September 2006 A "Killer" Sore Throat: Volume 3, Number 9 Inflammatory Disorders Of The Author Charles Stewart, MD, FAAEM, FACEP Pediatric Airway Emergency Physician, Colorado Springs, CO. Peer Reviewers “It’s only a kid with a sore throat.” The triage nurse said at 0100. Sharon Mace, MD Associate Professor, Emergency Department, Ohio You had a full ED and she assured you that the 13-year-old with a recent State University School of Medicine, Director of Pediatric Education And Quality Improvement and extraction of her wisdom teeth was fine. You put the sore throat to the Director of Observation Unit, Cleveland Clinic, Faculty, back of the rack and took care of “more serious“cases. When you saw the MetroHealth Medical Center, Emergency Medicine Residency. patient four hours later, her respiratory rate was 36, her pulse was 160, Paula J Whiteman, MD and she had retractions at rest. You noted a substantial swelling of her Medical Director, Pediatric Emergency Medicine, anterior neck. You started her on high-flow oxygen, stat paged the ENT Encino-Tarzana Regional Medical Center; Attending Physician, Cedars-Sinai Medical Center, doctor, set up for a possible cricothyrotomy or tracheostomy, ordered blood Los Angeles, CA cultures, chest x-ray, and neck x-ray, and told the nursing supervisor to CME Objectives get an OR crew in soon. Upon completing this article you should be able to: 1. Describe the anatomy of the throat. 2. Discuss the potential causes of sore throats in ore throats represent one of the top ten presenting complaints pediatric patients. 3. Discuss the treatment options available for bacterial 1 Sto the ED in the US. Many emergency physicians are jaded by tracheitis, croup, diptheria, epiglottitis, peritonsillar the healthy appearance of the vast majority of patients with a triage abscess, Retropharyngeal abscess, and Ludwig’s angina. note indicating a “sore throat.” Since triage is an inexact science, 4. Evaluate, diagnosis, and treat the pediatric patient these diseases don’t come to you as carefully labeled packages… presenting with a sore throat. but simply as sore-throats or possibly pharyngitis, URI, or Flu. Date of original release: September 1, 2006. A sore throat may be the hallmark of some of the most life- Date of most recent review: August 2, 2006. See “Physician CME Information” on back page. threatening diseases that we see as emergency physicians. Within this garbage can of disease labeled “sore throat,” are life-threaten- ing infections such as epiglottitis, tracheitis, croup, diphtheria and several of the deep neck abscesses. These diseases aren’t common… Editorial Board Michael J. Gerardi, MD, FAAP, FACEP, Assistant Director Emergency Island Region. Robert Luten, MD, Professor, Clinical Assistant Professor, Services, Lebonheur Children’s Pediatrics and Emergency Jeffrey R. Avner, MD, FAAP, Professor Andy Jagoda, MD, FACEP, Vice-Chair Medicine, University of Medicine Medical Center, Memphis TN. Medicine, University of Florida, of Clinical Pediatrics, Albert of Academic Affairs, Department of and Dentistry of New Jersey; Jacksonville, Jacksonville, FL. Einstein College of Medicine; Mark A. Hostetler, MD, MPH, Emergency Medicine; Residency Director, Pediatric Emergency Director, Pediatric Emergency Assistant Professor, Department of Program Director; Director, Ghazala Q. Sharieff, MD, FAAP, Medicine, Children’s Medical Service, Children’s Hospital at Pediatrics; Chief, Section of International Studies Program, FACEP, FAAEM, Associate Center, Atlantic Health System; Montefiore, Bronx, NY. Emergency Medicine; Medical Mount Sinai School of Medicine, Clinical Professor, Children’s Department of Emergency Director, Pediatric Emergency New York, NY. Hospital and Health Center/ Lance Brown, MD, MPH, FACEP,Chief, Medicine, Morristown Department, The University of University of California, San Division of Pediatric Emergency Memorial Hospital. Tommy Y Kim, MD, FAAP, Attending Chicago, Pritzker School of Diego; Director of Pediatric Medicine; Associate Professor of Physician, Pediatric Emergency Ran D. Goldman, MD, Associate Medicine, Chicago, IL. Emergency Medicine, California Emergency Medicine and Department; Assistant Professor of Professor, Department of Emergency Physicians. Pediatrics; Loma Linda University Alson S. Inaba, MD, FAAP, PALS-NF, Emergency Medicine and Pediatrics, Pediatrics, University of Toronto; Medical Center and Children’s Pediatric Emergency Medicine Loma Linda Medical Center and Gary R. Strange, MD, MA, FACEP, Division of Pediatric Emergency Hospital, Loma Linda, CA. Attending Physician, Kapiolani Children’s Hospital, Loma Linda, CA. Professor and Head, Department of Medicine and Clinical Medical Center for Women & Emergency Medicine, University of T. Kent Denmark, MD, FAAP, FACEP, Pharmacology and Toxicology, The Brent R. King, MD, FACEP, FAAP, Children; Associate Professor of Illinois, Chicago, IL. Residency Director, Pediatric Hospital for Sick Children, Toronto. FAAEM, Professor of Emergency Pediatrics, University of Hawaii Emergency Medicine; Assistant Medicine and Pediatrics; Chairman, Martin I. Herman, MD, FAAP, FACEP, John A. Burns School of Medicine, Professor of Emergency Medicine Department of Emergency Professor of Pediatrics, Honolulu, HI; Pediatric Advanced and Pediatrics, Loma Linda Medicine, The University of Texas Division Critical Care and Life Support National Faculty University Medical Center and Houston Medical School, Emergency Services, UT Health Representative, American Heart Children’s Hospital, Loma Linda, CA. Houston, TX. Sciences, School of Medicine; Association, Hawaii & Pacific but then, some of them really aren’t rare either. What sore throats that can obstruct the airway. is terribly frightening is that these patients can dete- The respiratory tract from the larynx to the riorate rapidly and sometimes irretrievably; even bronchus is composed of connective tissue, cartilage, when the initial symptoms of the disease are mild. muscle, and mucosa. This article will talk about airway obstructing infec- The neck contains several potential spaces and tious diseases: sore throats that truly kill. fascial planes. Infection in any of them can spread easily and rapidly. Spreading of infection in the neck Abbreviations Used In This Article occurs by continuity along the path of least resist- ance – the fascial plane and the potential spaces. BET – Best Evidence Topics This spread can include swelling that surrounds the CBC – Complete blood count airway, the great vessels, and the lower cranial CT – Computerized Tomography imaging nerves. ENT – Ear Nose, and Throat Unfortunately, each anatomist describes the GBS – Group B streptococcus species layers of the neck and cervical fascia using different HIB - H. influenza type B terminology that muddles an already complicated MRI – Magnetic Resonance Imaging subject. It seems that every time you learn the RPA – Retropharyngeal abscess nomenclature of the neck, another paper gives RSI – Rapid Sequence Intubation another set of synonyms. In this paper, the terms WBC – White blood cell count accepted by the otolaryngologist will be used since, if an infection is found, definitive therapy will most Critical Appraisal Of The Literature likely be the province of the otolaryngologist. There are two main divisions of the cervical fascia: the Medline, Ovid, Best BETs (Best Evidence Topics), superficial layer and the deep layer. (Please see the Google Scholar, and Google were all searched using table below). the terms epiglottitis, pediatrics, children, Ludwig’s The potential spaces of the neck can be divided angina, deep neck space infections, retropharyngeal into groups that relate to the hyoid bone. There are abscess, peritonsillar abscess, croup, diphtheria, six suprahyoid spaces, one infrahyoid space, and five infectious airway obstruction, and bacterial tra- spaces that span the length of the neck. cheitis. The terms were used in Boolean combination The spaces that span the entire neck allow com- and separately in each database as appropriate. munication into the mediastinum and deep struc- Over 1600 articles have been published in the last ten tures of the back and chest. years on the combination of these subjects. Neck spaces are interconnected with each other As might be expected in this disease process, and also communicate with the mediastinum so there are few large, prospective, randomized, place- infections can spread easily to a variety of areas. bo-controlled studies of these diseases and their Common clinical conditions which can occur in these treatments. There were multiple retrospective stud- ies, analyses of case reports, and many individual Fascial Layers Of The Neck case reports and short series. A few small prospec- tive studies of treatments were found that compared The superficial cervical fascia has no subdivisions one treatment entity with another. These studies are The superficial cervical fascia lies beneath the skin all noted in the body of the text. and is superficial to the platysma muscle of the neck. The deep cervical fascia has three subdivisions: Epidemiology, Etiology, Pathophysiology Anterior layer (superficial) - surrounds the sternoclei- Anatomy domastoid, trapezius muscles and strap muscles. Anatomic differences between the pediatric and the adult airway make children more susceptible to Middle (visceral) - envelopes the trachea, larynx, and hypopharynx. acute airway compromise from infectious diseases. Because of the potentially high morbidity and mor- Deep (prevertebral) fascia - runs