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 abscesssuppuration 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