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HeadNeckPA

ENT Picture of the Day 3-23-11

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23 yr-old male with 2 day history of severe throat pain, predominantly on the right side. Also complains of right sided ear pain and moderate - severe odynophagia. He has a low grade fever and a history a similar episode 3 years ago.

 

No meds, NKDA. OTC ibuprofen PTA.

 

Is there anything else you would want to know about his history?

 

What would you do to work this patient up, if anything?

 

Diagnosis?

How would you treat?

 

PTA.jpg

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I'm completely unqualified to say having only a BS from a state school and no technical training, but it sounds like a peritonsillar abscess. Admit to hospital for surgery (I&D) / IV antibiotics.

 

Am I right? [if so, no one will be able to live with me for about a week due to self worship.]

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pta's usually do not require admission. ent either does them in the e.d. or some of the more cowboy er providers aspirate them.

haven't done so myself but would if ent unavailable. there is a way to make a guard for an 18 g needle using the needle cap so you don't go too deep. seen it done successfully a few times.

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EMED is correct, most do not need admission and IV antibiotics.....also of importance is that most PTAs DO NOT need a CT scan. Unless the patient has obvious airway impingement, respiratory distress or they are unable to handle secretions. Some patients also look extremely septic....these are the patients I work up further with CBC and occasional CT.

 

An obvious PTA can be drained with a large bore needle (great trick to cut the cap off so that only 5mm of needle extrude).....extreme care must be taken to go anterior to post to prevent entering the carotid, as it isnt very far away! When there is a large fluctuant asbcess it is also reasonable to incise with a small scalpel......ths isn't something you would ever want to do on yr own without experience and it is very dependent on the degree of trismus the patient has. The degree with which the patient can open his or her mouth is critical to being able to I&D.

 

Quinsy tonsillectomy is rarely performed but does have it's place in certain settings.

 

For those they do not look as though the need an I&D, we will frequently treat with broad spectrum antibiotics (Augmentin or Clinda as anaerobes are a common culprit).....and prob as important is dexamethasone, either IM or IV......it's amazing what 10mg of Decadron an do for these patient's in the course of 12-24 hours.

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agree with steroids - we admitted a pta to our obs unit for steroids and iv abx and when ent finally showed up 12 hrs later the pta was resolved so the tonsils both looked the same(nl).

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there is a way to make a guard for an 18 g needle using the needle cap so you don't go too deep. seen it done successfully a few times.

 

You can also use this trick for doing an inferior alveolar dental block;works quite nicely to prevent you from going too deep.

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For an inferior alveolar block I was taught to go at an angle from the opposite canine tooth (bottom) and insert near the ramus until you hit bone.....withdrawal slightly and aspirate to ensure you aren't in the inf alv artery and infiltrate........I have had great success with these blocks.....they're a great tool for drug seekers with "dental pain".....a little marcaine and a number for the dental clinic.

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