RESUMO
Resumen La mononucleosis infecciosa (MI) es un cuadro clínico generalmente benigno y autolimitado en la infancia y adolescencia debido a la primoinfección del virus de Epstein-Barr caracterizado por la triada de faringitis, fiebre y adenopatías. El riesgo de complicaciones aumenta con la edad y la inmunosupresión, siendo las complicaciones letales más frecuentes las asociadas a rotura esplénica, alteraciones neurológicas y obstrucción de la vía aérea por el aumento del tamaño amigdalar. Los abscesos cervicales asociados a MI son poco frecuentes, siendo mayoritariamente periamigdalinos e intraamigdalares. Presentamos dos casos quirúrgicos de abscesos cervicales profundos de gran tamaño con afectación retrofaríngea y parafaríngea en adolescentes sanos de corta edad (14 y 15 años), sin ningún tipo de inmunosupresión o factores de riesgo, uno de ellos asociado además, a una relevante hemorragia amigdalar espontanea, condición no descrita previamente en la literatura en relación a MI en un paciente tan joven.
Abstract Infectious mononucleosis (MI) is a generally benign and self-limited condition in childhood and adolescence due to the primary EBV infection characterized by the triad of pharyngitis, fever, and lymphadenopathies. The risk of complications increases with age and immunosuppression. The most frequent fatal complications are those associated with splenic rupture, neurological alterations, and airway obstruction due to increased tonsillar size. Cervical abscesses associated with MI are rare, being mostly peritonsillar and intra-tonsil. We present two surgical cases of big deep cervical abscesses with retropharyngeal and parapharyngeal involvement in healthy very young adolescents (14 and 15 years old), without any type of immunosuppression or risk factors, one of them associated with a clinically relevant spontaneous tonsillar bleeding, which had not been described in the literature associated with MI in such young patient.
Assuntos
Humanos , Feminino , Adolescente , Abscesso Peritonsilar/complicações , Abscesso Peritonsilar/terapia , Mononucleose Infecciosa/complicações , Mononucleose Infecciosa/terapia , Faringite/etiologia , Tomografia Computadorizada por Raios X , Abscesso Peritonsilar/diagnóstico por imagem , Febre/etiologia , Hemorragia/etiologia , Mononucleose Infecciosa/diagnóstico por imagemRESUMO
Peritonsillar abscess is the most common complication of acute bacterial tonsillitis, defined as the presence of purulent exudate between the peritonsillar capsule and the superior constrictor muscle of the pharynx. Usually, its presentation is unilateral; its bilateral involvement is rare. It is more common in adults, being uncommon in children. Clinically, it presents odynophagia, trismus, sialorrhea, fever, guttural voice, symptoms that it shares with the unilateral abscess, evidencing in the physical examination bulging of both anterior pillars, edema of the uvula and soft palate, but without asymmetries of pharyngeal structures. A high level of clinical suspicion is required to achieve early diagnosis. The management of the airway, which could be difficult, is an important aspect in the treatment. It is reported the clinical case of a child with bilateral peritonsillar abscess, the diagnostic and therapeutic process.
El absceso periamigdalino es la complicación más frecuente de la amigdalitis aguda bacteriana, definido como la presencia de pus entre la cápsula periamigdalina y el músculo constrictor superior de la faringe. Habitualmente, su presentación es unilateral; es rara su afectación bilateral. Es más frecuente en adultos y poco común en niños. Cuando es bilateral, el paciente presenta odinofagia, trismus, sialorrea, fiebre y voz gutural, síntomas que comparte con el absceso unilateral, pero, en el examen físico, se evidencia abombamiento de ambos pilares anteriores, edema de úvula y paladar blando, sin asimetrías de las estructuras faríngeas. Se requiere un alto nivel de sospecha clínica para lograr el diagnóstico temprano. El manejo de la vía aérea, que podría ser dificultoso, es un aspecto importante en el tratamiento. Se presenta el caso clínico de un niño con absceso periamigdalino bilateral; se describe el proceso diagnóstico y terapéutico.
Assuntos
Abscesso Peritonsilar/diagnóstico , Tonsilite/complicações , Adolescente , Humanos , Masculino , Abscesso Peritonsilar/terapiaRESUMO
Abstract Introduction: Peritonsillar abscess is the most common deep neck infection. The infectious microorganism may be different according to clinical factors. Objective: To identify the major causative pathogen of peritonsillar abscess and investigate the relationship between the causative pathogen, host clinical factors, and hospitalization duration. Methods: This retrospective study included 415 hospitalized patients diagnosed with peritonsillar abscess who were admitted to a tertiary medical center from June 1990 to June 2013. We collected data by chart review and analyzed variables such as demographic characteristics, underlying systemic disease, smoking, alcoholism, betel nut chewing, bacteriology, and hospitalization duration. Results: A total of 168 patients had positive results for pathogen isolation. Streptococcus viridans (28.57%) and Klebsiella pneumoniae (23.21%) were the most common microorganisms identified through pus culturing. The isolation rate of anaerobes increased to 49.35% in the recent 6 years (p = 0.048). Common anaerobes were Prevotella and Fusobacterium spp. The identification of K. pneumoniae increased among elderly patients (age > 65 years) with an odds ratio (OR) of 2.76 (p = 0.03), and decreased in the hot season (mean temperature > 26 °C) (OR = 0.49, p = 0.04). No specific microorganism was associated with prolonged hospital stay. Conclusion: The most common pathogen identified through pus culturing was S. viridans, followed by K. pneumoniae. The identification of anaerobes was shown to increase in recent years. The antibiotics initially selected should be effective against both aerobes and anaerobes. Bacterial identification may be associated with host clinical factors and environmental factors.
Resumo Introdução: O Abscesso Peritonsilar é a infecção cervical profunda mais comum. O microrganismo infeccioso pode ser diferente de acordo com os fatores clínicos. Objetivo: Identificar o principal agente causador do abscesso peritonsilar e investigar a relação entre o patógeno causador, os fatores clínicos do hospedeiro e a duração da hospitalização. Método: Este estudo retrospectivo incluiu 415 pacientes hospitalizados diagnosticados com abscesso peritonsilar que foram internados em um centro médico terciário de junho de 1990 a junho de 2013. Coletamos dados através da análise dos arquivos médicos dos pacientes e analisamos variáveis como características demográficas, doença sistêmica subjacente, tabagismo, alcoolismo, hábito de mascar noz de betel, bacteriologia e duração da hospitalização. Resultados: Um total de 168 pacientes apresentaram resultados positivos para isolamento de patógenos. Streptococcus viridans (28,57%) e Klebsiella pneumoniae (23,21%) foram os microrganismos mais comuns identificados pela cultura da secreção. A taxa de isolamento de anaeróbios aumentou para 49,35% nos últimos 6 anos (p = 0,048). Os anaeróbios comuns foram Prevotella e Fusobacterium spp. A identificação de K. pneumoniae aumentou em pacientes idosos (idade > 65 anos) com razão de chances (Odds Ratio - OR) de 2,76 (p = 0,03) e diminuiu na estação do calor (temperatura média > 26 °C) (OR = 0,49, p = 0,04). Nenhum microrganismo específico foi associado à hospitalização prolongada. Conclusão: O patógeno mais comumente identificado através da cultura de secreção foi S. viridans, seguido por K. pneumoniae. A identificação de anaeróbios mostrou ter aumentado nos últimos anos. Os antibióticos selecionados inicialmente devem ser efetivos contra aeróbios e anaeróbios. A identificação bacteriana pode estar associada a fatores clínicos e fatores ambientais do hospedeiro.
Assuntos
Humanos , Adolescente , Adulto , Pessoa de Meia-Idade , Adulto Jovem , Abscesso Peritonsilar/microbiologia , Infecções por Bactérias Gram-Positivas/microbiologia , Fusobacterium necrophorum/isolamento & purificação , Bactérias Gram-Positivas/isolamento & purificação , Infecções por Klebsiella , Abscesso Peritonsilar/diagnóstico , Abscesso Peritonsilar/terapia , Estudos Retrospectivos , Fatores de Risco , Infecções por Bactérias Gram-Positivas/terapia , Prevotella , Estreptococos Viridans/isolamento & purificação , Infecções por Fusobacterium/microbiologia , Klebsiella pneumoniae/isolamento & purificação , Antibacterianos/uso terapêuticoRESUMO
INTRODUCTION: Peritonsillar abscess is the most common deep neck infection. The infectious microorganism may be different according to clinical factors. OBJECTIVE: To identify the major causative pathogen of peritonsillar abscess and investigate the relationship between the causative pathogen, host clinical factors, and hospitalization duration. METHODS: This retrospective study included 415 hospitalized patients diagnosed with peritonsillar abscess who were admitted to a tertiary medical center from June 1990 to June 2013. We collected data by chart review and analyzed variables such as demographic characteristics, underlying systemic disease, smoking, alcoholism, betel nut chewing, bacteriology, and hospitalization duration. RESULTS: A total of 168 patients had positive results for pathogen isolation. Streptococcus viridans (28.57%) and Klebsiella pneumoniae (23.21%) were the most common microorganisms identified through pus culturing. The isolation rate of anaerobes increased to 49.35% in the recent 6 years (p=0.048). Common anaerobes were Prevotella and Fusobacterium spp. The identification of K. pneumoniae increased among elderly patients (age>65 years) with an odds ratio (OR) of 2.76 (p=0.03), and decreased in the hot season (mean temperature>26°C) (OR=0.49, p=0.04). No specific microorganism was associated with prolonged hospital stay. CONCLUSION: The most common pathogen identified through pus culturing was S. viridans, followed by K. pneumoniae. The identification of anaerobes was shown to increase in recent years. The antibiotics initially selected should be effective against both aerobes and anaerobes. Bacterial identification may be associated with host clinical factors and environmental factors.
Assuntos
Bactérias Gram-Positivas/isolamento & purificação , Infecções por Bactérias Gram-Positivas/microbiologia , Abscesso Peritonsilar/microbiologia , Adolescente , Adulto , Antibacterianos/uso terapêutico , Infecções por Fusobacterium/microbiologia , Fusobacterium necrophorum/isolamento & purificação , Infecções por Bactérias Gram-Positivas/terapia , Humanos , Infecções por Klebsiella , Klebsiella pneumoniae/isolamento & purificação , Pessoa de Meia-Idade , Abscesso Peritonsilar/diagnóstico , Abscesso Peritonsilar/terapia , Prevotella , Estudos Retrospectivos , Fatores de Risco , Estreptococos Viridans/isolamento & purificação , Adulto JovemRESUMO
OBJECTIVES: Traditionally, emergency physicians (EPs) have used anatomic landmark-based needle aspiration to drain peritonsillar abscesses (PTAs). If this failed, an imaging study and/or consultation with another service to perform the drainage is obtained. Recently, some EPs have used ultrasound (US) to guide PTA drainage. This study seeks to determine which initial approach leads to greater successful drainage. The primary objective of this study was to compare the diagnostic accuracy of EPs for detecting PTA or peritonsillar cellulitis (PTC) using either intraoral US or initial needle aspiration after visual inspection (the landmark technique [LM]). Secondary objectives included the successful aspiration of purulent material in those patients with a PTA in each arm, the use of computed tomography (CT) scanning in each arm, and the otolaryngology (ENT) consultation rate in each arm. METHODS: This was a prospective, randomized, controlled clinical trial of a convenience sample of adult patients who presented to a single, large, urban university hospital. Patients were enrolled if they presented with a constellation of signs and symptoms that were judged to be a PTA. These patients were randomized to receive intraoral US or to undergo LM drainage. The US was performed using an 8-5 MHz intracavitary transducer immediately prior to the procedure. The probe was then withdrawn and the provider who did the US also performed the needle aspiration. The LM was performed using visual landmarks in a superior to inferior approach until pus was obtained or at least two sticks were performed. Anesthesia was standardized. Patients returned for follow-up in 2 days where a final diagnosis was rendered. RESULTS: There were 28 patients enrolled, with 14 in each arm. US established the correct diagnosis more often than LM [(100%, 95% confidence interval [CI] = 75% to 100% vs. 64%, 95% CI = 39% to 84%; p = 0.04)]. US also led to more successful aspiration of purulent material by the EP than LM in patients with PTA [(100%, 95% CI =63% to 100% vs. 50%, 95% CI = 24% to 76%; p = 0.04)]. The ENT consult rate was 7% (95% CI = 0% to 34%) for US versus 50% (95% CI = 27% to 73%) for LM (p = 0.03). The CT usage rate was 0% for US versus 35% for LM (p = 0.04). CONCLUSIONS: An initial intraoral US performed by EPs can reliably diagnose PTC and PTA. Additionally, using intraoral US to assist in the drainage of PTAs with needle aspiration leads to greater success compared to the traditional method of LM relying on physical exam alone.
Assuntos
Biópsia por Agulha , Drenagem/métodos , Boca/diagnóstico por imagem , Abscesso Peritonsilar/diagnóstico por imagem , Abscesso Peritonsilar/patologia , Adulto , Pontos de Referência Anatômicos , Celulite (Flegmão)/diagnóstico por imagem , Celulite (Flegmão)/patologia , Medicina de Emergência/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Boca/patologia , Abscesso Peritonsilar/terapia , Estudos Prospectivos , Tomógrafos Computadorizados , Ultrassonografia , Adulto JovemRESUMO
El flegmón (celulitis) y el absceso periamigdalino son infecciones difusas o una colección ubicada entre la cápsula fibrosa de la amígdala palatina, las fibras horizontales del músculo constrictor superior de la faringe y las verticales del músculo palatofaríngeo. Constituye la infección de tejidos y espacios profundos del cuello más frecuente. Material y método: Revisión retrospectiva de las fichas de pacientes adultos y niños hospitalizados con diagnóstico de absceso o flegmón periamigdalino en el Servicio de Otorrinolaringología del Hospital San Juan de Dios entre los años 1995 y 2001. Resultados y discusión: Se analizaron 124 pacientes. Se observó un acierto del diagnóstico clínico en 85,5 por ciento de los casos. El 100 por ciento de los pacientes presentó evolución clínica favorable según la modalidad terapéutica indicada. La mayoría de los pacientes con absceso periamigdalino fue tratado con drenaje y antimicrobiano, y los con flegmón periamigdalino con antimicrobiano. El antibiótico utilizado con mayor frecuencia fue penicilina. No existió diferencia significativa al usarlo en esquema asociado. La penicilina sódica sigue siendo un antimicrobiano de primera elección para este cuadro y no requeriría de asociaciones; dosis de 3 millones de Ul cada 6 horas endovenosa pueden ser recomendadas. El tratamiento en el Servicio de Otorrinolaringología del Hospital San Juan de Dios se ciñe a las reglas internacionales.
Assuntos
Humanos , Masculino , Feminino , Criança , Adolescente , Abscesso Peritonsilar/diagnóstico , Abscesso Peritonsilar/terapia , Celulite/diagnóstico , Celulite/terapia , Antibacterianos/uso terapêutico , Drenagem , Estudos Retrospectivos , Penicilinas/uso terapêutico , Recidiva , Tempo de Internação , Trismo/patologiaRESUMO
El absceso parafaríngeo es la segunda localización más frecuente de los abscesos profundos del cuello. Presentamos el caso de un varón de 37 años a quien se le diagnosticó un absceso parafaríngeo izquierdo, sin puerta aparente de entrada del foco séptico. Se logró el control y la curación del enfermo con tratamiento antibiótico, no requiriendo cirugía. Se revisa el tema en lo referente a la etiología, cuadro clínico, fisiopatología, diagnóstico, tratamiento y complicaciones.
Assuntos
Humanos , Masculino , Adulto , Abscesso Peritonsilar/diagnóstico , Abscesso Peritonsilar/etiologia , Abscesso Peritonsilar/terapia , Abscesso Retrofaríngeo/diagnóstico , Abscesso Retrofaríngeo/etiologia , Abscesso Retrofaríngeo/terapia , Pescoço/microbiologia , Antibacterianos/uso terapêutico , Bactérias/patogenicidade , Diagnóstico Diferencial , Diagnóstico por Imagem/tendênciasRESUMO
OBJECTIVE: Descending necrotizing mediastinitis (DNM) is a primary complication of cervical or odontogenical infections that can spread to the mediastinum through the anatomic cervical spaces. We reviewed the last 10 years of our surgical experience in DNM and commented on early diagnosis and aggressive surgical treatment in these patients. METHODS: Five males (71%) and two females (29%), mean age 34 years, with DNM, were surgically treated. Primary oropharyngeal infection occurred in three (43%) and odontogenic abscess in four (57%) patients. All had serious cervical and mediastinal infections with severe respiratory and hemodynamic repercussions, i.e. bacteremia, systemic arterial hypotension and obnubilation. Diagnosis was confirmed by computerized chest tomography. RESULTS: All patients underwent surgical drainage of the cervical region by bilateral transverse cervicotomy with debridement of the necrotic and infected tissues, associating ample mediastinal drainage with or without thoracotomy. Six patients (86%) evolved well and were discharged after a mean of 35 days. Two patients (29%) required reoperation due to local surgical complications: empyema and dehiscence of the sternum. One patient (14%) died on the second postoperative (p.o.) day due to renal and respiratory insufficiency. Cultures of DNM showed the development of associated aerobic and anaerobic flora in 71% of the operated patients and only aerobic in 29%. CONCLUSION: Early diagnosis by CAT scan of the neck and thorax aids in rapid indication of a surgical approach of DNM. Performing ample cervicotomy with mediastinal drainage generally associated with thoracotomy can significantly reduce the mortality rate for this condition to 14%.
Assuntos
Mediastinite/cirurgia , Sucção/métodos , Toracotomia , Adolescente , Adulto , Idoso , Antibacterianos , Bactérias/isolamento & purificação , Infecções Bacterianas/tratamento farmacológico , Infecções Bacterianas/microbiologia , Infecções Bacterianas/mortalidade , Infecções Bacterianas/cirurgia , Criança , Quimioterapia Combinada/uso terapêutico , Feminino , Humanos , Masculino , Mediastinite/diagnóstico por imagem , Mediastinite/microbiologia , Mediastinite/mortalidade , Pessoa de Meia-Idade , Necrose , Abscesso Periodontal/complicações , Abscesso Periodontal/microbiologia , Abscesso Periodontal/terapia , Abscesso Peritonsilar/complicações , Abscesso Peritonsilar/microbiologia , Abscesso Peritonsilar/terapia , Radiografia Torácica , Estudos Retrospectivos , Taxa de Sobrevida , Tomografia Computadorizada por Raios X , Resultado do TratamentoAssuntos
Relatos de Casos , Humanos , Feminino , Adolescente , Adulto , Pessoa de Meia-Idade , Faringite/terapia , Laringite/terapia , Ciclo Menstrual , Faringite/etiologia , Laringite/etiologia , Magnesia Carbonica/uso terapêutico , Lac Caninum/uso terapêutico , Saponinum/uso terapêutico , Gelsemium sempervirens/uso terapêutico , Graphites Naturalis/uso terapêutico , Heliotropinum peruvianum/uso terapêutico , Lachesis muta/uso terapêutico , Abscesso Peritonsilar/terapiaRESUMO
Se trataron 124 pacientes portadores de patología inflamatoria aguda, incluyendo 31 casos quirúrgicos, con glucametacina 120 mg tres veces al día. Esta atención se realizó en el servicio de Hospitalización (10-A) y consulta externa del Hospital Edgardo Rebagliati Martins. Los períodos de tratamiento fluctuaron entre 7 y 10 días. Se obtuvo remisión en un 100% de los casos, evidenciándose una excelente tolerancia gástrica