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Head and Neck InfectionsJonathan Fleurat, MD

Emergency Medicine, PGY-2Boston Medical Center

+Outline

Facial Infections Introduction

Common etiology Odontogenic infections Parotiditis Sinusitis Orbital Infections

Deep Neck Space Infections

Complications

Summary

+Some History

Pre-antibiotic era: 31 case Ludwig’s angina, 54% died

1940 Ashbel Williams

The antibiotic era: reduced to 4%.

1979 Hought RT

+Facial Infections

+Abscess vs. Cellulites

+Etiology

Odontogenic

Tonsillitis

IV drug injection

Trauma

Foreign body

Sialoadenitis

Parotitis

Osteomyelitis

Epiglottitis

URI

Iatrogenic

Congenital anomalies

Idiopathic

+Odontogenic Infections: Anatomy

+Odontogenic Infections: Microbiology

Multiple bacteria

anaerobic vs aerobic vs mixed

35% 5% 60%

Aerobic G(+) streptococci

Anaerobic G(+) cocci G(+) rods

+Odontogenic Infections: Management

Physical Exam Vital signs, palpation,

teeth, x-ray

History Taking When, Where, How,

Why, Duration

Signs and symptoms: pain swelling warmth redness trismus

Abscess vs. Cellulitis

Immunocompromised

11+

Odontogenic Infections: Treatment

Indications for antibiotics Rapid, diffuse or progressive swelling Immunocompromised Involvement of facial spaces Severe pericoronitis/abscess Osteomyelitis

Situations in which use of antibiotics is not necessary Dry socket Mild pericoronitis/chronic or vestibular abscess

Odontogenic Infections: Treatment

13

When to refer

Rapid infection spread

Breathing or swallowing difficulties

Facial space infection

Fever

Trismus (<10mm)

Toxic appearance

Compromised State

+Facial Infections: Parotiditis

• Usually viral: Paramyxovirus• Bacterial: elderlyimmunohigher risk with dehydration• Treatment: lemon dropsmassagehydrationwarmth

•If purulent- IV antibioticsCompetent: for oral bacteriaImmunocompromised: broad spectrum

+Facial Infections: Sinusitis

Signs and symptoms H/A, facial pain in sinus

distribution purulent yellow-green

rhinorrhea Fever CT more sensitive than

plain films

+Facial Infections: Sinusitis Continued Complications

ethmoid sinusitis: orbital cellulits and abscess

frontal sinusitis: may erode bone (Potts Puffy Tumor, Brain Abscess)

Orbital Cellulitis Cavernous Sinus Thrombosis

+At Risk: Cavernous sinus thrombosis

+Deep Neck Infections

+Deep Neck Infections: Clinical Presentation

Pediatric Symptoms:

- Fever

- Decreased PO

- Odynophagia

- Malaise

- Torticollis

- Neck pain

- Otalgia

Most Common Symptoms:

- Sore throat (72%)

- Odynophagia (63%)

- Neck swelling (70%) (excluding peritonsillar abscesses)

- Neck pain (63%)

- HA

- Trismus

- Neck swelling

- Vocal quality change

- Worsening of snoring

- Sleep apnea

+Deep Neck Infections: Imaging

Lateral neck plain film Normal:

7mm at C-2 14mm at C-6 for kids 22mm at C-6 for adults

Technique dependent Extension Inspiration

Sensitivity 83% compared to CT 100%

+ Imaging

+Mediastinitis Imaging

Plain films Widened mediastinum

(superiorly) Mediastinal emphysema Pleural effusions Changes appear late in the

disease

CT neck and thorax Esophageal thickening Obliterated normal fat

planes Air fluid levels Pleural effusions CT helps establish dx and

surgical plan

+Deep Neck Infections: Imaging MRI

Pros More precise Less dental artifact Better for floor of mouth No radiation Non iodine contrast

Cons Cost Pt cooperation Slower (19 to 35 minutes)

CT with contrast Pros

Widely available Faster (5-15 minutes) Abscess vs cellulitis Less expensive

Cons Contrast Radiation Uniplanar Dental artifacts

+Deep Neck Infections: Antibiotic Therapy

Initial Therapy Admit Antibiotics: Gm+ and

anaerobes If diabetic: also Gm- IV abx only If no clinical

improvement in 24-48 hours, proceed to surgical intervention

+LUDWIG’S ANGINA

Sublingual space

Submaxillary space

+Deep Neck Infections:Ludwig’s Angina Inflammation and cellulitis of

the submandibular space.

Tongue causes airway obstruction.

+/- abscess

Symptoms: drooling trismus pain submandibular mass dyspnea

Most require tracheostomy for airway control.

+Deep Neck Infections: Complications

Airway obstruction Trach: 10-20% Ludwig’s angina: 75%

Mediastinitis – 2.7%

UGI bleeding

Sepsis

Pneumonia

IJV thrombosis

Skin defect

Vocal cord palsy

Hemorrhage 20-80% mortality

Multiple space involvement

+Who Gets Complications?

Older pts

Immunodeficient pts

Cirrhosis

DM 33% with complications Higher mortality rate Prolonged hospital stay

20 days vs. 10 days

+Key Points

Anatomy can help predict spread and complications

Can be life threatening: recognize and consult early

Airway in very sick patients

+Bibliography• The Treatment Principle of Head & Neck Infection.• ENT Emergencies, Division of Emergency Medicine, Stanford University- slides.• Buyten, J, Francis, QB, Deep Neck Space Infections, Department of Otolaryngology, The University of Texas Medical Branch at Galveston, 2005.- slides• Emedicine.com •Herr RD, Serious Soft Tissue Infections of the Head and Neck, American Family Physician, September 1991, Vol 44, no 3, 878-888