Infections of the Head and Neck Overview

1. INFECTIONS OF THE HEAD AND NECK Brenda Beckett, PA-C Clinical Medicine II UNE PA Program

2. Topics • Rhinitis • Sinusitis • Stomatitis • Otitis/Mastoiditis • Pharyngitis • Viral • Group A strep • EBV • Tonsilitis • Soft tissue infections • Etiology/Epidemiology • Clinical Presentation • Clinical Course • Diagnostic Studies • Clinical Intervention • HPDP

3. Rhinorrhea • Causes: • Allergic • Viral URI • Influenza • Others

4. RHINITIS: “The Common Cold” Epidemiology/Etiology • Most common infection: 3-8/yr in school age, more in preschool. • Viral etiology: rhinoviruses, adenoviruses, coronaviruses. Many serotypes • Virus in nasal secretions, symptoms 2-3 days post exposure

5. Rhinitis • Clinical • Nasal congestion, watery rhinorrhea, sneezing, cough, post nasal drip, conjunctival injection, sore throat, +/- malaise. • Exam: edematous, erythematous nasal mucosa with watery discharge. Purulent discharge suggests bacterial infection.

6. Rhinitis Course • Self limiting • Resolves in 7-10 days (can take up to 3 weeks) • Risk of secondary bacterial infections

7. Rhinitis • Treatment • Symptomatic • Oral decongestants (pseudophedrine), mucolytics (guaifenasen) • Nasal sprays such as phenylephrine are effective short term, although chronic use can cause rebound congestion (Rhinitis Medicamentosa).

8. Rhinitis HPDP • Huge misconception by patients that antibiotics are helpfulantibiotic resistance • Hand washing

9. Sinusitis • Result of impaired mucociliary clearance and obstruction of the osteomeatal complex • Maxillary sinus is most commonly affected • Pathogens: • S pneumoniae • H influenza • S aureus • M catarrhalis

10. Sinusitis Clinical presentation: • Pain and pressure over forehead &/or cheeks • Pain to upper incisors • Pain worsens with forward bending • Purulent nasal discharge • Fever • URI lasting greater than 10-14 days

11. Sinusitis • Pain on palpation • Failure to transilluminate suggestive • CT more sensitive than x-ray (for recurrent)

12. Sinusitis

13. Sinusitis • TREATMENT • Amoxicillin, TMP-SMZ, Augmentin, decongestants, nasal saline, NSAIDS • Treatment should last 10-14 days minimum • Recurrent sinusitis requires referral to ENT • Complications – bacterial meningitis, brain abscess, subdural empyema

14. Stomatitis • Inflammation of the mucous membranes of mouth, multiple possible causes • Thrush • Aphthous ulcers or “canker sores” • HSV • Vincent’s stomatitis • Herpangina • Systemic disease, others (Syphilis)

15. Stomatitis • Thrush: Oral candidiasis • Chessy white exudate • Underlying mucosa inflamed • Caused by: Candidia albicans • At risk: diabetes, dentures, anemia, chemotherapy, on abx or steroids • Treat with clotrimazole (or other azoles)

16. Stomatitis • Aphthous ulcers • Common, cause uncertain • On labial or buccal mucosa • Discrete shallow painful ulcers on erythematous base, last days to weeks • Symptomatic treatment with saline mouthwash, topical anesthetics • ? Topical steroids

17. Stomatitis • Herpes Simplex Virus: • Burning, tingling, vesicles that rupture and form scabs • On vermillion border • Treat with acyclovir to shorten course

18. Stomatitis • Vincent’s disease: Trench mouth, necrotizing ulcerative gingivitis • d/t anaerobic fusobacteria and spirochetes • Ulcerative • Foul breath, ulcer covered with gray exudate • Treat with penicillin • Can cause peritonsilar and neck infections

19. Stomatitis • Herpangina • Caused by coxsackie A virus • Childhood disease • Discrete ulcerations on soft palate • Children <6 yrs • Symptomatic treatment • What else does coxsackie cause?

20. Name that Stomatitis

25. Otalgia • Otitis externa • Otitis media • Referred pain

26. Otitis • EXTERNA • Pseudomonas due to Swimmer’s Ear • Staph or strep (normal flora of the skin) due to trauma • Pain and/or pruritis, +/- d/c • Pain w/manipulation of pinna, inflamed, red canal • Tx w/topical neomycin (otic drops) with corticosteroid

27. Otitis Externa

28. Otitis • MEDIA • URI and obstruction to drainage due to edematous, congested eustachian tube • Common in kids d/t anatomy • Strep pneumo, H. influenza, M. catarrhalis, S. pyogenes, viral • Fever, pain, pressure, diminished hearing • Can lead to TM rupture (otorrhea) • Red TM NOT diagnostic! • Fluid or decreased mobility of TM

29. Otitis Media • Otitis media treatment: • ? Treat with abx? • <2 yrs, yes • >2 yrs, can treat with analgesics x24 hrs, then abx if no • Tx: amoxicillin 1st line, then cephalosporin, augmentin • PE tubes for recurrent

30. Otitis Media

31. TM perforation

32. Tubes(Sometimes they’re blue)

33. Otitis • Serous Otitis Media • Blocked eustachian tube with negative pressure leads to transudative fluid • More common in children • URI, barotrauma, allergies • Hypomobile, air bubbles, conductive hearing loss • Treatment controversial

34. Serous Otitis

35. Mastoiditis • Serious complication of inadequately treated OM—occurs mostly in peds group • H/O OM, abx use, persistent otalgia and/or otorrhea • Suspect with mastoid tenderness, erythema, and loss of postauricular crease, + fluctuance

36. Mastoiditis • CT scan is essential for Dx • Call ENT emergently and start on IV abx (cefuroxime, ceftriaxone, etc)

37. Mastoiditis

38. PHARYNGITIS • Caused by viral, Group A strep, others • Thorough history and exam is critical • Seven Danger Signs • Persistent symptoms >1 week w/o improvement • Respiratory difficulty, especially stridor • Difficulty swallowing • Difficulty handling secretions • Severe pain w/o erythema • Palpable mass • Blood (even small amount) in pharynx or ear

39. Pharyngitis • VIRAL • Influenza – rhinorrhea, cough, fever, myalgias • Rhinovirus or adenovirus – rhinorrhea, conjunctival injection, cough • EBV – malaise and fever, prominent cervical nodes • GROUP A STREP • Fever, exudate, tender cervical nodes, NO cough. Later – “sandpaper” rash

40. Other sx of strep • Headache • Stomach ache, N/V • Palatal petichiae – see up on palate • Always look at their skin for rash

41. Exudate

42. Palatal Petichiae

43. Diagnosing Strep Pharyngitis • Criteria for suspicion (Centor criteria) • Lack of cough • Swollen anterior cervical nodes • Marked exudate • Fever >38.3 C (100.9 F) • Age <15 yrs Group A strep screen or Throat culture +

44. Pharyngitis • TREATMENT • VIRAL • Symptomatic, decongestants, OTC pain relievers • GROUP A STREP • Self-limiting, but treat with Pcn, e-mycin if pcn allergy • Treatment shortens duration and decreases frequency of sequlae such as scarlet fever, glomerulonephritis, rheumatic myocarditis, and local abscess

45. EBV Pharyngitis • Symptoms: • Pain, difficulty swallowing • Marked lymphadenopathy • Tonsillar exudate • Lymphocytosis • Heptosplenomegaly 1/3 have strep concurrently

46. EBV • Diagnosis: Heterophile antibody and/or EBV antibodies • Treatment: Supportive. No contact sports

47. EBV

48. Soft Tissue Infections • EPIGLOTTITIS • Aggressive disease of children, but can affect adults • Early recognition is critical • H. influenza • Consider in any pt w/ST and any of the following • Difficulty swallowing • Copious oral secretions • Severe pain w/o erythema • Respiratory difficulty, especially stridor

49. Epiglottitis • Diagnosis: Lateral plain film (thumb sign) • Treat with IV abx (cefuroxime) and dexamethasone • Possible intubation • HPDP: Hib vaccine has decreased incidence

50. Epiglottitis