deep neck space infection mini lctr
TRANSCRIPT
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Agung D. Permana,dr.,M.Kes.,SpTHT-KL
Deep Neck Space Infection
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Introduction
DEEP NECK SPACE INFECTIONS
Life threateningdelay in diagnosis/inadequate/inappropriate treatment
complicationsmortality rates : 40%head and neck surgeon :cervical fascias & potential spacesunderstand thetreatment & potential complicationsantibiotics decreased the incidence and mortality
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Anatomy Of The Cervical Fascia
Superficial cervical fascia
Deep cervical fascia
1. Superficial layer2. Middle layer
- Muscular division
- Visceral division
3. Deep layer
- Prevertebral division- Alar division
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Sternocleidomastoid
TrapeziusDeep Cervical Fascia
Investing layer of deep cervical fascia
Prevertebral fascia
Pretrachealfascia
(visceral part)
Carotid sheath
Buccopharyngeal fascia
Alar fascia
Pretracheal fascia
(muscular part)
T
E
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Cervical Fascia
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Pathophysiology
Deep neck space infections can arise from a multitude of causes.Whatever the initiating event, development of a deep neck spaceinfection proceeds by one of several paths, as follows:
Spread of infection can be from the oral cavity, face, or superficial
neck to the deep neck space via the lymphatic system. Lymphadenopathy may lead to suppuration and finally focal
abscess formation. Infection can spread among the deep neck spaces by the paths of
communication between spaces. Direct infection may occur by penetrating trauma.
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Sign And Symptoms
Mass effect of inflamed tissue or abscess cavityon surrounding structures
Direct involvement of surrounding structureswith the infectious process
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Presentation Obtain a detailed history from patients in whom deep neck space
infection is suspected. Eliciting a history of the following isimportant:
Pain Recent dental procedures Upper respiratory tract infections (URTIs) Neck or oral cavity trauma Respiratory difficulties
Dysphagia Immunosuppression or immunocompromised status Rate of onset Duration of symptoms
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Retropharyngeal Space Infection
Source Nose
Sinuses
Adenoids
Nasopharynx
Manifestations Acute URTI in infants & children
Dysphagia & odynophagia
Drooling & difficult to expell excretions
Cervical rigidity
Muffled voice Dyspnea
Unilateral bulging of posterior pharyngeal wall
Sepsis
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Retropharyngeal Space Infection
Pediatrics "Cause> suppurative process in lymph nodes
#Nose, adenoids, nasopharynx, sinuses!
Adults Cause> trauma, instrumentation, extension
adjoining deep neck space
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Danger Space Infection
Source Retropharyngeal space
Prevetebral space
Parapharyngeal space
Manifestations Same as primary space infection
Severe sepsis
TreatmentSame as for primary space infection
Complications Potential for rapid spread through the loose areolar tissue
Inferior spread to the posterior mediastinum to the level of diafragma
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Prevertebral Space Infection
Manifestations
Midline abcess Cold abcess posterior pharynx
Slow spread of suppuration of this area
Treatment Needle aspiration w/ subsequent antituberculosis th/
Stabilization of spine
Source Vertebral bodies
Penetrating injuries
Tuberculosis of the spine
ComplicationsSpine instabilityprogression of vetebral process
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Visceral Vascular Space Infection
potential space within the carotid sheath infections remain relatively localized
compact space contains little areolarconnective tissue
lymphatics contained within this space receivesecondary drainage from most of thelymphatics of the head and neck
Lincoln Highway of The Neck(Mosher) all
three layers of the DCF contribute to thecarotid sheath
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Visceral Vascular Space Infection
Source Parapharyngeal space
Submandibular space
Visceral space
Manifestations
Pitting edema over SCM Torticollis
Treatment External drainage
I.V. antibiotics
Possible ligation of IJV
Complications Septic shock
Carotid artery erotions Endocarditis
Cavernous sinusthrombosis
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Pharingomaxillary Space Infection
Prestyloid Compartement [anterior-muscular] Fat
Lymph nodes
Internal maxilarry artery
Inferior alveolar, lingual,auriculotemporal nerves
Poststyloid Compartement [posterior-neurovascular] Carotid artery
Internal jugular vein
Symphatetic chain
IX, X, XI, XII nerves
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Pharingomaxillary Space Infection
Source Tonsil
Pharynx
Teeth
Temporal bone (petrous)
Parotis gland Lymph nodes of nose &
nasopharynx
Manifestations Medial displacement of lateral
pharyngeal wall and tonsils Trismus
Parotid edema
Retromandibular neck fullness
Dysphagia
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Peritonsillar Space Infection
SourceTonsils & pharynx
Manifestations Dysphagia/odynophagia
Drooling and hot potato voice
Muffleed voice
Reffered otalgia
Trismus
Displaced tonsil toward midline Deviated uvula
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Submandibular Space Infection
Sublingual space Sublingual gland
Hypoglossal nerve
Whartons ducts
Submaxillary spaceCentral compartement
Submental compartement
Submaxillary compartement
subdivided by anterior bellies ofdigastric m.
Contents
Submandibular gland
Lymph nodes
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Submandibular Space Infection
Source Teeth
Salivary glands
Pharynx & tonsils
Sinuses
Manifestations Dysphagia
Odynophagia
Treatment Underlying pathology
External drainage if it progress- sublingual
- submandibula
ComplicationsLudwigs Angina
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Ludwigs Angina
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Ludwigs angina
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Temporal Space Infection
Temporalis m. :- superficial compartments
- deep compartments
Manifestation
Pain in this area Trismus
Treatment
External drainage
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Anterior Visceral Space
Contents Pharynx
Esophagus
Larynx
Trachea Thyroid gland
Source Tonsils
Esophageal injury Blunt trauma w/ mucosal tear
Acute thyroiditis
Chest infection
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Anterior Visceral Space
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Microbiology
Preantibiotic eraS.aureus
Currentlyaerobic Strep species and non-strepanaerobes
Gram-negatives uncommon
Almost always polymicrobial
Remember resistance !!!
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Imaging
Lateral neck plain film
"Screening exammainly for retropharyngeal and
pretracheal spaces
"Normal: 7mm at C-2, 14mm at C-6 for kids,
22mm at C-6 for adults
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Imaging
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Imaging
High-resolution Ultrasound "Advantages
Avoids radiation
Portable
"Disadvantages Not widely accepted
Operator dependent
Inferior anatomic detail
"Uses
Following infection during therapy
Image guided aspiration
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Imaging
Contrast enhanced CT "Advantages
Quick, easy Widely available
Familiarity Superior anatomic detail Differentiate abscess and cellulitis
"Disadvantages Ionizing radiation Allergenic contrast agent Soft tissue detail Artifact
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Treatment
Airway protection
Antibiotic therapy
Surgical drainage
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Airway protection
"Observation
"Intubation Direct laryngoscopy: possible risk of rupture and
aspiration Flexible fiberoptic
"Tracheostomy Ideally = planned, awake, local anesthesia Abscess may overlie trachea Distorted anatomy and tissue planes
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Treatment
Antibiotic Therapy "Polymicrobial infections Aerobic Strep, anaerobes
Ampicillin/sulbactam with metronidazole "Beta-Lactam resistance in 17-47% of isolates
"Alternatives Third generation cephalosporins clindamycin
"Culture and sensitivity
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Treatment
Surgical Drainage
Transoral Preoperative CT where are the great vessels? CT
Cruciate mucosal incision, blunt spreading through superiorpharyngeal constrictor
External drainage
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Surgical Drainage
"External
EXPOSURE, EXPOSURE!!!
approach
Submandibular incision
Submental incision T-incision
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Complication
Airway obstruction Ruptured abscess
Internal Jugular Vein Thrombosis
Carotid artery Rupture Mediastinitis
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history
Physical examination
Secure airway
Culture, IV antibiotic
CT scan
Small abcess
Needle aspiration
for culture and drainage
Impending complication ?
No abcess Large abcess
Watch and wait
24-48 hours
Clinical improvement ?
Continue antibiotic,
Needle aspirations
Surgical incision
And drainage
No
YesYes No
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Pharingomaxillary Space Infection
Treatment External drainage
Tracheotomy
Complications Septic thrombosis of IJV
Carotid artery erosions
Cranial nerve involvement Mediastinitis
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Peritonsillar Space Infection
Treatment
Peroral drainage
tonsilectomy
Complications
Spread into pharyngomaxilaryspace through posteriorpharyngeal wall
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Retropharyngeal Space Infection
Treatment1. Fasting
2. I.V. antibiotics
3. Tracheotomy
4. Emergent surgical drainage- intraoral drainage
- external drainage
Complications1. Rupture of abcess w/
aspiration & pneumonia2. Mediastinitis
3. Airway obstruction
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PMS
MasticatorSubmandibular
Peritonsillar
VVSDanger
MediastinumAnterior Visceral
Temporal
Parotid
Prevertebral
Retropharingeal
Pharingomaxillary Space Infection
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