Infectious diseases
of the neck
What organisms cause
sinusitis
•
Common causes include
acute infective
rhinitis, following dental extraction, nasal obstruction, or
fractures
involving the sinus
•
The most common is
viral
•
Bacterial infections
include step pneumoniae, S. areus and
H. influenzae
What
are the complications of sinusitis
• Intra-cranial:
meningitis, extra-dural abscess, cerebral abscess, cavernous
sinus thrombosis
• Osteomylitis: Pott’s
puffy tumour – osteomylitis of frontal bone due to frontal
sinusitis
• Orbital:
orbital cellultis,
subperiosteal abscess, orbital abscess, opthalmoplegia
•
A complication
should be suspected if a fever, severe headache, facial
swelling, proptosis or
visual change develops.
How is
sinusitis diagnosed
•
Using nasal
endoscopy demonstrating pus eminating from ostium.
•
A high resolution
CT can be used to confirm complications of sinusitis
How is sinusitis
treated
•
Non-operative:
Abx, analgesia and vasoconstictive agents
•
Operative: Proof
puncture (drainage of maxillary sinus via inferior turbinate
using needle and
canula); antrostomy ( drainage via natural ostium – eg middle
meatus);
Caudwell-Luc ( drainage of antrum via gingivo-labial fold).
What are the causes of
pharyngitis and How is pharyngitis treated
•
It is an
inflammatory disorder of mucosal and submucosal structures of
the tonsils,
adenoids, oropharynx and hypopharynx
•
Causes may be
bacterial
(gamma or
alpha haemolytic streptococci,
staphylococcus, H.
influenzae, pneumococcus,
diptheroids,
bacteroides fragilis)
Viral
(Rhinovirus, adenovirus,
enterovirus, EBV)
fungal
(candida).
•
Pharyngitis may
be acute parenchmatous (diffuse swelling, erythema and oedema of
tonsil) or
acute follicular (crypts filled with infected fibrin – usually
due to strep).
What are the
complications of pharyngitis
•
Peritonsillar abscess (quinsy) – pus in the peri-tonsillar
space which tracks superiorly and points into the soft
palate
•
Retropharyngeal abscess – suppuration of lymph nodes
in the retropharyngeal space superficial to pre-vertebral
fascia which
can be treated drainage under GA through the pharynx
•
Parapharyngeal abscess – the lateral parapharyngeal
space is continuous with the peri-tonsillar space, but must be
drained via the
neck using an incision at the anterior border of SCM.
What are the deep neck
spaces that may become infected
•
Retropharyngeal
•
Parapharyngeal
•
Prevertebral
space (behind pre vertebral fascia usually due to spinal
infection)
How is deep neck
space infection treated
How do you treat a
quinsy
•
Quinsy is peri-tonsillar abscess.
•
In children it
causes laryngeal oedema and trismus due to spasm of the pterigoid
muscles.
•
Suspect the
diagnosis if the patient complains of extreme sore throat,
trismus, dysphagia
for solids and liquids, and drooling because swallowing saliva
is too painful.
•
The pus collects
between the tonsillar
capsule and superior pharyngeal constrictor. The
tonsil is
medialized, the uvula shifted and there is a bulge in the
palate.
•
Most quinsy can
be treated initially with benzyl penicillin 1.2g QID and
metronidazole
•
If symptoms
persist or worsen then incision and drainage can be performed
under LA
•
A 16G hypodermic
needle can be inserted without local anaethetic to localize the
abscess pocket
•
The needle is
inserted at the point where a horizontal line through the base
of the uvula
intersects the vertical line drawn from the anterior pillar of
the fauces.
•
Once the pocket
has been localized, formal incision and drainage must be
performed.
•
Infiltrate 2%
lignocaine with 1:80000 adrenaline using a dental syringe.
•
Use a 15 blade
knife and a bard-parker handle. Adhesive tape is wrapped around
the blade so
that no more than 1cm is exposed to prevent excessively deep
penetration of the
blade.
•
Insert the blade
until a gush of pus is seen and then wide with sinus forceps.
Cultures are sent
How do you incise
and drain a retropharyngeal abscess
•
These abscesses
should be drained if broad-spectrum Abx fail to resolve the
problem and
significant respiratory obstruction develops
•
The patient
should be anaesthetized with a cuffed ET tube
•
The abscess can
be aspirated with a needle through the mouth.
•
A search should
be made for foreign body and specimens sent for microbiology
What
is the cause of deep space neck
infections
• 70% are due to direct
spread from localized abscess from the
pharyngeal-tonsillar areas
• Submaxillary
abscesses may be caused by dental and salivary gland disease.
• Any new onset neck swelling and pain
in a patient with recent
tonsillitis, pharyngitis, dental infections or recental dental
work should be
assumed to be a deep neck space infection.
• Odynophagia, trismus and
respiratory compromise may
all accompany deep neck space infection.
• Drainage must be achieved by wide drainage
of the whole space.
• The airway must be secured by endotracheal
intubation or tracheosomy
if intubation is not possible prior to drainage.
Discuss acute
epiglottitis in adults
• inflammation of epiglottis
and surrounding structures
as a result of infection
(mucosa here is
loose and vascular and swells easily)
•
Supraglotitis is
a more general term
• declining in children as a
result of Hib immunization
•
Since the
introduction of Hib vaccine step pyogenes and Haemophilus
influenzae B are the
more common causes.
• increase in adult cases,
but still uncommon (1 per
100,000 per year)
• slight male predominance
(1.8:1)
• usually occurs at onset of
spring
• organisms
• H.
influenzae type b
• H.
parainfluenzae
• pneumococcus
• S.
Aureus
• group A
Streptococci
• presentation
• sore throat
• fever
• dysphagia
• Odynophagia
• hoarseness
• stridor
• diagnosis
• diagnosis by
flexible laryngoscopy with local anaesthetic (cherry-red
epiglottis) - well
tolerated in adults but not children
• lateral neck
X-ray - "thumb sign" (sensitivity only 85%)
• treatment
•
For adults
• Antibiotics (3rd
generation cephalosporin)
• close
observation
• one-quarter
require intubation – indication for intubation is
Rapid onset of
symptoms (<4 hours)
Temp
>38
WCC
> 20.
• If the conditions are not met then can be
treated with Abx, humidified
air, steroid therapy and close observation in ICU
• For Children
• Secure airway by
intubation by experienced anaesthetist using
inhalational agent in presence of ENT
surgeon
• Tracheostomy is
rarely required
• Throat cultures,
blood cultures and throat swabs after intubation
• Steroids before extubation