gemc- oral and facial infections- resident training

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/

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Oral  and  Facial  Infec.ons  

12-­‐06-­‐2011  

Shannon Langston, MD

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tracilawson, flickr

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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13

James Heilman,MD, Wikimedia Commons

14 Source Undetermined

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Source undetermined

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Source undetermined

18 http://academiclifeinem.com/trick-of-the-trade-peritonsillar-abscess-aspiration-technique/

19 Dr. Hagod Afafum

Differen.al?  

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Source Undetermined

21 Source Undetermined

22 Source Undetermined

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

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

37 Source Undetermined

Diagnosis?  

38 DentalLecNotes

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Modteque (Wikimedia Commons)

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

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

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

55 Source Undetermined

56 Gorgas Courses

•  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

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

73 Source Undetermined

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Source Undetermined

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