A recent patient interaction provided me with some insight regarding the value of the thank you in health care.

As a primary care provider, many times the thank-you's I receive are half-hearted or more of a formality.

“Thanks for sending that prescription in” or “thanks for squeezing us in”, are common ones that I hear in the office, but seldom do they have much meaning from patients, as it is mostly expected that I will work a patient in or take on extra work.

More often than not, I am the center of blame for many things...

  • The labs not getting better
  • The weight gain from the new medication that has significantly improved depression and anxiety symptoms
  • The bad guy who took away a potentiall dangerous medication, despite a half hour conversation about why it was done.

So, when I had a truly meaningful thank you recently, it stuck with me and continues to stick with me, reminding me just what it means to impact lives in a positive way and make a difference in another person’s life.

It was a recent office visit follow up for a patient who had been in the hospital with a severe and devastating infection.

At the end of the follow up, she stood up, voice quavering a bit, “Hey, I don’t know how to say this, but you know, I don’t know why you thought to order that test. The hospitalist said I was really close…”

My voice quavered a bit as well, “Thank you. I was just doing my job”.

It does leave a little bit of desire, for the follow up to be in the same exam room, where just one short week ago, the patient was quite literally dying in front of me.

The afternoon started similar to any other, multiple triages, patient calls, pharmacy requests and a patient on my schedule for “possible strep”. In primary care, the day can be dictated by the types of complaints and the types of visits put on my schedule. In a day full of complicated follow ups and complicated patients, a sore throat was a welcome addition, or so I thought.

As we have discussed previously, during the patient visit, it is important to think about the patient’s symptoms and what that does for the differential diagnosis. Each question asked allows differentials to be included, excluded, more likely, or less likely.

In this case, the visit started like any other. I introduced myself as one of the PAs and quickly found there was a great deal more to the story than a simple sore throat. The patient had  already been seen for this very concern at the emergency department, just two days earlier. She had started a course of penicillin for “a right sided ear infection”, and was anything but better.

In some cases, we can be frustrated that a patient is back in our office so soon. Shouldn’t they know it takes a few days for the antibiotic to start working? This, I will admit was one of my initial thoughts. But as the history unfolded, it quickly became clear that nothing about this case was typical, normal, or straightforward.

She did admit to some ear pain previously, but now there were many new symptoms of concern:

  • drooling
  • neck pain
  • “the worst sore throat I have ever had”
  • difficulty swallowing
  • fever

The heart rate taken by nursing was a little too high.

The penicillin did not seem to make a difference.

Modern medicine has provided us with numerous aides for diagnosis. We have symptom checkers that can help us narrow down a differential. We have criteria that tell us when to take a throat culture. We have decision trees, algorithms, and flow charts that are supposed to guide us in the right direction.

However, the most important piece to diagnosis still remains our gut. In many cases, patients have lived because of a clinician’s gut.

In this case, my gut was screaming and my mind was full of thoughts. As I moved through my thought process, this voice inside me became more prominent.

Something is wrong, really wrong.”

“Does this sound like an ear infection to you, because it isn’t.”

“Why would you do a strep? You would still think something else is going on!”

“Don’t delay, this patient is in trouble”

Fortunately in this case, my exam provided me with clarity that made my decision making a bit easier, but also made me worry for my patient.

A general impression indicated that something was horribly wrong. It is the skill that we, as clinicians are taught, to simply know that something is wrong. My stomach had started to churn the second I started to talk to the patient.

The ear exam also proved what I had known from the history, a clear tympanic membrane and a good cone of light. No infection.

“Move quickly and save a life. Time is running out”

The oropharyngeal exam showed a cherry red pharynx void of any exudate. The tonsils were large, 3+ with the uvula midline.

Neck exam was most concerning: significant lymphadenopathy in the setting of an exquisitely tender anterior neck with erythema over the skin on the neck as well.

Something bad is going on, order the right test”.

The patient was in the CT scanner within two hours and in the emergency department with an IV administering broad spectrum anti-biotics within three.

The call from radiology indicated a significant deep space neck infection with propagation to the vertebrae and a large loculated abscess, retropharyngeal in origin.

No otitis media.

Sometimes in medicine our gut is the thing that matters most for the patient and for our diagnosis. In this case, the diagnosis didn't matter, but the feeling of an overwhelming sense of doom and dread guided the visit, making the algorithm very simple: if your gut is worried, you should be too.

Deep space neck infections are particularly serious because of their risk for quick progression into life threatening infection. Etiology includes progression of mandibular, ear, sinus, or parotid gland infections (Chow, 2019).

A comprehensive review of neck anatomy will be saved for your anatomy and physiology course in PA school and will not specifically be discussed here. Areas where infection can harbor include the para-pharyngeal space, retropharyngeal space, pre-tracheal space, parotid space, and the so called “danger zone”. The danger zone is the space just posterior to the retropharyngeal space which has easy access for spread to the mediastinum and chest cavity. An infection here can cause rapid progression.

The pathogen responsible for deep neck infection tends to be polymicrobial. Infections due to dental pathology or dental abscess left untreated usually also include anaerobes. Common pathogens include Streptococcus, Strep viridans,  Peptostreptococcus, and Streptococcus pyogenes. Infections arising from sequelae of otitis media and mastoiditis also include Staphylococcus aureus andPseudomonas aeruginosa.

Patients with deep space neck infections may paint a history of recent diagnosis of tooth, sinus, or ear infection that is worsening. Symptoms include sore throat, dysphagia, drooling, odynophagia, trismus, neck pain, difficulty moving the neck. Stridor as well as dyspnea should clue the clinician into a worsening infection. Interestingly, dysphonia and hoarseness are late findings, which may indicate the involvement of Cranial nerve 10 (Chow, 2019).

The most accurate test to diagnose a deep space neck infection is the CT scan. The management of an acute airway should not be delayed by imaging to diagnose the neck infection. The CT scan is also used widely by ENT surgeons or interventional radiology to plan possible aspiration or surgical management of the neck abscess in the operating room. Findings on CT scan may show lack of anatomic delineation between structures, tissue inflammation, and abscess.

Retropharyngeal abscess is one of the more serious and potentially devastating neck infections, as there can be quick propagation into mediastinal involvement and sepsis. One of the more sinister complications of a retropharyngeal abscess is that of “acute necrotizing mediastinitis” in which the infection manifests down into the mediastinum, with a mortality rate of 25% even with early anti-biotics. (Chow, 2019).

According to Chow (2019), the decision to pursue operative management is usually when an abscess has formed. Needle aspiration, depending on location may be an opinion, or in severe infection, open neck exploration or even thoracotomy may be required. The determination of type and duration of anti-biotics depends on patient’s immunocompetency status as well as the source of the original infection, but broad spectrum are typically used. Specific antibiotic choices based on type of infection goes beyond the scope of today’s article.

As discussed above, deep space neck infections are a must not miss during primary care or urgent care visits, especially due to their quick propensity to become life threatening in nature.  Clinicians should consider the diagnosis in patients coming in for reevaluation after a recent course of antibiotics for ear, tooth, or sinus diagnoses and should act quickly to make the diagnosis.

References

Chow, Anthony W. (2019). Deep Space Neck Infections in Adults. UptoDate. Date of access 8 April 2019.