Fever and ENT complaints (neck pain or ear pain)

  1. Core 1
    • Microbiology and Infectious Diseases 1, Week 1: Properties of Bacteria, Bacterial Pathogenesis, Gram Positives Part 1 and 2
    • Microbiology and Infectious Diseases 1, Week 2: Respiratory Bacteria, Antibiotics
    • Microbiology and Infectious Diseases 1, Week 5: Influenza Virus, Respiratory Bacteria 
    • Integrative Systems, Pulmonology, Week 3: ENT: anatomy and physiology of the nose
    • Integrative Systems, Pulmonology, Week 4: ENT: sinusitis
  2. Core 2
    • Pediatrics Clerkship didactics on Fever
  3. Core 3 (Electives that may further your knowledge)
    • Peds SubI, PEM, Peds PICU, Peds ID, Peds ENT

A 7-year-old male presents with 2 days of fever and progressively worsening swelling and erythema over the left side of the neck.  

History

  • Obtain details regarding progression and appearance of swelling in neck 
  • Difficulty with movement of neck 
  • Difficulty swallowing, drooling, trismus, change in voice quality 
  • Concern for foreign body 
  • Recent history of trauma or surgery/dental procedures 
  • History of recurrent otitis media or recent otitis media 
  • Sore throat, history of prior pharyngitis 

Physical Exam 

  • General: assess mental status, increased work of breathing, drooling, changes in voice quality, tripoding 
  • Mouth: assess dentition, assess oropharynx to assess tonsillar swelling, palatal swelling, oral lesions 
  • Neck: assess for range of motion of neck, tenderness, swelling, erythema, or lymphadenopathy 
  • Chest: assess for increased work of breathing, auscultate for wheezing, stertor/stridor 

Utilize chief complaint and history/PE to narrow down differential diagnosis for ENT problems:  

Ear Pain 

  • Acute otitis externa 
  • Acute otitis media 
  • Otitis media with effusion 
  • Mastoiditis 

Neck pain or swelling 

  • Retropharyngeal abscess 
  • Viral or bacterial cervical lymphadenitis 
  • Ludwig’s angina 
  • Lemierre’s disease 

Sore throat 

  • Viral pharyngitis 
  • Bacterial pharyngitis 
  • Peritonsillar abscess 
  • Epiglottitis  

Infectious pharyngitis 

  • Viral versus bacterial etiologies
  • Differentiate Streptococcal pharyngitis from viral pharyngitis using the Centor criteria and test as appropriate
  • Treatment: if rapid strep or throat culture positive – treat with 10 days of amoxicillin
  • In those having oral sex, consider gonococcal pharyngitis and testing with a throat swab
  • Viral pharyngitis is managed with supportive care (NSAIDs, fluids) 

Peritonsillar abscess: peritonsillar swelling +/- uvular deviation, palatal fullness, trismus 

  • Most common causative pathogens: Staphylococcus aureus, Streptococcus pyogenes, oral anaerobes 
  • Management includes bedside drainage of abscess with ENT if patient able to tolerate 
  • Treatment includes ampicillin-sulbactam (IV) versus amoxicillin-clavulanate (PO) if patient tolerating oral intake 

Retropharyngeal abscess: limited neck range of motion due to pain, dysphagia, “hot potato voice”, possible airway compromise 

  • Evaluate with lateral neck XR to assess for expansion of retropharyngeal soft tissues 
  • Consider CT of neck if severe disease or if diagnostic uncertainty is present 
  • Treatment 
    • Non-severe disease: ampicillin-sulbactam versus clindamycin if MRSA risk factors present 
    • Severe disease (respiratory compromise, ICU needs): ampicillin-sulbactam and vancomycin 
  • Can consider ENT and ID consultation if not improving as well as need for further imaging such as CT of the neck to assess for drainable collection that may need surgical intervention 

Cervical Lymphadenitis 

  • Viral cervical lymphadenitis 
    • Typically, bilateral and associated with mild upper respiratory symptoms 
    • Does not require any further workup or management (aside from supportive care) unless enlarging or not resolving 
  • Bacterial cervical lymphadenitis 
    • Acute unilateral cervical lymphadenitis typically associated with fever, warmth/erythema, and tenderness 
    • Perform ultrasound of soft tissue of neck to assess for abscess/drainable collection that may require surgical intervention 
    • Most common pathogens involve include Staphylococcus aureus, Streptococcus pyogenes, and oral anaerobes 
    • Consider empiric therapy with ampicillin-sulbactam (IV) or amoxicillin-clavulanate (PO) if tolerating PO. Narrow therapy as able based on culture growth if obtained.  
    • Consider ENT consultation if drainable collection seen on imaging or concern that patient is not improving with antimicrobials alone 

Acute otitis media 

  • Presents with fever, ear pain, possibly otorrhea and bulging, purulent TM 
  • Most common pathogens include Streptococcus pneumoniae, H. flu, Moraxella catarrhalis, and viruses 
  • Treatment can vary based on age (see CHOP Pathway) 

Mastoiditis 

  • Presents with fever, mastoid swelling, erythema, tenderness, and proptosis 
  • Most common causative pathogens include Streptococcus pneumoniae, Haemophilus influenzae, and Staphylococcus aureus 
  • Workup includes CT to assess for evidence of mastoiditis and complications such as subperiosteal abscess and intracranial extension 
  • Consult ENT to determine need for mastoidectomy, consider consultation with neurosurgery pending intra-cranial extension 
  • No standard treatment course or duration – many providers choose initial empiric therapy with ampicillin-sulbactam (IV) or amoxicillin-clavulanate pending culture data 

  • Understand the use of the Centor criteria in determining need for testing for Strep pharyngitis. 
  • Understand common pathogens causing ENT infections and which antimicrobials may be used to treat them.  

Click the drop down to reveal the correct answers

Q1: 4-year-old male presents with fever and refusal to extend his neck with new onset drooling. What is the most likely diagnosis?

Q2: 16-year-old female presents with fever and difficulty opening mouth. On exam, she has unilateral enlargement of the right tonsil with erythema and exudate. What antibiotic would you treat with? 

Answers

Q1: retropharyngeal abscess

Q2: ampicillin-sulfbactam (IV) vs amoxicillin-clavulanic acid (PO) 

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