Page 953 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

684 PART 5: Infectious Disorders

A B

FIGURE 73-10. Lateral radiograph of the neck. A. Normal lateral cervical view. B. Expansion of the retropharyngeal soft tissues due to lateral pharyngeal space infection. (Reproduced with
permission from Gorbach SL, Bartlett JG, Blacklow NR. Infectious Diseases. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2003.)

for surgical incision and more formal exploration. Delays increase the vaccination in children against this organism has greatly reduced its
risk of spontaneous rupture. Aspiration of purulent material is the main prevalence, so that other bacteria, such as Streptococcus pneumoniae,
hazard, particularly in the recumbent patient. More serious complica- S aureus, Haemophilus parainfluenzae, and oral anaerobes, are
tions include (a) airway obstruction, especially with bilateral disease or increasingly implicated. Also because of vaccination in children, the
when laryngeal edema develops and (b) lateral dissection (usually from majority of cases now occur in adults. 18
infections of the middle or lower portions of the tonsil) through the In older children and adults, the chief initial complaint is a sore throat
superior pharyngeal constrictor muscle to involve the lateral pharyngeal and later odynophagia. Typically, the triad of fever, stridor, and drooling
space (Fig. 73-5B). Continued signs of sepsis after drainage of the peri- is present. The patient tends to sit up and remain quiet, often leaning
tonsillar space usually indicate coexisting, undrained lateral pharyngeal forward to facilitate breathing. The voice is muffled rather than hoarse.
space infection. Fatalities associated with peritonsillar abscess (over 50% Inspiration tends to draw down the epiglottis and further obstruct the
in the pre-antibiotic era) were due largely to this complication. airway, so respirations are deliberately slow rather than rapid. Cyanosis,
Ideally, antibiotics should be tailored according to the results of pallor, and bradycardia are late signs of severe airway obstruction that
cultures of aspirated pus, but these are infrequently performed. Also, signal the urgent need to establish an artificial airway.
cultures are unlikely to be helpful unless specimens are collected with- Once the diagnosis is suspected, rapid confirmation by imaging
out oropharyngeal contamination and are transported anaerobically in studies is recommended, bearing in mind that the patient’s condition
appropriate media. Group A β-hemolytic streptococci (often as part can change rapidly and unexpectedly due to impending airway obstruc-
of a mixed flora containing anaerobes) are most commonly isolated. tion. Radiographic views of the lateral neck usually show an enlarged
Occasionally other β-hemolytic streptococci, Haemophilus influenzae, epiglottis with edematous supraglottic structures and ballooning of the
S aureus, or anaerobes alone are cultured. Penicillin G plus metroni- hypopharynx (Fig. 73-11). A concurrent pneumonia is demonstrated
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dazole or a β-lactam-β-lactamase inhibitor combination is effective in on chest x-ray in about 25% of cases. If the patient (particularly an
most cases. Bilateral tonsillectomy should be performed once the patient adult) appears not to be in great distress, antimicrobial therapy and
has recovered to avoid recurrences. Interim antibiotic prophylaxis close observation in an ICU without endotracheal intubation is fre-
should be considered in high-risk cases. quently all that is required. However, approximately 20% of adults
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and 70% of children may require placement of an artificial airway due
■ ACUTE EPIGLOTTITIS AND LARYNGOTRACHEOBRONCHITIS to worsening stridor with respiratory distress or inability to easily clear
secretions. If intubation is indicated, it should be performed by direct
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Acute Epiglotitis: Acute epiglottitis is a nonsuppurative infection visualization and in the operating room, preferably by a skilled anesthe-
causing inflammatory edema in the supraglottic structures and the tist. Equipment including a laryngoscope and personnel necessary for
epiglottis. Once caused mainly by H influenzae, widespread use of emergency tracheostomy should be immediately available. Attempts to

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