatment Retropharyngeal Abscess Emergency!- secure airway NPO Blood Cx (usually negative) CT-guided needle aspiration Clinda + Rocephin +Flagyl IV then PO when symptoms have resolved (complete days) Peritonsillar Abscess Aspiration or surgical I&D (provides immediate relief) AND Antibiotics (7-10 days) Cover aerobes and anaerobes (Empiric: PCN or Clinda) Alt: Unasyn, Augmentin, Cefuroxime Surgery if refractory to antibiotics or abscess is mature

17 Our patient s course Rocephin + Clindamycin To OR for I&D Wound culture: light growth β-hemolytic strep Discharged on Clindamycin x7 days

18 Complications Retropharyngeal Abscess Aspiration pneumonia due to abscess rupture Extension into parapharyngeal space Carotid sheath rupture/death Acute necrotizing mediastinitis* Airway obstruction Peritonsillar Abscess Aspiration pneumonia due to abscess rupture Local extension Bleeding if carotid artery is injured Poststreptococcal glomerulonephritis Rheumatic fever Poststreptococcal glomerulonephritis Rheumatic Fever

19 Show Credits Recognize that viral infections are the most common cause of acute pharyngitis in infants and preschool children Peritonsillar abscess: Recognize the signs and symptoms; know the laboratory tests (imaging studies), treatments (drug(s) of choice, alternative drugs, ineffective drugs, surgical drainage), and microbiology Retropharyngeal abscess: Know how to treat retropharyngeal abscess (drug(s) of choice, alternative drugs, ineffective drugs, surgical drainage) and the microbiology; recognize the clinical manifestations and that imaging studies may aid in the diagnosis Know that a child with a persistent positive throat culture for GAS who is still symptomatic following a complete course of therapy for proven GAS pharyngitis deserves culture and further management

20 No Noon Conference Today Enjoy Lunch!