Tag Archives: ent

Lemierre’s Syndrome

15 Oct

What is it?  Lemierre’s Syndrome also known as postanginal septicemia refers to thrombophlebitis of the internal jugular vein.  See figure 1 below.

lem1

Figure 1:  Red arrow indicating infected thrombus of internal jugular vein.

 

Signs and Symptoms:  Lemierre’s Syndrome usually develops as a complication of a bacterial pharyngitis in young, healthy adults. Patients usually start with a sore throat, fever, and general body weakness. These are followed by swollen cervical lymph nodes, a tender or painful neck, with continued fevers. Sepsis and even septic shock can ensue. Karkos et. al did systematic review in 2009 looking at 84 studies/114 patients who had Lemierre’s syndrome . Table 1 shows the sources of infections.

lem2

Pathophysiology: Lemierre’s syndrome occurs most often when a bacterial throat infection, usually Fusobacterium necrophorum) progresses to the formation of a peritonsillar abscess. When the abscess wall ruptures internally, the drainage carrying bacteria seeps through the soft tissue and infects the nearby structures. Spread of infection to the nearby jugular vein leads to  inflammation surrounding the vein and compression of the vein may lead to clot formation.

 

Why is it so dangerous?  The infected thrombus of the internal jugular vein is a perfect gateway for the spread of bacteria through the bloodstream. Besides causing sepsis and septic shock, pieces of the infected clot break off leading to septic emboli of the pulmonary vasculature, where abscesses, nodules, cavitary lesions and pleural effusions develop.  Emboli can also affect the joints, muscles and soft tissues, liver, spleen, kidneys and brain.

 

Treatment:  Fusobacterium necrophorum is generally highly susceptible to beta-lactams, metronidazole, clindamycin and third generation cephalosporins. Additionally, a co-infection by another bacterium may co-exist. For these reasons is often advised not to use monotherapy in treating Lemierre’s syndrome.  The role of anticoagulation in treating Lemierre’s syndrome remains controversial.  Karkos et al. showed overall mortality to be 5%.

 

Submitted by Joran Sequeira, M.D.

 

References

  • Karkos et al. Lemierre’s Syndrome: a systematic review. August 2009. Laryngoscope, 119 (8): 1552-1559.
  • Syed et al. Lemierre syndrome: two cases and a review. September 2007. The Laryngoscope(The American Laryngological, Rhinological & Otological Society; Lippincott Williams & Wilkins). 117 (9): 1605–1610

 

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visual aid: mastoiditis

10 Jun

Not usually the focus of most of our head CT’s, but worth remembering what to look for, particularly for those with ear symptoms, and certainly if they have mastoid tenderness

 

QUICK HITS on MASTOIDITIS

rare complication of otitis media

more common in kids than adults

mastoid lies superior to the middle ear cavity

can have redness, swelling, tenderness over the mastoid process

pus entering mastoid cells under pressure -> dissolution of surrounding bone (not awesome)

infection can spread to nearby structures (e.g. neck, CNS)

treatment: IV abx

 

QUICK VISUALS

(opacification of mastoid air cells–tip: use bone windows)

 

 

mastoiditis

File it away in the mental Rolodex.

 

References: uptodate.com; mastoid process; picture 1; picture 2

syringe TMJ reduction

16 Apr

cool trick from a 2014 JEM article:

 

TMJ dislocation:

  • commonly from excessive mouth opening (e.g. yawning, laughing)
  • anterior TMJ dislocations most common (non-traumatic)

 

Study:

  • 30/31 successful reductions (all anterior dislocations)
  • 77% took < 1 min

Technique:

  • take 5-10 mL syringe
  • pt gently bites down on syringe (placed across molars)
  • ask pt to roll syringe back & forth

 

Benefits:

  • hands-free (no bite risk to provider)
  • quick
  • no procedural sedation needed

 

Seems pretty cool.  Add it to the toolbox.

 

References: JEM article; picture

mumps: out and about with epidemic parotitis

25 Nov

I recently saw a patient in the ED with fever, bilateral parotitis and trismus with inability to open mouth greater than 1 finger width, concerning for mumps. I thought this would be a great opportunity to review this disease and recent epidemiology data from the US

 

MUMPS!

–viral illness

symptoms appear 14-18 days s/p infection. however, may be as short as 12 or as long as 25 days 

–those infected are contagious 2 days before sx onset and 5 days after sx onset

 

symptoms:

  • parotitis (95% of cases),
  • low-grade fever,
  • HA and stiff neck,
  • malaise,
  • loss of appetite,
  • hoarse voice,
  • orchitis (s/p puberty, may experience testicular atrophy, but rarely aspermia),
  • oophoritis (7% of post-pubertal females),
  • breast inflammation,
  • deafness u/l or b/l (1 in 20k cases).
  • infrequently causes aseptic meningitis.

 

ASYMPTOMATIC INFECTION OCCURS IN 15-20% OF CASES

 

–prevention: need 2 dose MMR. 80-90% effective

 

treatment: supportive care. NSAIDs, antipyretics, IVF, isolation. in patients with orchitis, also supportive care (bed rest, NSAIDs, testicle supports, ice packs)

 

–testing: IgG and IgM at UVa (PCR and viral cx available elsewhere)

 

Mumps exposure history IgM IgG Comments References
Unvaccinated; no history of mumps + + or − IgM may be detected for weeks to months; low levels of IgG may be present at symptom onset Meurman et al. 1982; Sakata et al. 1985
1–dose vaccine history + or − Likely + 50% of serum samples collected 1–10 days after symptom onset were IgM-positive; 50%–80% of serum samples collected >10 days after symptom onset were IgM-positive Narita et al. 1998; Jin et al. 2004; Krause et al. 2007
2–dose vaccine history + or − Likely + 13%–15% of serum samples collected 1–3 days after symptom onset were IgM-positive* Bitsko et al. 2008; Rota et al. 2009

*30%–35% of buccal samples collected 1–3 days after symptom onset were positive by real-time RT-PCR among persons with 2 doses of MMR (Bitsko et al. 2008; Rota et al. 2009)

 

epidemiology in the US

–reported US cases in 2014 from 1/1 to 8/15: 965 (438 reported in 2013)

 

US outbreaks in 2014: 

–central Ohio/ Columbus: 8/3-9/20. 484 cases. highest case report since 1979 outbreak (930)

–U of W-Madison: 25 confirmed cases as of 8/8/14

–U of I-Urbana-Champaign: 14 confirmed cases in 2014

 

Submitted by Paddy Fannon.

 

SOURCES:

The Centers for Disease Control and Prevention. Website: Fast Facts About Mumps (24 March 2010). Retrieved 24 November 2014. http://www.cdc.gov/mumps/about/mumps-facts.html

 

The Centers for Disease Control and Prevention. Website: 2014 Mumps Cases and Outbreaks (18 August 2014). Retrieved 24 November 2014. http://www.cdc.gov/mumps/outbreaks.html#outbreaks-2014

 

The Centers for Disease Control and Prevention . Graph: Overview of Laboratory Confirmation by IgM Serology (13 April 2010). Retrieved 24 November 2014. http://www.cdc.gov/mumps/lab/overview-serology.html

 

Wharton M, Cochi SL, Williams WW. Measles, mumps and rubella vaccines. Infect Dis North Am. 1990; 4(1):47

 

picture

tracheostomy complications

2 Sep

There are generally three categories of tracheostomy complications

Immediate after placement, early, and late.

  • Immediate and early happen within 48 hours of placement.
  • Late happens after

 

the most concerning late complication is tracheoinnominate fistula

  • this is severe with high mortality.
  • may be heralded by small amounts of bleeding in the days prior to a large hemorrhage.
  • Usually it takes about 5 days for a tracheostomy tract to mature.
  • Tracheoinnominate fistula usually occurs in the first three weeks after placement, peaking in the 1st to 2nd week.

Treatment for hemorrhage is pressure

Usually by first hyperinflating the trach tube cuff in attempt to tamponade the bleeding.

If this is unsuccessful, then next is placing a finger in the tracheostomy and applying direct digital pressure by pressing the artery against the manubrium.

Surgical consultation should be immediate.  And tamponade of the artery should be maintained to the operating room.

 

Other complications may be recurring tracheitis or bronchitis related to tracheostomy tube site infection.

Gauze soaked with 0.25% acetic acid can treat local wound infections.

 

Submitted by J. Stone.

 

References: Tintinalli’s Emergency Medicine Chapter 242 Compications of Airway Devices; picture

transexamic acid for epistaxis?

29 Aug

recent article on use of transexamic acid (which binds plasminogen and prevents it turning into plasmin):

 

Randomized trial for anterior bleeding:

using soaked cotton pledgets with TXA in one group vs. cotton pledget with epinephrine + lidocaine for ten minutes and packing with several cotton pledgets covered with tetracycline.  Nasal packing was removed after 3 days.

Results

  • significantly higher rate of bleeding arrest in TXA group (71% to 31%)
  • significantly higher discharge with TXA at 2 hours or less (95% vs 6.4%),
  • non-significant rates of rebleeding at 24 hours (4.7% TXA vs 11% ANP).
  • higher patient satisfaction in the TXA group. 

 

However, it should be noted that this is not compared to rapid rhino or other commercially available products, simply to anterior nasal packing with cotton pledgets in place for ten minutes. No mention of holding pressure was noted.

 

 

Submitted by J. Stone. 

 

References: Zahed R et al. A new and rapid method for epistaxis treatment using injectable form of tranexamic acid topically: a randomized controlled trial. Am J Emerg Med. 2013 Sep;31(9):1389-92. PMID: 23911102.; picture

Anterior Epistaxis: When compression isn’t enough

25 Aug

Usually patients come back from triage with some form of compression, be it fingers, tongue-blades, clothespin… Compression should be held for at least 20-30 minutes

 

If still actively bleeding, first thing is to clean out the nose. Have them blow out all clots (ONCE.  Not every 5 minutes)

Take a look to make sure an anterior bleed, and where exactly that bleed is.

If compression not working, here are some options:

 

Afrin:  Afrin or phenylephrine is a vasoconstrictor which usually does the trick

 

LET or 4% Lidocaine:  the UVA ER is stocked with Epistaxis kits which have nasal cannula, cotton balls, small plastic cup. 

Put 5-10cc 4% Lidocaine into cup, Dab cotton or gauze in the lidocaine, squeeze excess and apply to bleeding site.

Alternatively, using LET (lidocaine 4%, epinephrine 0.1%, and tetracaine 0.4%)

 

Silver nitrate:  If site dry, can apply Chemical cautery with silver nitrate. Roll on site.epi1

 

Surgicel:  Surgicel is fast-acting absorbable hemostat material. Cut to fit and place over site. Absorbs in
7-10 days.

 

Nasal packing or Rapid Rhino: Rapid Rhino is an inflatable balloon coated with a compound that eip2acts as a platelet aggregator and also forms a lubricant upon contact with water. Different sizes available.

 

Extra Pearls:

  • Once bleeding stopped, make sure the patient walks, bends down, squats to make sure no re-bleeding.
  • ENT follow-up if persistent problem.
  • Admit if cannot get it under control.

 

 

Submitted by Joran Sequeira, MD.

 

References: Gilman, Charles. “Focus on: Treatment of Epistaxis”. June 2009. ACEP News.