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Agung D. Permana,dr.,M.Kes.,SpTHT-KL
Introduction
DEEP NECK SPACE INFECTIONS Life threatening delay in diagnosis/inadequate/inappropriate treatment complications mortality rates : 40% head and neck surgeon : cervical fascias & potential spaces understand the treatment & potential complications antibiotics decreased the incidence and mortality
Sternocleidomastoid
T E
Pretracheal fascia (muscular part)
Prevertebral fascia
Trapezius
Cervical Fascia
Pathophysiology
Deep neck space infections can arise from a multitude of causes.
Whatever the initiating event, development of a deep neck space infection proceeds by one of several paths, as follows:
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.
on surrounding structures Direct involvement of surrounding structures with the infectious process
Presentation Obtain a detailed history from patients in whom deep neck space
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
"
#Nose,
Adults
Cause > trauma, instrumentation, extension
Manifestations
Same as primary space infection Severe sepsis
Treatment
Same 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
Manifestations
Midline abcess Cold abcess posterior pharynx Slow spread of suppuration of this area
Treatment
Needle aspiration w/ subsequent antituberculosis th/ Stabilization of spine
Complications
Spine instability progression of vetebral process
compact space contains little areolar connective tissue lymphatics contained within this space receive secondary drainage from most of the lymphatics of the head and neck Lincoln Highway of The Neck (Mosher) all three layers of the DCF contribute to the carotid sheath
Treatment
Complications Manifestations
Pitting edema over SCM
Torticollis
Manifestations
Manifestations
Dysphagia/odynophagia Drooling and hot potato voice Muffleed voice Reffered otalgia Trismus Displaced tonsil toward midline Deviated uvula
Sublingual space
Sublingual gland Hypoglossal nerve Whartons ducts
Treatment
Underlying pathology External drainage if it progress
- sublingual - submandibula
Manifestations
Dysphagia Odynophagia
Complications
Ludwigs Angina
Ludwigs Angina
Ludwigs angina
Manifestations
1.
2.
Extreme trismus Edema & tenderness over the posterior ramus of mandible
Treatment
External drainage
- deep compartments
Manifestation
Pain in this area Trismus
Treatment
External drainage
Source
Tonsils Esophageal injury Blunt trauma w/ mucosal tear Acute thyroiditis Chest infection
Microbiology
Preantibiotic eraS.aureus
Currentlyaerobic Strep species and non-strep
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
Imaging
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
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
Imaging
MRI "Advantages
No radiation Safer contrast agent Better soft tissue detail Imaging in multiple planes No artifact by dental fillings
"Disadvantages
Treatment
Airway protection
Antibiotic therapy Surgical drainage
Airway protection
"Observation
"Intubation
Direct laryngoscopy: possible risk of rupture and
Ideally = planned, awake, local anesthesia Abscess may overlie trachea Distorted anatomy and tissue planes
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
Treatment
Surgical Drainage
Transoral Preoperative CT where are the great vessels? CT Cruciate mucosal incision, blunt spreading through superior pharyngeal constrictor External drainage
Surgical Drainage
"External EXPOSURE, EXPOSURE!!!
approach
Submandibular incision Submental incision
T-incision
Complication
Airway obstruction
Ruptured abscess
Internal Jugular Vein Thrombosis Carotid artery Rupture Mediastinitis
history Physical examination Secure airway Culture, IV antibiotic CT scan No abcess Small abcess Needle aspiration Watch and wait 24-48 hours for culture and drainage Large abcess
No
Impending complication ?
Clinical improvement ?
Yes
Yes No
Surgical incision And drainage
Complications
Septic thrombosis of IJV Carotid artery erosions Cranial nerve involvement Mediastinitis
Complications
Spread into pharyngomaxilary space through posterior pharyngeal wall
Fasting I.V. antibiotics Tracheotomy Emergent surgical drainage - intraoral drainage - external drainage
Rupture of abcess w/ aspiration & pneumonia Mediastinitis Airway obstruction
Complications
1. 2. 3.
Peritonsillar
PMS
Parotid
Retropharingeal VVS
Danger
Prevertebral
Anterior Visceral
Mediastinum