tonsillar parapharyngeal space abscess 04.27.2012

7/31/2019 Tonsillar Parapharyngeal Space Abscess 04.27.2012

1/15

Sara Jager, PGY2


2/15

HPI: 3 month old female with 3 days of fever, fussiness, inconsolableepisodes that are worse when lying flat. Tmax 100.6 with decreased PO;no vomiting. Mom feels like it might be painful for her to eat but it couldalso be positional as she is breastfed. 2 weeks ago had frequent looserunny stools with slight cough and runny nose and diagnosed with a viralsyndrome. 1 day PTA was seen at instacare and had UA that wasnormal.

PMH: Term NSVD following uncomplicated pregnancy. GBS negative.Hyperbili requiring phototherapy x 1 day.

FHx: liver cancer

Soc Hx: lives with 2 older siblings and her parents. Denies travel and sickcontacts.


3/15

VS: T 37.7, HR 147, RR 27, BP 109/53, 97% RAGen: Tired appearing but curious and interactiveHEENT: AFOSF, EOMI, PERRL, TM pearly gray B,

oropharynx normal, MMM

Cor: RRR, no murmurResp: No increased WOB, breath sounds symmetric.Abd: Soft, NT, ND, NABSGU: normal femaleExt: nontender, no erythema or edema, not tender to

palpationNeuro: Full ROM of all major joints, normal reflexes,CN intact


4/15

CBC: WBC 24.5, 52% N, 0 B, 39% L; Hgb 9.7, Platelets 633CSF: 4 WBC, 3 N, 46 L, 51 M, RBC 27, Protein 12, Glucose

63; gram stain negativeUA: SG 1.02, neg nitrite, LCE neg

ESR 53 CRP 4.4CMP normalKUB: moderate large and small bowel air; aerophagia, no

obstruction, no mass

CXR: normal


5/15

Treated with Rocephin withsignificant improvement insymptoms and feeding.

Lateral neck X-ray normal.ENT consult no findings.Bone scan normal. WBC andCRP improved after 4 days ofantibiotics. Discharged to

home without antibiotics andable to PO requirements.


6/15

10 days after admission she isreadmitted to PCMC ED for 2

days of fever to 102, refusal toPO, dehydration. Had bloodypus on her left lateral pharynx.WBC was 31 with a CRP of 13upon readmission. CT scanobtained in ED.


7/15

2x2x2cm left tonsillar and parapharyngeal space abscess


8/15


9/15


10/15

Neck Mass 91% Lymphadenopathy 83%Agitation 14-50% Trismus 14-53%Swelling of face and neck, erythema, purulent oral

discharge

Dysphagia and odynophagia


11/15


12/15

Cx Results: 3+ Mixed Respiratory flora

and 2+ S. Aureus

Polymicrobial Strep Viridans

Peptostreptococcus Fusobacterium Prevotella Actinomyces Staph Aureus Psudomonsa Enterobacter (including ESBL types) Strep pyogenes


13/15

CT scanENT for incision and drainageAntibiotics

Strep Erythromycin 86-100%

Staphdont use PCN Clindamycin 93-100%

Erythromycin 85-93% Oxacillin 91-100%

Intermediate for TMP-SMX


14/15

Unasyn = ampicillin and sulbactam

Beta-lactamase inhibitor with ampicillin.

Interferes with bacterial cell wall synthesisduring active replication, causing bactericidalactivity against susceptible organisms.Alternative to amoxicillin when unable to take

medication orally.

Covers skin, enteric flora, and anaerobes.Not ideal for nosocomial pathogens.


15/15

Happy Friday!

tonsillar parapharyngeal space abscess 04.27.2012

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