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)
• 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
• 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
• H. influenzae type b
• H. parainfluenzae
• S. Aureus
• group A Streptococci
• sore throat
• 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%)
• For adults
• Antibiotics (3rd generation cephalosporin)
• close observation
• one-quarter require intubation – indication for intubation is
Rapid onset of symptoms (<4 hours)
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