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Shirish Patil

Head and neck space infections

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HEAD AND NECK SPACE INFECTIONS Dr. Shirish Patil Head neck & Skull base surgeon BIMS , Bgm
Spaces Risk factors Etiology Anatomy, clinical features & approach Investigations treatment
SPACES IN THE FACE MAXILLARY 1. Canine 2. Buccal Others 1. Parotid space MANDIBULAR Primary 1. Submental 2. Sub mandibular 3. Sub lingual Secondary/ Masticator 1. Pterygomandibular 2. Massetric 3. Temporal
Spaces of the neck Entire length of neck Deep neck spaces a. Retropharyngeal b. Danger c. Prevertebral d. Carotid Suprahyoid a. Submandibular b. Submental c. Sublingual d. Parapharyngeal e. Peritonsillar Infrahyoid Pretracheal space
RISK FACTORS Immunocompromised conditions Long term steroid intake Hepatitis Diabetes mellitus Malignancies Chemotherapy Collagen vascular diseases
ETIOLOGY OF DEEP NECK SPACE INFECTIONS Odontogenic ( MC ) Oropharngeal infections: tonsillits, pharyngitis Acute sinusitis in children Sialadenitis with or without obstruction Impacted upper aerodigestive tract FB Trauma iatrogenic / accidental Needle injection in IV drug users ( neck) Necrotic malignant LN Acute mastoiditis with Bezolds abscess Infected congenital lesions viz branchial clefts cysts, thyroglossal cysts The initiating site of infection is not known in 50% of DNSI ..Parischar . Deep neck abscesses: a retrospective review of 215 cases. Ann Oto Lary 110: 1025-1030, 1991
ORGANISMS IN DNSI Streptococcus viridans, Staphylococcus epidermidis, Staphylococcus aureus, group A beta-hemolytic Streptococcus (Streptococcus pyogenes), Bacteroides, Fusobacterium, and Peptostreptococcus species. NORMAL FLORA OF THE OROPHAARYNX
MC organisms in odontogenic infections viridans streptococci, Peptococcus, Peptostreptococcus, Eubacterium, Prevotella ( Bacteroids ) Fusobacterium
Microbiology The microbiology of deep neck space infections most often yields a mixture of aerobic and anaerobic organisms, usually representative of the oropharyngeal flora Methicillin-resistant Staphylococcus aureus (MRSA)-associated neck space infections is significantly increasing
Mech of anaerobic infection aerobic or facultative streptococci release exotoxins and lytic enzymes spreading cellulitis infection progresses, a mixed streptococcal/anaerobic infection hypoxic state increases, the predominance of anaerobic bacteria becomes evident
Routes of spread Lymphatic Arterial / venous Direct extensions
Example of venous spread Para nasal Sinus Facial planes Upper dentition Ophthalmic Vn Facial Vn Orbital cellulitis ..Cummings ORL & HNS
Spread of odontogenic infections Vestibule Palate Maxillary sinus Buccal space Sublingual space Submandibular space
BUCCAL SPACE Between buccinator muscle & skin C/F Cheek swelling Drained intra orally- Inadequate Extra orally - scar
CANINE SPACE Between the anterior surface of maxilla and the levator labii superioris Swelling lateral to the nose Obliteration of nasolabial fold - HALLMARK Intra oral stab incision
DIVISION OF SUB MANDIBULAR SPACE Sub lingual 1st molar They communicate posteriorly Odontogenic cause is MC etiology Sub- mandibular- 2nd / 3rd molar
Swelling of the floor of mouth Dysphagia Elevated tongue Swelling over the submandibular region of the neck SUB LINGUAL SPACE SUB MANDIBULAR SPACE
srp head and neck space infections UG.pptx
SUBMANDIBULAR AND SUBLINGUAL SPACE Horizontal incision along the inferior border of mandible 0.5 to 5 cm long
SUBMENTAL SPACE Laterally : Anterior bellies of digastric Post : mylohyoid Ant : skin & superficial fascia
srp head and neck space infections UG.pptx
MASTICATOR SPACE/ SECONDARY MANDIBULAR SPACES Deep cervical fascia splits between the Zygomatic arch and the inferior border of mandible Contents: Mandible Muscles of mastication 3rd part of maxillary artery Trigeminal nerve Divisions: Massetric Pterygoid Temporal
MASTICATOR SPACE MC cause odontogenic 3rd molars from the sub mandibular Trismus is a hall mark of involvement of masticator space
Temporal Pterygoid & Massetric
PAROTID SPACE Deep cervical fascia splits between the Zygomatic arch and the inferior border of mandible Parotid gland Facial nerve Ext. carotid artery Post facial Vein
srp head and neck space infections UG.pptx
LUDWIGS ANGINA Wilhelm Fredrich von Ludwig first described it in 1836
PSEUDO LUDWIGS Suppurative lymphadenitis in scarlet fever, measles and diptheria.
severe trismus, drooling, inability to swallow, tachypnea, and dyspnea Edema in the floor of mouth Fluctuation is not appreciated Strangulation - ANGINA COD Airway compromise
INCISION AND DRAINAGE Horizontal incision 2 and 遜 finger breadths below the lower margin of mandible and can be extended further Mylohyoid is split Gross app : - salt pork appearance, woody induration, watery fluid and little bleeding
PARAPHARYNGEAL SPACE Medialtonsillar fossa, pterygomandibular ligament Lateralmedial pterygoid, acsending ramus, Sup- skull base Inf- Hyoid Post- prevertebral fascia Poststyloid Carotid sheath- CA & IJV Cranial nerves IX, X, XI, XII Sympathetic chain
Parapharyngeal Space Communicates with several deep neck spaces. Parotid Masticator Peritonsillar Submandibular Retropharyngeal
PARAPHARYNGEAL SPACE Horizontal skin incision 2 1/2 finger breadth below the inferior margin of mandible, at the level of carotid bifurcation Dissect between the sub mandibular gland & SCM, medial to the mandible
RETROPHARYNGEAL SPACE Boundaries: Upper: skull base Lower: mediastinum at the tracheal bifurcation Anterior: buccopharynge al fascia, lining of the posterior pharynx and esophagus Posterior: alar fascia
srp head and neck space infections UG.pptx
Content: lymph node of Rouvier Routes of entry: 1. direct spread from the parapharyngeal space, 2. 2. lymphatic spread from the paranasal sinuses nasopharyngeal region suppuration of Lymph nodes 3. From prevertebral space
ADULTS CHIDREN < 5 years Onset Chronic Acute Etiology Potts spine Suppuration of LN of Rouvier URTI ACUTE SINUSITIS C/F Dysphagia Meningismus- de to irritation of paraspinal muscles
X ray STN Lateral C2 - > 7mm / > 1/3 the width of body of C2 C6 Children ( <15 yrs) > 14 mm Adults > 22mm
srp head and neck space infections UG.pptx
RETROPHARYNGEAL SPACE Small : intra oral drainage : Trendelenburg position Large: Transcutaneous : Vertical skin incision along anterior border of SCM : retract great vessels & SCM posteriorly
DANGER SPACE Potential Space, dangerous for rapid inferior spread of infection to the posterior mediastinum through its loose areolar tissue Boundaries Superior: skull base Inferior: diaphragm Anterior: alar fascia, retropharyngeal space Posterior: prevertebral fascia Lateral: transverse processes of vertebrae Contains: sympathetic trunk Routes of entry: retropharyngeal, parapharyngeal, or prevertebral spaces
srp head and neck space infections UG.pptx
DANGER SPACE
PREVERTEBRAL SPACE Potential space Boundaries Superior: clivus of the skull base Inferior: coccyx Anterior: prevertebral fascia Posterior: vertebral bodies Lateral: transverse processes Contains: paraspinous, prevertebral, and scalene muscles, vertebral artery and vein, brachial plexus, and phrenic nerve Routes of entry: infection of the vertebral bodies and penetrating injuries
PREVERTEBRAL SPACE
PERI TONSILLAR SPACE Medialcapsule of palatine tonsil Lateralsuperior pharyngeal constrictor Antanterior tonsil pillar Postposterior tonsil pillar
C/f trismus, dysphagia, Hot potato Voice, Otalgia, deviated uvula George Washington died of Quinsy
CAROTID SPACE Formed by all three layers of deep fascia Anatomically separate from all layers. Contains carotid artery, internal jugular vein, and vagus nerve Lincolns Highway Travels through para pharyngeal space Extends from skull base to thorax.
Anterior Visceral Space Infrahyoid Pretracheal space Enclosed by visceral division of middle layer of deep fascia Contains thyroid Surrounds trachea Superior border - thyroid cartilage Inferior border - anterior superior mediastinum down to the arch of the aorta. Posterior border anterior wall of esophagus Communicates laterally with the retropharyngeal space below the thyroid gland.
Iatrogenic perforation ( UGI ) FB Trauma Horizontal midline incision
Clinical presentation Most common symptoms Sore throat Odynophagia Neck swelling Neck Pain Pediatric Fever Decreased apetite Odynophagia Malaise Torticollis Neck pain Otalgia Trismus Neck swelling Vocal quality change Worsening of snoring, sleep apnea
FEVER Represents systemic involvement Due to Interleukin 1 < 102 0 ----- enhance phagocytic activity > 102 0 ---- sign of toxemia/ sepsis
BLOOD INVESTIGATIONS Screening Hemogram LEUCOCYTOSIS 1. Lack of Leucocytosis tumour / Immunodeficiency status 2. Daily monitoring of response to the antibiotic / surgical drainage S. Creat / RBS/ B.urea - hydration status - Renal assessment
IMAGING - RADIOGRAPHY OPG( Orthopantogram) to r/o dental sources of infection STN - space involvement - status of airway - air-fluid level anaerobic org CXR - to r/o mediastinitis/ aspiration
IMAGING - USG Easy availability in emergency departments No radiation Cost effective
IMAGING -CECT CT is mandatory in all cases of deep neck infections 1. cellulitis/ frank abscess - Cellulitis intravenous antibiotics - Abscess Incision & drainage Mc clay LE & Murray A, Booth. IV antibiotic therapy for DNSA defined by CT. Arch Otorhinolaryngology HNS 129; 1207-1212. 2003.
Cellulitis uniform heterogenous enhancement Abscess- peripheral rim enhancement
IMAGING- CT/ MRI CT with contrast Pros Widely available Faster Abscess vs cellulitis Less expensive Cons Contrast Radiation Uniplanar Dental artifacts MRI Pros MRI superior to CT in initial assessment More precise identification of space involvement (multiplanar) Better detection of underlying lesion Less dental artifact Better for floor of mouth No radiation Non iodine contrast Cons Cost Pt cooperation Slower
TREATMENT MEDICAL 1. AIRWAY 2. FLUID 3. ANTIBIOTIC SURGICAL 1. NEEDLE ASPIRATION 2. INCISION & DRAINAGE
srp head and neck space infections UG.pptx
AIRWAY Assessed by 1. Fibreoptic laryngoscope 2. Pulse oximetry ( not ideal ) Intervention by No obstruction :- Oxygen with face mask, humid air, steroid and epinephrine nebulization < 50 % obstruction : Medical Mx with observation in ICU > 50% obstruction : Intervention Fibreoptic intubation Oro tracheal intubation Tracheostomy Airway compromise is a major cause for mortality in Ludwigs angina, Parapharyngeal and retropharyngeal abscess
INDICATIONS FOR TRACHEOSTOMY Stridor / Stertor Aspiration- Inability to handle secretions
ANTIBIOTIC CHOICE
ODONTOGENIC The drug of choice for odontogenic infections continues to be parenteral penicillin. Even for serious fascial space infections, including Ludwig's angina, penicillin is preferred. Large doses of up to 20 million units daily for intravenous penicillin may be required for serious infections. ( with metronidazole ) Greenberg SL, et al: Surgical management of Ludwig's angina. Aust N Z J Surg 2007; 77:540-543. In the penicillin-allergic patient, clindamycin is the second drug of choice
Pennicillin 1st gen cephalosporins 2nd gen cephalosporins 3rd gen cephalosporins Anti streptolytic activity Anaerobic activity
FLUID RESUSCITATION ISOTONIC FLUIDS RL/NS/DNS MAINTENCE REGIMEN 4ml/kg/hr first 10 kgs 2ml/kg/hr next 5 kgs 1ml/kg/hr next subsequent kg
SURGERY INDICATIONS: 1. Air-fluid level in the neck or evidence of gas-producing organisms 2. abscess visualized in the fascial spaces of the head and neck 3. threatened airway compromise from abscess or phlegmon 4. failure to respond to 48 to 72 hours of empiric intravenous antibiotic therapy GOALS : - Tissue/ fluid for Grams staining & Culture sensitivity - therapeutic irrigation of the infected body cavity - stable external drainage pathway to prevent the reaccumulation of abscess
srp head and neck space infections UG.pptx
COMPLICATIONS Lemierres syndrome Cavernous sinus thrombosis Carotid artery pseudoaneurysm Mediastinitis Necrotizing fascitis
Lemmieres syndrome Tonsillar vein Bacteria spreads to IJV Toxin induces platelet aggregation Septic thrombi in IJV Lungs Joints- arthritis
MC organism Fusobacterium Inv CT neck with contrast Treatment : 1. Antibiotics 2. Heparin Anti-coagulation
Cavernous sinus Thrombosis Para nasal Sinus Facial planes Upper dention Ophthalmic Vn CST
Carotid Artery Pseudoaneurysm / rupture Pulsatile neck mass Horners syndrome Lower cranial nerve palsies Echymosis of neck If rupture bright red blood from mouth and nose
Necrotizing Fascitis More common in Diabetics and immunocompromised * Rapidly progressing cellulitis with ptting neck edema and orange peel appearance of skin No frank pus Foul smelling grey-brown tissue fluid with necrotic tissue ( Liquefactive necrosis ) Necrotic tissue must be debrided Wound should be left open May require repeated debridement ( rule rather than exception ) Hyperbaric oxygen may help *Tung-Yiu W, Jehn-Shyun H, Ching-Hung C, et al: Cervical necrotizing fasciitis of odontogenic origin: a report of 11 cases. J Oral Maxillofac Surg 2000; 58:1347-1352.
Mediastinitis Etio :- retropharyngeal & parapharyngeal infections C/F :- Diffuse neck edema Dyspnea Pleuritic chest pain , inc. on breathing Tachycardia & hypoxia Interscapular pain CT Thorax Broad spectrum antibiotic Thoracotomy sos
Pus in the neck calls for the surgeons best judgement, his best skill and often for all his courage .. Mosher on Deep Neck Infections References: 1. Cummings Otorhinolaryngology & HNS 5th edition. 2. Scott browns Otorhinolarynogoly & HNS 6th Edition 3. Eugene Myers Operative

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srp head and neck space infections UG.pptx

  • 1. HEAD AND NECK SPACE INFECTIONS Dr. Shirish Patil Head neck & Skull base surgeon BIMS , Bgm
  • 2. Spaces Risk factors Etiology Anatomy, clinical features & approach Investigations treatment
  • 3. SPACES IN THE FACE MAXILLARY 1. Canine 2. Buccal Others 1. Parotid space MANDIBULAR Primary 1. Submental 2. Sub mandibular 3. Sub lingual Secondary/ Masticator 1. Pterygomandibular 2. Massetric 3. Temporal
  • 4. Spaces of the neck Entire length of neck Deep neck spaces a. Retropharyngeal b. Danger c. Prevertebral d. Carotid Suprahyoid a. Submandibular b. Submental c. Sublingual d. Parapharyngeal e. Peritonsillar Infrahyoid Pretracheal space
  • 5. RISK FACTORS Immunocompromised conditions Long term steroid intake Hepatitis Diabetes mellitus Malignancies Chemotherapy Collagen vascular diseases
  • 6. ETIOLOGY OF DEEP NECK SPACE INFECTIONS Odontogenic ( MC ) Oropharngeal infections: tonsillits, pharyngitis Acute sinusitis in children Sialadenitis with or without obstruction Impacted upper aerodigestive tract FB Trauma iatrogenic / accidental Needle injection in IV drug users ( neck) Necrotic malignant LN Acute mastoiditis with Bezolds abscess Infected congenital lesions viz branchial clefts cysts, thyroglossal cysts The initiating site of infection is not known in 50% of DNSI ..Parischar . Deep neck abscesses: a retrospective review of 215 cases. Ann Oto Lary 110: 1025-1030, 1991
  • 7. ORGANISMS IN DNSI Streptococcus viridans, Staphylococcus epidermidis, Staphylococcus aureus, group A beta-hemolytic Streptococcus (Streptococcus pyogenes), Bacteroides, Fusobacterium, and Peptostreptococcus species. NORMAL FLORA OF THE OROPHAARYNX
  • 8. MC organisms in odontogenic infections viridans streptococci, Peptococcus, Peptostreptococcus, Eubacterium, Prevotella ( Bacteroids ) Fusobacterium
  • 9. Microbiology The microbiology of deep neck space infections most often yields a mixture of aerobic and anaerobic organisms, usually representative of the oropharyngeal flora Methicillin-resistant Staphylococcus aureus (MRSA)-associated neck space infections is significantly increasing
  • 10. Mech of anaerobic infection aerobic or facultative streptococci release exotoxins and lytic enzymes spreading cellulitis infection progresses, a mixed streptococcal/anaerobic infection hypoxic state increases, the predominance of anaerobic bacteria becomes evident
  • 11. Routes of spread Lymphatic Arterial / venous Direct extensions
  • 12. Example of venous spread Para nasal Sinus Facial planes Upper dentition Ophthalmic Vn Facial Vn Orbital cellulitis ..Cummings ORL & HNS
  • 13. Spread of odontogenic infections Vestibule Palate Maxillary sinus Buccal space Sublingual space Submandibular space
  • 14. BUCCAL SPACE Between buccinator muscle & skin C/F Cheek swelling Drained intra orally- Inadequate Extra orally - scar
  • 15. CANINE SPACE Between the anterior surface of maxilla and the levator labii superioris Swelling lateral to the nose Obliteration of nasolabial fold - HALLMARK Intra oral stab incision
  • 16. DIVISION OF SUB MANDIBULAR SPACE Sub lingual 1st molar They communicate posteriorly Odontogenic cause is MC etiology Sub- mandibular- 2nd / 3rd molar
  • 17. Swelling of the floor of mouth Dysphagia Elevated tongue Swelling over the submandibular region of the neck SUB LINGUAL SPACE SUB MANDIBULAR SPACE
  • 19. SUBMANDIBULAR AND SUBLINGUAL SPACE Horizontal incision along the inferior border of mandible 0.5 to 5 cm long
  • 20. SUBMENTAL SPACE Laterally : Anterior bellies of digastric Post : mylohyoid Ant : skin & superficial fascia
  • 22. MASTICATOR SPACE/ SECONDARY MANDIBULAR SPACES Deep cervical fascia splits between the Zygomatic arch and the inferior border of mandible Contents: Mandible Muscles of mastication 3rd part of maxillary artery Trigeminal nerve Divisions: Massetric Pterygoid Temporal
  • 23. MASTICATOR SPACE MC cause odontogenic 3rd molars from the sub mandibular Trismus is a hall mark of involvement of masticator space
  • 24. Temporal Pterygoid & Massetric
  • 25. PAROTID SPACE Deep cervical fascia splits between the Zygomatic arch and the inferior border of mandible Parotid gland Facial nerve Ext. carotid artery Post facial Vein
  • 27. LUDWIGS ANGINA Wilhelm Fredrich von Ludwig first described it in 1836
  • 28. PSEUDO LUDWIGS Suppurative lymphadenitis in scarlet fever, measles and diptheria.
  • 29. severe trismus, drooling, inability to swallow, tachypnea, and dyspnea Edema in the floor of mouth Fluctuation is not appreciated Strangulation - ANGINA COD Airway compromise
  • 30. INCISION AND DRAINAGE Horizontal incision 2 and 遜 finger breadths below the lower margin of mandible and can be extended further Mylohyoid is split Gross app : - salt pork appearance, woody induration, watery fluid and little bleeding
  • 31. PARAPHARYNGEAL SPACE Medialtonsillar fossa, pterygomandibular ligament Lateralmedial pterygoid, acsending ramus, Sup- skull base Inf- Hyoid Post- prevertebral fascia Poststyloid Carotid sheath- CA & IJV Cranial nerves IX, X, XI, XII Sympathetic chain
  • 32. Parapharyngeal Space Communicates with several deep neck spaces. Parotid Masticator Peritonsillar Submandibular Retropharyngeal
  • 33. PARAPHARYNGEAL SPACE Horizontal skin incision 2 1/2 finger breadth below the inferior margin of mandible, at the level of carotid bifurcation Dissect between the sub mandibular gland & SCM, medial to the mandible
  • 34. RETROPHARYNGEAL SPACE Boundaries: Upper: skull base Lower: mediastinum at the tracheal bifurcation Anterior: buccopharynge al fascia, lining of the posterior pharynx and esophagus Posterior: alar fascia
  • 36. Content: lymph node of Rouvier Routes of entry: 1. direct spread from the parapharyngeal space, 2. 2. lymphatic spread from the paranasal sinuses nasopharyngeal region suppuration of Lymph nodes 3. From prevertebral space
  • 37. ADULTS CHIDREN < 5 years Onset Chronic Acute Etiology Potts spine Suppuration of LN of Rouvier URTI ACUTE SINUSITIS C/F Dysphagia Meningismus- de to irritation of paraspinal muscles
  • 38. X ray STN Lateral C2 - > 7mm / > 1/3 the width of body of C2 C6 Children ( <15 yrs) > 14 mm Adults > 22mm
  • 40. RETROPHARYNGEAL SPACE Small : intra oral drainage : Trendelenburg position Large: Transcutaneous : Vertical skin incision along anterior border of SCM : retract great vessels & SCM posteriorly
  • 41. DANGER SPACE Potential Space, dangerous for rapid inferior spread of infection to the posterior mediastinum through its loose areolar tissue Boundaries Superior: skull base Inferior: diaphragm Anterior: alar fascia, retropharyngeal space Posterior: prevertebral fascia Lateral: transverse processes of vertebrae Contains: sympathetic trunk Routes of entry: retropharyngeal, parapharyngeal, or prevertebral spaces
  • 44. PREVERTEBRAL SPACE Potential space Boundaries Superior: clivus of the skull base Inferior: coccyx Anterior: prevertebral fascia Posterior: vertebral bodies Lateral: transverse processes Contains: paraspinous, prevertebral, and scalene muscles, vertebral artery and vein, brachial plexus, and phrenic nerve Routes of entry: infection of the vertebral bodies and penetrating injuries
  • 46. PERI TONSILLAR SPACE Medialcapsule of palatine tonsil Lateralsuperior pharyngeal constrictor Antanterior tonsil pillar Postposterior tonsil pillar
  • 47. C/f trismus, dysphagia, Hot potato Voice, Otalgia, deviated uvula George Washington died of Quinsy
  • 48. CAROTID SPACE Formed by all three layers of deep fascia Anatomically separate from all layers. Contains carotid artery, internal jugular vein, and vagus nerve Lincolns Highway Travels through para pharyngeal space Extends from skull base to thorax.
  • 49. Anterior Visceral Space Infrahyoid Pretracheal space Enclosed by visceral division of middle layer of deep fascia Contains thyroid Surrounds trachea Superior border - thyroid cartilage Inferior border - anterior superior mediastinum down to the arch of the aorta. Posterior border anterior wall of esophagus Communicates laterally with the retropharyngeal space below the thyroid gland.
  • 50. Iatrogenic perforation ( UGI ) FB Trauma Horizontal midline incision
  • 51. Clinical presentation Most common symptoms Sore throat Odynophagia Neck swelling Neck Pain Pediatric Fever Decreased apetite Odynophagia Malaise Torticollis Neck pain Otalgia Trismus Neck swelling Vocal quality change Worsening of snoring, sleep apnea
  • 52. FEVER Represents systemic involvement Due to Interleukin 1 < 102 0 ----- enhance phagocytic activity > 102 0 ---- sign of toxemia/ sepsis
  • 53. BLOOD INVESTIGATIONS Screening Hemogram LEUCOCYTOSIS 1. Lack of Leucocytosis tumour / Immunodeficiency status 2. Daily monitoring of response to the antibiotic / surgical drainage S. Creat / RBS/ B.urea - hydration status - Renal assessment
  • 54. IMAGING - RADIOGRAPHY OPG( Orthopantogram) to r/o dental sources of infection STN - space involvement - status of airway - air-fluid level anaerobic org CXR - to r/o mediastinitis/ aspiration
  • 55. IMAGING - USG Easy availability in emergency departments No radiation Cost effective
  • 56. IMAGING -CECT CT is mandatory in all cases of deep neck infections 1. cellulitis/ frank abscess - Cellulitis intravenous antibiotics - Abscess Incision & drainage Mc clay LE & Murray A, Booth. IV antibiotic therapy for DNSA defined by CT. Arch Otorhinolaryngology HNS 129; 1207-1212. 2003.
  • 57. Cellulitis uniform heterogenous enhancement Abscess- peripheral rim enhancement
  • 58. IMAGING- CT/ MRI CT with contrast Pros Widely available Faster Abscess vs cellulitis Less expensive Cons Contrast Radiation Uniplanar Dental artifacts MRI Pros MRI superior to CT in initial assessment More precise identification of space involvement (multiplanar) Better detection of underlying lesion Less dental artifact Better for floor of mouth No radiation Non iodine contrast Cons Cost Pt cooperation Slower
  • 59. TREATMENT MEDICAL 1. AIRWAY 2. FLUID 3. ANTIBIOTIC SURGICAL 1. NEEDLE ASPIRATION 2. INCISION & DRAINAGE
  • 61. AIRWAY Assessed by 1. Fibreoptic laryngoscope 2. Pulse oximetry ( not ideal ) Intervention by No obstruction :- Oxygen with face mask, humid air, steroid and epinephrine nebulization < 50 % obstruction : Medical Mx with observation in ICU > 50% obstruction : Intervention Fibreoptic intubation Oro tracheal intubation Tracheostomy Airway compromise is a major cause for mortality in Ludwigs angina, Parapharyngeal and retropharyngeal abscess
  • 62. INDICATIONS FOR TRACHEOSTOMY Stridor / Stertor Aspiration- Inability to handle secretions
  • 64. ODONTOGENIC The drug of choice for odontogenic infections continues to be parenteral penicillin. Even for serious fascial space infections, including Ludwig's angina, penicillin is preferred. Large doses of up to 20 million units daily for intravenous penicillin may be required for serious infections. ( with metronidazole ) Greenberg SL, et al: Surgical management of Ludwig's angina. Aust N Z J Surg 2007; 77:540-543. In the penicillin-allergic patient, clindamycin is the second drug of choice
  • 65. Pennicillin 1st gen cephalosporins 2nd gen cephalosporins 3rd gen cephalosporins Anti streptolytic activity Anaerobic activity
  • 66. FLUID RESUSCITATION ISOTONIC FLUIDS RL/NS/DNS MAINTENCE REGIMEN 4ml/kg/hr first 10 kgs 2ml/kg/hr next 5 kgs 1ml/kg/hr next subsequent kg
  • 67. SURGERY INDICATIONS: 1. Air-fluid level in the neck or evidence of gas-producing organisms 2. abscess visualized in the fascial spaces of the head and neck 3. threatened airway compromise from abscess or phlegmon 4. failure to respond to 48 to 72 hours of empiric intravenous antibiotic therapy GOALS : - Tissue/ fluid for Grams staining & Culture sensitivity - therapeutic irrigation of the infected body cavity - stable external drainage pathway to prevent the reaccumulation of abscess
  • 69. COMPLICATIONS Lemierres syndrome Cavernous sinus thrombosis Carotid artery pseudoaneurysm Mediastinitis Necrotizing fascitis
  • 70. Lemmieres syndrome Tonsillar vein Bacteria spreads to IJV Toxin induces platelet aggregation Septic thrombi in IJV Lungs Joints- arthritis
  • 71. MC organism Fusobacterium Inv CT neck with contrast Treatment : 1. Antibiotics 2. Heparin Anti-coagulation
  • 72. Cavernous sinus Thrombosis Para nasal Sinus Facial planes Upper dention Ophthalmic Vn CST
  • 73. Carotid Artery Pseudoaneurysm / rupture Pulsatile neck mass Horners syndrome Lower cranial nerve palsies Echymosis of neck If rupture bright red blood from mouth and nose
  • 74. Necrotizing Fascitis More common in Diabetics and immunocompromised * Rapidly progressing cellulitis with ptting neck edema and orange peel appearance of skin No frank pus Foul smelling grey-brown tissue fluid with necrotic tissue ( Liquefactive necrosis ) Necrotic tissue must be debrided Wound should be left open May require repeated debridement ( rule rather than exception ) Hyperbaric oxygen may help *Tung-Yiu W, Jehn-Shyun H, Ching-Hung C, et al: Cervical necrotizing fasciitis of odontogenic origin: a report of 11 cases. J Oral Maxillofac Surg 2000; 58:1347-1352.
  • 75. Mediastinitis Etio :- retropharyngeal & parapharyngeal infections C/F :- Diffuse neck edema Dyspnea Pleuritic chest pain , inc. on breathing Tachycardia & hypoxia Interscapular pain CT Thorax Broad spectrum antibiotic Thoracotomy sos
  • 76. Pus in the neck calls for the surgeons best judgement, his best skill and often for all his courage .. Mosher on Deep Neck Infections References: 1. Cummings Otorhinolaryngology & HNS 5th edition. 2. Scott browns Otorhinolarynogoly & HNS 6th Edition 3. Eugene Myers Operative