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1. Project: Ghana Emergency Medicine Collaborative
Document Title: Selected E.N.T. Emergencies Related to Sepsis
Author(s): Jim Holliman (Uniformed Services University), MD, FACEP, 2012
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3. Selected E.N.T. Emergencies
Related to Sepsis
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Jim Holliman, M.D., F.A.C.E.P.
Program Manager, Afghanistan Health Care
Sector Reconstruction Project
Center for Disaster and Humanitarian Assistance
Medicine
Uniformed Services University
Bethesda, Maryland, U.S.A.
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4. Selected E.N.T. Emergencies
Lecture Outline
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Complications of acute sinusitis
© Frontal and orbital abscesses
Acute mastoiditis
Acute chondritis
Mucormycosis
Peritonsillar abscess
Retropharyngeal and parapharyngeal abscesses
Ludwig’s angina
Vincent’s Angina
Acute epiglottitis
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5. Acute Sinusitis Complications
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Frontal or orbital abscess
Need facial CT scan for Dx
Need IV antibiotics, hospital
admission, and surgical drainage
5

6. Signs of Potentially Dangerous
Complications of Acute Sinusitis
ƒ Periorbital, frontal, or cheek edema
ƒ Proptosis
ƒ Manifestation of orbital abscess
ƒ Ophthalmoplegia
ƒ Ptosis
ƒ Diplopia
ƒ Meningeal signs
ƒ Neuro deficits of cranial nerves II to VI
6

7. Source undetermined
CT scan showing fluid with pockets of air in frontal air
cells from frontal sinusitis in a six year old male
7

8. Source undetermined
CT scan showing orbital & brain abscesses from ethmoid
sinusitis
8

9. Source undetermined
CT scan showing epidural abscess from frontal sinusitis (six 9
year old male with headache, emesis, and fever)

10. Subdural
abscess
from
frontal
sinusitis
10
Source undetermined

11. Source undetermined
Surgical drainage for same
patient in prior slide
11

12. Source undetermined
Patient with bony destruction
from frontal sinus abscess
12

13. Source undetermined
Coronal CT scan showing left ethmoid opacification and
displacement of globe by intraorbital mass (patient was a 2
year old male presenting with fever, proptosis, and left orbital
13
cellulitis)

14. Source undetermined
Patient with left orbital abscess
14

15. Source undetermined
CT scan of same patient with left
orbital abscess
15

16. Source undetermined
Another patient with right retro-orbital abscess16

17. Preseptal
cellulitis
(important to
differentiate from
orbital abscess ;
Use facial CT to
do this)
-tripp-, flickr
These patients
should be
admitted and
receive IV and
topical antibiotics
17
Source Undetermined

18. Antibiotics to Consider for Rx
of Sinusitis Complications
ƒ Ceftriaxone 1 gm IV q 12h
ƒ Cefotaxime 2 gm IV q 4h
ƒ Ceftizoxime 4 gm IV q 8h +
metronidazole 30 mg/Kg/d
ƒ Ampicillin / sulbactam 3 gm IV q 6h
ƒ Vancomycin 500 mg q 6h + aztreonam
1 gm q 8h or chloramphenicol ( for PCN
- allergic patients)
18

19. Acute Mastoiditis
ƒ Uncommon now due to antibiotic use for otitis media
ƒ Most common causative bug is Strep pneumoniae
ƒ Rx is IV antibiotics, myringotomy, & drainage
ƒ Mastoidectomy for resistant or complicated cases
ƒ Related serious problem is Necrotizing External
Otitis (or “Malignant External Otitis”)
ƒ Usually caused by Pseudomonas
ƒ Requires IV antibiotics for 4 weeks and radical
surgical debridement
19

20. Source Undetermined
Source Undetermined
Child with acute mastoiditis from
concurrent otitis media
20

21. Acute Chondritis
ƒ Can be complication of ear piercing
ƒ Most commonly caused by Pseudomonas
but can be due to Strep or Staph
ƒ Requires IV antibiotics
ƒ Also needs incision, drainage, and
pressure dressing if abscess present
21

22. Patients
with acute
chondritis
Source undetermined
22

23. Mucormycosis
ƒ An aggressive opportunistic fungal
infection usually with Mucor or Rhizopus
ƒ Occurs in immunocompromised and poorly
controlled diabetic patients
ƒ Mortality 30 to 70 %
ƒ Requires IV and topical amphotericin B and
aggressive surgical debridement
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24. Source Undetermined
Source Undetermined
24

25. Source undetermined
25

26. Source undetermined
32 year old diabetic presented with
coma and DKA ; the hard palate was
necrotic with mucormycosis
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27. Peritonsillar Abscess
ƒ Complication of acute tonsillitis
ƒ Unilateral peritonsillar and soft palate swelling
with uvular deviation
ƒ Most commonly caused by Strep species but
can be polymicrobial
ƒ Usually have trismus, drooling, muffled “hot
potato” voice
ƒ May need CT to r/o parapharyngeal abscess
ƒ Requires antibiotics, needle aspiration, and
later interval tonsillectomy
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28. Appearance of
peritonsillar
abscess
Image sources undetermined
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29. Axial CT scan of
peritonsillar
abscess in a
child
29
Source undetermined

30. Retropharyngeal and
Parapharyngeal Abscesses
ƒ Sx are neck swelling, fever, dysphagia, muffled
voice, neck hyperextension
ƒ Due to suppuration of retro- or parapharyngeal
lymph nodes, or direct trauma
ƒ Requires CT scan to delineate extent of
abscess, IV antibiotics, surgical drainage, and
sometimes airway protection with intubation
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31. Plain film of
retropharyngeal
abscess
Source undetermined
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32. Another plain film
of retropharyngeal
abscess
Source undetermined
32

33. Source undetermined
Parapharyngeal abscess on CT
33

34. Parapharyngeal
abscess (note
endotracheal
tube in place)
34
Source undetermined

35. Ludwig’s Angina
ƒ The most common neck space infection
ƒ Is a rapidly swelling cellulitis (+/- abscess) of the
sublingual and submaxillary spaces, usually
arising from molar and premolar tooth root
infections ; usually polymicrobial infection
including anerobes
ƒ Most patients are toxic, severely ill, dehydrated
ƒ Risk of airway obstruction due to upward tongue
swelling
ƒ Need CT to delineate any abscess present
ƒ Rx: tracheostomy, IV antibiotics, incision and
drainage of the neck, excision of source teeth
35

36. Kulkarni et. al., Wikimedia Commons
Patient with Ludwig’s angina (note
typical brawny swelling of the
submandibular area)
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37. Vincent’s Angina
ƒ An acute necrotizing infection of the pharynx
and/or tonsils caused by a combination of
fusiform bacilli and spirochetes (the same
organisms that cause acute gingivostomatitis or
“trench mouth”
ƒ May have fever, lymphadenopathy, and metallic
taste
ƒ Need CT to look for gas and if any associated
abscess in the soft tissues
ƒ Rx : IV penicillin and/or clindamycin, surgical
debridement of necrotic tissue
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38. Source undetermined
Acute necrotizing ulcerative
gingivitis
38

39. Acute Epiglottitis
ƒ Due to HiB vaccine, is now rare (I’ve never
seen a case in my entire career)
ƒ Most cases now are in men age 40 to 60
ƒ Usually caused by Hemophilus sp. and Strep
pneumoniae
ƒ Adult mortality reportedly 7 %
ƒ Most patients febrile, toxic, drooling, muffled
voice
ƒ Need CT to r/o parapharyngeal abscess
ƒ Rx : IV ceftriaxone, +/- airway control
39

40. Plain film
showing
enlarged
epiglottis from
epiglottitis in an
adult
Source undetermined
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41. Acute epiglottitis
in a 66 year old
male
Source undetermined
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42. Source undetermined
CT scan of
same patient as
on prior slide ;
note column of
air around the
epiglottis (E) ;
the right side of
the epiglottis is
more swollen
than the left ;
hypoattenuation at
“A” is
suggestive of 42
early abscess

43. E.N.T. Emergencies Related to
Sepsis : Lecture Summary
ƒ Maintain low threshold for workup with facial CT,
particularly in immunocompromised patients
ƒ Start IV antibiotics early
ƒ Don’t forget routine resuscitative measures (such as
IV fluid bolus) and blood cultures in febrile or toxic
patients
ƒ Early consultation with your friendly otolaryngologist
ƒ May require additional consults to neurosurgery or
ophthalmology
ƒ Use consultant to decide if pre-operative needle
aspirates for culture
43