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DEEP FASCIAL SPACES IN OMFS AND THEIR
MANAGEMENT
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CONTENTS
Introduction The problem Etiology Pathophysiology Cervical fascia Deep neck spaces and their presentation Microbiology
Lab studies Imaging Treatment
-Medical-Surgical
Follow up care Complications Special considerations Future and controversies References
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INTRODUCTION
For centuries, the diagnosis and
treatment of deep neck spaceinfections have challenged physiciansand surgeons.
The complexity and the deep locationof this region make diagnosis andtreatment of infections in this areadifficult.
These infections remain an importanthealth problem with significant risks ofmorbidity and mortality.
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infections of the deep neck spaces were
associated with high rates of morbidity andmortality
Complication rate of the past has been
reduced with the advent of modernmicrobiology and hematology, the
development of sophisticated diagnostic
tools (eg, CT, MRI),
The effectiveness of modern antibiotics, andthe continued development of medical
intensive care protocols and surgical
techniques.
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The Problem:
Complex anatomy
Deep location
Access
Proximity
Communication
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ETIOLOGY:
Tonsillar and pharyngeal infections
Dental infections or abscesses Oral surgical procedures or removal of
suspension wires
Salivary gland infection or obstruction
Trauma to the oral cavity and pharynx
Foreign body aspiration
Cervical lymphadenitis
Branchial cleft anomalies Thyroglossal duct cysts
Thyroiditis
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Mastoiditis with petrous apicitis and Bezold
abscess Laryngopyocele
IV drug use
Necrosis and suppuration of a malignant
cervical lymph node or mass patients who are immunosuppressed
because of human immunodeficiency virus(HIV) infection, chemotherapy, or
immunosuppressant drugs fortransplantation.
As many as 20-50% of deep neck infectionshave no identifiable cause
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PATHOPHYSIOLOGY
Spread of infection can be from the oral
cavity, face, or superficial neck to the deepneck 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 penetratingtrauma.
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The signs and symptoms of a deep neck
abscess develop because of thefollowing:
Mass effect of inflamed tissue or
abscess cavity on surroundingstructures
Direct involvement of surrounding
structures with the infectious process
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Peritonsillar infections (49%)
Retropharyngeal infections (22%)
Submandibular infections (14%)
Buccal infections (11%) Parapharyngeal space infections (2%)
Canine space infections (2%)
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study by Asmar of retropharyngeal
abscess microbiology demonstratedpolymicrobial culture results in almost90% of patients. Aerobes were found in
all cultures, and anaerobes werefound in more than 50% of patients.Other studies have shown an average
of at least 5 isolates from cultures.
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CLINICAL ASPECTS:
Eliciting a history
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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Physical examination should focus on:
determining the location of theinfection,
the deep neck spaces involved,
and any potential functionalcompromise or complications thatmay be developing.
A comprehensive head and neckexamination should be performed,including examination of the dentitionand tonsils.
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The most consistent signs of a deep
neck space infection are
fever,
elevated WBC count,
and tenderness.
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Other signs and symptoms :
Asymmetry of the neckand associated neck massesor lymphadenopathy - 70% of pediatricretropharyngeal abscesses (Thompson )
Medial displacement of the lateral pharyngeal wall
and tonsil caused by parapharyngeal spaceinvolvement
Trismus - inflammation of the pterygoid muscles
Torticollis and decreased range of motion of the neck- inflammation of the paraspinal muscles
Fluctuance that may not be palpable because of thedeep location and the extensive overlying soft tissueand muscles (eg, sternocleidomastoid muscle)
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Possible neural deficits, particularly of the
cranial nerves (eg, hoarseness from truevocal cord paralysis with carotid sheath andvagal involvement), and Horner syndrome
from involvement of the cervical
sympathetic chain
Regularly spiking fevers (may suggest
internal jugular vein thrombophlebitis and
septic embolization) Tachypnea and shortness of breath (may
suggest pulmonary complications and warn
of impending airway obstruction)
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Cervical Fascia
Superficial Layer
Deep Layer
Superficial
Middle Deep
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C
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Cervical Fascia
Superficial Layer
Platysma
Muscles of Facial
Expression
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C i l F i
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Cervical Fascia
Superficial Layer of
the Deep CervicalFascia
Muscles
Sternocleidomastoid
Trapezius
Glands
Submandibular
Parotid
Spaces
Posterior Triangle
Suprasternal space ofBurns
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C i l F i
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Cervical Fascia
Middle Layer of the
Deep CervicalFascia
Muscular Division
Infrahyoid StrapMuscles
Visceral Division Pharynx, Larynx,
Esophagus,Trachea, Thyroid
Buccopharyngeal
Fascia
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Deep Layer of Deep Cervical
Fascia Alar Layer
Posterior to visceral layer of middlefascia
Anterior to prevertebral layer
Prevertebral Layer
Vertebral bodies
Deep muscles of the neck
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Ce ical Fascia
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Cervical Fascia
Carotid Sheath
Formed by all three layers of deep fascia
Contains carotid artery, internal jugularvein, and vagus nerve
Lincolns Highway
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Deep Neck Spaces
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Deep Neck Spaces
Described in relation to the hyoid
Entire length of the
neck
Suprahyoid
Infrahyoid
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Deep Neck Spaces
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Deep Neck Spaces
Entire Length of Neck: Superficial
Space
Surrounds platysma
Contains areolar tissue, nodes, nerves
and vessels Subplatysmal Flaps
Involved with cellulitis and superficialabscesses
Treat with incision along Langers lines,drainage and antibiotics
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Deep Neck Spaces
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Deep Neck Spaces
Entire Length of Neck:
Retropharyngeal Space Posterior to pharynx and esophagus
Anterior to alar layer of deep fascia
Extends from skull base to T1-T2
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Deep Neck Spaces
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Deep Neck Spaces
Entire Length of Neck: Danger
Space Anterior border is alar layer of deep
fascia
Posterior border is prevertebral layer
Extends from skull base to diaphragm
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Deep Neck Spaces
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Deep Neck Spaces
Entire Length of Neck:Prevertebral Space
Anterior border is prevertebral fascia
Posterior border is vertebral bodies
and deep neck muscles
Extends along entire length ofvertebral column
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Deep Neck Spaces
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Deep Neck Spaces
Entire Length of Neck: VisceralVascular Space
Carotid Sheath
Lincolns Highway
Can become secondarily involved with anyother deep neck space infection by directspread
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Deep Neck Spaces
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Deep Neck Spaces
Suprahyoid: Submandibular
Space Anterior/Lateralmandible
Superiormucosa
Inferiorsuperficial layer of deep
fascia
Posterior/Inferior--hyoid
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Deep Neck Spaces
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Deep Neck Spaces
Suprahyoid:
SubmandibularSpace
Sublingual Space
Areolar tissue
Hypoglossal and lingualnerves
Sublingual gland
Whartons duct
Submylohyoid Space Anterior bellies of
digastrics
Submandibular gland
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Deep Neck Spaces
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Deep Neck Spaces
Suprahyoid: Parapharyngeal
Space Superiorskull base
Inferiorhyoid
Anteriorptyergomandibular
raphe Posteriorprevertebral fascia
Medialbuccopharyngeal fascia
Lateralsuperficial layer of deep
fascia
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Deep Neck Spaces
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Deep Neck Spaces
Suprahyoid: Parapharyngeal
Space Prestyloid
Medialtonsillar fossa
Lateralmedial pterygoid
Contains fat, connective tissue, nodes
Poststyloid
Carotid sheath
Cranial nerves IX, X, XII
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Deep Neck Spaces
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Deep Neck Spaces
Suprahyoid: Peritonsillar Space
Medialcapsule of palatine tonsil Lateralsuperior pharyngeal
constrictor
Superioranterior tonsillar pillar
Inferiorposterior tonsillar pillar
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Deep Neck Spaces
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Deep Neck Spaces
Infrahyoid: Anterior Visceral Space
Middle layer of deep fascia Contains thyroid, trachea, esophagus
Extends from thyroid cartilage intosuperior mediastinum
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Deep Neck Space Infections
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Deep Neck Space Infections
Presentation/Origin of Infection
Microbiology
Imaging
Treatment
Complications
Special Consideration
Presentation/Origin
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Presentation/Origin
Retropharyngeal Abscess 50% occur in patients 6-12 months of age
96% occur before 6 years of age
Children--fever, irritability, lymphadenopathy,torticollis, poor oral intake, sore throat,drooling
Adults--pain, dysphagia, anorexia, snoring,
nasal obstruction, nasal regurgitation Dyspnea and respiratory distress
Lateral posterior oropharyngeal wall bulge
Presentation/Origin
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Presentation/Origin
Pediatrics
Causesuppurativeprocess in lymphnodes
Nose, adenoids,nasopharynx, sinuses
Adults
Causetrauma,instrumentation,extension fromadjoining deep neck
space
Presentation/Origin
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Presentation/Origin
Danger Space
Presentation and exam nearly identical toretropharyngeal space infection
Causeextension from retropharyngeal,
prevertebral or parapharyngeal space
Presentation/Origin
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Presentation/Origin
Prevertebral Space
Back, shoulder, neck pain made worseby deglutition
Dysphagia or dyspnea
CausePotts abscess, trauma,
osteomyelitis, extension from
retropharyngeal and danger spaces
Presentation/Origin
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Presentation/Origin
Visceral Vascular Space
Induration and tenderness over SCM
Torticollis toward opposite side
Spiking fevers, sepsis
Causeintravenous drug abuse,extension from other deep neck spaces
Presentation/Origin
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Presentation/Origin
Submandibular Space Pain, drooling, dysphagia,
neck stiffness
Anterior neck swelling, floorof mouth edema
Cause70-85% haveodontogenic origin
First molar and anterior
Second and third molars
Sialadenitis, lymphadenitis,lacerations of the floor ofmouth, mandible fractures
Presentation/Origin
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Presentation/Origin
Ludwigs angina
Cellulitis, not abscess
Foul serosanguinous fluid,no frank purulence
Fascia, muscle, connectivetissue involvement, sparing
glands Direct spread rather than
lymphatic spread
Tender, firm anterior neckedema without fluctuance
Hot potato voice,drooling
Tachypnea, dyspnea,stridor
Presentation/Origin
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Presentation/Origin
Parapharyngeal Space
Fever, chills, malaise
Pain, dysphagia, trismus
Medial bulge of lateralpharyngeal wall
Causeinfection ofpharynx, tonsil, adenoids,dentition, parotid,mastoid, suppurative
lymphadenitis, extensionfrom other deep neckspaces
Presentation/Origin
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Presentation/Origin
Peritonsillar Space
Fever, malaise Dysphagia,
odynophagia
Hot-potato voice,
trismus, bulging ofsuperior tonsil pole andsoft palate, deviationof uvula
Causeextensionfrom tonsillitis
Presentation/Origin
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Presentation/Origin
Masticator
TemporalSpace
Pain, trismus
Posterior FOMedema
Swelling alongramus ofmandible
Causeodontogenic,from thirdmolars
Parotid
Space Pain,trismus
Medialbulge ofposteriorlateralpharyngealwall
Causeparotitis,sialolithiasis,Sjogrenssyndrome
Presentation/Origin
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Presentation/Origin
Anterior Visceral Space
Hoarseness, dyspnea, dysphagia,odynophagia
Erythema, edema of hypopharynx, may
extend to include glottis and supraglottis Anterior neck edema, pain, erythema,
crepitus
Causeforeign body, instrumentation,
extension of infection in thyroid
Microbiology
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c ob o ogy
Preantibiotic eraS.aureus
Currentlyaerobic Strep species andnon-strep anaerobes
Gram-negatives uncommon
Almost always polymicrobial Resistance
The microbiology of deep neck infections
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gy p
Mixed aerobic and anaerobic organisms, often with apredominance of oral flora.
Both gram-positive and gram-negative organisms may becultured.
Group A beta-hemolytic streptococcal species(Streptococcus pyogenes),
alpha-hemolytic streptococcal species (Streptococcusviridans, Streptococcus pneumoniae),
Staphylococcus aureus, Fusobacterium nucleatum, Bacteroides melaninogenicus,
Bacteroides oralis, andSpirochaeta, Peptostreptococcus, and Neisseria species Pseudomonasspecies,
Escherichia coli, and Haemophilus influenzae
Lab Studies :
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Blood chemistries
Complete blood cell count Clotting profile (particularly important in
patients who require surgical drainage)
Blood cultures (may be indicated in septicpatients)
Abscess cultures with Gram stains (critical
to direct antimicrobial therapy
Imaging
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g g
Lateral neck plain film
Screening exammainly forretropharyngeal andpretracheal spaces
Normal: 6mm at C-2,14mm at C-6 forchildren
22mm at C-6 for adults
Technique dependent
Extension
Inspiration
Nagy, et al Sensitivity 83%,
compared to CT 100%
Imaging
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g g
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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Chest radiography:
To evaluate the mediastinum,
Check for subcutaneous air orpneumomediastinum,
Displacement of the air stripe, orconcurrent pneumonia suggesting
aspiration.
Imaging
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g g
Contrast enhanced
CT Advantages
Quick, easy
Widely available
Familiarity Superior anatomicdetail
Differentiate abscessand cellulitis
Disadvantages Ionizing radiation Allergenic contrast
agent
Soft tissue detail
Artifact
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Imaging
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Contrast enhanced CT
Modality of choice
Miller, et al: CT vs. PE
Accuracy of diagnosis: CT = 77%, PE = 63%
Sensitivity: CT = 95%, PE = 55%
Imaging
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MRI
Advantages No radiation
Safer contrast agent
Better soft tissue detail
Imaging in multiple
planes No artifact by dental
fillings
Disadvantages
Increased cost
Increased exam time
Dependent on patientcooperation
Availability
Munoz, et al: MRI vs. CT
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Arteriography:
This may be helpful when carotid,jugular, or innominate involvement issuggested.
Treatment
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Medical therapy:
Airway
Cultures
Volume andmetabolicresuscitation
I.V Antibiotics
Treatment
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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
Treatment
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LUDWIGS ANGINA = PERILOUS AIRWAY Parhiscar and Har-El Review of 210 patients with
deep neck abscess
Overall, 20.5% requiredtracheostomy
Ludwigs angina, 75%
required tracheostom
Attempted intubation in20 patients
Failed in 11 patients,
Treatment
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Antibiotic Therapy
Cellulitis
Improvement in 24-48 hours
Abscess?
Mayor, et al: review of 31 patients, 19 withCT evidence of abscess, 90% response
Nagy, et al: review of 47 pediatric patients,51% response rate, only 7 of these had CT
evidence of abscess
Treatment
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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
Treatment
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Surgical Drainage
Incision and drainage is the cornerstone oftherapy for the treatment of deep neckspace abscesses
Transoral
Preoperative CTwhere are the great vessels?
Cruciate mucosal incision, blunt spreading throughsuperior pharyngeal constrictor
Nagy, et al: retro-, parapharyngeal or combo in kids
22/23 successfully treated with intraoral incision anddrainage
External
INTRAOPERATIVE DETAILS
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Surgical approaches to the deep neck
spacesApproach used depends on
the precise location of the abscess,
the size of the collection,
and its relation to the great vessels andother important anatomic structures of
the neck.
Treatment
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Surgical Drainage
ExternalEXPOSURE, EXPOSURE, EXPOSURE
Levitt: anterior vs. posterior
approach
Submandibular incision
Submental incision
T-incision
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Treatment
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Image-guided Aspiration Patient selection Smaller abscesses, limited extension,
uniloculated
Poe, et al: CT guided aspiration Early specimen collection, reduced expense,
avoidance of neck scar
Yeow, et al: Ultrasound guided aspiration
8/10 patients successfully treated with needleaspiration
5/5 patients successful treated with pigtailcatheter insertion
NEEDLE ASPIRATION
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FNA may be used in patients with small
easily reachable abscesses or inpatients who are too unstable toundergo general anesthesia.
This procedure may require theassistance of CT scanning orultrasound guidance.
It may provide preliminary culturespecimens before formal incision anddrainage
PRE OPERATIVE DETAILS
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The most important preoperative
considerations are :
stabilization of the airway
volume and metabolic resuscitation
initiation of antibiotics.
POSTOPERATIVE DETAILS :
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Observe the patient for signs of a responseto therapy
Reaccumulation of fluid must be recognizedand treated with appropriate drainageprocedures
Cultures and sensitivities must be monitored,and antibiotics must be tailoredappropriately
The patient's airway must also be monitored
closely for signs of obstruction Finally, the patient must be monitored for
signs of impending complications
FOLLOW UP CARE :
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Monitoring the complete resolution of
the infection Surgical sites must be monitored for
complete healing and to ensure that
reaccumulation of an abscess doesnot occur
Any question of redevelopment of an
infection warrants reimaging andpossible reexploration.
Complications
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Airway obstruction from compression of thetrachea
Aspiration -Due to perforation of aretropharyngeal abscess with drainage ofpus into the airway.
Aspiration may occur spontaneously or
during endotracheal intubation. Vascular complications (ie, thrombosis of
the internal jugular vein, carotid arteryerosion and rupture)
Mediastinitis from inferior spread alongfascial lines
Neurologic deficits:
Complications:
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Septic emboli: These emboli can lead topulmonary, brain, or joint seeding andresultant abscesses.
Septic shock
Necrotizing cervical fasciitis: This is a
fulminant infection involving necrosis of theconnective tissue that spreads via fascialplanes. It has particularly high morbidity andmortality rates.
Osteomyelitis due to local spread to bonesof the spine, mandible, or skull base
Grisel syndrome (ie, inflammatory torticolliscausing cervical vertebral subluxation)
Complications
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Internal Jugular Vein Thrombosis Lemierres syndrome
prostration, swelling and pain alongSCM
Bacteremia, septic embolization, duralsinus thrombosis
IV drug abusers
Treatment
IV antibiotic therapy Anticoagulation?
Ligation and excision
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NECROTISING FASCITIS
Fulminant bacterial infection causingnecrosis of the superficial fascialplanes with widespread involvement
of the surrounding soft tissues andconcurrent systemic toxicity.
Joseph Jones 1871
TermedWilson 1952
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Clinical presentation:
Begins 2-4 days after insult Skin-red, tense, shiny
Within hoursdusky discoloration of
skin with small ill defined purplishpatches.
Blisters and vesicles
Skin beneath blistersnecrotic andblue
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Klabacha (depth of involvement)
Type IEpidermis Type IIDermis
Type IIIFascia
Type IVMuscle
Space 1to galea superiorly,chestwall inferiorly
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Treatment:
Early recognition Definitive surgical drainage and
debridement
- Apron incison
- Fasciotomy (Bear claw) incisions
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Grey foul serosanguinous dishwater
exudate Irrigation
Wound caredigital exploration
Iv antibotics
Autogenous split thickness grafts
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HBOUniv of Maryland protocol
Min of 30 dives at 2-2.4 atm for 90 to 120 min3 times the first day
Twice daily thereafter
Mortality rate30%
COMPLICATIONS:
IJV thrombosis
Carotid erosionMediastinitis
DIC
Intracranial involvement
Complications
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Mediastinitis
Descending necrotizing mediastinitis(DNM)
Mortality of 40%
Increasing dyspnea, chest pain CXR = widened mediastinum
Treatment
EARLY RECOGNITION AND INTERVENTION
Aggressive IV antibiotic therapy
Surgical drainage
Transcervical approach
Chest tube vs. thoracotomy
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Mediastinitis
Descending necrotizing mediastinitis (DNM) Estera- criteria for DNM
Clinical evidence of severe 1.oropharyngeal
infection
2.Characteristic radiographic features ofmediastinitis
3.Documentation of necrotizing mediastinal
infection at operation4.Establishment of relationship between DNM
and oropharyngeal source
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Clinical presentation:
Males 5:1
High fever
Tachycardia
Tachypnea
Hypotension Pleuritic chest pain Dyspnea
Retrosternal discomfort
Brawny edema Induration of neck, chest
Crepitus
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Chest x raywidening of the
mediastinum Pneumomediastinum
Pleural effusion
Obliteration of retrosternal orretrocardiac clarity
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Routes of spread from neck (Flynn)
Pearse8% of cervical infections-pretracheal space to anteriormediastinum
21% - middle mediastinumviscerovascular space 3Alincolnshighway
71% - posterior mediastinum via
Retropharyngeal space to the dangerspace which is continous with theposterior mediastinum.
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TREATMENT :
Early recognition Airway control
Aggressive surgical intervention
Transcervical approach
Chest tube vs. thoracotomy
Appropriate antibiotic therapy
Supportive systemic care
Hbo
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Special Consideration
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Recurrent Deep Neck SpaceInfection
CONGENITAL ABNORMALITY ??
Imaging - diagnosis
Nusbaum, et al: 12 cases of recurrentdeep neck infection
Most Common: second branchial cleft cyst
Others: first, third, fourth branchial cleftcysts, lymphangiomas, thyroglossal ductcysts, cervical thymic cyst
OUTCOME AND PROGNOSIS
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Patients treated for deep neck infectionscan be expected to fully recover as long asthe infection is treated properly and in atimely manner.
Patients whose treatment is delayed canexpect a greater number of complicationsand a prolonged course of recovery.
Once a deep neck infection has fullyresolved, no particular predisposition existsfor recurrence.
FUTURE AND CONTROVERSIES
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The greatest controversy regarding deep
neck infections concerns whether all deepneck abscesses require surgical treatment orwhether some abscesses can be treated
medically.
Surgical therapy can be reserved forpatients whose symptoms do not respond
within 48 hours
However, this issue is still being debated in
the literature, and clinical judgment must be
used with each individual patient.
REFERENCES:
O l d M ill f i l i f ti 4th diti
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Oral and Maxillofacial infections-4th editionTopazian and Goldberg
Anatomy for surgeons-head and neck -Hollinshead Contemporary Oral and maxillofacial surgery-
Larry J Peterson vol-2 Surgical pathology Vol 5-Fonseca series
Surgical anatomy of the head and neck-Mcvay Surgical Management of orofacial infections
Thomas R Flynn - Atlas of oral and maxillofacialclinics of North America Vol 8, number 1, March2000.
Diagnostic imaging of maxillofacial infectionsOMSCNA 2003 39-49
CummingsHead and neck surgery Vol 2
Nonsurgical management of deep neck infections - Tipsfrom Other Journals American Family Physician, May,1992
Necrotizing soft tissue infections: a primary care review
http://www.findarticles.com/p/articles/mi_m3225http://www.findarticles.com/p/articles/mi_m3225/is_n5_v45http://www.findarticles.com/p/articles/mi_m3225/is_n5_v45http://www.findarticles.com/p/articles/mi_m3225http://www.findarticles.com/p/articles/mi_m3225/is_n5_v45http://www.findarticles.com/p/articles/mi_m3225/is_n5_v45http://www.findarticles.com/p/articles/mi_m3225http://www.findarticles.com/p/articles/mi_m3225/is_2_68http://www.findarticles.com/p/search?tb=art&qt=%22Adrienne+J.+Headley%22http://www.findarticles.com/p/articles/mi_m3225/is_n5_v45http://www.findarticles.com/p/articles/mi_m3225/is_n5_v45http://www.findarticles.com/p/articles/mi_m3225 -
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Necrotizing soft tissue infections: a primary care reviewAmerican Family Physician, July 15, 2003 by AdrienneJ. Headley
Extensive deep neck space abscess due to B-Haemolytic group G Streptococci-A case reportMalini A, Mohiyuddin S MA, Indian Journal of MedicalMicrobiology: 2004 : 22 : 263-265
Int J Oral Maxillofac Surg. 2002 Jun;31(3):327-9.
Ultrasound-guided surgical drainage of face and neckabscesses.
Deep Fascial Space Infection of the Neck: A ContinuingChallenge Nashaat S. Hamza, MD, John Farrel, MD,Melvin Strauss, MD, Robert A. Bonomo, MD South Med J
96(9):928-932, 2003. Acute neck infections in children: Turkish Journal ofpediatrics 2004:46
http://www.findarticles.com/p/articles/mi_m3225http://www.findarticles.com/p/articles/mi_m3225/is_2_68http://www.findarticles.com/p/search?tb=art&qt=%22Adrienne+J.+Headley%22http://www.findarticles.com/p/search?tb=art&qt=%22Adrienne+J.+Headley%22http://www.findarticles.com/p/articles/mi_m3225http://www.findarticles.com/p/articles/mi_m3225/is_2_68http://www.findarticles.com/p/search?tb=art&qt=%22Adrienne+J.+Headley%22http://www.findarticles.com/p/search?tb=art&qt=%22Adrienne+J.+Headley%22http://www.findarticles.com/p/search?tb=art&qt=%22Adrienne+J.+Headley%22http://www.findarticles.com/p/search?tb=art&qt=%22Adrienne+J.+Headley%22http://www.findarticles.com/p/articles/mi_m3225/is_2_68http://www.findarticles.com/p/articles/mi_m3225