Chapter 031. Pharyngitis, Sinusitis, Otitis, and Other Upper Respiratory Tract Infections (Part 14)

Infection of the submandibular and/or sublingual space typically originates from an infected or recently extracted lower tooth. The result is the severe, lifethreatening infection referred to as Ludwigs angina (see "Oral Infections," above). Infection of the lateral pharyngeal (or parapharyngeal) space is most often a complication of common infections of the oral cavity and upper respiratory tract, including tonsillitis, peritonsillar abscess, pharyngitis, mastoiditis, or periodontal infection. This space, located deep to the lateral wall of the pharynx, contains a number of sensitive structures, including the carotid artery, internal jugular vein, cervical sympathetic chain, and portions of cranial nerves IX...
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Chapter 031. Pharyngitis, Sinusitis, Otitis, and Other Upper Respiratory Tract Infections (Part 14) Chapter 031. Pharyngitis, Sinusitis, Otitis, and Other Upper Respiratory Tract Infections (Part 14) Infection of the submandibular and/or sublingual space typically originatesfrom an infected or recently extracted lower tooth. The result is the severe, life-threatening infection referred to as Ludwigs angina (see Oral Infections, above).Infection of the lateral pharyngeal (or parapharyngeal) space is most often acomplication of common infections of the oral cavity and upper respiratory tract,including tonsillitis, peritonsillar abscess, pharyngitis, mastoiditis, or periodontalinfection. This space, located deep to the lateral wall of the pharynx, contains anumber of sensitive structures, including the carotid artery, internal jugular vein,cervical sympathetic chain, and portions of cranial nerves IX through XII; at itsdistal end, it opens into the posterior mediastinum. Involvement of this space withinfection can therefore be rapidly fatal. Examination may reveal some tonsillardisplacement, trismus, and neck rigidity, but swelling of the lateral pharyngealwall can easily be missed. The diagnosis can be confirmed by CT. Treatmentconsists of airway management, operative drainage of fluid collections, and atleast 10 days of IV therapy with an antibiotic active against streptococci and oralanaerobes (e.g., ampicillin/sulbactam). A particularly severe form of this infectioninvolving the components of the carotid sheath (postanginal septicemia, Lemierresdisease) is described above (see Oral Infections,). Infection of theretropharyngeal space can also be extremely dangerous, as this space runsposterior to the pharynx from the skull base to the superior mediastinum.Infections in this space are more common among children inspection. A soft tissue mass is usually demonstrable by lateral neck radiographyor CT. Because of the risk of airway obstruction, treatment begins with securing ofthe airway, which is followed by a combination of surgical drainage and IVantibiotic administration. Initial empirical therapy should cover streptococci, oralanaerobes, and S. aureus; ampicillin/sulbactam, clindamycin alone, or clindamycinplus ceftriaxone is usually effective. Complications result primarily fromextension to other areas; for example, rupture into the posterior pharynx may leadto aspiration pneumonia and empyema. Extension may also occur to the lateralpharyngeal space and mediastinum, resulting in mediastinitis and pericarditis, orinto nearby major blood vessels. All these events are associated with a highmortality rate. Further Readings American Academy of Pediatrics Subcommittee on Management of AcuteOtitis Media: Diagnosis and management of acute otitis media. Pediatrics113:1451, 2004 American Academy of Pediatrics Subcommittee on Management ofSinusitis and Committee on Quality Improvement: Clinical practice guideline:Management of sinusitis. Pediatrics 108:798, 2001 Cooper RJ et al: Principles of appropriate antibiotic use for acutepharyngitis in adults: Background. Ann Intern Med 134:509, 2001 [PMID:11255530] Dowell SF et al: Otitis media—principles of judicious use of antimicrobialagents. Pediatrics 101:165, 1998 Gonzales R et al: Principles of appropriate antibiotic use for treatment ofnonspecific upper respiratory tract infections in adults: Background. Ann InternMed 134:490, 2001 [PMID: 11255526] Hickner JM et al: Principles of appropriate antibiotic use for acuterhinosinusitis in adults: Background. Ann Intern Med 134:498, 2001 [PMID:11255528] Piccirillo JF: Acute bacterial sinusitis. N Engl J Med 351:902, 2004[PMID: 15329428] Rafei K et al: Airway infectious disease emergencies. Pediatr Clin NorthAm 53:215, 2006 [PMID: 16574523] Schwartz B et al: Pharyngitis—principles of judicious use of antimicrobialagents. Pediatrics 101:171, 1998 Sinus and Allergy Health Partnership: Antimicrobial treatment guidelinesfor acute bacterial rhinosinusitis. Otolaryngol Head Neck Surg 130:1, 2004 Van Zuijlen DA et al: National differences in incidence of acutemastoiditis: Relationship to prescribing patterns of antibiotics for acute otitismedia? Pediatr Infect Dis J 20:140, 2001 Wenzel RP et al: Acute bronchitis. N Engl J Med 355:2125, 2006 [PMID:17108344]