Anatomy of Sinuses

Acute Rhinosinusitis (Viral)• Common Symptoms: Nasal discharge, nasal

congestion, facial pressure, cough, fever, muscle aches, joint pains, sore throat with hoarseness.

• Symptoms resolve in 10-14 days

• Common in fall, winter and spring.

• Treatment: Symptomatic

Acute Bacterial Sinusitis

• Causative agents are usually the normal inhabitants of the respiratory tract.

• Common agents: Streptococcus pneumoniae Nontypeable Haemophilus Influenzae Moraxella Catarrhalis

Diagnosis

• Based on clinical signs and symptoms• Physical Exam: Palpate over the sinuses, look

for structural abnormalities like DNS.• X-ray sinuses: not usually needed but may

show cloudiness and air fluid levels• Limited coronal CT are more sensitive to

inflammatory changes and bone destruction

Signs and Symptoms• Feeling of fullness and pressure over the

involved sinuses, nasal congestion and purulent nasal discharge.

• Other associated symptoms: Sore throat, malaise, low grade fever, headache, toothache, cough > 1 week duration.

• Symptoms may last for more than 10-14 days.

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MANIFESTATIONS

nasal drainage and congestion facial pain or pressure headache. Thick, purulent or discolored nasal discharge is often thought to indicate bacterial sinusitis, but it

also occurs early in viral infections such as the common cold

Other nonspecific symptoms include cough, sneezing, and fever

Tooth pain, most often involving the upper molars, is associated with bacterial sinusitis

Dr. Farzin khorvash

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MANIFESTATIONS

sinus pain or pressure often localizes and be worse when the patient bends over or is supine

symptoms of advanced sphenoid or ethmoid sinus: severe frontal or retroorbital pain radiating to the occiput, thrombosis of the cavernous sinus, and signs of orbital cellulitis

advanced frontal sinusitis ,Pott's puffy tumor, swelling and pitting edema over the frontal bone ,subperiosteal abscess

Dr. Farzin khorvash

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DIAGNOSIS

illness duration acute bacterial sinusitis is uncommon in patients whose

symptoms have lasted <7 days facial or tooth pain in combination with purulent nasal

discharge that have persisted for >7 days

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Diagnosis and Management of Acute Sinusitis Update of 2001 guideline Focuses on ages 1–18 years Not subacute or chronic; not <1 year Not anatomic abnormalities; immunodeficiencies,

cystic fibrosis, ciliary dyskinesia

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Diagnosis and Management of Acute Sinusitis

Areas of change:

1.Addition of “worsening course”

2.New data on effectiveness of antibiotics

3.Option to observe for 3 days in “persistent” infection

4.Imaging is not necessary to identify or confirm a diagnosis of acute sinusitis

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Key Action Statement 1

Clinicians should make a diagnosis of acute bacterial sinusitis (ABS) when a child with an upper respiratory infection (URI) presents with: Persistent illness (nasal discharge or daytime cough or both for ≥10 days without improvement)Worsening course (worsening or new onset of nasal discharge, daytime cough or fever after initial improvement)Severe onset (concurrent fever and purulent nasal discharge for 3 days)

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Common Clinical Presentations for ABS

Persistent Symptoms

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Acute Sinusitis “Persistent Symptoms” 10–30 days (no improvement) Nasal discharge (any quality) Daytime cough (worse at night) Fever – variable Headache and facial pain – variable

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Persistent Symptoms Only 6–8% of children meet criteria

Before concluding that child has sinusitis: Differentiate between sequential episodes of URI

and sinusitis Establish that symptoms are NOT improving

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Acute Sinusitis “Severe Symptoms” High fever (T ≥39o C) and Purulent nasal discharge concurrently for at least

3–4 days

Need to distinguish from uncomplicated viral infections with moderate illness

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“Worsening Symptoms” Typical viral URI symptoms Nasal discharge or cough or both for 5–6 days which

is improving Sudden worsening manifests as

O Increase nasal discharge or cough or bothO Onset of severe headacheO Onset of new fever

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Images – Key Action Statement 2A

Clinicians should not obtain imaging studies (plain x-rays, computed tomography [CT] , magnetic resonance imaging [MRI] or ultrasound [U/S]) to distinguish ABS from viral URI

Brian Evans/Photo Researchers/Getty Images

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Images Historically, imaging was confirmatory No longer recommended Continuity of respiratory mucosa leads to diffuse

inflammation during viral URI Responsible for controversy regarding images

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COMPUTED TOMOGRAPHY, SINUS RADIOGRAPHY

patients who meet these criteria, only 40 to 50% have true bacterial sinusitis

CT or XR is not recommended for routine cases, particularly early in the course of illness (i.e., at <7 days)

persistent, recurrent, or chronic sinusitis, CT of the sinuses is choice.

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Imaging of Sinuses 1940s – Observations made regarding frequency of

abnormal sinus radiographs in “healthy” children 1970s and 1980s – Children with URI had frequent

abnormalities of paranasal sinuses As CT scanning of central nervous system (CNS) and

skull became prevalent, incidental abnormalities observed

When MRI performed in children with URI, 70% show major abnormalities of mucosa

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Computed Tomographic Study of the Common Cold

31 healthy young adults with new “cold” Recruited within 48–96 hours To have CT of paranasal sinuses 87% had significant abnormalities of their maxillary

sinuses; with air-fluid level Conclusion: Common cold associated with frequent

and striking abnormalities of sinuses

Gwaltney JM Jr, Phillips CD, Miller RD, et al. Computed tomography study of the common cold. N Engl J Med. 1994;330(1):25–30

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Image provided by speaker.

Coronal computed tomographic scan showing ethmoidal polyps. Ethmoid opacity is total as a result of nasal polyps, with a secondary fluid level in the left maxillary antrum.

Ethmoid Sinusitis

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Abnormalities on CT Scan

Image provided by speaker.

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Summary of Imaging

When paranasal sinuses are imaged in any way in children with uncomplicated URI, majority will be significantly abnormal

Normal images = No sinusitis

Abnormal images cannot confirm diagnosis and are not necessary in children with uncomplicated clinical sinusitis

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Images – Key Action Statement 2B

Clinicians should obtain a contrast-enhanced CT scanof the paranasal sinuses and/or an MRI with contrast whenever a child is suspected of having orbital or CNS complications of ABS

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Complications of Sinusitis

Orbital

a. sympathetic effusion

b. subperiosteal abscess

c. orbital abscess

d. orbital cellulitis

e. cavernous sinus thrombosis

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Orbital Complications of Sinusitis Proptosis – anterior and lateral displacement of

globe Impairment of extraocular movements Loss of visual acuity Chemosis – edema of conjunctiva

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Image provided by speaker.

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CNS Complications of ABS

Suspected with very severe headache, photophobia, seizure, other focal neurologic findingsSubdural empyemaEpidural empyemaVenous thrombosisBrain abscessMeningitis

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Initial Management of ABS

Key Action Statement 3A: Clinician should prescribe antibiotic therapy for ABS in children with severe onset or worsening course

Key Action Statement 3B: Clinician should either prescribe antibiotic therapy OR offer additional outpatient observation for 3 days to children with persistent illness

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Initial Management of ABS

Guidance for clinician regarding management of children with persistent symptoms:

O Antibiotic therapy – starting as soon as possible after the encounter

O Additional outpatient observation – for 3 days with plan to begin antibiotics if child does not improve or worsens at any time

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Initial Management of ABS Contrasts with 2001 AAP guideline Acknowledges that although ABS is a bacterial

infection O spontaneous resolution ~ commonO 10 days is a guideline; no likely harm in allowing up to 3

more days in persistent onset

Reinforces antibiotic treatment as soon as possible in severe or worsening illness

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TREATMENT

Most patients ,improve without antibiotic therapy

mild to moderate symptoms of <7 days' duration facilitating sinus drainage, such as oral and topical

decongestants, nasal saline lavage in patients with a history of chronic sinusitis or

allergies — nasal glucocorticoids.

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ANTIBIOTICS

not improve after 7 days more severe symptoms (regardless

of duration)

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ANTIBIOTICS

Empirical therapy ,S. pneumoniae and H. influenzae amoxicillin drug-resistant S. pneumoniae Up to 10% of patients do not respond to initial

antimicrobial therapy these patients should be considered for sinus

aspiration and/or lavage prophylactic antibiotics to prevent episodes of

recurrent acute bacterial sinusitis is not recommended.

Dr. Farzin khorvash

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Key Action Statement 4

Clinicians should prescribe amoxicillin with or without clavulanate as first-line treatment when a decision has been made to initiate antibiotic treatment of ABS

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Microbiology of Acute Sinusitis

Gleaned from microbiology of acute otitis media (AOM)

Similar pathogenesis and pathophysiology

Middle ear is a paranasal sinus

Brian Evans/Photo Researchers/Getty Images

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Microbiology of ABS, 1984

Streptococcus pneumoniae 30%

Haemophilus influenzae 20%

Moraxella catarrhalis 20%

Streptococcus pyogenes 4%

Sterile 25%

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Suspected Microbiology of ABS, 2013

Streptococcus pneumoniae 15–20%

Haemophilus influenzae 45–50%

Moraxella catarrhalis 10–15%

Streptococcus pyogenes 5%

Sterile 25%

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Antibiotic Resistance S pneumoniae: 10–15%; can increase up to 50% H influenzae: 10–68% M catarrhalis: 100%

LIMITED CURRENT DATA ON MICROBIOLOGY

Treatment• About 2/3rd of patients will improve without treatment in

2 weeks.

• Antibiotics: Reserved for patients who have symptoms for more than 10 days or who experience worsening symptoms.

• OTC decongestant nasal sprays should be discouraged for use more than 5 days

• Supportive therapy: Humidification, analgesics, antihistaminics

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Treatment Amoxicillin – traditional first-line therapy Amoxicillin at 45 mg/kg/day in 2 doses If high prevalence of penicillin-resistant S pneumoniae Amoxicillin at 90 mg/kg/day in 2 doses

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Treatment Amoxicillin ineffective against beta-lactamase

producing bacteria Choices:O drug inherently resistant to beta-lactamaseO combine amoxicillin with irreversible beta-lactamase

inhibitor = K clavulanate

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Treatment If S pneumoniae remains low or continues to decrease

and H influenzae remains high or continues to increase (including β-lactamase (+) strains)

Amoxicillin-clavulanate 45 mg/kg/day Amoxicillin-clavulanate 90 mg/kg/day

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Treatment 50 mg/kg Ceftriaxone IV or IM

Allergy: Cephalosporins: cefdinir, cefuroxime, cefpodoxime Clindamycin (or linezolid) + cefixime Levofloxacin

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Treatment Optimal duration: no systematic study Duration of therapy: 10, 14, 21, 28 days Treat until patient is free of symptoms plus 7 days

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Key Action Statement 5A

Clinicians should reassess initial management if there is caregiver report of worsening OR failure to improve within 72 hours

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Response to Appropriate Management Most patients with ABS who are treated with an

appropriate antimicrobial agent respond promptly (within 48–72 hours)

Worsening = progression of signs/symptoms Failure to improve = not better or worse

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Key Action Statement 5B

If worsening symptoms or failure to improve clinicians should change antibiotics or initiate antibiotics in child managed with observation

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Management of ABS at 72 Hours

Whether or not antibiotics are used, a system must be in place to either add antibiotic or change the antibiotic if symptoms do not improve in 48–72 hours

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Management of Worsening or No ImprovementInitial

ManagementWorse in72 Hours

No Improvement in 72 Hours

Observation Amoxicillin + clavulanate ObservationORInitiate antibiotic

Amoxicillin Amoxicillin-clavulanate ObservationORAmoxicillin-clavulanate

Amoxicillin-clavulanate Clindamycin + cefiximeORLinezolid + cefiximeORLevofloxacinORCefuroxime, Cefdinir OR Cefpodoxime

Amoxicillin-clavulanateORSame choices as in preceding box

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Adjuvant Therapies – No Recommendation Antihistamines Intranasal steroids Intranasal saline Decongestants

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Summary Use stringent criteria to diagnose sinusitis in children Avoid obtaining images Amoxicillin with or without clavulanate High-dose amoxicillin plus clavulanate for resistance

(most comprehensive) Adjuvant therapy rarely indicated

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NOTE:

evidence of fungal hyphal elements and tissue invasion acute nosocomial sinusitis should be confirmed by a sinus CT

scan sinus aspirate , if possible, for culture and susceptibility

testing.

Dr. Farzin khorvash

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TREATMENT OF NOSOCOMIAL SINUSITIS

broad-spectrum antibiotics to cover common pathogens such as S. aureus and gram-negative bacilli

Therapy should then be tailored to the results of culture and susceptibility testing of sinus aspirates.

Dr. Farzin khorvash

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SURGICAL INTERVENTION AND INTRAVENOUS ANTIBIOTICS

severe disease intracranial complications, such as abscess or orbital

involvement acute invasive fungal sinusitis usually require extensive

surgical debridement Intravenous antifungal such as amphotericin B

Dr. Farzin khorvash

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CHRONIC SINUSITIS

symptoms of sinus inflammation lasting >12 weeks bacteria or fungi clinical cure in most cases is very difficult Many patients have undergone repeated courses of

antibacterial agents and multiple sinus surgeries increasing their risk of colonization with antibiotic-

resistant pathogens and of surgical complications

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CHRONIC BACTERIAL SINUSITIS

nasal congestion and sinus pressure, with intermittent periods for years

CT scan be helpful in defining the extent of disease and the response to therapy

endoscopic examinations and obtain tissue samples for histologic examination and culture.

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CHRONIC BACTERIAL SINUSITIS

impairment of mucociliary clearance from repeated infections rather than to persistent bacterial infection

pathogenesis of this condition is poorly understood certain conditions (e.g., cystic fibrosis) most patients do not have obvious underlying

conditions that result in the obstruction of sinus drainage, the impairment of ciliary action, or immune dysfunction

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CHRONIC FUNGAL SINUSITIS

immunocompetent hosts usually noninvasive, although slowly progressive Aspergillus species

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CHRONIC FUNGAL SINUSITIS

In mild, indolent disease repeated failures of antibacterial therapy only nonspecific mucosal changes may be seen on sinus CT Endoscopic surgery is usually curative in these patients, with

no need for antifungal therapy

Dr. Farzin khorvash

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CHRONIC FUNGAL SINUSITIS

mycetoma (fungus ball) within the sinus Treatment for this condition is also surgical systemic antifungal therapy may be warranted in the rare case

where bony erosion occurs.

Dr. Farzin khorvash

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CHRONIC FUNGAL SINUSITIS

allergic fungal sinusitis history of nasal polyposis and asthma thick, eosinophilic mucus with the consistency of peanut

butter that contains sparse fungal hyphae on histologic examination.

Patients often present with pansinusitis.

Dr. Farzin khorvash

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TREATMENT

administration of intranasal glucocorticoids; and mechanical irrigation of the sinus with sterile saline solution

When this management approach fails, sinus surgery may be indicated

Dr. Farzin khorvash

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ACUTE PHARYNGITIS

Millions of visits the majority by typical respiratory viruses important is with group A ß-hemolytic Streptococcus (S.

pyogenes), which can progress to acute rheumatic fever and acute glomerulonephritis

the risk for both of which can be reduced by timely penicillin therapy.

Dr. Farzin khorvash

Acute Pharyngitis• Fewer than 25% of patients with sore throat

have true pharyngitis.• Primarily seen in 5-18 years old. Common in

adult women.

EtiologyA) Viral: Most common. Rhinovirus (most common). Symptoms usually last for 3-5 days.

B) Bacterial: Group A beta hemolytic streptococcus (GABHS).

Early detection can prevent complications like acute

rheumatic fever and post streptococcal GN.

Signs and Symptoms• Absence of Cough• Fever• Sore throat• Malaise• Rhinorrhoea• Classic triad of GABHS: High fever, tonsillar

exhudates and ant. cervical lymphadenopathy. NO COUGH

Diagnosis• Physical Exam: Tonsillar exhudates, anterior

cervical LAD• Rapid strep: Throat swab. Sensitivity of 80% and

specificity of 95%. Throat Cultures: Not required usually. Needed only when

suspicion is high and rapid strep is negative.

Exhudates

Management

A) Symptomatic: Saline gargles, analgesics, cool-mist humidification and throat lozenges.

B) Antibiotics: a) Benzathine Pn-G 1.2 million units IM x 1OR Pn V orally for 10 days b) For Pn allergic pts: Erythromycin 500mg QID x 10 days OR Azithro 500 mg Qdaily x 3 days.

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ACUTE BACTERIAL PHARYNGITIS

S. pyogenes, (~5 to 15% of all cases ) children 5 to 15 years of age Streptococci of groups C and G account Neisseria gonorrhoeae Corynebacterium diphtheriae Corynebacterium ulcerans Yersinia enterocolitica Treponema pallidum (in secondary syphilis) M. pneumoniae C. pneumoniae

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ANAEROBIC BACTERIA

Vincent's angina can contribute to more serious polymicrobial infections peritonsillar or retropharyngeal abscess

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COMPLICATIONS

rheumatic feveracute glomerulonephritis numerous suppurative conditions, such as

peritonsillar abscess ,otitis media, mastoiditis, sinusitis, bacteremia, and pneumonia

Therapy of acute streptococcal pharyngitis can prevent the development of rheumatic fever

no evidence that it can prevent acute glomerulonephritis

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TREATMENT

Antibiotic benefit:S. pyogenes a decrease in the risk of rheumatic fever rheumatic fever is now a rare disease, even in

untreated patients When therapy is started within 48 h of illness onset,

however, symptom duration is also decreased. reduce the spread of streptococcal pharyngitis,

overcrowding or close contact

Dr. Farzin khorvash

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STREPTOCOCCAL PHARYNGITIS

single dose of intramuscular benzathine penicillin 10-day course of oral penicillin Erythromycin :penicillin Testing for cure is unnecessary and may reveal only

chronic colonization. Penicillin prophylaxis (benzathine penicillin G, 1.2

million units intramuscularly every 3 to 4 weeks) for patients at risk of recurrent rheumatic fever

Dr. Farzin khorvash

Non specific URI’s• Common Cold• Etiology: Rhinovirus Adenovirus RSV Parainfluenza EnterovirusesDiagnosis: ClinicalTreatment: Adequate fluid intake, rest, humidified air,

and over-the-counter analgesics and antipyretics.

Influenza• Etiology: Influenza A & B• Symptoms: Fever, myalgias, headache, rhinitis,

malaise, nonproductive cough, sore throat• Diagnosis: Influenza A &B antigen testing• Treatment: Supportive care, oseltamivir,

amantidine

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ETIOLOGY

30% have no identified cause. Respiratory viruses :rhinoviruses ,coronaviruses

Influenza virus, parainfluenza virus, and adenovirus the latter as part of the more clinically severe syndrome of pharyngoconjunctival fever

HSV types 1 and 2, coxsackievirus A, CMV, EBV Acute HIV infection

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MANIFESTATIONS

viruses :not severe and is typically associated with a constellation of coryzal symptoms

Findings on physical examination are uncommon; fever is rare, tender cervical adenopathy and pharyngeal exudates are not

seen.

Dr. Farzin khorvash

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MANIFESTATIONS

influenza virus can be severe with fever as well as with myalgias, headache, and cough

pharyngoconjunctival fever due to adenovirus infection is similar

Since pharyngeal exudate may be present on examination

adenoviral pharyngitis is distinguished by the presence of conjunctivitis in one-third to one-half of patients.

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MANIFESTATIONS

primary HSV :mimic streptococcal pharyngitis in some cases, with pharyngeal inflammation and exudate

vesicles and shallow ulcers on the palate coxsackievirus ( herpangina):small vesicles that

develop on the soft palate and uvula and then rupture to form shallow white ulcers

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INFECTIOUS MONONUCLEOSIS Acute exudative pharyngitis coupled with fever, fatigue,

generalized lymphadenopathy, splenomegaly CMV,EBV

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HIV fever acute pharyngitis myalgias, arthralgias, malaise nonpruritic maculopapular rash lymphadenopathy mucosal ulcerations without exudate.

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STREPTOCOCCI A, C, AND G ranging from a relatively mild illness without many

accompanying symptoms to clinically severe cases pharyngeal pain, fever, chills, and abdominal pain A hyperemic pharyngeal membrane with tonsillar

hypertrophy and exudate is usually seen tender anterior cervical adenopathy Coryzal manifestations, including cough, are typically

absent

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SCARLET FEVER Strains of S. pyogenes that generate erythrogenic toxin characterized by an erythematous rash and strawberry

tongue

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DIAGNOSIS

Throat swab culture Rapid antigen-detection tests offer good specificity (>90%) but

lower sensitivity that varies across the clinical spectrum of disease (65 to 90%)

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RADT all negative rapid antigen-detection tests in children be

confirmed by a throat culture do not recommend backup culture when adults have a

negative rapid antigen-detection test

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DIAGNOSIS

Cultures and rapid diagnostic tests for influenza virus, adenovirus, HSV, EBV9, CMV, and M. pneumoniae, are available

the monospot test for EBV HIV RNA or antigen (p24) when acute primary HIV infection cultures : N. gonorrhoeae, C. diphtheriae, or Y. enterocolitica

Dr. Farzin khorvash

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INFLUENZA VIRUS

amantadine, rimantadine, and the two newer agents oseltamivir and zanamivir

All of these agents need to be started within 36 to 48 h of symptom onset to reduce illness duration meaningfully

Of these agents, only oseltamivir and zanamivir are active against both influenza A and influenza B

Dr. Farzin khorvash

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PERITONSILLAR ABSCESS

severe pharyngeal pain dysphagia, fever, medial displacement of the tonsil therapy :Oral penicillin ,with clindamycin as an alternative Early use of antibiotics in these cases has substantially

reduced the need for surgical drainage

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VINCENT'S ANGINA

acute necrotizing ulcerative gingivitis painful, inflamed gingiva ulcerations of the interdental papillae that bleed

easily halitosis ,fever, malaise, and lymphadenopathy oral anaerobes Treatment :debridement and oral penicillin

+ metronidazole clindamycin alone as an alternative.

Dr. Farzin khorvash

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LUDWIG'S ANGINA

is a rapidly progressive, potentially fulminant cellulitis involving the sublingual and submandibular spaces

typically originates from an infected or recently extracted tooth, most commonly the lower second and third molars

dysphagia, odynophagia, and "woody" edema in the sublingual region, forcing the tongue up and back with the potential for airway obstruction.

Fever, dysarthria, and drooling , speak in a "hot potato" voice

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TREATMENT

Intubation or tracheostomy may be necessary to secure the airway

asphyxiation is the most common cause of death monitored closely and intravenous antibiotics directed against

streptococci and oral anaerobes ampicillin/sulbactam high-dose penicillin plus metronidazole.

Dr. Farzin khorvash

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POSTANGINAL SEPTICEMIA (LEMIERRE'S DISEASE)

oropharyngeal infection by Fusobacterium necrophorum starts as a sore throat (most commonly in adolescents and

young adults), exudative tonsillitis or peritonsillar abscess

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Infection of the deep pharyngeal tissue allows organisms to drain into the lateral pharyngeal space

which contains the carotid artery and internal jugular vein Septic thrombophlebitis of the internal jugular vein: pain,

dysphagia, and neck swelling and stiffness

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Sepsis occurs 3 to 10 days after the onset metastatic infection to the lung and other distant sites extend along the carotid sheath and into the posterior

mediastinum mediastinitis, erode into the carotid artery, with the early sign

of repeated small bleeds into the mouth The mortality rate as 50% Treatment : intravenous antibiotics (penicillin G or

clindamycin) and surgical drainage The concomitant use of anticoagulants to prevent

embolization remains controversial but is often advised.

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LARYNGITIS

inflammatory process involving the larynx are acute by the same viruses responsible for many other URI

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ETIOLOGY

rhinovirus, influenza virus, parainfluenza virus, adenovirus, coxsackievirus, coronavirus, and RSV

acute bacterial respiratory infections, such as group A Streptococcus or C. diphtheriae ,M. catarrhalis

Dr. Farzin khorvash

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CHRONIC LARYNGITIS

Mycobacterium tuberculosis Histoplasma and Blastomyces may cause laryngitis Candida species :thrush or esophagitis and particularly in

immunosuppressed patients to Coccidioides and Cryptococcus.

Dr. Farzin khorvash

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MANIFESTATIONS

hoarseness other symptoms and signs of URI, including

rhinorrhea, nasal congestion, cough, and sore throat Direct laryngoscopy :diffuse laryngeal erythema and

edema, along with vascular engorgement of the vocal folds

tuberculous laryngitis, mucosal nodules and ulcerations visible on laryngoscopy

these lesions are sometimes mistaken for laryngeal cancer

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TREATMENT

humidification voice rest Antibiotics are not recommended except when group A

Streptococcus is cultured chronic laryngitis usually requires biopsy with culture. Patients with laryngeal tuberculosis are highly contagious

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CROUP

viral respiratory illnesses characterized by marked swelling of the subglottic region of

the larynx Croup primarily affects children <6 years old

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EPIGLOTTITIS

Acute epiglottitis :acute, rapidly progressive cellulitis of the epiglottis and adjacent

airway obstruction in both children and adults Before the widespread use of H. influenzae type b

(Hib) vaccine, this entity was much more common among children, with a peak incidence at ~3.5 years of age

a medical emergency, particularly in children, and prompt diagnosis and airway protection are of utmost importance.

Dr. Farzin khorvash

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ETIOLOGY

Hib12 group A Streptococcus S. pneumoniae Haemophilus parainfluenzae S. aureus Viruses have not yet been established as a cause of acute

epiglottitis.

Dr. Farzin khorvash

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MANIFESTATIONS

more acutely in young children than in adolescents or adults

On presentation, most children have had symptoms for <24 h, including high fever, severe sore throat, tachycardia, systemic toxicity, and drooling while sitting forward

Symptoms and signs of respiratory obstruction may also be present and may progress rapidly

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PHYSICAL EXAMINATION

moderate or severe respiratory distress inspiratory stridor and retractions of the chest wall These findings diminish as the disease progresses and the

patient tires

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DIAGNOSIS

often made on clinical grounds direct fiberoptic laryngoscopy is frequently

performed in a controlled environment :"cherry-red" epiglottis and to facilitate placement of an endotracheal tube

Direct visualization in an examination room (e.g., with a tongue blade and indirect laryngoscopy) is not recommended

Dr. Farzin khorvash

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Lateral neck radiographs and laboratory tests but may delay the critical securing of the airway Neck radiographs :enlarged edematous epiglottis

(the "thumbprint sign"), usually with a dilated hypopharynx and normal subglottic structures.

Laboratory tests :mild to moderate leukocytosis with a predominance of neutrophils

Blood cultures are positive in a significant proportion of cases.

Dr. Farzin khorvash

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TREATMENT

Security of the airway blood and epiglottis specimens have been obtained

for culture intravenous antibiotics, particularly H. influenzae Because rates of ampicillin resistance in this

organism have risen therapy : a ß-lactam/ß-lactamase inhibitor

combination or a second- or third-generation cephalosporin

Dr. Farzin khorvash

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ampicillin/sulbactam, cefuroxime, cefotaxime, or ceftriaxone

clindamycin and TMP-SMX reserved for patients allergic to ß-lactams

continued for 7 to 10 days household contacts of a patient with H. influenzae

epiglottitis include an unvaccinated child under the age of 4, all members of the household (including the patient) should receive prophylactic rifampin for 4 days to eradicate H. influenzae carriage.

Dr. Farzin khorvash

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RETROPHARYNGEAL ABSCESS

sore throat, fever, dysphagia, and neck pain and are often drooling , pain with swallowing

tender cervical adenopathy, neck swelling, and diffuse erythema and edema of the posterior pharynx , bulge in the posterior pharyngeal wall

A soft tissue mass :by lateral neck radiography or CT Because of the risk of airway obstruction, treatment

begins with securing of the airway combination of surgical drainage and

intravenousantibiotic administration

Dr. Farzin khorvash

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RETROPHARYNGEAL ABSCESS

streptococci, oral anaerobes, and S. aureus ampicillin/sulbactam, clindamycin alone, or

clindamycin plus ceftriaxone Complications :rupture into the posterior pharynx,

which may lead to aspiration pneumonia and empyema

Extension may also occur to the lateral pharyngeal space and mediastinum: mediastinitis and pericarditis

or into nearby major blood vessels

Dr. Farzin khorvash

Questions?