INFECTIONS OF THE HEAD AND NECK

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INFECTIONS OF THE HEAD AND NECK

• Brenda Beckett, PA-C
• Clinical Medicine II
• UNE PA Program

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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

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Rhinorrhea

• Causes
• Allergic
• Viral URI
• Influenza
• Others

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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

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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.

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Rhinitis

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

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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).

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Rhinitis

• HPDP
• Huge misconception by patients that antibiotics
  are helpful?antibiotic resistance
• Hand washing

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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

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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

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Sinusitis

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

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Sinusitis
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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

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Stomatitis

• Inflammation of the mucous membranes of mouth,
  multiple possible causes
• Thrush
• Aphthous ulcers or canker sores
• HSV
• Vincents stomatitis
• Herpangina
• Systemic disease, others (Syphilis)

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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)

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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

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Stomatitis

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

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Stomatitis

• Vincents 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

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Stomatitis

• Herpangina
• Caused by coxsackie A virus
• Childhood disease
• Discrete ulcerations on soft palate
• Children lt6 yrs
• Symptomatic treatment
• What else does coxsackie cause?

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Name that Stomatitis
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Otalgia

• Otitis externa
• Otitis media
• Referred pain

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Otitis

• EXTERNA
• Pseudomonas due to Swimmers 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

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Otitis Externa
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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

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Otitis Media

• Otitis media treatment
• ? Treat with abx?
• lt2 yrs, yes
• gt2 yrs, can treat with analgesics x24 hrs, then
  abx if no
• Tx amoxicillin 1st line, then cephalosporin,
  augmentin
• PE tubes for recurrent

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Otitis Media
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TM perforation
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Tubes(Sometimes theyre blue)
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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

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Serous Otitis
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Mastoiditis

• Serious complication of inadequately treated
  OMoccurs 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

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Mastoiditis

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

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Mastoiditis
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PHARYNGITIS

• Caused by viral, Group A strep, others
• Thorough history and exam is critical
• Seven Danger Signs
• Persistent symptoms gt1 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

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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

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Other sx of strep

• Headache
• Stomach ache, N/V
• Palatal petichiae see up on palate
• Always look at their skin for rash

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Exudate
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Palatal Petichiae
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Diagnosing Strep Pharyngitis

• Criteria for suspicion (Centor criteria)
• Lack of cough
• Swollen anterior cervical nodes
• Marked exudate
• Fever gt38.3 C (100.9 F)
• Age lt15 yrs
• Group A strep screen or Throat culture

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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

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EBV Pharyngitis

• Symptoms
• Pain, difficulty swallowing
• Marked lymphadenopathy
• Tonsillar exudate
• Lymphocytosis
• Heptosplenomegaly
• 1/3 have strep concurrently

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EBV

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

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EBV
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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

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Epiglottitis

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

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Epiglottitis
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Soft Tissue Infections

• Peritonsillar abscess
• Pain, difficulty swallowing, trismus, hot
  potato voice
• Swollen peritonsillar tissue laterally
  displaced uvula
• CT for dx, Surgical drainage and antibiotics for
  tx (or tonsillectomy)
• Untreated can progress to invade vascular
  structures

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Peritonsillar Abscess
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Soft Tissue Infections

• Ludwigs Angina
• Extension of infection from tooth
• Floor of mouth inflamed, tongue pushed upwards
• Firm induration of submandibular space and neck
• Laryngeal edema and respiratory compromise
• PCN metronidazole
• Protect airway, drain

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EXTRA RESPIRATORY PHARYNGITIS

• Onset w/activity
• Abrupt onset of tearing pain
• Tenderness in anterior neck, enlarged thyroid
• Sore mouth with beefy red tongue
• Angina
• Dissecting aorta
• Thyroiditis
• Vitamin B deficiency