GEMC- Oral and Facial Infections- Resident Training
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Based on the information provided, this case is most consistent with a diagnosis of actinomycosis. Key features include: - Chronic (2 month) infection - Inflammation and pain over facial region and nasal area - Occupation as a farmer (exposure to soil/animals which are risk factors) Actinomycosis is a chronic bacterial infection caused by Actinomyces species, which are gram positive bacteria commonly found in the mouth and GI tract. Risk factors include poor dental hygiene or penetrating injuries that allow entry into tissues. The infection can spread locally or systemically and form draining sinus tracts and abscesses. The facial region is a common site of infection. Treatment requires prolonged high dose
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GEMC- Oral and Facial Infections- Resident Training
- 1. Project: Ghana Emergency Medicine Collaborative Document Title: Oral and Facial Infections Author(s): Shannon Langston (University), MD, 2011 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1
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- 3. Oral and Facial Infec.ons 12-‐06-‐2011 Shannon Langston, MD 3
- 5. Peritonsillar Abscess • History – – – – – Sore throat Fever Odynophagia Dysphagia Otalgia • Examina.on – – – – – Trismus “hot potato voice” Drooling Effaced anterior pillar Contralateral devia.on of uvula 5
- 6. • History – Sore throat – Fever – Odynophagia – Dysphagia – Otalgia 6
- 7. • Examina.on – Trismus – Vocal Changes – Drooling – Effaced anterior pillar – Contralateral devia.on of uvula 7
- 8. • Pathogens – Polymicrobial – Group A streptococcus – Staphylococcus aureus – Respiratory anaerobes • Fusobacteria, Prevotella 8
- 9. • Management – Suppor.ve – Radiographs +/-‐ – Labs +/-‐ – An.bio.cs – Aspira.on 9
- 10. • Steroids – Controversial – Single dose effec.ve – No evidence of harm 10
- 11. Steroids in PTA 11
- 12. Steroids in PTA 12
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- 23. Ludwigs Angina • Sublingual space infec.on • Bilateral • OUen mul.ple .ssue planes 23
- 24. Physical Findings • • • • • Toxic Appearance Brawny bilateral woody edema Submandibular, submental, sublingual Trismus Tongue eleva.on 24
- 25. Gray’s Anatomy, Wikimedia Commons Tongue Sublingual gland Supramylohyoid portion of submandibular space Mylohyoid muscle Inframylohyoid portion of submandibular space Submandibular gland Digastric muscle (anterior belly) 25
- 26. Geniohyoid muscle Submandibular space: Sublingual space Submaxillary space Mylohyoid muscle Superficial fascial layer Gray’s Anatomy, Wikimedia Commons 26
- 29. History • • • • • • Recent dental extrac.on or work Dental caries Fever Swelling of mouth, face, neck Compromised host Co-‐morbidi.es 29
- 30. Pathogens • Streptococcus viridans • Staphylococcus species • Mixed aerobic/anaerobic infec.on – Peptostreptococcus species, Fusobacterium, Bacteroides 30
- 31. Treatment • Aggressive airway control – Fiberop.c – Cricothyrotomy or tracheostomy • Surgical consulta.on mandatory – Oral maxillofacial surgeon or ENT • An.bio.cs • Steroids? • ICU admission 31
- 32. • Steroids – Controversial – Dosing: • 10 mg Dexamethasone IV • 4 mg q 6 hours for 48 hours 32
- 33. Treatment • An.bio.c Therapy – Ampicillin-‐sulbactam (3 g IV every six hours) or – Clindamycin (600 mg IV every six to eight hours) PLUS – Vancomycin (15 to 20 mg/kg IV every 12 hours) or – Linezolid (600 mg orally or IV every 12 hours). 33
- 34. Ludwigs Angina • Take Home Points – Aggressive airway management – An.bio.cs – CT Scan – Surgical Consulta.on Early 34
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- 40. ANUG • Acute Necro.zing Ulcera.ve Gingivi.s – AKA Trench Mouth – Vincent’s Disease 40
- 41. Clinical Features • • • • • Gingival necrosis, especially .ps of papillae Bleeding Pain Fe.d breath Pseudomembrane forma.on 41
- 42. • Predisposing Factors – Emo.onal stress – Poor oral hygiene – Cigarede smoking – Poor nutri.on – Immunosuppression 42
- 43. ANUG • • • • Prevalence 0.6% Young adults (mean age 23 years) More common in Caucasians Bacterial flora – – Spirochetes (Treponema sp.) – Prevotella intermedia – Fusiform bacteria 43
- 44. • Treatment – Amoxicillin – Clindamycin – Doxycycline – Chlorhexidine Rinse – Hydrogen Peroxide 3% – Oral Hygiene 44
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- 47. Ducts of sublingual glands Parotid glands Submandibular glands Submandibular duct Sublingual glands Arcadian, Wikimedia Commons 47
- 48. Suppura.ve Paro..s • Clinical Findings • Firm, Erythematous swelling • Pain • Fever • Trismus 48
- 49. E.ology • Staphylococcus* – Most Common Isolate • Aerobic: 34% • Anaerobes: 41% • Mixed: 25% 49
- 50. Predisposing Factors • • • • • • Advanced age Dehydra.on Diabetes HIV Alcoholism, Poor oral hygiene 50
- 51. • Management – An.bio.cs – Hydra.on – Culture – Imaging – Surgical Consulta.on 51
- 52. An.bio.cs Or Vancomycin 15-20 mg/kg IV Q 12 h Or Linezolid 600 mg orally or IV Q 12 h PLUS Either metronidazole 500 mg IV Q 6-8 h 52
- 53. Case • 65 year old farmer presents with 2 month history of inflamma.on and pain over the facial region and nasal mucosa. • Denies fevers or systemic symptom. • PMH: Unremarkable. • Course of an.bio.cs “the white one” unsuccessful. 53
- 57. • Physical Exam: – Nasal mucosal ulcera.ons noted – No drainage, minimal warmth – Oropharynx: Ulcera.ve lesion – General exam unrevealing, no LAD 57
- 58. Differen.al? 58
- 59. • Fungal – Paracoccidioidomycosis, sporotrichosis, blastomycosis • Bacterial – Staphylococcal and streptococcal infec.ons, syphilis, tuberculosis, leprosy 59
- 60. Differen.al • Inflammatory – Sarcoidosis, lupus • Neoplas.c – – Cutaneous T-‐cell lymphoma, basal cell carcinoma, squamous cell carcinoma, psoriasis 60
- 62. Mucocutaneous Leishmaniasis • Leishmaniasis: vector-borne diseases caused by parasites of the genus Leishmania • Multifaceted clinical manifestations: – Mucocutaneous – Cutaneous – Visceral 62
- 63. Leishmanaisis § The global annual incidence is estimated at 1.5-2 million new cases per year: § 1-1.5 million cases of CL § 500,000 cases of VL. § Overall prevalence of 12 million cases. § 500 US Soldiers in 18 month period 63
- 64. Mucocutaneous Leishmanisis • Distribu.on: – Present in 88 countries within Central America, South America, Africa, India, the Middle East, Asia, southern Europe, and the Mediterranean. 64
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- 67. Vectors • Transmided by the bite of female sandflies – Genus Lutzomyia in the New World – Genus Phlebotumus in the Old World • Reservoir host: – Domes.c and/or wild animals – Humans. 67
- 68. Leishmania Species • Two Groups (15 species cause disease) – Those restricted to the skin and cause dermal leishmaniasis: • L. mexicana, • L. braziliensis • L. tropica, L. major, L. aethiopica. – Visceral: • L. donovani 68
- 69. Extension of MCL § Nose § Nasopharynx § Palate § Epiglottis § Larynx § Vocal chords § Trachea 69
- 70. Diagnosis • Immunologic: Skin test (80-‐92%) • Visual methods: – Impression smear (37.9%) – Dermal scrapping (32.7%) – Histopathology (21.4%) • Isola.on methods: – In vitro culture (57% -‐ 85%) • Demonstra.on methods: – PCR 92-‐94% 70
- 71. Treatment • • • • • Pentavalent an.monials Amphotericin B (Liposomal Preferred) Pentamidine Ketoconazole, Itraconazole Allopurinol 71
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