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PTA, RPA, PHARYNGITIS & TRACHEITIS

DAVID AHEE, M.D.

HENRY FORD HOSIPTAL

DEPARTMENT OF EMERGENCY MEDICINE

1, 2, 3 Pokes To Empowerment!

Goals & Objectives

Clinical presentation, diagnosis & treatment of various throat pathology

Give you all the confidence of “ENT Bob” (in sticking an 18ga needle within inches of one’s carotid artery)

Prove that RPA is an actual entity

Highlight potential morbidity / mortality

A Primer…

Deep tissue infections of the neck

Easy communication to / interference with high risk areas…mastoid bone, mediastinum, trachea…

Not especially common…essential to diagnose & treat correctly

Case #1

One afternoon in Cat 3…

26yo Female with complaint of ear infection / sore throat…

Otherwise healthy, ear pain and sore throat worsening x 4 days, worse on the left, associated with fever of 38.2, dysphagia and change in voice. No ear drainage, no decreased auditory acuity. Using Motrin with minimal relief…

Anatomy

Uvula

Palatoglossal Fold

Palatopharyngeal Fold

Retropharyngeal Space

Sagittal View

In real life…

Physical Exam

Quinsy Clinical Features

Unilateral Sore Throat

Fever/Chills

Dysphagia / Odynophagia

Change in Voice Quality “Hot Potato”

Trismus (pain / muscle spasm with opening mouth)

PTA PE

Erythema / edema / exudates of affected tonsil

Bulging (swelling) of affected tonsil

Contralateral deviation of uvula

Palpate for area of fluctuance (SHOULD NOT PULSATE)

Tender Cervical Adenopathy

PTA Organisms

Usually Polymicrobial

Staphylcoccus aureua, Streptococci (Group A, Beta-Hemolytic), Hemophilus Influenzae, Anaerobes

PTA Imaging

CT Neck with IV Contrast Areas of fluid collection

Fat Stranding

Ultrasound Intraoral verse Transcutaneous

Endocavitary “Vaginal” Probe

Allows visual of carotid artery

An Amazing Machine…

June 2012 Academic Emergency Medicine

Constantino et al, at Temple University

Intraoral US verse Landmark-based Needle Aspiration

Treatment

Evaluate the airway! Airway distortion + trismus = Potential Disaster

If compromised preferred by awake fiberoptic

Antibiotics Clindamycin

Penicillin + Flagyl

Ampicillin / Sulbactam or Ampicillin / Clavulanate

Corticosteroids

Needle Aspiration Diagnostic & Therapeutic

No need for ENT consult!

Incision & Drainage Okay, go ahead and call ENT

Needle Aspiration

1. Equipment

2. Position

3. Anesthesia

4. Three Pokes

Needle Aspiration

1. Equipment: Cetacaine Spray

1% lidocaine with Epi

3cc Syringe

10cc Syringe

25ga Needle

18ga Needle

Tongue Blades (2-3)

Kidney Basin

Normal Saline with Drinking Cup

Suction (Yaunker)

Light Source (Headlamp)

+/- Sterile Tube or Culture Swabs

2. Position Sitting Upright

+/- Head Support

3. Anesthesia Parental – Fentanyl 25-50

mcg IV x1

Topical – Viscous Lidocaine, CetacaineSpray, Tetracaine, Local Infiltration

1. Equipment

Now a close up…

A few more tricks…

Try a macintosh blade as tongue depressor & light!

Use a spinal needle for better visualization!

Photo courtesy of Dr. Hagop Afarian (Fresno)

Needle Aspiration

4. Three PokesSuperior Pole Middle Pole Inferior Pole

Sagittal Plane – never angle needle/syringe laterally

Keep needle medial to second molar

Internal carotid artery 2.5 cm posterolateral to tonsil

Usually 2-6 mL of purulent fluid

Complications

Bleeding

Aspiration of purulent material / blood Suction

Cyanosis + DIB = Methemoglobinemia Methylene Blue

Carotid Artery Puncture Use of Ultrasound

SUCCESS!

Case #2

One sunny afternoon at Fairlane…

3yo male with c/o fever…

Mom gives hx of fever x 3 days, Tmax = 102.1, decreased oral intake, decreased activity, no sick contacts, immunizations UTD…

5 days ago patient fell while eating a popsicle…

Anatomy

How?

Direct Extension (Anteriorly or Posteriorly)

Local Trauma (think iatrogenic)

Suppuration of Lymph Nodes

But does it really exist?

In US in 2003, 1321 cases of RPA

In Detroit…

Retropharyngeal abscess in children: the rising incidence of methicillin-resistant Staphylococcus aureus.Abdel-Haq N; Quezada M; Asmar BIDivision of Infectious Diseases, Children's Hospital of Michigan, and Carman and Ann Adams Department of Pediatrics, Wayne State University, Detroit, MI, USA

114 children (61 males) with RPA identified from 2004-2010, 2.8-fold increase in incidence (per 10,000 admissions) over the previous 11-year period (1993-2003)

Clinical Features

By History:

Fever

Sore Throat

Dysphagia

Trismus

Neck Pain / Stiffness

Muffled Voice

By Physical Exam:

Bulge in Posterior Pharynx

Stridor / Drooling = Airway Compromise

Nuchal Rigidity

Agitation / Lethargy

What’s Next? A B C…X

Lateral View Soft Tissue Neck

Treatment

1-800-CHM-KIDS

Admission and IV antibiotics Clindamycin + Ceftriaxone

Pen G + Flagyl

Zosyn

Pediatric ENT Consultation

+/- OR I&D

Prophylactic Endotracheal Intubation

Complications

Airway Obstruction

Aspiration

Mediastinitis

Epidural Abscess

Internal Jugular Vein Thrombosis

Erosion to Carotid Sheath

Necrotizing Fasciitis

Sepsis

Case #3 – Treat? Test? Do Nothing?

Back in Cat 4 on a cool April morning…

13yo male who c/o sore throat, decreased PO intake due to the pain, tactile fever and swollen glands. Denies runny nose, cough and nasal congestion. You note erythema, no exudates.

19yo female who c/o sore throat, afebrile, states third similar episode over last 5 months, you note several Cat 3 visits “to be checked out,” with negative cultures.

Case #3 – Treat? Test? Do Nothing?

16yo male with c/o sore throat and malaise, you note significant tonsillar exudates and posterior cervical and occipital adenopathy.

9yo female with c/o sore throat associated with a watery eye, runny nose, cough and nasal congestion. Younger sibling with similar symptoms.

Oh The Possibilities…

Viral pharyngitis: rhinovirus, adenovirus, influenza, CMV, EBV, HIV, HSV, coxsackieviruses

Fungal pharyngitis: Candida sp.

Bacterial pharyngitis: GABHS, GC, chlamydia trachomatis, mycoplasma pneumoniae, diptheria, TB, chlamydia pneumoniae, anaerobes

Allergic Pharyngitis

Diagnostic Strategies

GABHS Centor Criteria RSA Screen

EBV Monospot

STIs – GC/Chlamydia Cultures

Assessing each clinical situation (patient age, risk factors, toxic/non-toxic)

Picture Quiz!

Picture Quiz!

Diptheria

Corynebacteriumdiphtheriae produce systemic toxin

Grey or white exudates that form pseudomembrane

Well demarcated

May extend into larynx and tracheobronchial tree

Bull Neck Appearence

Diptheria

Throat Culture & Gram Stain

Diptheria Antitoxin

Penicillin / Erythromycin

Td immunization every 10 years

Case #4

At your last Fairlane shift of the month…

7yo female with hx of recent URI presents with DIB…

39.4 C, 102/72, 144, 38, 94%RA

Ill appearing, accessory muscle use, inspiratory and expiratory stridor…

Bacterial Laryngotracheobronchitis

AKA: Bacterial Tracheitis, Bacterial Croup, Pseudomembranous Croup

Hybrid of croup and epiglottitis

Precedent viral URI, damages tracheal mucosa

Bacterial superinfection with copious secretions

Bacterial Laryngotracheobronchitis

3 – 5 years of age

Classically S. aureus; also…

H. Influenza, Moraxella catarrhalis, Peptostreptococcus, Prevotella and Fusobacterium

Diagnosis

Lateral Soft Tissue Neck Xray

Irregular “shaggy” tracheal air column

Treatment

Airway majority require intubation Suctioning Direct Laryngoscopy aids in diagnosis

Smaller ET Size

Bronchoscopy

Antibiotics 3rd Gen Cephalosporin + Penicillinase-resistant Penicillin

Clindamycin

Vancomycin

Recap

High Clinical Suspicion Less common but serious complications

PTA ≠ ENT

PTA = US

Consider the zebras next time you see c/o “Sore Throat”

ABC

Questions?

References

Marx, Rosen's Emergency Medicine, 7th Edition

Roberts, Clinical Procedures in Emergency Medicine, 5th Edition

LeBlond RF, DeGowin RL, Brown DD. Chapter 7. The Head and Neck. In: LeBlond RF, DeGowin RL, Brown DD, eds. DeGowin's Diagnostic Examination. 9th ed. New York: McGraw-Hill; 2009. http://www.accessmedicine.com/content.aspx?aID=3660155. Accessed February 20, 2013.

Gunn III JD. Chapter 119. Stridor and Drooling. In: Tintinalli JE, Stapczynski JS, Cline DM, Ma OJ, Cydulka RK, Meckler GD, eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York: McGraw-Hill; 2011. http://www.accessmedicine.com/content.aspx?aID=6372228. Accessed February 20, 2013.

Stallard TC. Chapter 32. Emergency Disorders of the Ear, Nose, Sinuses, Oropharynx, & Mouth. In: Humphries RL, Stone C, eds. CURRENT Diagnosis & Treatment Emergency Medicine. 7th ed. New York: McGraw-Hill; 2011. http://www.accessmedicine.com/content.aspx?aID=55753058. Accessed February 20, 2013.

Lyon M, Blavias M. Intraoral ultrasound in the diagnosis and treatment of suspected peritonsillarabscess in the emergency department. Acad Emerg Med. 2005; 12:85–8.

Abdel-Haq N; Quezada M; Asmar BI. Retropharyngeal abscess in children: the rising incidence of methicillin-resistant Staphylococcus aureus. Pediatr Infect Dis J. 2012; 31(7):696-9

Thomas G. Costantino, MD, Wayne A. Satz, MD, Wade Dehnkamp, MD, and Harry Goett, MD. Randomized Trial Comparing Intraoral Ultrasound to Landmark-based Needle Aspiration in Patients with Suspected Peritonsillar Abscess. Acad Emerg Med. 2012; 19:626-631

Medscape Reference

UpToDate.com

The Pocket Guide to Needle Aspiration of Quinsy (PTA) – 4 Easy Steps!

1. Equipment Cetacaine Spray 1% lidocaine with Epi 3cc Syringe 10cc Syringe 25ga Needle 18ga Needle (? Spinal Needle) Tongue Blades (2-3) Kidney Basin Normal Saline with Drinking Cup Suction (Yaunker) Light Source

Headlamp Macintosh Laryngoscope

+/- Sterile Tube or Culture Swabs

2. Position Seated, facing forward +/- Head Support

3. Anesthesia Parental – Fentanyl 25-50 mcg IV x1 Topical – Viscous Lidocaine,

Cetacaine Spray, Tetracaine, Local Infiltration

4. Three PokesSuperior Pole Middle Pole

Inferior Pole (1cm spacing)

Sagittal Plane – never angle needle/syringe laterally

Keep needle medial to second molar

Internal carotid artery 2.5 cm posterolateral to tonsil

2 – 6 mL of Pus

Tips & Tricks Cut needle cap to expose 1cm of

needle, acts as a guard Use the US to evaluate PTA verse

Cellulitis!