My EM Notes

Oro-pharyngeal infections

the most common deep head and neck infection that affects patients of all ages
favoured treatment is antibiotic therapy combined with abscess drainage.
Abscess drainage takes the form of needle aspiration, intra-oral incision and drainage, or quinsy tonsillectomy.
indications for abscess tonsillectomy became controversial over the past years due to increased risk of spread of infection and postoperative tonsillar bed bleeding

Tonsillitis

Peritonsillar cellulitis

Peritonsillar abscess

Typical presentation:

Diagnosed as Triad:

Peritonsillar cellulitis is a variation on the theme of a true abscess, but the cellulitic phase is easy to confuse with a true abscess
true adult peritonsillar abscess usually will not resolve without some type of surgical drainage procedure, peritonsillar cellulitis is much more likely to respond to antibiotics alone
dysphagia and drooling tend to be discriminators for an abscess, and trismus is more common in cellulitis but patients presenting with either process have quite similar clinical scenarios.

Bacteria involved include Strep Grp A, Viridans Strep, Fusobacterium necrophorum (anaerobe) amongst many others, therefore antibiotic choice varies
antibiotic Rx - usually Penicillin based but beware Amoxycillin as illness may be EBV. Choices include:
- Amoxicillin/clavulanic acid 875mg BID x 10 days
- Penicillin VK 500mg QID + Metronidazole 500mg QID x 10 days
- PCN Allergy: Clindamycin 150mg QID x 10 days
dexamethasone 6mg recommended by some
analgesia - paracetamol, NSAIDs
surgical Rx - needle drainage, formal incision & drainage

Several scoring systems have been proposed to aid Mx:

Novel PTA score	Points
Halitosis	1
Uvula oedema	1
Unilat swelling of arched palate	1
Trismus	1
S100A8/A9 serum >2550ng/ml	1
S100A8/A9 saliva >8180ng/ml	1
Score ≤2: Primary medical Rx Score >2: surgical Rx S100A8/A9 are myeloid related proteins

Liverpool Peritonsillar Abscess Score (LPS)	Points
Unilateral sore throat	3
Trismus	2
Male gender	1
Pharyngeal voice change	1
Uvular deviation	1
Score <4: unlikely to have PTA

Ludwig's angina usually originates as a dental infection of the second or third mandibular molars, including partially erupted third molars.
infection initially spreads to the sublingual space and progresses to the submandibular space.
usually polymicrobial involving oral flora, both aerobes and anaerobes.
most commonly:
- neck swelling, neck pain - “bull neck,” with increased fullness of the submental area and loss of mandibular angle definition
- trismus
- odynophagia, dysarthria, dysphagia - increased tongue prominence indicates sublingual space involvement.
- Fever and chills are common.
Stridor indicates impending airway obstruction
typically NO lymphadenopathy. The presence of crepitus should raise suspicion for other pathologies, such as necrotizing fasciitis.

peritonsillar abscess, retropharyngeal abscess, submandibular abscess, epiglottitis, oral carcinoma, angioedema, submandibular hematoma, and diphtheria.