Can actually involve the supraglottic tissue and spare the epiglottis. Muffled voice and anterior neck tenderness. If there is no respiratory distress, you may perform laryngoscopy. Start 3rd gen. Cephalosporin (or bactrim, zosyn). Consider ICU admit or intubation.
Ducic and colleagues described the vallecula sign, which is easily learned and applied by practitioners at all levels of training [ix]. In this prospective, blinded study involving 26 laryngoscopically-proven cases of epiglottitis and 26 controls, staff emergency physicians, radiology and otolaryngology residents, and senior medical students were asked to evaluate randomly mixed radiographs for epiglottitis, both before and after a 5-minute tutorial on the vallecula sign. The sign increased sensitivity and specificity from 78.5% and 82.8% to 98.2% and 99.5% respectively, with no difference between evaluator groups. This sign is based on evaluating the vallecula, which appears as an air pocket at the level of the hyoid that should be roughly parallel to the pharyngotracheal air column. To do this, first start at the base of the tongue, trace down to the hyoid bone where you should then find the epiglottis. If the air column anterior to this is not deep, sharp, and roughly parallel to the pharyngotracheal air column, then epiglottitis is present. In this study, the vallecula was deemed abnormal in all cases of epiglottitis, including those patients with minor symptoms, as well as those that needed urgent airway intervention. Furthermore, the vallecula was deemed abnormal in cases where the epiglottis itself was difficult to evaluate (and hence signs like the thumb sign could not be applied). A normal appearing vallecula accurately predicted a normal epiglottis (see Figure 4 below of a normal vallecula and an abnormal vallecula found with epiglottitis, both outlined in red). It is noted that the x-ray must be taken with the patients mouth closed, as an open mouth may artificially obliterate the vallecula by epiglottic repositioning.
The Vallecula Sign
Step 1: Ensure that the patients mouth is closed for x-ray. Step 2: Identify the base of the tongue. Step 3: Trace the tongue to the level of the hyoid. Step 4: Locate the epiglottis. Step 5: Locate the air pocket extending nearly to the hyoid. Is the vallecula deep and roughly parallel to the pharyngotracheal air column? YES: No epiglottitis NO: Epiglottitis present
neck masses c sulfa granules.
grey or white pseudomembrane. Can be associated c polyneuritis, tubular necrosis, or myocarditis.
horse anti-toxin, erythromycin
From the Greek for skin or hide
C. diphtheriae (gram +)-humans are the only carriers
Resp tract and skin
Exotoxin induces grayish/brown membrane, which does not effect gingival. Bleeding will occur if removal is attempted.
2-4 day incubation period
can cause cervical nodes extensive enough to give bull neck.
Myocarditis is possible 1-2 weeks after.
Can also give muscle weakness/paralysis 2° to exotoxin which looks like G. Barre
Indigent population can present c cutaneous presentation
Alert lab, b/c special cx is needed.
Give antitoxin (equine) 20000-400000 for pharyngeal disease and 80000-100000 for extensive disease
and 14 days erythromycin or PCN
Can get carrier state.
Booster immunizations every decade.
Pertussis (Whooping Cough)
Means violent cough. Airborne transmission. 7-10 day incubation.
Catarrhal phase-non-specific uri. Most contagious
Paroxysmal-cough, decreased fever. Post-tussive vomiting. Lasts 2-4 weeks
Convalescent-can last months
Complications-aspiration pneumonia, CNS
Presents c very elevated WBC, get nasopharyngeal cx
Erythromycin may help, definitely give to non-immunized exposures
Pertussis component of DPT most likely to cause complications.
cough is usually absent.
Give 60 mg POPrednisone x 1
Oral Dex helps subset of strep + kiddies, but only marginal improvement ((Ann Emerg Med. 2003 May;41(5):601-8))
im or oral dex helps pt >15 y/o (Laryngoscope. 2002 Jan;112(1):87-93)
A randomized clinical trial of oral versus intramuscular delivery of steroids in acute exudative pharyngitis. (Acad Emerg Med. 2002 Jan;9(1):9-14) They are the same and help im dex. (Ann Emerg Med. 1993 Feb;22(2):212-5) Dexamethasone as adjuvant therapy for severe acute pharyngitis.
only strep worth treating is group A B-hemolytic strep to decrease risk of RF and quinsy. Antibiotics probably do not reduce risk of glomerulonephritis.
Centor criteria (Ann Int Med 2001;134:506)
- Fever (or reliable history thereof): 1 point
- Exudate: 1 point
- Cervical adenitis (tender enlargement of nodes): 1 point
- NO cough: 1 point
4 points: treat with penicillin (Bicillin 1.2 million units)
0,1 or 2 points: do not treat
3 points: flip a coin (trust your instinct, give an antibiotic if the patient
wants one, etc.)
If the Centor score is 4, the percentage of patients who have the disease is
50-70% depending on time of year, current outbreak in the community, etc. Add
a scarletiniform rash (uncommon), and that takes the patient well into the 90’s%.
Sore throat score adds age
One point for age less than 15 years. One point is subtractedif the person is 45 years of age or older
Better than rapid strep (Can J Emerg Med 4 (3):178 2002) Score had sensitivity of 97% and spec. of 78% while rapid strep testing was 75% and 99%. Gold standard was throat cultures
Validated in Kids:
ACP Journal Club. v136(1):p.37, January/February, 2002.
Culture after Negative Rapid Strep is not necessary or cost effective (Preventative Medicine 35 25-257, 2002) Reviewed Source Attia MW, Zaoutis T, Klein JD, Meier FA. Performance of a predictive model for streptococcal pharyngitis in children. Arch Pediatr Adolesc Med. 2001 Jun;155:687-91.
cervical lymphadenopathy, tonsillar swelling (2-category severity scale: absent or mild and moderate or severe), coryza, and scarletiniform rash (present or absent)
218 children (37%) had positive culture results for GABHS. The prediction model did better than the physicians’ probability estimates and was comparable to the rapid antigen detection test . The model did not differ in performance according to setting (emergency department vs outpatient clinic) or study period (in season [January to March] vs off season [April to December]).
anti-streptolysin-O titers were not done leading to problem of differentiating carrier state
AAP standard evaluated vs. two rapids in a row.
Single Rapid: Sens-88%, Spec 96.2%
Double Rapid: 92% and 95%
Rapid and Cx: 96% and 96%
(Pediatrics 111(6):666, June 2003)
anaerobes, foul breath, pseudomembrane, sub-mandibular nodes. From poor oral hygiene
Rx with Penicillin
gonorrhea and chlamydia
From Epstein Barr Virus (EBV), a herpesvirus
Tender, large anterior or posterior cervical lymph nodes
Get CBC c Diff, Monospot, throat culture and LFTs. Check for hepatosplenomegaly
Give prednisone 40 mg PO for 5 days
If you give ampicillin, they will get rash which is not allergic
Incubation period of 1-2 months, most occur 4-6 weeks after exposure. Can stay contagious for months after the infection. (even years in a small percentage)
Anginose: fever, sore throat, and adenopathy
Typhoidal: prolonged fever, minimal pharyngitis, and delayed lymphadenopathy
Glandular: dramatic LA, with minimal fever and pharyngitis
Splenic Rupture: 1:1000 cases.
Airway Obstruction: from hypertrophied tonsils and lymphoid tissues. Steroid therapy is efficacious.
Occurs only post-tonsillectomy. Pain worsens c tongue movement
R/o epiglotittis, steroids help with quicker recovery
relatively uncommon. etiologies include staph, strep pneumo, and h. flu. Diphtheria, TB, and syphyllis can also be causes.
histoplamsosis, blastomycosis, coccidiomycosis (San Joaquin), and candidiasis
Deep Space Infections
Masticator Space Abscess
bounded by masseter and internal pterygoid muscles
from extension of anterior space infection
lateral face swelling and trismus
Progressive cellulitis of mouth and neck beginning in the submandibular space. Dental disease is the most common cause. Can cause airway obstruction. Neck tenderness, sub-Q emphysema. Cellulitis of connective tissue, not glands. Bilateral.
Neck will have woody edema. If retropharyngeal involvement, can track into mediastinum. Airway compromise is possible. Lateral neck films. Strep or staph.
High dose PCN (4 million units IV q4 hours), add flagyl or clinda for better anaerobic coverage.
Duck quaking voice. Usually seen in 3-6 year olds. Pt supine c neck extended is position of comfort. Lateral neck films, then CT/MRI. Medial or Bilat. Treat as above.
Local extension of oropharyngeal infections such as tonsillitis, pharyngitis, or adenitis in children can lead to retropharyngeal lymph node infection. These infections may progress from cellulitis to phlegmon and finally to retropharyngeal abscess (RPA), which requires drainage. Abscesses in the retropharyngeal or prevertebral spaces are collectively known as RPA. As the retropharyngeal lymph nodes typically regress by age 4 to 6, the main cause of RPA in older children and adults is either extension of odontogenic infection or local trauma (as with a fish bone or holding an object in the mouth). Patients with an RPA may present with symptoms and signs similar to that of acute epiglottitis, including dysphagia, odynophagia, hoarse voice, fever, and neck extension or unusual positioning. Unlike the tripod positioning common in epiglottitis, patients with RPA often lay flat with their neck held in extension. When severe, there may be enough local swelling and pharyngeal pain to cause reluctance in swallowing solids, liquids or secretions, which therefore leads to drooling
The lateral soft tissue neck x-ray may suggest the diagnosis of RPA. Look for soft-tissue swelling in the retropharyngeal space or retrotracheal space, with the limits described below:
Soft Tissue Measurements
Retropharyngeal space (measured at C2) < 7mm Retrotracheal space (measured at C6)
< 22mm (adults) < 14mm (children < 15 years)
The retropharyngeal space is measured from the anteroinferior aspect of C2 to the posterior pharyngeal wall, and should not exceed 7mm in children or adults. The retrotracheal space, measured from the anteroinferior aspect of C6 to the posterior pharyngeal wall, should not exceed 22mm in adults or 14mm in children. The most reliable x-rays are taken during deep inspiration with the neck extended. Films taken during expiration (particularly in children less than 24 months) or that are rotated can increase the apparent width of neck soft tissues.
Can cause lemierre
Oropharyngeal infection leading to septic thrombophlebitis of internal jugular vein.
Preceding tonsillar or Peritonsillar infection
Infection usually resolves before presentation, latent period 1-3 weeks
IJV Thrombosis and sepsis develops accompanied by high fever, neck swelling. Pain at angle of mandible and anterior and medial border of sternocleidomastoid muscles. May also have dysphagia and trismus. Infection can met to lung. causing ARDS. Also osteomyelitis, septic arthritis, meningitis, and liver abscess. Most common bacteria is fusobacterium, especially necrophorum
SpRx c Unasyn for 2-6 weeks
Can occur even post removal. Drooling, trismus, odynophagia, dysphagia, otalgia, inferior and medial displacement of the tonsil. Usually unilateral. Seen in 20-40 year olds.
CT, MRI, UTS. PCN is drug of choice. Also Unasyn then PO augmentin
Needle aspiration or I/D
Space between c-spine and prevertebral fascia
can lead to cervical osteomyelitis
consider staph or m. tuberculosis
Admit, Abx, Neurosurgical Consult
Frontal, maxillary, ethmoid (can spread to CNS), sphenoid (Can invade sella turcica)
Sphenoid Sinusitis can progress to bacterial meningitis
Mucormycosis-black or grey covering. Invasive to blood vessels.
ACP Guidelines for ABX in Sinusitis
DX: Gold standard for bacterial dx is sinus puncture, but never done
Viral illnesses can last up to 33 days (JAMA 202 1967)
But >7 days of SX c
Purulent nasal discharge; maxillary, dental, or facial pain; unilateral sinus tenderness; or worsening sx after improvement (bacterial superinfection); along with severe SX should be treated with narrow spectrum ABX such as amox, doxy, or bactrim.
Even bacterial sinusitis will self resolve if treated symptomatically so only treat severe sx.
in patients with sx of ~48 hrs with signs of bacterial sinusitis, there was no difference between treatment with augmentin or placebo (Arch Intern Med 2003;163:1793-1798)
5 clinical elements are predictive: maxillary toothache, poor response to decongestants, abnormal transillumination, colored nasal discharge, and purulent nasal mucus. When none are present, 9% had sinusitis, when all are rpesent 92% had sinusitis (Ann Intern Med 117:705, 1992)
Allergic Rhinitis 2005;353:1934
>5 days of purulent rhinitis may benefit from ABX-a SR and MA (BMJ 2006;333:279)
Phenylephrine drops .5% q 4hours x 3 days
Atrovent Nasal Spray 2 sprays each nostril QID
stimulate the soft palate with tongue blade or cotton tip just short of making patient gag; sugar on base of tongue may do the same
Look in ears, consider chest x-ray. MS can cause intractable hiccups as can hyponatremia
Can try chlorpromazine 25 to 50 po TID or QID (can also be given IM), Haldol 2-5 mg IM then 1-4 mg po TID, Reglan 10 mg IV or IM then 10 to 20 mg PO QID. (Minor Emergencies) My favorite is baclofen.
Six patients, four men and two women, aged 1851 years, presented with hiccups of duration ranging from 30 min to 8 h. Physical examinations were otherwise normal. These patients were instructed to expire maximally, then inspire maximally (take a very deep breath). After holding the breath for 10 seconds, an additional small supramaximal inspiration was added (breathe in some more), and held for 5 more seconds. Finally, a third small supra-supramaximal inspiration was taken and held for 5 seconds. In these three cumulative breaths, the lung volume asymptoticallyapproaches functional vital capacity. The patients then returned to normal breathing. An immediate and permanent termination to hiccups was achieved in all six patients, who were satisfied with the expediency of this therapy. (JEM 2004 27(4) 2416)
Dextromethorphan 10-20 mg Q 4-6, at night 30 mg
Demulcents-licorice, glycerin, honey
Expectorants-guaifenesin 100-200 mg TID
guaifenesin was effective in URI subjects and not in healthy subjects (Chest. 2003;124:2178-2181.)
Nebulized lidocaine For Cough Suppression and Asthma Patients frequently present to the ED with intractable and unproductive cough as a result of acute asthma or reactive airways disease, despite the widespread use of cough suppressants. Inhalation of lidocaine to suppress troublesome cough is an extension from its routine use in bronchoscopy which has found it to be very safe. In addition, lidocaine has been studied extensively in asthma (1-3). In the ED, nebulized lidocaine has found to be of benefit by providing relief of cough, while awaiting the effect of definitive therapy (1). Nebulized lidocaine solutions varying in concentration from 1% to 4% have been used without ill effects on patients. A typical regimen is the administration of 1cc of a 1% solution in 4mL of saline to give 0.25% solution administered until nebulization is complete. This has been found to produce almost instantaneous relief of cough (1). Because lidocaine can cause bronchospasm in asthmatic patients (1,3), it has been recommended to precede its use by giving a standard dose of a nebulized beta-agonist bronchodilator. References: (1) Udezue E Lidocaine inhalation for cough suppression Am J Emerg Med 2001;19(3):206-7 (2) Prakash GS, et al. Effect of 4% lidocaine inhalation in bronchial asthma J Asthma 1990;27(2):81-5. (3) Fish JE, et al. Effects of inhaled lidocaine on airway function in asthmatic subjects Respiration 1979;37(4):201-7
Arthritis and ankylosis of TMJ joint affects 50-75% and limits the ability to open the mouth. Atlantoaxial cervical spine arthritis, The cricoarytenoid joint can also become arthritic and fix the vocal cords causing upper airway obstruction.
20% have atlantoaxial subluxation making intubation with neck extension risky just like RA patients
Endotracheal Tube Injuries
Most commonly occurs at two levels:
old style cuffs caused circumferential ischemic necrosis resulting in laryngomalacia. This should not be seen with current low pressure cuffs unless over inflated. The other site is at the tip of the tube with mucosal irritation and ulceration leading to subglottic stenosis.
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