Chapter 031. Pharyngitis, Sinusitis, Otitis, and Other Upper Respiratory Tract Infections (Part 13) potx

Pharyngitis, Sinusitis, Otitis, and Other Upper Respiratory Tract Infections Part 13 Clinical Manifestations and Diagnosis Epiglottitis typically presents more acutely in young childr

Chapter 031 Pharyngitis, Sinusitis, Otitis, and Other

Upper Respiratory Tract Infections

(Part 13)

Clinical Manifestations and Diagnosis

Epiglottitis typically presents 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 (in many cases) drooling while sitting forward Symptoms and signs of respiratory obstruction may also be present and may progress rapidly The somewhat milder illness in adolescents and adults often follows 1–2 days of severe sore throat and is commonly accompanied by dyspnea, drooling, and stridor Physical examination

of patients with acute epiglottitis may reveal moderate or severe respiratory distress, with inspiratory stridor and retractions of the chest wall These findings

diminish as the disease progresses and the patient tires Conversely, oropharyngeal

examination reveals injection that is much less severe than would be predicted from the symptoms—a finding that should alert the clinician to a cause of symptoms and obstruction that lies beyond the tonsils The diagnosis is often made

on clinical grounds, although direct fiberoptic laryngoscopy is frequently performed in a controlled environment (e.g., an operating room) in order to visualize and culture the typical edematous "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 because

of the risk of immediate laryngospasm and complete airway obstruction Lateral neck radiographs and laboratory tests can assist in the diagnosis but may delay the critical securing of the airway and cause the patient to be moved or repositioned more than is necessary, thereby increasing the risk of further airway compromise Neck radiographs typically reveal an enlarged edematous epiglottis (the

"thumbprint sign," Fig 31-2), usually with a dilated hypopharynx and normal subglottic structures Laboratory tests characteristically document mild to moderate leukocytosis with a predominance of neutrophils Blood cultures are positive in a significant proportion of cases

Figure 31-2

Acute epiglottitis In this lateral soft tissue radiograph of the neck, the

arrow indicates the enlarged edematous epiglottis (the "thumbprint sign")

Epiglottitis: Treatment

Security of the airway is always of primary concern in acute epiglottitis, even if the diagnosis is only suspected Mere observation for signs of impending airway obstruction is not routinely recommended, particularly in children Many adults have been managed with observation only since the illness is perceived to

be milder in this age group, but some data suggest that this approach may be risky and probably should be reserved only for adult patients who have yet to develop dyspnea or stridor Once the airway has been secured and specimens of blood and

epiglottis tissue have been obtained for culture, treatment with IV antibiotics

should be given to cover the most likely organisms, particularly H influenzae

Because rates of ampicillin resistance in this organism have risen significantly in recent years, therapy with a β-lactam/β-lactamase inhibitor combination or a second- or third-generation cephalosporin is recommended Typically, ampicillin/sulbactam, cefuroxime, cefotaxime, or ceftriaxone is given, with clindamycin and TMP-SMX reserved for patients allergic to β-lactams Antibiotic therapy should be continued for 7–10 days and should be tailored, if necessary, to

the organism recovered in culture If the 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 carriage of H influenzae

Infections of the Deep Neck Structures

Deep neck infections are usually extensions of infection from other primary sites, most often within the pharynx or oral cavity Many of these infections are life-threatening but are difficult to detect at early stages when they may be more easily managed Three of the most clinically relevant spaces in the neck are the submandibular (and sublingual) space, the lateral pharyngeal (or parapharyngeal) space, and the retropharyngeal space These spaces communicate with one another and with other important structures in the head, neck, and thorax, providing pathogens with easy access to areas including the mediastinum, carotid sheath,

skull base, and meninges Once infection reaches these sensitive areas, mortality rates can be as high as 20–50%