Rosen & Barkin's 5-Minute Emergency Medicine Consult (749 page)

Dependent upon etiology and associated structural involvement (pharyngitis, epiglottitis, laryngitis, etc.)

• Generally rapid in onset (<4–6 hr) depending on etiology
  
• All types:
  
  • Foreign-body sensation
    
  • Sore throat
    
  • Dysphagia
    
  • Odynophagia
    
  • Dyspnea
    
• Infectious:
  
  • Fever (reported)
    
• Noninfectious:
  
  • Trauma or recent procedure
    
  • New medication exposure (ACEi)
    
  • Caustic or thermal ingestion
    
• Prior event of tongue, lip, or mouth swelling
  
• Immunization history in pediatric population
  
• Medical comorbidity leading to immune compromise
  

• Ranging from limited and well appearing to severe and marked distress
  
• General:
  
  • “Toxic” appearance
    
  • Muffled or “hot-potato” voice
    
  • Drooling
    
  • Stridor
    
  • Gagging
    
  • Respiratory distress
    
• HEENT:
  
  • Erythematous or pale uvula
    
  • Uvular edema
    
  • Exudate (present on uvula or oral pharynx)
    
  • Cervical lymphadenopathy
    
  • Pharyngitis
    
• Associated findings:
  
  • Fever
    
  • Hypoxia
    
  • Urticaria
    
  • Wheezing
    

• Evaluation and stabilization of airway as needed
  
• Determine infectious vs. noninfectious etiology
  
• Initiate treatment based on suspected etiology (antibiotics, steroids, antihistamine, etc.)
  
• Consultation with otolaryngologist as warranted
  

• Rapid GAS antigen
  
• Surface mucosa bacterial culture
  
• CBC:
  
  • Leukocytosis suggesting bacterial infection
    
  • Eosinophilia suggesting allergic etiology
    
• Complement testing:
  
  • Elevated C4 level suggesting esterase deficiency
    
  • C1 esterase immunochemical assay
    

• Used to rule out other conditions in the differential diagnosis when clinical suspicion exists or when physical exam is limited
  
• Lateral neck x-ray to visualize and evaluate the epiglottis or for foreign-body aspiration
  
• CT scan soft tissue neck with IV contrast to evaluate for space occupying fluid collection, cellulitis, deep tissue involvement
  

• As warranted and in consultation with otolaryngology when severity of disease warrants:
  
  • Fiberoptic nasopharyngeal endoscopy
    
  • Cricothyrotomy
    
  • Uvular aspiration/decompression
    
  • Uvulectomy
    

• Pharyngitis
  
• Peritonsillar abscess
  
• Retropharyngeal abscess
  
• Epiglottitis
  
• Angioedema
  
• Aspirated foreign body
  

TREATMENT

• Rapid assessment of airway, definitive management as warranted
  
• Supplemental oxygen
  
• Peripheral IV access
  
• Assessment of patient surroundings, potential ingestions/inhalants
  
• Per pre-hospital protocol, IM epinephrine injection, nebulized β-agonist, or racemic epinephrine
  
• Rapid/emergent transport
  

• Initial focus on managing ABCs
  
• Rapid assessment of airway and need for definitive management
  
• Peripheral IV access
  
• Cardiac and oxygen saturation monitoring
  
• Continued pre-hospital therapy or initiate respiratory therapy:
  
  • Supplemental oxygen
    
  • Nebulized β-agonists or racemic epinephrine
    
• Definitive airway:
  
  • Endotracheal intubation:
    
    • Rapid sequence
      
    • Delayed sequence/awake
      
    • Fiberoptic assist and indirect laryngoscopy
      
  • Cricothyrotomy in severe cases
    
• Early consultation with otolaryngology as warranted
  

• Basic ED treatment is focused on rapid reversal of inflammatory conditions (allergic, angioedema)
  
• Oral therapy vs. parenteral dependent upon severity of condition
  

• Severe conditions (airway compromise):
  
  • Epinephrine, 1:1,000: 0.3–0.5 mg (peds: 0.01 mg/kg) SQ or IM q30min × 3 doses
    
  • Diphenhydramine: 25–50 mg (peds: 1–2 mg/kg) IV
    
  • Methylprednisolone: 125 mg (peds: 0.5–1 mg/kg) IV q4h
    
• Suspected infectious etiology:
  
  • Empiric parenteral antibiotic to cover most common etiologies (GAS and Hib)
    
  • Several options based on patient profile/allergy:
    
    • Ceftriaxone: 1–2 g (peds: 50 mg/kg) IV (max. dose 2 g/d)
      
    • Clindamycin: 300 mg (peds: 25–40 mg/kg) IV q8h
      
  • Empiric oral antibiotic options:
    
    • Penicillin V: 500 mg (peds: <27 kg 250 mg, >27 kg 500 mg) PO BID–TID × 10 days
      
    • Amoxicillin: 875 mg (peds: 50 mg/kg/d PO div. q8h) PO q8h × 10 days
      
    • Clindamycin: 300 mg (peds: 25–40 mg/kg) PO QID × 10 days
      
• Suspected hereditary angioedema:
  
  • Anabolic steroid:
    
    • Danazol: 200 mg PO BID–TID
      
  • Purified C1 inhibitor concentrate:
    
    • Berinert: 20 U/kg IV × 1
      
    • Cinryze: 1,000 U IV
      
  • Selective bradykinin B
    ₂
    -receptor antagonist:
    
    • Icatibant: 30 mg SC × 1
      
  • Reversible inhibitor of plasma kallikrein:
    
    • Ecallantide: 30 mg SQ × 1 (as 3–10 mg injections)
      
  • Fresh frozen plasma:
    
    • Generally not for acute attacks
      

FOLLOW-UP

Disposition dependent upon severity of condition and response to therapy

• Severe airway obstruction warranting definitive airway and ventilatory management
  
• Need for surgical intervention
  
• Indication of systemic bacterial infection and need for parenteral antibiotics
  
• Moderate to severe conditions not responsive to treatment:
  
  • Hypoxia or oxygen requirement
    
  • Ongoing respiratory compromise
    
  • Inability to tolerate oral intake
    
  • Intractable pain
    
• Significant comorbid illness
  
• Poor social conditions limiting outpatient care
  

• Rapid reversal of condition
  
• Observation in the ED for 4–6 hr without recurrent symptoms
  
• No respiratory compromise
  
• Able to tolerate oral medications and liquids
  
• Close follow-up available within 24–48 hr
  
• Access to prescription medications
  

History of recurrent angioedema warrants adjustment of medication, possible referral to Otolaryngology

• Severe infectious etiologies warrant close follow-up with primary physician (24–48 hr) to ensure improvement
  
• For suspected angioedema, immediately discontinue use of ACEi and ARB
  

• Uvulitis can be caused by several etiologies ranging from infection to hereditary disorder
  
• Treatment should be directed toward the suspected etiology based on history and exam
  
• Uvulitis in isolation rarely causes respiratory compromise. If severe respiratory distress, look for additional causes (epiglottitis, anaphylaxis, retropharyngeal abscess, etc.)
  
• Emergent definitive airway management should be anticipated with tools, medications, and other resources kept near the patient at all times
  
• Early consultation with otolaryngology when anticipated
  

• Buyantseva LV, Sardana N, Craig TJ. Update on treatment of hereditary angioedema.
  Asian Pac J Allergy Immunol.
  2012;30:89–98.
  
• Cohen M, Chhetri DK, Head C. Isolated uvulitis.
  Ear, Nose & Throat J.
  2007;86:462, 464.
  
• Gilmore T, Mirin M. Traumatic uvulitis from a suction catheter.
  J Emerg Med.
  2012;43:479–480.
  
• Lathadevi HT, Karadi RN, Thobbi RV, et al. Isolated uvulitis: An uncommon but not a rare clinical entity.
  Indian J Otolaryngol Head Neck Surg.
  2005;57:139–140.
  
• Mohseni M, Lopez MD. Images in emergency medicine: Uvular Angioedema.
  Ann Emerg Med.
  2008;51:8, 12.
  

CODES

528.3 Cellulitis and abscess of oral soft tissues

BASICS