GEMC- Oral and Facial Infections- Resident Training
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Transcript of GEMC- Oral and Facial Infections- Resident Training
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Project: Ghana Emergency Medicine Collaborative Document Title: Oral and Facial Infections Author(s): Shannon Langston (University), MD, 2011 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/
We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact [email protected] with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers.
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Attribution Key
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Oral and Facial Infec.ons
12-‐06-‐2011
Shannon Langston, MD
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tracilawson, flickr
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Peritonsillar Abscess
• History – Sore throat – Fever – Odynophagia – Dysphagia – Otalgia
• Examina.on – Trismus – “hot potato voice” – Drooling – Effaced anterior pillar – Contralateral devia.on of
uvula
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• History – Sore throat – Fever – Odynophagia – Dysphagia – Otalgia
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• Examina.on – Trismus – Vocal Changes – Drooling – Effaced anterior pillar – Contralateral devia.on of uvula
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• Pathogens – Polymicrobial – Group A streptococcus – Staphylococcus aureus – Respiratory anaerobes
• Fusobacteria, Prevotella
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• Management – Suppor.ve – Radiographs +/-‐ – Labs +/-‐ – An.bio.cs – Aspira.on
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• Steroids – Controversial – Single dose effec.ve – No evidence of harm
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Steroids in PTA
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Steroids in PTA
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James Heilman,MD, Wikimedia Commons
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14 Source Undetermined
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Source undetermined
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Source undetermined
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18 http://academiclifeinem.com/trick-of-the-trade-peritonsillar-abscess-aspiration-technique/
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19 Dr. Hagod Afafum
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Differen.al?
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Source Undetermined
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21 Source Undetermined
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22 Source Undetermined
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Ludwigs Angina
• Sublingual space infec.on • Bilateral • OUen mul.ple .ssue planes
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Physical Findings
• Toxic Appearance • Brawny bilateral woody edema • Submandibular, submental, sublingual • Trismus • Tongue eleva.on
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Gray’s Anatomy, Wikimedia Commons
Tongue
Sublingual gland
Submandibular gland
Supramylohyoid portion of submandibular space
Mylohyoid muscle
Inframylohyoid portion of submandibular space
Digastric muscle (anterior belly)
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Submandibular space: Sublingual space
Submaxillary space
Geniohyoid muscle
Mylohyoid muscle
Superficial fascial layer Gray’s Anatomy, Wikimedia Commons
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Source undetermined
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Source undetermined
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History
• Recent dental extrac.on or work • Dental caries • Fever • Swelling of mouth, face, neck • Compromised host • Co-‐morbidi.es
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Pathogens
• Streptococcus viridans • Staphylococcus species • Mixed aerobic/anaerobic infec.on
– Peptostreptococcus species, Fusobacterium, Bacteroides
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Treatment
• Aggressive airway control – Fiberop.c – Cricothyrotomy or tracheostomy
• Surgical consulta.on mandatory – Oral maxillofacial surgeon or ENT
• An.bio.cs • Steroids? • ICU admission
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• Steroids – Controversial – Dosing:
• 10 mg Dexamethasone IV • 4 mg q 6 hours for 48 hours
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Treatment
• An.bio.c Therapy – Ampicillin-‐sulbactam (3 g IV every six hours) or – Clindamycin (600 mg IV every six to eight hours)
PLUS
– Vancomycin (15 to 20 mg/kg IV every 12 hours) or – Linezolid (600 mg orally or IV every 12 hours).
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Ludwigs Angina
• Take Home Points – Aggressive airway management – An.bio.cs – CT Scan – Surgical Consulta.on Early
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36 Source Undetermined
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37 Source Undetermined
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Diagnosis?
38 DentalLecNotes
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Modteque (Wikimedia Commons)
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ANUG
• Acute Necro.zing Ulcera.ve Gingivi.s – AKA Trench Mouth – Vincent’s Disease
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Clinical Features
• Gingival necrosis, especially .ps of papillae • Bleeding • Pain • Fe.d breath • Pseudomembrane forma.on
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• Predisposing Factors – Emo.onal stress – Poor oral hygiene – Cigarede smoking – Poor nutri.on – Immunosuppression
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ANUG
• Prevalence 0.6% • Young adults (mean age 23 years) • More common in Caucasians • Bacterial flora –
– Spirochetes (Treponema sp.) – Prevotella intermedia – Fusiform bacteria
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• Treatment – Amoxicillin – Clindamycin – Doxycycline – Chlorhexidine Rinse – Hydrogen Peroxide 3% – Oral Hygiene
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46 Source Undetermined
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Parotid glands
Submandibular glands
Ducts of sublingual glands
Submandibular duct
Sublingual glands
Arcadian, Wikimedia Commons
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Suppura.ve Paro..s
• Clinical Findings • Firm, Erythematous swelling • Pain • Fever • Trismus
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E.ology
• Staphylococcus* – Most Common Isolate
• Aerobic: 34% • Anaerobes: 41% • Mixed: 25%
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Predisposing Factors
• Advanced age • Dehydra.on • Diabetes • HIV • Alcoholism, • Poor oral hygiene
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• Management – An.bio.cs – Hydra.on – Culture – Imaging – Surgical Consulta.on
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An.bio.cs
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Or Vancomycin 15-20 mg/kg IV Q 12 h
Or
Linezolid 600 mg orally or IV Q 12 h
PLUS
Either metronidazole 500 mg IV Q 6-8 h
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Case
• 65 year old farmer presents with 2 month history of inflamma.on and pain over the facial region and nasal mucosa.
• Denies fevers or systemic symptom. • PMH: Unremarkable. • Course of an.bio.cs “the white one” unsuccessful.
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Source Undetermined
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55 Source Undetermined
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56 Gorgas Courses
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• Physical Exam: – Nasal mucosal ulcera.ons noted – No drainage, minimal warmth – Oropharynx: Ulcera.ve lesion – General exam unrevealing, no LAD
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Differen.al?
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• Fungal – Paracoccidioidomycosis, sporotrichosis, blastomycosis
• Bacterial – Staphylococcal and streptococcal infec.ons, syphilis, tuberculosis, leprosy
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Differen.al
• Inflammatory – Sarcoidosis, lupus
• Neoplas.c – – Cutaneous T-‐cell lymphoma, basal cell carcinoma, squamous cell carcinoma, psoriasis
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Source Undetermined
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Mucocutaneous Leishmaniasis
• Leishmaniasis: vector-borne diseases caused by parasites of the genus Leishmania
• Multifaceted clinical manifestations: – Mucocutaneous – Cutaneous – Visceral
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Leishmanaisis
§ The global annual incidence is estimated at 1.5-2 million new cases per year:
§ 1-1.5 million cases of CL
§ 500,000 cases of VL.
§ Overall prevalence of 12 million cases.
§ 500 US Soldiers in 18 month period
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Mucocutaneous Leishmanisis
• Distribu.on: – Present in 88 countries within Central America, South America, Africa, India, the Middle East, Asia, southern Europe, and the Mediterranean.
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65 World Health Organization
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Vectors
• Transmided by the bite of female sandflies – Genus Lutzomyia in the New World – Genus Phlebotumus in the Old World
• Reservoir host: – Domes.c and/or wild animals – Humans.
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Leishmania Species
• Two Groups (15 species cause disease) – Those restricted to the skin and cause dermal leishmaniasis:
• L. mexicana, • L. braziliensis • L. tropica, L. major, L. aethiopica.
– Visceral: • L. donovani
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Extension of MCL § Nose § Nasopharynx § Palate § Epiglottis § Larynx § Vocal chords § Trachea
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Diagnosis
• Immunologic: Skin test (80-‐92%) • Visual methods:
– Impression smear (37.9%) – Dermal scrapping (32.7%) – Histopathology (21.4%)
• Isola.on methods: – In vitro culture (57% -‐ 85%)
• Demonstra.on methods: – PCR 92-‐94%
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Treatment
• Pentavalent an.monials • Amphotericin B (Liposomal Preferred) • Pentamidine • Ketoconazole, Itraconazole • Allopurinol
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72 Source Undetermined
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73 Source Undetermined
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Source Undetermined
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