Conference Review – Nose and HEENT infections

Thanks to Dr. Brad End for this conference review on our HEENT Nose and HEENT Head and Neck infections small groups

EPISTAXIS

Anterior bleeds (90%) from Kiesselbach’s plexus, posterior bleeds (10%) from sphenopalatine artery

Digital trauma and medications are the most common cause.  Consider substance abuse or septal perforations.  Possibility of neoplasm or hereditary hemorrhagic telengectasia.

Hypertension has not been a proven risk factor for epistaxis

Possible treatment algorithm: 15 minutes of pressure with head tilted forward à topical vasoconstrictor such as oxymetazoline à chemical cautery (silver nitrate) à anterior packing (rhinorocket or gauze coated with petroleum jelly) or absorbable packing with gelfoam or floseal à consider posterior packing (epistat or foley catheter) with ENT consult

There is no evidence of risk toxic shock syndrome or otitis media when withholding antibiotics for ANTERIOR nasal packing of a duration of 24-48 hrs

Antibiotics should be provided for those requiring prolonged anterior packing or posterior packing, providing adequate staph coverage (amoxicillin-clavulanic acid)

 

NASAL FOREIGN BODIES

If attempting a manual removal, topical vasoconstrictors may help with visualization and topical anesthetics may make removal more tolerable by the patient

In children, a foreign body may be removed by having the child blow the nose, or having a parent blow air into the child’s mouth while holding the opposite nasal passage closed

Alligator forceps, currettes and suction may be considered.  Removal may also be attempted by passing a small balloon catheter distal to the object, inflating the balloon and gently pulling the balloon through the nasal passage

Retained foreign bodies increase the risk of aspiration (of the foreign body), infection (sinusitis), or necrosis/perforation

 

SINUSITIS

Acute <4 weeks, Chronic >12 weeks, Recurrent >4 episodes per year

Most caused by viruses (rhinovirus,  influenza, parainfluenza) but may also be caused by bacteria (S. Pneumoniae, H. influenza,  M. catarrhalis)

Bacterial versus viral distinguishment dependent on severity and duration of symptoms (more likely bacterial with associated high fevers, severe symptoms, >7-10 days, double worsening)

For suspected bacterial infections, amoxicillin is first line with doxycycline for penicillin allergic patients

Saline irrigation can help with symptoms, as do intranasal glucocorticoids.  No proven benefit of intranasal antihistamines.

Complications of untreated bacterial sinusitis include facial/periorbital cellulitis, osteomyelitis, epidural abscess, meningitis, cavernous sinus venous thrombosis

LUDWIG’S ANGINA

Typically seen with infection of the 2nd/3rd mandibular molars or after trauma to the floor of the mouth, most often caused by mixed oropharyngeal flora

Signs and symptoms include swelling and erythema, pain, dysphagia, dysphonia, tongue protrusion

Mild to moderate cases may not require prophylactic intubation, if intubation is attempted, strongly consider concurrently setting up for a surgical airway

Antibiotics should be started in the ED (penicillin + metronidazole, clindamycin, ampicillin-sulbactam), many will require surgical drainage during admission

Complications include progressive airway obstruction and descending mediastinitis

 

EPIGLOTTITIS

H. influenzae (typically more ill appearing), S. pneumoniae, M. catarrhalis. Also may be non-infectious resulting from noxious gas inhalation or thermal injury

Signs and symptoms include severe progressive pain, dysphagia, odynophagia and possibly dyspnea.  Dysphonia can be seen, but is less common

Imaging modalities include soft tissue films of the neck (thumbprint sign) or CT (distortion of halloween sign), or indirect visualization (laryngoscopy) only in non-toxic appearing patients

Antibiotics in the ED should include ceftriaxone, ampicillin-sulbactam or (less often used) chloramphenicol.  Steroids are often used, however their utility is controversial

 

RETROPHARNGEAL ABSCESS

Typically seen in those between 6 months and 3 years of age as a complication of acute otitis media or nasopharyngitis.  May also be caused by trauma

Signs and symptoms include fever, neck pain/stiffness, dysphagia or trismus, muffled voice, stridor, posterior oropharyngeal edema, cervical lymphadenopathy

Imaging modalities may include soft tissue films of the neck, but the gold standard is CT

Antibiotics in the ED include penicillin + metronidazole, clindamycin or ampicillin-sulbactam

Complications include abscess rupture with concomitant aspiration, or spread of infection (pneumonia, mediastinitis)

 

PERITONSILAR ABSCESS

Seen most often in adolescents and young adults, this represents an infectious process with purulent discharge occupying the space between the tonsilar capsule and palatopharyngeus muscle

Often caused by group A streptococcus or S. aureus

Signs and symptoms include severe unilateral pharyngitis, referred ear pain, odynophagia, hot potato voice, displacement of the uvula

Treatment may include either needle aspiration (use needle cover to ensure depth of penetration <1 cm) or I&D.  Antibiotics should include clindamycin, penicillin, amoxicillin-clauvaunic acid

Complications include septic thrombophlebitis (Lemierre syndrome) which can lead to septic emboli to the lungs/joints (caused by fusobacterium necroformans), mediastinitis, carotid extension with hemorrhage, or progression of edema causing airway compromise

 

ASSORTED PHARYNGITIS

Most often caused by viruses, may be due to Group A strep or EBV/CMV

Consider use of Centor criteria prior to testing/treatment in patients with suspected GAS pharyngitis.  Treatment is with bicillin (IM) or amoxicillin (PO).  Treatment decreases symptoms by approximately one day, but also protects against development of rheumatic fever.  It does not decrease the risk of post-infectious glomerulonephritis

Infectious mononucleosis presents with fevers, fatigue and exudative tonsillitis/pharyngitis.  Adenopathy is common, typically in the posterior cervical chain.  Evaluate for splenomegaly.  Treatment is supportive, but remind patient to avoid contact sports for at least one month.

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