URTI WADA 11.pptx diagnosis and medication

Symptom and signs

1. Upper Respiratory Tract Infections Presented by: Fawaz Abdullah Alqahtani , FM-R 1 Nora Alhumaid, FM-R3 Supervised by: Dr. Reema Alghofaili

2. Table of contents Definition & Introduction Approach to Common URTI

3. Definition Upper respiratory tract infections (URTIs) is a comprehensive term for acute inflammation of upper respiratory tract mucosa which include nose, sinuses, pharynx and larynx.

4. URTIs Most common acute illness evaluated in the outpatient setting. Reason for absence from school or work Mismanaged by primary care providers Range from mild, self-limited ( e.g the common cold) to life-threatening illnesses ( e.g epiglottitis)

5. A 30-year-old man presents with a 2-day history of runny nose and sore throat. He feels hot and sweaty, has a mild headache, is coughing up clear sputum, and complains of muscle aches. He would like antibiotics as he was prescribed some last year for similar symptoms. On examination: He is afebrile and has a normal pulse, a slightly inflamed pharynx, and non-tender cervical lymphadenopathy. There is no neck stiffness, and his chest is clear. He has tried over-the-counter cough medicines but has not found these helpful. He smokes 10 cigarettes per day. What is the most likely Dx?

6. What is the most likely diagnosis? Influenza Acute bacterial pharyngitis Common cold (nasopharyngitis)

7. What is the most likely diagnosis? Influenza Acute bacterial pharyngitis Common cold (nasopharyngitis)

8. Common Cold 01

9. Common cold (nasopharyngitis) Benign self-limiting condition Most frequent acute illness around the world The average incidence is 5 to 7 episodes per year in preschool children, and 2 to 3 per year in adults Over 200 subtypes of viruses have been associated with the common cold. Rhinoviruses cause 30 to 50 percent of colds It is not possible to identify the likely viral pathogen on the basis of clinical symptoms

10. Transmission Hand contact (majority) Direct contact with an infected person Indirect contact with a contaminated surface Airborne Small droplets (droplet nuclei or aerosols) from sneezing or coughing Droplet Large droplets that typically require close contact with an infected person

11. Severity The intensity and type of symptoms depends on Type of infecting virus Host factors including age, underlying illnesses, and prior immunological experience Risk factors for increased severity of URTI include: Underlying chronic diseases Congenital immunodeficiency disorders Malnutrition Smoking

12. Signs & Symptoms Nasal obstruction (80 -100%) Sneezing (50 -70%) Scratchy throat (50%) Cough (40%) Hoarseness (30%) Malaise (20- 25%) Headache (20%) Fever uncommon Average duration 3-7 day Often lasting 10 days

13. Diagnosis CLINICAL BASED ON THE PATIENT’S SYMPTOMS Nasal exam shows: Red, edematous mucosa Narrowed nasal passages Watery discharge

14. General considerations in Management Primary goals of treatment are reduction of symptoms duration and severity For most people and most colds, symptoms are self-limited Symptomatic therapy remains the mainstay of common cold treatment

15. Treatment SYMPTOMATIC THERAPY Fever: can be treated with paracetamol (for children older than three months) or ibuprofen (for children older than six months): Acetaminophen – 10 to 15 mg/kg/dose orally every 4-6 hours PRN . Ibuprofen – 10 mg/kg/dose orally every 6 hours PRN. Nasal symptoms: first-line therapy of bothersome nasal symptoms we suggest one or more supportive interventions ( eg : nasal suction; saline nasal drops, spray, or irrigation; adequate hydration; cool mist humidifier) Cough : oral hydration, warm fluids ( eg , tea, chicken soup), honey (in children older than one year), or cough lozenges( strepsils )

16. treatment OTC cough and cold medications Avoided in children <6 years and are not suggested in children 6-12 years Ipratropium Intranasal ipratropium may decrease rhinorrhea It should not be used in children younger than five years.

17. Role of zinc and vitamin c in common cold Vitamin c is Not suggested to be used by pediatrics to treat common cold because it showed no efficacy in common cold treatment . Zinc is also not suggested for treatment of common cold in children. The efficacy of zinc in reducing the duration or severity of common cold symptoms remain unclear and side effects are common

18. Role of zinc and vitamin c in common cold A 2013 meta-analysis of 29 trials showed regular supplementation of vitamin c did not significant reduce the incidence of cold . Although zinc preparations may decrease cold symptoms severity and duration , we generally do not use zinc because of its minimal potential benefits are outweighed by known adverse effects ( bad taste , nausea m irreversible anosmia when administer IV)

19. A 30-year-old woman presents in the winter months with a 2-day history of fever, cough, headache, and generalized weakness. She was in her usual state of health before an abrupt onset of these symptoms. A few viral illnesses have affected her during the current winter, but not to this severity. She says she has sick co-workers and did not receive the influenza vaccine this season. What is the most likely Dx?

20. What is the most likely diagnosis? Influenza Adenovirus infection Rhinovirus infection Middle East Respiratory Syndrome (MERS- CoV )

21. What is the most likely diagnosis? Influenza Adenovirus infection Rhinovirus infection Middle East Respiratory Syndrome (MERS- CoV )

22. Influenza 02

23. Influenza Acute respiratory tract infection typically caused by seasonal influenza A or B virus Influenza virus is classified into influenza A, B, and C based on antigenic differences Transmitted through infected respiratory droplets from coughing, sneezing, or talking Epidemics usually occur from late autumn to early spring

24. Diagnosis Clinically diagnosed by history and physical examination but we can do: Rapid Antigen testing ; detect influenza A & B Results in < 30 minutes. Direct immunofluorescent antibody staining ( nasopharyngeal swab ) Results in 2-4 hours. Viral culture (for confirming screening tests and for public health surveillance) Results in 3-10 days Chest x-ray : used to rule out either primary viral or secondary bacterial pneumonia

25. Prevention and vaccination All people 6 months and older should receive influenzas vaccine (who do not have contraindications) Vaccination is most effective if received by the end of October When vaccine supply is limited, it should be given to: Higher-risk people Household contacts and caregivers of higher risk people Health care professionals Pregnant ladies

26. Un-complicated influenza infection Complicated influenza infection Acute respiratory infection caused by influenza A or B viruses A more severe, complicated illness, associated often with influenza A Treatment is aimed at supportive care of the symptoms Complications of upper and lower respiratory tracts infection Antipyretics/analgesics for fever and increased fluid intake to counter dehydration Treatment require more aggressive supportive care, hospitalization accompanied by antibiotics and/or antiviral treatment

27. Treatment Antipyretics/Analgesics Medication Dosage Paracetamol 500-1000 mg orally every 4-6 hours when required , maximum 4000 mg / day . Ibuprofen 200-400 mg orally every 4-6 hours when required , maximum 2400 mg / day .

28. Treatment Antiviral treatment of early influenza infection Medication Dosage Oseltamivir Children <3 months of age : consult specialist for guidance on dose . Children 3 months to <1 year of age : 3 mg / kg orally once daily . Children ≥1 year of age and body weight ≤15 kg : 30 mg orally once daily . 15-23 kg : 45 mg orally once daily . 23-40 kg : 60 mg orally once daily . >40 kg and adults : 75 mg orally once daily . Zanamivir Children ≥5 years of age and adults : 10 mg ( two inhalations ) once daily . Peramivir Children ≥2 years of age : 12 mg / kg intravenously as a single dose , maximum 600 mg / dose . Adults : 600 mg intravenously as a single dose . Baloxavir marboxil Children ≥12 years of age and adults ( body weight <80 kg ): 40 mg orally as a single dose . Children ≥12 years of age and adults ( body weight ≥80 kg ): 80 mg orally as a single dose

29. Acute bacterial rhinosinusitis is caused most commonly by which of the following organisms? (A) S. pneumoniae (B) Haemophilus influenzae (C) Moraxella catarrhalis (D) Streptococcus pyogenes (E) Staphylococcus aureus

30. Acute bacterial rhinosinusitis is caused most commonly by which of the following organisms? (A) S. pneumoniae (B) Haemophilus influenzae (C) Moraxella catarrhalis (D) Streptococcus pyogenes (E) Staphylococcus aureus

31. Rhinosinusitis 03

32.   Rhinosinusitis – Definitions  A symptomatic inflammation of the mucosal lining of the nasal cavity and paranasal sinuses   Classified depend on duration : Acute: ≤4 weeks or less Subacute: 4-12 weeks Chronic: ≥12 weeks Recurrent acute: ≥4 episodes per year.

33. Acute Rhinosinusitis: Viral – Rhinovirus most common  Bacterial – less than 2 % Streptococcus pneumoniae  Haemophilus influenzae Moraxella catarrhalis Chronic Rhinosinusitis: - inflammation rather than infection Genetic/physiological factors (e.g., cystic fibrosis/primary ciliary dyskinesia). Environmental factors (e.g., smoking). Structural factors (e.g., severe mid-septal deviations). Etiology

34. NO difference between viral & bacterial infection in early S&S. Clinical course of acute viral infection 7-10 days  Symptoms start after upper respiratory tract infection  Facial pain ,pressure or fullness ( pain on bending forward ) Purulent rhinorrhea  Maxillary toothache Nasal obstruction  fever Approach – History   

35. Facial tenderness to gentle palpation  Post-nasal pharyngeal secretions or exudate  Tender maxillary dentition Approach – Physical examination

36. Clinical diagnosis Usually No imaging is required to diagnose acute rhinosinusitis CT sinus for recurrent episodes of sinusitis, suspected anatomical abnormalities. Lateral neck x-rays can be helpful in children to evaluate the patient for adenoid hypertrophy in patients with nasal obstruction Approach

37. WATCHFUL WAITING ; in initial 7-10 days of symptoms Symptomatic :  Analgesic for fever or pain Normal Saline nasal irrigation ( sodium chloride ) Intranasal steroids: adjunct to antibiotics, low efficacy alone Decongestants, antihistamines, and guaifenesin are not recommended   Management of Acute sinusitis

38. 1 st line :  Amoxicillin with or without clavulanate In high risk of pneumococcal resistance: High dose of amoxicillin- clavulanic acid  Second line or penicillin allergy: Adults: Doxycycline Children: cefuroxime (if tolerated) or levofloxacin Antibiotics

39. Diagnostic Criteria for Chronic Rhinosinusitis At least two out of four cardinal symptoms for  at least 12 consecutive weeks: A. Nasal obstruction B. Nasal drainage C. Facial pain/pressure D. Hyposmia/anosmia – in children cough Objective evidence on physical examination (e.g., mucopurulent drainage, edema, polyps in the middle meatus). imaging findings (sinus computed tomography) Chronic Rhinosinusitis

40. NASAL SALINE IRRIGATION & INTRANASAL CORTICOSTEROIDS Nasal saline irrigation:   irrigation superior to sprays  1-4 times daily  Intranasal corticosteroids:  No evidence to suggest that any spray is superior Corticosteroid nasal irrigations, need further studies Chronic Rhinosinusitis Management

41. Systemic Corticosteroids  Indicated for short term use in CRS with polyps ( medical polypectomy!)   prednisone 40 mg for 5 days, followed by 20 mg daily for 5 days Antibiotics: Unclear role CRS  In patients with evidence of an infection (e.g., mucopurulent drainage)  antibiotic therapy guided by endoscopic culture of fluid obtained via nasal endoscopy (By ENT specialist) Chronic Rhinosinusitis Management

42. Surgical management appropriate when medical therapy is ineffective does not cure the condition, and patients will require medical therapy postoperatively Acute exacerbations: sudden worsening of symptoms with return to baseline after treatment If bacterial infection suspected treat with Abx.  Observation and short course of oral corticosteroids are other options Chronic Rhinosinusitis Management

43. Anatomic defects causing obstruction Complications Frequent recurrences (3-4 episodes per year) Immunocompromised host Nosocomial infection Severe infection with persistent fever greater than 39°C Treatment failure When to refer ?

44. thank YOU references

45. 7-year-old boy Sore throat and fever 38 °C Denies cough, rhinorrhea, or nasal congestion What is the most likely Dx? Exudate Enlarged tender anterior cervical lymph nodes

46. What is the most likely diagnosis? Adenovirus infection Rhinovirus infection Sore Throat (Pharyngitis) Middle East Respiratory Syndrome (MERS- CoV )

47. What is the most likely diagnosis? Adenovirus infection Rhinovirus infection Sore Throat (Pharyngitis) Middle East Respiratory Syndrome (MERS- CoV )

48. Sore Throat (Pharyngitis) 04

49. Pharyngitis Infection of the pharynx, tonsils, or both Transmitted via respiratory secretions Incubation period is 1 to 5 days Common condition encountered by the family physician

50. Etiologies Viral (Most common) Bacterial (GAS) Allergies GERD Smoking Postnasal drip secondary to rhinitis Non-infectious Infectious

51. DDX to keep in mind Sexually active or abused individuals with pharyngitis HIV, Chlamydia, Gonorrhea Immunocompromised and use of ICS with pharyngitis Candida Ingestion of contaminated raw or undercooked meat Tularemia

52. Diphtheria Early-stage diphtheritic membrane

53. Viral vs bacterial May be difficult to distinguish viral and bacterial Factors are suggestive of GAS throat infection: Children aged 4-7 years Sudden onset Hx of rheumatic fever Contact with GAS pt. or rheumatic fever pt. Headache Vomiting, though not exclusively Absence of cough

54. Viral vs bacterial One study conducted in primary care centers in Saudi Arabia included 104 cases of bacterial pharyngitis Of which 79% were prescribed antibiotics and only 28% were evidence based correct prescriptions Physicians need to be able to differentiate between the two to provide effective treatment Olwi, R. I., & Olwi, D. I. (2021). Trends in the use of antibiotics for pharyngitis in Saudi Arabia.  Journal of infection in developing countries ,  15 (3), 415–421. https://doi.org/10.3855/jidc.12822

55. Clinical manifestation Viral Red, swollen tonsils Sore throat Headache Coryza Bacterial High grade fever Exudate on the tonsils Difficult or painful swallowing Enlarged, tender lymph nodes in the neck In young children Drooling due to difficult or painful swallowing Stomachaches Refusal to eat

56. Modified Centor’s Score Absence of Cough=1 point Swollen/tender anterior cervical lymph nodes=1point Temperature > 38 =1 point Tonsillar exudate = 1 point Age: 3-14 = 1 point 15-44 = 0 point 45 and older = -1 point

57. Interpretation of Modified Centor’s Score A score of 0–1 Indicates low risk and no need for further testing with a sensitive rapid antigen detection test (RADT) or culture A score of 2–3 Indicates testing with RADT and/or culture. A score of >4 consider RADT and/or culture, empiric antibiotics may be appropriate.

58. Treatment Most cases are relatively benign and self-limited Symptomatic management 82% resolve within 7 days Symptomatic management

59. Antibiotic treatment 1 st line: Penicillin Amoxicillin; 10 day course 50mg/kg/day given in 2 divided doses for 10 days in children 500mg BID for adult for 10 days Penicillin allergy/ not tolerated Macrolides ( e.g. Azithromycin) First-generation cephalosporins

60. History Viral Pharyngitis GA S Pharyngitis Age Any age Common age 4 - 15y Sore throat Present Present Onset of pharyngitis After several days of coughing or rhinorrhea Sudden Fever Present/absent Present Cough Present Absent Anterior neck pain “swollen glands” Absent Present Abdominal Pain, N/V Present Present Nasal congestion, coryza, hoarseness, sinus discomfort or tenderness, ear pain Present Absent

61. Referral for tonsillectomy If recurrent tonsillitis: ≥7 episodes in one year ≥5 episodes in each of two years ≥3 episodes in each of three years

62. 2-year-old child presents with her parents High fever (40ºC) , hoarse voice and difficulty swallowing Child had been in her usual state of health but awoke with these symptoms On examination Sitting in a tripod position, drooling, inspiratory stridor, nasal flaring, and retractions What is the most likely Dx?

63. What is the most likely diagnosis? Influenza Croup Bacterial pharyngitis Epiglottitis

64. What is the most likely diagnosis? Influenza Croup Bacterial pharyngitis Epiglottitis

65. Epiglottitis 05

66. Epiglottitis Inflammation of the epiglottis and adjacent supraglottic structures Rapid progression to life-threatening airway obstruction An emergency until the airway is examined and secured Common between 2-6 years, but can present in any age

67. Etiology Infectious Bacterial Haemophiles influenzae type b (Hib) H. influenzae types A and F , S. pneumoniae, Staphylococcus aureus (Including MRSA) Viral Influenza A, B HSV 1,2 Parainfluenza EBV, HIV Fungal – Candida species and Histoplasma capsulatum Immunocompromised hosts   – Pseudomonas aeruginosa ,Candida species

68. Etiology Noninfectious causes Traumatic –  thermal injury, foreign body i ngestion Complication of bone marrow or solid organ transplantation (Rare) Chronic granulomatous diseases (Rare)

69. Clinical manifestation Young children (<5 years) Respiratory distress , anxiety Characteristic "tripod" or "sniffing" posture Drooling = present Cough = absent Older children, adolescents & adults S evere sore throat Dysphagia Drooling Minimal respiratory distress

70. D ysphagia, D rooling, and D istress (” the 3 D's ") are hallmarks High fever , severe sore throat, odynophagia Stridor “ Toxic ” Appearance M uffled sound , described as a “ Hot potato ” voice 

71. Subacute Older children, adolescents, and adults  S evere sore throat Dysphagia Drooling A nterior neck pain but a Relatively normal oropharyngeal examination Mild respiratory distress Young children with Hib epiglottitis Fever Stridor D rooling Respiratory distress A nxiety ” S niffing" posture  Acute

72. Diagnosis Clinical diagnosis Lateral neck radiographs Blood cultures Laryngoscopy

73. Individualized according to: Severity of illness Immunization status Clinician's suspicion

74. Diagnostic approach Involvement of airway experts is warranted prior to any attempts of visualization. The choice of setting where any endoscopic procedure is to be performed (OR, ICU, or ED) D irect pharyngoscopy with aid of a tongue blade represents the usual approach in most emergency departments If it fails to permit visualization of the epiglottis, or seems unsafe, consider lateral neck films or laryngoscopy. Epiglottitis unlikely Epiglottitis likely

75. Investigations Laboratory evaluation Complete blood count with differential Blood culture E piglottal culture obtained ONLY In patients with secured ET tube

76. Lateral neck radiographs Can c onfirm the diagnosis Enlarged epiglottis protruding from the anterior wall of the hypopharynx “Thumb sign” Enlarged epiglottis protruding from the anterior wall of the hypopharynx “Thumb sign”

77. Laryngoscopic visualization of the epiglottis is likely the gold standard for clinical diagnosis

78. DDx Noninfectious causes Angioedema Foreign body Congenital anomalies of the upper airway Upper airway trauma or thermal injury I nfectious causes Croup Tonsillitis Bacterial tracheitis Uvulitis Parapharyngeal and peritonsillar abscesses

79. Securing the airway is the most important part of treatment Management

80. Management Early consultation of specialists skilled in airway management Empirical antibiotic – infectious epiglottitis Haemophilus influenzae type b Streptococcus pneumoniae Group A Streptococcus Staphylococcus aureus, including (MRSA)

81. Empiric combination therapy Third-generation cephalosporin (e.g.  ceftriaxone or cefotaxime) AND Antistaphylococcal agent (e.g.  Vancomycin  )

82. Management Glucocorticoids  – Not recommended Direct evidence of a benefit is lacking Not been associated with reduced length of stay, duration of intubation, or duration of stay in the ICU Racemic epinephrine – Not recommended Benefit of administration to reduce edema prior to airway intervention is not established  Young children may cause some might by frightened and anxious exacerbating airway compromise

83. Prevention Vaccination – if not previously done V accinated patient + recurrent epiglottitis C onsultation with an immunology specialist is for immunodeficiency evaluation

84. 3-year-old boy was brought for evaluation of a harsh cough and difficulty breathing Hx of cold with a runny nose 3 days Mother said he was awake most of the previous night with a barking cough and noisy breathing. Pulse 130/min, RR 40/min, BP of 90/60 mmHg, and Temp. 37.3°C Examination Auscultation: inspiratory stridor transmitted through the lung fields No cyanosis and no other abnormal physical signs. What is the most likely Dx?

85. What is the most likely diagnosis? Retropharyngeal abscess Nasopharyngitis Laryngotracheitis (Croup) Allergic reaction

86. What is the most likely diagnosis? Retropharyngeal abscess Nasopharyngitis Laryngotracheitis (Croup) Allergic reaction

87. Croup 06

88. Croup Inflammation of the larynx, trachea, and subglottic area Common age (6- 36 month) I nspiratory stridor, cough, and hoarseness Barking cough - infants and young children (Hallmark) Hoarseness - Older children Usually mild and self-limited illness

89. Etiology Viral Parainfluenza viru s – Type 1; most common cause Rhinovirus RS V A denoviruses SARS-CoV-2 Measles Influenza virus - (uncommon but more sever)

90. Etiology Bacterial – Rare Mycoplasma pneumoniae  Secondary bacterial infection Staph. A ureus S. pyogenes S. pneumoniae 

91. Clinical manifestations 0-3 days: N asal congestion, rhinorrhea, cough, low-grade fever 3-7 days: H arsh barking cough, hoarse voice, and stridor Gradual return to normal; Symptoms subsiding

92. Evaluation Rapid assessment and initial management Westly Croup Severity score

93. Evaluation Description of the onset Duration Progression of symptoms Factors that are associated with increased severity Sudden onset Rapid progressing Previous episodes Underlying abnormality of the upper airway Medical conditions that predispose to respiratory failure ( eg , neuromuscular disorders) Signs of dehydration

94. Examination Measure the child's weight , vital signs & appearance Westley croup score   & assess for other causes Oropharynx and cervical lymph node examination Chest auscultation

95. Examination Measure the child's weight , vital signs & appearance Westley croup score   & assess for other causes Oro

96. Diagnosis Clinical diagnosis Laboratory tests Radiographs

97. Imaging Posterior-anterior chest Lateral view Subglottic narrowing "steeple sign” O verdistention of the hypopharynx during inspiration S ubglottic haziness 

98. DDx Noninfectious causes Angioedema Foreign body Upper airway trauma or thermal injury I nfectious causes Acute epiglottitis   Peritonsillar P arapharyngeal abscess R etropharyngeal abscess

99. Difficulty swallowing Drooling Throat pain Fever Barking cough Hoarseness More common in croup M ore common in epiglottitis

100. Epiglottitis Croup

101. Laboratory Studies R arely indicated in children with croup Blood tests Neutrophil or lymphocyte predominance may be present Neutrophils is suggestive of bacterial infection Microbiology   N ot necessary - since croup is a self-limited illness

102. Steroids For all patients - oral steroids as a one-time dose Dexamethasone - equally effective given parenterally or orally Treatment Moderate to severe croup Observation of at least 3 hours after Nebulized Epinephrine

103. Mild Croup Symptomatic management - antipyretics, mist, and oral fluids Instructions when to seek medical attention AND Single dose of oral Dexamethasone 0.15 to 0.6 mg/kg Westley croup score ≤2

104. Moderate to Severe Croup Supportive care - Humidified air or oxygen, antipyretics, and encouragement of fluid intake. AND Single dose of oral Dexamethasone 0.15 to 0.6 mg/kg Nebulized budesonide - Alternative option 2 mg [2 mL solution] via nebulizer Nebulized epinephrine  Racemic epinephrine 0.05 mL/kg per dose (maximum of 0.5 mL) of a 2.25% solution Diluted to 3 mL total volume with normal saline L-epinephrine (parenteral product) 0.5 mL/kg per dose (maximum of 5 mL) of a 1 mg/mL solution Westley croup score 3-7 Westley croup score >8

105. Indications To Seek Medical Attention Stridor at rest Difficulty breathing Pallor or cyanosis Drooling or difficulty swallowing Fatigue Worsening course Fever (>38.5ºC) Prolonged symptoms (>7 days) Suprasternal retraction

106. Prevention Hand washing Avoid contact with sick patients

107. 14-year-old previously healthy male Fever 40.1°C, sore throat, and difficulty breathing for 3 days Associated with Pain while swallowing & poor oral intake development of trismus and muffled “hot potato” voice What is the most likely Dx?

108. What is the most likely diagnosis? Bacterial pharyngitis Retropharyngeal abscess Epiglottitis Tonsillitis

109. What is the most likely diagnosis? Bacterial pharyngitis Retropharyngeal abscess Epiglottitis Tonsillitis

110. Retropharyngeal Abscess 07

111. Retropharyngeal Abscess Collection of pus in the tissue behind the pharyngeal wall Occurs mostly in children between the ages of 2 to 4 years Often a polymicrobial infection

112. Evaluation & Diagnosis Address airway obstruction Rapid assessment of the degree of upper airway obstruction Clinical manifestations Depends upon the stage of illness Early disease - indistinguishable from uncomplicated pharyngitis

113. Clinical Manifestations Generally appear ill with moderate fever Dysphagia, Odynophagia Respiratory distress (stridor, tachypnea, or both) Neck swelling, mass, or lymphadenopathy Drooling with decreased oral intake Neck pain Muffled or "hot potato" voice Trismus

114. Investigations Laboratory evaluation CBC - High WBC Blood culture – Aerobic & anaerobic Imaging Lateral neck radiography Swelling of the retropharyngeal space with more than 7 mm at level C2 vertebra (80% of the time) Diagnostic imaging is a computed tomography (CT) scan w/o contrast

115. Management Refer patients immediately to an appropriate secondary care facility Emergency with a high mortality rate Apply supplemental oxygen – If available

116. Management Initial therapy depends on: Severity of respiratory distress Likelihood of drainable fluid - based upon CT findings and clinical features Secure Airway - In patients with severe airway compromise IV empiric antibiotics Incision and drainage (abscesses ≥2.5 cm2 by CT)

117. Antibiotic therapy Coverage of group A Streptococcus, S. aureus, and respiratory anaerobes Empiric therapy can be amended as necessary based upon culture results If drainage is performed or clinical response to treatment

118. Empiric regimen Ampicillin-sulbactam Clindamycin & Ceftriaxone

119. THANK YOU Questions?