Neck and upper airway emergencies

Pharyngitis/tonsillitis

• Viral 
  • Rhinovirus (15-20%)
  • Coronavirus 5%
  • Adenovirus 6%
  • HSV
  • Parainfluenza
  • Influenza
  • RSV
  • Coxsackie A
  • EBV
  • CMV
  • HIV

Pharyngitis/tonsillitis

• Bacterial
  • S. pyogenes (GABHS) 10-22%
  • Fusobacterium 5-10%
  • Streptococcus dysgalactiae 3-5%
  • Neisseria gonorrhoeae
  • Corynebacterium diphtheriae
  • Arcanobacterium haemolyticum
  • Chalmydia pneumoniae
  • Mycoplasma pneumoniae

Pharyngitis/tonsillitis

• Viral pharyngitis
  • Generally petechial or vesicular pattern on soft palate and tonsils
  • Associated rhinorrhoea
  • 15% have tonsilar exudate, 55% have cervical lymphadenopathy and 64% lack cough
  • Testing warranted if suspected influenza, infectious mononucleosis or acute retroviral syndrome
  • Symptomatic therapy

Pharyngitis/tonsillitis

• Group A beta-haemolytic strep
  • 5-15% of pharyngitis in adults
  • Incubation period 2-5 days, then sudden sore throat, odynophagia, chills, fever, headache, N&V
  • Marked erythema of tonsils and tonsillar pillars (62% of cases), tonsillar exudate (32%), enlarged tender cervical nodes (72%)
  • Only 6% have fever and 28% have a cough
  • Less likely to have rhinorrhoea or conjunctivitis vs. viral pharyngitis
• Uvula oedema
  • Quincke’s oedema
  • Seen with GABHS, peritonsilar abscess and epiglottitis
  • Can also be idiopathic
  • If isolated finding or uncomfortable, 4mg dex IV

Pharyngitis/tonsillitis

• Centor criteria: Tonsillar exudates, tender anterior cervical lymphadenopathy, absence of cough and history of fever
• If 2 or more criteria met, swab and treat positive cultures only
• Treat ATSI/high-risk individuals with antibiotics
• Untreated GABHS lasts 7-10 days and antibiotics shorten resolution by 1-2 days if indicated if initiated within 2-3 days of onset
• Antibiotics prevent suppurative complications and rheumatic fever but NOT glomerulonephritis
• Penicillin remains first-line as GABHS has never shown penicillin resistance
• IM benzathine penicillin 1.2 million units, Pen V 500mg BD for 10/7 or amoxicillin 500mg BD daily +- dexamethasone 4mg IV/PO stat

Modified centor

• Cough absent -1
• Exudate – 1
• Nodes -1
• Temperature – 1
• OR – Young <15 or old >44 + 1 point if young, minus 1 if old
• Score
  • -1, 0 or 1 point = Risk <10% of GAS
  • 2 or 3 – Swab and treat if positive (15% risk if 2, 32% if 3)
  • 4 or 5 – Swab and treat if positive (56% risk of GAS)

Lemierre’s syndrome

• Fusobacterium necrophorum, a gram-negative anaerobe, causes suppurative thrombophlebitis of the internal jugular vein +- bacteraemia and septic emboli
• Suspect if worsening symptoms, neck swelling, neurology
• Treatment – Penicillin, clindamycin or ceftriaxone

Peritonsillar cellulitis and abscess

• Classic presentation of PTA – Severe sore throat, hot potato voice, fever, drooling and trismus
• If obvious trismus, unilateral swelling, bulging of soft palate near tonsil with palpable fluctuance, uvula deviation = Suspected PTA
• Liverpool peritonsillar abscess score (LPS)
  • Unilateral sore throat +3
  • Trismus +2
  • Male gender +1
  • Hot potato voice +1
  • Score of 4+ = Likely PTA
  • Score of 6+ = 80% likely PTA
• Differentiation may require USS, CT, trial of antibiotics
• All get empirical Ab
• Needle aspiration if cooperative with exam findings suggestive of PTA and no indication for tonsillectomy
• Trial of antibiotics if suspected peritonsillar cellulitis
  • If fails to improve in 24 hours – PTA more likely

Differentiating quinsy from tonsillitis

• Degree of trismus
• Anterior arch pushed medially
• Palate loses concave shape and becomes convex towards examiner\
• Uvula pushed away from affected side
• Mucosa of arch and palate is erythematous
• A unilateral swollen tonsil is NOT a quinsy

Peritonsillar cellulitis and abscess

• Microbes
  • GAS, Strep. anginosus, Staph aureus (incl. MRSA), anaerobes (fusobacterium, Prevotella), Haemophilus
• Trismus is due to spasm of internal pterygoid
• Signs suggestive of deep neck space infection (e.g. retropharyngeal abscess)
  • Severe neck pain
  • Pain on neck extension
  • Neck stiffness
  • Chest pain (mediastinal spread)
  • Toxic
  • Pharyngeal mucosal bulging posterior to tonsillar pillars

Peritonsillar cellulitis and abscess

• If cannot differentiate PTA from PTC
  • Admit for IV hydration, analgesia and antibiotics
  • If responds within 24 hours – PTC likely
  • If fails to respond within 24 hours or deteriorates – Aspiration or I&D or tonsillectomy
• Antibiotics
  • IV Clindamycin 600mg TDS +- IV vanc if MRSA risk
  • Continue to 14 day oral course of PO Augmentin +- anti-MRSA clindamycin 450mg QID

Peritonsillar abscess

• Pus collection between tonsillar capsule, superior constrictor and palatopharyngeus muscles
• Risk factors
  • Periodontal disease
  • Smoking
  • Chronic tonsillitis
  • Multiple antibiotic courses
  • Previous quinsy
• Mostly young adults without seasonal variation
• Typically polymicrobial, however, in young adults Fusobacterium necrophorum is most common

Peritonsillar abscess

• Presentation
  • Ill appearing, sore throat, fever (54%), malaise, odynophagia, dysphagia and/or otalgia
  • Inferior and medial displacement of infected tonsil (46%), contralateral deflection of swollen uvula (43%), tender cervical lymphadenopathy (41%), trismus (31%), hot potato voice, palatal oedema and dehydration
  • DDX
    • Peritonsillar cellulitis, mononucleosis, lymphoma, herpes simplex tonsillitis, retropharyngeal abscess, neoplasm, internal carotid artery aneurysm
    • Intraoral USS has sensitivity 90% and specificity 79-100%
    • CT with contrast if concern for spread beyond peritonsillar space or lateral neck space

Peritonsillar abscess

• Treatment
  • Drainage by needle aspiration, I&D or immediate tonsillectomy
  • Quinsy tonsillectomy only indicated if strong indication for tonsillectomy anyway i.e. sleep apnoea, recurrent tonsillitis or recurrent quinsy
  • 90% of patients can be effectively treated with a single aspiration
  • Antibiotics
    • IV Clindamycin 600mg TDS +- IV vanc if MRSA risk
    • Continue to 14 day oral course of PO Augmentin +- anti-MRSA clindamycin 450mg QID
• Complications
  • Airway obstruction, rupture of abscess with aspiration, haemorrhage due to erosion into carotid sheath, retropharyngeal abscess, mediastinitis and streptococcal sequelae

Acute epiglottitis

• Mostly adults now since Hib vaccination
• Mean age 45 years
• Most cases Streptococcus, Staphylococcus, viral, fingal
• In most cases no organism ever identified

Acute epiglottitis

• Presentation
  • 1-2 days of worsening dysphagia, odynophagia and dyspnoea
  • Classical 3 D’s (drooling, dysphagia and distress) is rare
  • Other symptoms include fever, tachycardia, cervical adenopathy, anterior neck tenderness with gentle palpation of larynx
  • Stridor
  • Often sitting up, mouth open, head extended
  • X-ray or nasendoscopy is diagnostic
  • Lateral soft-tissue neck X-ray shows obliteration of vallecula, swelling of aryepiglottic folds, oedema of prevertebreal and retropharyngeal soft tissues and ballooning of hypopharynx with thumb-shaped epiglottis
  • If worsening dyspnoea in upright position – do NOT send to CT

Acute epiglottitis

• Treatment
  • Urgent ENT review
  • Airway planning
  • 1:1 nursing upright
  • Supplemental humidified O2, IV hydration, monitoring and IV antibiotics
    • Cefotaxime 50mg/kg IV q8h + Vancomycin 15mg/kg q12h
  • Humidification and hydration can reduce risk of sudden airway obstruction
  • Steroids methylpred 125mg IV or dex 10mg IV may reduce swelling

Retropharyngeal abscess

• Potential space anterior to prevertebral fascia extending from base of skull to tracheal bifurcation
• In adults, usually secondary to oral procedures, trauma, foreign body (e.g. fishbone) or extension from odontogenic infection
• Usually polymicrobial: GABHS, Staph aureus, H. influenzae, Bacteroides, Peptostreptococcus and Fusobacterium
• Clinical
  • Sore throat, dysphagia +- stridor
  • Cervical lymphadenopathy, muffled voice, respiratory distress
• Imaging
  • Lateral soft tissue X-ray shows thickening and protrusion of retropharyngeal wall >5-7cm at second cervical vertebra
  • Contrast CT is test of choice
    • Necrotic nodes with central low attenuation and ring enhancement = abscess

Retropharyngeal abscess

• Treatment
  • Urgent ENT
  • IV hydration + IV PipTaz
  • Most patients require surgical drainage
• Complications
  • Extension into mediastinum
  • Upper airway asphyxia from direct pressure
  • Aspiration after rupture

Odontogenic abscess

• Can arise from infected tooth or after extraction
• Develops over 1 day to 1-3 weeks after onset of tooth pain and may occur despite antibiotics
• Polymicrobial: Strep viridans, Peptostreptococcus, Prevotella, Staphylococci
• Most deep neck infections arise from odontogenic source, usually mandibular teeth
• May spread into parapharyngeal and retropharyngeal spaces
• Presenting features include neck mass, trismus, fever, leukocytosis, dysphagia and dyspnoea
• Potential complications include necrotising mediastinitis, orbital infections and haematogenous dissemination

Odontogenic infections

• Diffuse cellulitis, abscess formation in labial or buccal gingiva
• Intraoral or dentocutaneous fistulas can form
• Maxillary teeth
  • Infections of maxillary teeth tend to spread into face planes
  • Infections of maxillary molars extend into masticator space, which can extend into the parapharyngeal space and downward into the neck and mediastinum
• Mandibular teeth
  • Anterior mandibular teeth tend to spread into the neck
  • Infections of anterior mandibular teeth, bicuspids and first molars of mandible tend to enter sublingual space with oedema of floor of mouth and minimal extraoral swelling
  • Second and third mandibular molars spread to submandibular space

Odontogenic infections

• Diagnosis and Rx
  • Bedside USS for superficial abscesses
  • Suspected deep space infection requires contrast CT to identify need for surgical intervention
  • Aerobic and anaerobic cover and surgical drainage of any abscesses
  • PO Augmentin 
  • If deep neck infections – PipTaz
• Complications
  • Ludwig’s angina
  • Necrotising infections

Odontogenic infection

• Pulpitis
  • Progression of dental caries to pulp with severe toothache elicited by hot/cold drinks
  • Reversible
    • Mild inflammation
  • Irreversible
    • Rapid pressure build-up, occlusion of blood vessels at apical foramen, ischaemia and necrosis
    • Acute and intense pain and main cause of presentation to ED
    • Needs root canal
    • A minority of dentises provide oral augmentin prior to this

Odontogenic infection

• Pulp sensitivity test
  • Ice to neck of tooth
    • Response = pulp nerves intact
    • No response = pulp necrosis
• Percussion test
  • Painful response = Periapical inflammation
• Palpation
• Short, sharp, shooting pain
  • Triggered by hot/cold/sweet = Gingival recession, lost filling, caries/pulpitis
  • Triggered by biting = Cracked cusp, loose filling, fractured tooth
• Dull/throbbing/persistent pain
  • Localised tender tooth to percussion = Periapical infection, sinusitis
  • Local inflammation – Impacted food, pericoronitis
  • Generalised inflammation = Acute necrotizing ulcerative gingivitis
  • Local/diffuse pain = Dry socket, TMJ disorder

Odontogenic infection

• Acute gingivitis
  • Chlorhex mouth washes
• Trench mouth (Vincent’s angina/acute necrotizing ulcerative gingivitis)
  • Chlorhex mouth washes +
  • Systemic augmentin
• OPG
  • May show periapical abscess, caries or osteomyelitis

Odontogenic infection

• When are antibiotics indicated?
  • Periapical abscess
  • Deep-space infection
  • Malaise
  • Fever
  • Lymphadenopathy
  • Immunocompromise
  • Cellulitis/spreading infection
• Which antibiotics
  • PO Augmentin if mild or Amoxycillin + Metronidazole
  • IV BenPen/Metronidazole or IV PipTaz if severely unwell/immunocompromised

Odontogenic infections

• Ludwig’s angina
  • Infection of submental, submandibular and sublingual spaces
  • Trismus and oedema of entire upper neck and floor of mouth
  • Infections progresses rapidly with posterior displacement of tongue, airway compromise
  • Early definitive airway management is key
  • Systemic antibiotics come second and can take a week for oedema to resolve
• Necrotising infections
  • Critically ill, overlying skin discolouration, crepitus, fever, tachycardia, hypotension, confusion
  • CT shows subcutaneous emphysema, pockets of suppuration
  • Cultures for identification of cause
  • Immediate surgery, fasciotomy with wide local debridement and IV piptaz
• Mediastinal extension has 10-40% mortality and carries risk of great vessel erosion, retroperitoneal extension, pleural abscess, pericardial effusion and sepsis

Neck masses

• In adults >40yo, >80% of lateral neck masses persistent for >6 weeks are malignant
• Need to divide into:
  • Possibly infectious
  • Possibly malignant
  • Possibly non-malignant
• If any airway compromise – need nasendoscopy and airway management first
• Then CT
• All need follow-up
• If possibly infectious based on hx/ex
  • Empirical PO augmentin is appropriate and resolution is expected within 2 weeks then again in 2-4 weeks for resolution
  • If fails to respond – need further workup for malignancy

Neck masses

• Features suggestive of malignancy
  • Age >40
  • No infectious history
  • >2 weeks
  • >1.5cm
  • Firm to palpation
  • Fixed
  • Ulceration of overlying skin
  • Smoking/alcohol history
  • History of head/neck cancer
  • Immunocompromised

Neck masses

• Features suggestive of malignancy…
  • Hoarseness/voice change
  • Otalgia/hearing loss ipsilaterally
  • Nasal congestion/epistaxis ipsilaterally
  • Oral cavity ulcer
  • Pharyngitis
  • Haemoptysis
  • Dyspnoea
  • Weight loss
  • Non-tender neck mass
  • Posterior triangle

Post-tonsillectomy bleed

• 1-8.8% rates of secondary haemorrhage
• Primary haemorrhage within 24 hours is most common
• 50% of these need surgical intervention
• Most significant haemorrhage occurs at day 5-10 (secondary)
• Significantly higher incidence of bleeding in patients aged 21-30 and >70
• Can be fatal and need early ENT involvement

post-tonsillectomy bleed

• Treatment
  • Chlorhex 3% in 3 parts water gargles or H2O2 gargles
  • Nebulised adrenaline 5mg
  • Consider TXA
  • Keep NBM, sitting upright, monitored with IV access
  • Send FBC, coags, G&H and X-match
  • Gray-white eschar is normal post-tonsillectomy
  • Apply direct pressure on bleeding tonsillar bed with 4×4 gauze on a long clamp, moistened with lignocaine + adrenaline
  • Place pressure on lateral pharyngeal wall, avoiding midline pressure to decrease gag reflex stimulation
  • ENT consult

Last Updated on February 22, 2021 by Andrew Crofton