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Chapter 9 Deep Neck And Odontogenic Infections > Anatomy > Flashcards

Anatomy Flashcards

1
Q

Primary maxillary spaces

A

Canine space
Buccal space

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2
Q

Apical infection of the root of maxillary canine almost exclusively infects what space

A

Canine space

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3
Q

Common manifestation pf canine space infection

A

Swelling lateral to the nose and loss of ipsilateral nasolabial fold

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4
Q

Location of canine space

A

Between the anterior surface of maxilla and the levator labii superioris

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5
Q

Infection of what tooth/teeth will involve the buccal space

A

Maxillary molars

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6
Q

Buccal space becomes involved when?

A

When infection of maxillary molars break out superior to the attachment of buccinator

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7
Q

Buccal space boundaries

A

It lies between the buccinator muscle and the skin
Ovoid space below the zygomatic arch and above the inferior border of mandible

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8
Q

Infection of this space is dramatic in appearance and causes trismus

A

Buccal space

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9
Q

Primary mandibular spaces

A

Submental space,
Sublingual space
Submandibular space

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10
Q

Submental space boundaries

A

Between anterior bellies of digastric
Between mylohyoid muscle and skin

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11
Q

This space is involved when the mandibular incisors, whose roots are long enough to erode the attachment of mentalis muscle, are infected

A

Submental space

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12
Q

This space is involved when the mandibular premolars or molars are infected

A

Sublingual or submandibular space

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13
Q

This determines whether SL or SM space is involved

A

Location of perforation relative to the mylohyoid attachment or the mylohyoid line.

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14
Q

Infection of the premolars and first molar will involve what space?

A

Sublingual space
-apices of premolars and 1st molar is superior to the mylohyoid line

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15
Q

The submandibular space is affected when the following tooth are infected

A

2nd and 3rd molar
Apices are inferior to the mylohyoid line

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16
Q

Boundaries of sublingual space

A

Between the lingual oral mucosa and mylohyoid muscle

It is open posteriorly and communicates freely with the submandibular space and secondary spaces located posteriorly and superiorly

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17
Q

Clinical picture of patients with sublingual space infection

A

Marked intraoral lingual swelling of the FOM.

If bilaterally involved, tongue is elevated and dysphagia

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18
Q

Submandibular space boundaries

A

Between the mylohyoid and skin
Open posteriorly and communicates with secondary spaces easily

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19
Q

Clinical picture of submandibular neck space infection

A

Swelling of inferior lateral border of mandible extending medially to digastric area and posteriorly to the hyoid bone

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20
Q

Infection of all (3) mandibular spaces bilaterally will cause what infection

A

Ludwig’s angina

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21
Q

Characterized by rapid, BILATERAL gangrenous cellulitis of all 3 primary mandibular spaces, manifesting as gross swelling, elevation, displacement of tongue, and tense BRAWNY induration of the submandibular region superior to the hyoid bone and inability to tolerate supine position, severe trismus, drooling, inability to swallow, tachypnea and dyspnea.

A

Ludwig angina

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22
Q

What is the usual cause of ludwig angina?

A

Ondontogenic infection from mandibular molar,

Streptococci then becomes mixed

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23
Q

Known microorganisms that produce tissue destroying enzymes that help spread and infect neck fascial planes

A

Streptococcus anginosus (S.milleri grp)

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24
Q

What does anaerobes produce that helps destroy and spread infection along neck fascial planes?

A

Hyaluronidase
Collagenase
Fibrinolysin

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25
Q

Neck space that is a common site for DNI that subsequently spreads easily to connected spaces. It is an inverted pyramid extending from the skullbase to the hyoid bone. It is divided into two compartments that contains vascular and nervous structures

A

Parapharyngeal space

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26
Q

This structure divides the parapharyngeal space into two compartments

A

Styloid and its muscular attachments
(Pre and poststyloid compartments)

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27
Q

What structures are contained in the post styloid compartment?

A

Sympathetic chain
Cranial Nerves: IX, X, XI, XII

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28
Q

Infection of the poststyloid compartment may lead to an infected thrombus of the internal jugular vein, also known as

A

Lemierre syndrome

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29
Q

Infection of the poststyloid compartment may lead to:

A

Lemierre syndrome
Carotid aneurysm
Horner syndrome
CN Palsies

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30
Q

Horner syndrome triad

A

Ptosis
Miosis
Hemifacial Anhydrosis

(aka oculosympathetic paresis)

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31
Q

This is characterized by thrombophlebitis of the internal jugular vein and bacteremia caused by primarily anaerobic organisms, following a recent oropharyngeal infection (pharyngitis, tonsillitis,w/w/o peritonsillar or retropharyngeal abscess)

A

Lemierre syndrome

32
Q

Lemierre syndrome

A

Invasive infection of Fusobacterium necrophorum
Extracellular leucocidin - plt aggregate w/o lysis which results in intravascular coagulation - septic thrombophlebitis

33
Q

Parapharyngeal neck compartment with higher potential for spread to other neck spaces

A

Prestyloid space (more likely to liquefy fat)

34
Q

Boundaries, contents, and communicating spaces of Peritonsillar space

A

Boundaries:
Palatine tonsil medially
Sup constrictor muscle laterally

Contents:
LCT, tonsillar branches of lingual, facial ascending pharyngeal vessels

CS - parapharyngeal space

35
Q

Boundaries, contents, and communicating spaces of Parapharyngeal space

A

Boundaries:
S- mid fossa base
I- Hyoid bone
A- Pterygomandibular raphe
P- Prevertebral fascia
M- Sup Constri
L- Parotid deep lobe, med pterygoid

Contents:
Prestyloid- fat, LN, IMA, auriculotemporal lingual inf alveolar nerves, pterygoids, deep lobe parotid

Poststyloid- IJV, sup sympathetic chain, CN IX-XII

CS - periton, subman, visceral, retrophar, carotid, masticator, parotid spaces

36
Q

Space located in the kidline, posterior to the pharynx and esophagus, extending from the skull base to T2 vertebra

A

Retropharyngeal space

37
Q

Boundaries, contents, and communicating spaces of Retropharyngeal space

A

Boundaries:
S- Base of skull
I- Sup Mediastinum
A- Pharynx & esophagus
P- Alar fascia
M- Midline raphe of sup constri
L- Carotid sheath

Contents:
LCT and Lymph nodes (draining np, and waldeyer ring)

CS - carotid sheath, sup mediastinum, parapharyngeal space, danger space

38
Q

This is the only barrier that prevents spread of retropharyngeal space infection to the danger space that will allow spread to the diaphragm and access to the superior mediastinum

A

Alar fascia

39
Q

Boundaries, contents, and communicating spaces of Danger space

A

Boundaries:
S- base of skull
I- diaphragm
A- alar fascia of deep layer pf deep cervical fascia
P- prevertebral fascia of deep layer pf deep cervical fascia

Contents:
Loose areolar tissue

CS- regropharyngeal, prevertebral spaces, mediastinum

40
Q

Spread along the vasculature from superior mediastinum to the aortic arch is also known as

A

Lincoln highway

41
Q

Difficulty with mouth opening indicates that inflammation has already spread to what space/s?

A

Parapharyngeal, pterygoid and masseteric spaces

42
Q

Unilateral pharyngeal swelling without inflammatory symptoms

A

Parapharyngeal tumors

(No biopsy or incision without further evaluation)

43
Q

Unilaterally enlarged irregular or ulcerated tonsil with prolonged exposure to tobacco and alcohol

A

Tonsillar malignancy

44
Q

Plain radiography identifies dental sources of infection and salivary stones of what size

A

> 5mm

45
Q

Neck STL finding in retropharyngeal infection

A

(+) Air fluid level
(+) greater than 5mm (pedia) or greater than 7mm (adult) thickening of prevertebral tissue at C2

46
Q

Supraglottitis radiographic findings

A

Thickening of epiglottis or thumbprint sign and/or arytenoids

47
Q

Standard radiographic technique for evaluation of DNI

A

CT scan of head and neck

CT with contrast - bony and soft tissues ,
visualization of vessels and enhancement of areas of inflammation.
Determines if infection is confined within the LN or has spread beyond into fascial planes

Low dose for pedia - 80kVP vs 120kVP (traditional)

48
Q

Role of Ultrasonography in DNI

A

Attractive imaging for pedia d/t noninvasive nature and lack of radiation exposure

For FNA to obtain culture or for therapeutic drainage

49
Q

Initial management of patient suspected of DNI

A

Secure the airway

Airway management - Fiberoptic eval of Upper airway at initial evaluation

*pulse Oximetry may provide false security

50
Q

First line airway therapy

A

Oxygenated face tent with cool mist humidity
IV steroids
Epinephrine nebulizers

Mild airway S/Sx, <50% obstruction at glottic or supraglottic level - usually responds to med therapy alone while at the ER suite or ICU

51
Q

Urgent airway management

A

(+) Greater level of stridor and dyspnea
(+) Airway obstruction >50%

Awake fiberoptic intubation (airway large enough to allow passage of ave flexible bronchoscope (5-6mm)
-airway prep with lido nebulization lido lubricated nasal trumpet, w/w/o light sedation

Elective tracheotomy (if extubation is not anticipated within 24-48hrs, idlf surg drainage are likely to result in significant or prolonged airway edema

52
Q

Antibiotic therapy

A

Broad spectum coverage is mandatory

<2yo - CLINDAMYCIN is initial therapy of choice
- shift to TMP/SMX or vancomycin (clinda resistance or no improvement in 2 days)

Ampicillin-Sulbactam - FIRST LINE DRUG
1.5-3g TIV Q6

53
Q

First line antibiotic for DNI [Community acquired (+ cocci, -rods, anaerobes]

A
  1. Ampicillin Sulbactam 1.5-3g TIV Q6
  2. Clindamycin (pen allergy) 600-900mg TIV Q8
  3. Ampi 1-2g Q6 PLUS Metro 500mg TIV Q6
54
Q

First line antibiotic for DNI [Compromised pt/Nosocomial (Pseudomonas;MRSA) pseudomonal and g-]

A
  1. Pip-Tazo 3g TIV Q6
  2. Imipinem-Cilastatin 500mg TUV Q6
  3. Levoflox (Pen allergy) 750mg TIV Q24
  4. Ciprofloxacin 400mg TIV Q12
55
Q

First line antibiotic for DNI [MRSA]

A
  1. Clindamycin 600-900mg TIV Q8 PLUS Vancomycin 1g TIV Q12
  2. TMP/SMZ (if Clinda resistant) 10m/k/d ➗Q8 PLUS Vancomycin 1g TIV Q12
56
Q

First line antibiotic for Necrotizing Fasciitis [Mixed positive and anaerobes]

A

Ceftriaxone 2g TIV Q8 PLUS Clindamycin 600-900mg TIV Q8, PLUS Metronidazole 500mg TIV Q6

57
Q

Antibiotic regimen

A

Clinical improvement after 48-72 hrs, extend for 24hrs after normalization of symptoms then 2 weeks equivalent of oral antibiotics

58
Q

Principles in considering SURGICAL management of DNI

A
  • Antibiotic availability in pus filled spaces is limited
  • Treatment of fascial space infection depends on open incision and dependent drainage
  • Fascial planes are contiguous (should open all primary and secondary spaces, drain and possibly irrigation catheters placed)
  • involved teeth should be extracted ideally at time of I&D
59
Q

Absolute indications for surgical drainage

A

Surgical drainage is necessary when:

  • Air fluid level in the neck or evidence of gas producing organisms
  • airway compromise from abscess or phlegmon
  • Failure to respond to 48-72 hrs empiric antibiotics
  • Presence of complications
60
Q

Needle aspiration

A

Use of G16-18 IV cannula

Done for small abscess comtained within the confines of the LN or acute infection of suspected congenital cyst or fibrotic pseudocyst

61
Q

Procedures that promote high likelihood for success of peritonsillar I&D

A

IVF rehydration, Pain meds, Antibiotics and steroids administered at least 1 hour before procedure.

62
Q

Steps in doing peritonsillar I&D

A
  • Topical anesthetic spray
  • Lido epi 1:100,000 - 1-2 cc injected into mucosa of soft palate
  • Initial attempt of aspiration
  • 1-2cm mucosa & submucosa incision along normal curvature 1cm behind the edge of anterior pillar
  • Vertical spreading
  • Irrigation with NSS thru the incision using G18 angiocatheter
  • Discharged and ff up after 48-72hrs

Tonsillectomy at a later date(periton abscess hx, recurrent/chronic tonsillitis, obstructive sx d/t tonsillar hypertrophy)

63
Q

Quinsy Tonsillectomy

A

Acute tonsillectomy done at time of presentation in cases of recurrent periton abscess, tonsillitis or if GA is needed due to patient discomfort and or poor exposure

  • more difficult and bloody d/t surrounding inflamm
64
Q

Surgical Incision & drainage of Ludwig angina

A

Neck incision with dependent drainage in bilateral FOM thru the mylohyoid muscle

1/2 inch Penrose drain or gauze wick secured with silk

65
Q

Surgical Incision & drainage of buccal space involvement

A

Transoral incision of buccal mucosa and blunt dissection parallel to CN VII through the buccinator

1/2 inch Penrose drain or gauze wick secured with silk

66
Q

Surgical Incision & drainage of masticator space involvement

A

Incision of retromolar trigone bwith blunt dissection through the masseter

1/2 inch Penrose drain or gauze wick secured with silk

67
Q

Surgical Incision & drainage of retropharyngeal space involvement

A

Transoral - transmucosal aspiration after securing airway and use of tonsil gag

68
Q

What are the 4 transcervical incisions for DNI?

A

Preauricular parotid incision with neck extension (parotid & temporal abscess)

Horizontal neck incision ( masticator, parapharyngeal, pterygoid, submandibular, prevertebral, retropharyngeal, carotid, lateral neck space)

Midline horizontal neck incision ( strap muscles, thyroid & trachea)

Horizontal submental incision (bilateral submandibular space, FOM)

69
Q

Thrombophlebitis of internal jugular vein

A

Lemierre Syndrome

70
Q

Common course of disease in Lemierre syndrome

A

Period of pharyngitis before progression to fever, lethargy, lateral neck tenderness and edema, occasional trismus, septic emboli commonly seen as bilateral nodular infiltrates on chest xray

71
Q

Confirmatory imaging for Lemierre syndrome

A

Neck CT with contrast
- filling defect in the IJV

72
Q

Management of Lemierre Syndrome

A

IV B lactamase resistant IV antibiotics w/w/o heparin
Surgical excision of IJV if with worsening clinical course

73
Q

Cavernous sinus thrombosis Signs and symptoms

A

FEVER
LETHARGY
ORBITAL PAIN
PROPTOSIS
REDUCED EOM
DILATED PUPIL
SLUGGISH PUPILLARY LIGHT REFLEX

74
Q

Mechanism of infection in CST

A

Retrograde spread from upper dentition or PNS via the VALVELESS OPHTHALMIC VENOUS SYSTEM to the cavernous sinus

75
Q

Carotid artery pseudoaneurysm or rupture hallmarks

A

Pulsatile neck mass,
Horner syndrome
CN palsies 9-12
Expanding hematoma or neck ecchymosis
Bright red blood from the nose or mouth in the setting of DNI

76
Q

Mediastinitis presentation

A

Diffuse neck edema
Dyapnea
Pleuritic pain
Tachycardia
Hypoxia
Pleural effusion
Mediastina widening on cxr

(Pedia <2yo, MRSA, retropharyngeal space involvement)

77
Q

Rapidly progressive cellulitis with pitting edema and peau d’ orange with or without subcutaneous crepitus

A

Necrotizing fasciitis

Chapter 9 Deep Neck And Odontogenic Infections (2 decks)

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