Deep Space Neck [EDocFind.com][1]
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Transcript of Deep Space Neck [EDocFind.com][1]
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Deep space infections of the neck and floor of mouth
Dr David Maritz
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Introduction
• Penicillin 1940’s
• Odontogenic infections
• Deep anatomic fascial space
• Threaten vital structures
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Introduction
• Most important:• Submandibular• Lateral Pharyngeal• Retropharyngeal / Danger / Prevertebral
• Clinical examination underestimate extent in 70%
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Potential pathways of extension of deep fascial space infections of the head and neck
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Fascial spaces around the mouth and face
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Figure 69-4 Natural progression of dental infection. The pathways by which such infections may travel are: 1, postzygomatic (from canine fossa in cuspid and bicuspid region; pterygomaxillary fossa communicates from rear); 2, vestibular; 3, facial; 4, submandibular; 5, sublingual; 6, palatal; 7, antral; 8, pterygomandibular; 9,
parapharyngeal; 10, masseteric. (Redrawn from Rose LF, Hendler BH, Amsterdam JT: Temporomandibular disorders and odontic infections. Consultant 22:125, 1982.)
Downloaded from: Rosen's Emergency Medicine (on 15 January 2009 05:57 PM)
© 2007 Elsevier
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Clinical examination of odontogenic infections
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Stages of infection
• 4 stages
• Inoculation
Cellulitis
Abscess
Rupture
• Spreading odontogenic infection
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Trismus
• Inability to open mouth widely
• Inflammation muscles of mastication
• Masticator space / Pterygomandibular space
• Difficult intubation
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Airway / Physical evaluation
• Pharyngeal swelling – difficulty swallowing
• Difficulty sleeping supine
• Sniffing position – Retropharyngeal space
• Head deviated to opposite side – Lateral pharyngeal space
• Muffled voice – Epiglottitis
• Distant quality to voice – Retropharyngeal / Lateral Pharyngeal
• Elevated tongue – Sublingual space
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Intraoral examination
• Caries• Swellings of oral vestibule• Periodontal disease• Tooth mobility• Pericoronitis• Swellings• Position of uvula
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Radiographic evaluation
• Rapid CT scanners
• Contrast enhanced CT
• Postero-anterior / lateral soft tissue x-rays of neck
• Dental panoramic view (Orthopantomogram)
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Lateral radiograph of the neck
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Figure 69-5 Periapical abscesses (arrows) as seen on Panorex film.
Downloaded from: Rosen's Emergency Medicine (on 15 January 2009 06:07 PM)
© 2007 Elsevier
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Culture and sensitivity testing
• Penicillin resistance 30 – 50%
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1. Submandibular Space
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Introduction
• ‘’Ludwigs angina’’
• ‘’Angina maligna’’
• ‘’Morbus strangulatorius’’
• ‘’Garotillo’’
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Early appearance of patient who has Ludwig’s angina with characteristic submandibular ‘’woody’’ swelling
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Anatomy and pathogenesis
• Sublingual and submylohyoid spaces
• Odontogenic ( periapical abscesses of mandibular molars – 2nd / 3rd)
• Communicate freely:• Entire submandibular space• Buccopharyngeal gap – lateral pharyngeal space – retropharyngeal space
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Anatomic relationships in submandibular infections
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Routes of spread of odontogenic orofacial infections along planes of least resistance
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Clinical manifestations
• Mouth pain / stiff neck / drooling / dysphagia
• No trismus
• Woody inflammation
• No lymph node involvement
• Protruding tongue
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Ludwig's Angina
• Involvement submandibular spaces bilaterally and submental space in midline
• Rapid spread to lateral pharyngeal / retropharyngeal space
• Rapidly obstruct upper airway
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Early Ludwig's angina
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Early Ludwig's angina
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Submandibular space abscess and Cellulitis
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Potential complications
• Airway compromise
• Spread into the lateral pharyngeal space and beyond
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Figure 69-6 Extensive spread of infection of odontogenic origin involving masseteric, sublingual, submental, and submandibular spaces with extension to mediastinum. A, Preoperative. B, Postoperative. Note drainage from mediastinum. (From Guernsey LH: Practical problem solving in oral surgery. In Cohen DW [ed]: Continuing
Dental Education, vol 2, suppl 10. Philadelphia, University of Pennsylvania School of Dental Medicine, 1979.)
Downloaded from: Rosen's Emergency Medicine (on 15 January 2009 06:09 PM)
© 2007 Elsevier
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Figure 69-6 Extensive spread of infection of odontogenic origin involving masseteric, sublingual, submental, and submandibular spaces with extension to mediastinum. A, Preoperative. B, Postoperative. Note drainage from mediastinum. (From Guernsey LH: Practical problem solving in oral surgery. In Cohen DW [ed]: Continuing
Dental Education, vol 2, suppl 10. Philadelphia, University of Pennsylvania School of Dental Medicine, 1979.)
Downloaded from: Rosen's Emergency Medicine (on 15 January 2009 06:07 PM)
© 2007 Elsevier
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Therapeutic considerations
• Mixed infection – synergistic interaction
• Immunocompromised
• MRSA
• Candida / Aspergillus
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2. Lateral Pharyngeal Space
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Potential pathways of extension of deep fascial space infections of the head and neck
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Anatomy and pathogenesis
• Anterior / muscular compartment
• Posterior / neurovascular compartment• Carotid sheath• 9 to 12 cranial nerves• Sympathetic trunk
• Peritonsillar abscesses
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Clinical manifestations
• Anterior compartment• Dysphagia• Trismus• pain
• Posterior compartment• No trismus• Neurologic / vascular• Edema epiglottis / larynx
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Abscess of lateral Pharyngeal space
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Potential complications
• NB: Posterior compartment
• Laryngeal edema
• Vagal nerve
• Horner's syndrome
• Cranial nerve palsies
• Suppurative jugular thrombophlebitis (lemierre syndrome)
• Carotid artery erosion
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Lemierre’s Syndrome
• Septic thrombophlebitis of internal jugular vein
• Septic emboli – lung / liver abscesses / septic arthritis
• Fusobacterium necrophorum
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Jugular venous thrombosis
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Therapeutic considerations
• Suppurative
• Posterior more conservative
• Anterior more aggressive treatment
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3. Retropharyngeal / Prevertebral / Danger Space
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Introduction
• Caudal extension of infection
• Considered together
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Anatomy and pathogenesis
• Between pharynx-esophagus and spine
• Delineated by fascial planes: 3 layers of deep cervical fascia
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Retropharyngeal space
• Base skull to C7 / T1
• Mediastinal spread
• Pleural / pericardial spread
• Deep cervical chain of nodes in children
• Other causes eg: oesophageal instrumentation, foreign bodies….
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Retropharyngeal abscess
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Retropharyngeal space
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Danger space
• Base skull to diaphragm
• Contiguous spread from adjacent spaces
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Prevertebral space
• Between prevertebral fascia and vertebral bodies
• Base skull to coccyx
• Contiguous with psoas muscle sheath
• Haematogenous spread NB• Local instrumentation• Contiguous spread
• Different microbiology
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Clinical manifestations
Retropharyngeal danger space
• Sore throat / dysphagia / stiff neck
• Upper airways obstruction
• Head tilt contralateral side
• Pleuritic chest pain
• Bulging posterior oropharynx
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Lateral radiograph of the neck
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Prevertebral space
• Spinal cord compression
• Epidural abscess
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Potential complications
• Laryngeal inflammation
• Rupture with aspiration
• Descending necrotizing mediastinitis
• Pyothorax / pericardial involvement
• Spinal epidural collections
• Psoas muscle infection
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Therapeutic considerations
• Retropharyngeal / danger space:• Adequate anaerobic / oral gram + cover• Surgery if indicated
• Prevertebral:• Surgical drainage• NB gram + / MRSA / gram - rods
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4. Buccal space
• Subcutaneous space
• Connects to: infraorbital space, periorbital tissues, superficial temporal space
• Hemophilus influenzae Cellulitis:• Children• Recent URTI / sinusitis
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Buccal Cellulitis (Hib)
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5. Infraorbital space
• Lower lid / periorbital swelling
• Point medially (inner canthus) or laterally (lateral canthus)
• Septic thrombophlebitis angular vein → cavernous sinus
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6. Orbital space
• Preseptal Cellulitis
• Subperiosteal abscess (orbital wall)
• Orbital Cellulitis / abscess → optic nerve damage / cavernous sinus thrombosis
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7. Vestibular space
• Diffuse facial swelling
• Elevation of the oral vestibule
• Potential space between oral mucosa and muscles facial expression
• Draining sinus
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8. Subperiosteal space
• Dental infection
• Perforates cortical layer but not periosteum
• Eg: mandibular subperiosteal infection
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9. Submental space
• Secondary spread from submandibular space
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10. Masticator space
• Severe trismus
• Surrounding muscles of mastication
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Masticator space infection with trismus
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Masticator space abscess
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11. Temporal space
• Trismus (infratemporal fossa – part of masticator space)
• Cavernous sinus thrombosis
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Deep temporal space infection with spread to parotid space
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Treatment
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The admission decision
• Airway issues
• High fever
• Dehydration
• Need for I+D
• Inpatient control systemic disease
• Immune compromise
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Airway security
• Protect against aspiration
• ETT ruptures abscess
• Trismus / Swelling
• Maintain airway reflexes during intubation
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Surgical treatment
• Gravity dependent surgical drainage
• Antibiotics secondary
• Tooth extraction
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Antibiotic therapy
• Predominately anaerobic nature
• Initially: aerobic streptococci ( penicillin )
• Later: anaerobic bacteria ( penicillin resistant )
• Synergistic interaction
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Complications
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Mediastinitis
• Airway security
• Contrast CT
• Open thoracotomy
• Broad spectrum antibiotics
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Cavernous sinus thrombosis
• Ascending septic thrombophlebitis
• Anterior route – angular vein (infraorbital space)
• Posterior route – facial vein (buccal space)
• Congestion retinal veins
• CN 6 paresis → ophthalmoplegia / blindness
• Severe orbital / periorbital / infraorbital swelling
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Cavernous Sinus Thrombosis
• Treatment:
• Tooth extraction root canal• Drainage deep spaces• High dose IV antibiotics• Anticoagulation
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Summary
• Preventative dental care
• Effective antibiotics