srp head and neck space infections UG.pptx

Head and neck space infections

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 Canine Buccal Others Parotid space MANDIBULAR Primary Submental Sub mandibular Sub lingual Secondary/ Masticator Pterygomandibular Massetric Temporal

4. Spaces of the neck Entire length of neck Deep neck spaces Retropharyngeal Danger Prevertebral Carotid Suprahyoid Submandibular Submental 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 – 1 st molar They communicate posteriorly Odontogenic cause is MC etiology Sub- mandibular- 2 nd / 3 rd 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

18. SUBMANDIBULAR AND SUBLINGUAL SPACE Horizontal incision along the inferior border of mandible 0.5 to 5 cm long

19. SUBMENTAL SPACE Laterally : Anterior bellies of digastric Post : mylohyoid Ant : skin & superficial fascia

20. MASTICATOR SPACE/ SECONDARY MANDIBULAR SPACES Deep cervical fascia splits between the Zygomatic arch and the inferior border of mandible Contents: Mandible Muscles of mastication 3 rd part of maxillary artery Trigeminal nerve Divisions: Massetric Pterygoid Temporal

21. MASTICATOR SPACE MC cause – odontogenic – 3 rd molars from the sub mandibular Trismus is a hall mark of involvement of masticator space

22. Temporal Pterygoid & Massetric

23. 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

24. LUDWIGS ANGINA Wilhelm Fredrich von Ludwig first described it in 1836

25. PSEUDO LUDWIGS Suppurative lymphadenitis in scarlet fever, measles and diptheria .

26. severe trismus , drooling, inability to swallow, tachypnea, and dyspnea Edema in the floor of mouth Fluctuation is not appreciated Strangulation - ANGINA COD – Airway compromise

27. INCISION AND DRAINAGE Horizontal incision 2 and ½ finger breadth’s 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

28. PARAPHARYNGEAL SPACE Medial— tonsillar fossa, pterygomandibular ligament Lateral—medial pterygoid , acsending ramus, Sup- skull base Inf - Hyoid Post- prevertebral fascia Poststyloid Carotid sheath- CA & IJV Cranial nerves IX, X, XI, XII Sympathetic chain

29. Parapharyngeal Space Communicates with several deep neck spaces. Parotid Masticator Peritonsillar Submandibular Retropharyngeal

30. 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

31. RETROPHARYNGEAL SPACE Boundaries: Upper: skull base Lower: mediastinum at the tracheal bifurcation Anterior: buccopharyngeal fascia, lining of the posterior pharynx and esophagus Posterior: alar fascia

32. Content: lymph node of Rouvier Routes of entry: direct spread from the parapharyngeal space, 2. lymphatic spread from the paranasal sinuses nasopharyngeal region  suppuration of Lymph nodes 3. From prevertebral space

33. ADULTS CHIDREN < 5 years Onset Chronic Acute Etiology Pott’s spine Suppuration of LN of Rouvier URTI ACUTE SINUSITIS C/F Dysphagia Meningismus - de to irritation of paraspinal muscles

34. X ray STN Lateral C2 - > 7mm / > 1/3 the width of body of C2 C6 Children ( <15 yrs ) > 14 mm Adults > 22mm

35. RETROPHARYNGEAL SPACE Small : intra oral drainage : Trendelenburg position Large: Transcutaneous : Vertical skin incision along anterior border of SCM : retract great vessels & SCM posteriorly

36. 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

37. DANGER SPACE

38. 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

39. PREVERTEBRAL SPACE

40. PERI TONSILLAR SPACE Medial—capsule of palatine tonsil Lateral—superior pharyngeal constrictor Ant—anterior tonsil pillar Post—posterior tonsil pillar

41. C/f – trismus , dysphagia, Hot potato Voice, Otalgia , deviated uvula George Washington died of Quinsy

42. CAROTID SPACE Formed by all three layers of deep fascia Anatomically separate from all layers. Contains carotid artery, internal jugular vein, and vagus nerve “Lincoln’s Highway” Travels through para pharyngeal space Extends from skull base to thorax.

43. 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.

44. Iatrogenic perforation ( UGI ) FB Trauma Horizontal midline incision

45. 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

46. FEVER Represents systemic involvement Due to Interleukin 1 < 102 -----  enhance phagocytic activity > 102 ---- sign of toxemia/ sepsis

47. BLOOD INVESTIGATIONS Screening Hemogram  LEUCOCYTOSIS Lack of Leucocytosis – tumour / Immunodeficiency status Daily monitoring of response to the antibiotic / surgical drainage S. Creat / RBS/ B.urea - hydration status Renal assessment

48. 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

49. IMAGING - USG Easy availability in emergency departments No radiation Cost effective

50. IMAGING -CECT CT is mandatory in all cases of deep neck infections 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 .

51. Cellulitis – uniform heterogenous enhancement Abscess- peripheral rim enhancement

52. 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

53. TREATMENT MEDICAL AIRWAY FLUID ANTIBIOTIC SURGICAL NEEDLE ASPIRATION INCISION & DRAINAGE

54. AIRWAY Assessed by Fibreoptic laryngoscope 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

55. INDICATIONS FOR TRACHEOSTOMY Stridor / Stertor Aspiration- Inability to handle secretions

56. ANTIBIOTIC CHOICE

57. 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

58. Pennicillin 1 st gen cephalosporins 2 nd gen cephalosporins 3 rd gen cephalosporins Anti streptolytic activity Anaerobic activity

59. 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

60. SURGERY INDICATIONS: Air-fluid level in the neck or evidence of gas-producing organisms abscess visualized in the fascial spaces of the head and neck threatened airway compromise from abscess or phlegmon 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

61. COMPLICATIONS Lemierre’s syndrome Cavernous sinus thrombosis Carotid artery pseudoaneurysm Mediastinitis Necrotizing fascitis

62. Lemmiere’s syndrome Tonsillar vein Bacteria spreads to IJV Toxin induces platelet aggregation Septic thrombi in IJV Lungs Joints- arthritis

63. MC organism – Fusobacterium Inv – CT neck with contrast Treatment : Antibiotics Heparin Anti-coagulation

64. Cavernous sinus Thrombosis Para nasal Sinus Facial planes Upper dention Ophthalmic Vn CST

65. 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

66. 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.

67. 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

68. “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: Cummings Otorhinolaryngology & HNS 5 th edition. Scott brown’s Otorhinolarynogoly & HNS 6 th Edition Eugene Myer’s Operative Otorhinolaryngology & HNS Papparella ‘s Otorhinolaryngology & HNS