Anatomy Flashcards
Primary maxillary spaces
Canine space
Buccal space
Apical infection of the root of maxillary canine almost exclusively infects what space
Canine space
Common manifestation pf canine space infection
Swelling lateral to the nose and loss of ipsilateral nasolabial fold
Location of canine space
Between the anterior surface of maxilla and the levator labii superioris
Infection of what tooth/teeth will involve the buccal space
Maxillary molars
Buccal space becomes involved when?
When infection of maxillary molars break out superior to the attachment of buccinator
Buccal space boundaries
It lies between the buccinator muscle and the skin
Ovoid space below the zygomatic arch and above the inferior border of mandible
Infection of this space is dramatic in appearance and causes trismus
Buccal space
Primary mandibular spaces
Submental space,
Sublingual space
Submandibular space
Submental space boundaries
Between anterior bellies of digastric
Between mylohyoid muscle and skin
This space is involved when the mandibular incisors, whose roots are long enough to erode the attachment of mentalis muscle, are infected
Submental space
This space is involved when the mandibular premolars or molars are infected
Sublingual or submandibular space
This determines whether SL or SM space is involved
Location of perforation relative to the mylohyoid attachment or the mylohyoid line.
Infection of the premolars and first molar will involve what space?
Sublingual space
-apices of premolars and 1st molar is superior to the mylohyoid line
The submandibular space is affected when the following tooth are infected
2nd and 3rd molar
Apices are inferior to the mylohyoid line
Boundaries of sublingual space
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
Clinical picture of patients with sublingual space infection
Marked intraoral lingual swelling of the FOM.
If bilaterally involved, tongue is elevated and dysphagia
Submandibular space boundaries
Between the mylohyoid and skin
Open posteriorly and communicates with secondary spaces easily
Clinical picture of submandibular neck space infection
Swelling of inferior lateral border of mandible extending medially to digastric area and posteriorly to the hyoid bone
Infection of all (3) mandibular spaces bilaterally will cause what infection
Ludwig’s angina
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.
Ludwig angina
What is the usual cause of ludwig angina?
Ondontogenic infection from mandibular molar,
Streptococci then becomes mixed
Known microorganisms that produce tissue destroying enzymes that help spread and infect neck fascial planes
Streptococcus anginosus (S.milleri grp)
What does anaerobes produce that helps destroy and spread infection along neck fascial planes?
Hyaluronidase
Collagenase
Fibrinolysin
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
Parapharyngeal space
This structure divides the parapharyngeal space into two compartments
Styloid and its muscular attachments
(Pre and poststyloid compartments)
What structures are contained in the post styloid compartment?
Sympathetic chain
Cranial Nerves: IX, X, XI, XII
Infection of the poststyloid compartment may lead to an infected thrombus of the internal jugular vein, also known as
Lemierre syndrome
Infection of the poststyloid compartment may lead to:
Lemierre syndrome
Carotid aneurysm
Horner syndrome
CN Palsies
Horner syndrome triad
Ptosis
Miosis
Hemifacial Anhydrosis
(aka oculosympathetic paresis)
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)
Lemierre syndrome
Lemierre syndrome
Invasive infection of Fusobacterium necrophorum
Extracellular leucocidin - plt aggregate w/o lysis which results in intravascular coagulation - septic thrombophlebitis
Parapharyngeal neck compartment with higher potential for spread to other neck spaces
Prestyloid space (more likely to liquefy fat)
Boundaries, contents, and communicating spaces of Peritonsillar space
Boundaries:
Palatine tonsil medially
Sup constrictor muscle laterally
Contents:
LCT, tonsillar branches of lingual, facial ascending pharyngeal vessels
CS - parapharyngeal space
Boundaries, contents, and communicating spaces of Parapharyngeal space
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
Space located in the kidline, posterior to the pharynx and esophagus, extending from the skull base to T2 vertebra
Retropharyngeal space
Boundaries, contents, and communicating spaces of Retropharyngeal space
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
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
Alar fascia
Boundaries, contents, and communicating spaces of Danger space
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
Spread along the vasculature from superior mediastinum to the aortic arch is also known as
Lincoln highway
Difficulty with mouth opening indicates that inflammation has already spread to what space/s?
Parapharyngeal, pterygoid and masseteric spaces
Unilateral pharyngeal swelling without inflammatory symptoms
Parapharyngeal tumors
(No biopsy or incision without further evaluation)
Unilaterally enlarged irregular or ulcerated tonsil with prolonged exposure to tobacco and alcohol
Tonsillar malignancy
Plain radiography identifies dental sources of infection and salivary stones of what size
> 5mm
Neck STL finding in retropharyngeal infection
(+) Air fluid level
(+) greater than 5mm (pedia) or greater than 7mm (adult) thickening of prevertebral tissue at C2
Supraglottitis radiographic findings
Thickening of epiglottis or thumbprint sign and/or arytenoids
Standard radiographic technique for evaluation of DNI
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)
Role of Ultrasonography in DNI
Attractive imaging for pedia d/t noninvasive nature and lack of radiation exposure
For FNA to obtain culture or for therapeutic drainage
Initial management of patient suspected of DNI
Secure the airway
Airway management - Fiberoptic eval of Upper airway at initial evaluation
*pulse Oximetry may provide false security
First line airway therapy
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
Urgent airway management
(+) 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
Antibiotic therapy
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
First line antibiotic for DNI [Community acquired (+ cocci, -rods, anaerobes]
- Ampicillin Sulbactam 1.5-3g TIV Q6
- Clindamycin (pen allergy) 600-900mg TIV Q8
- Ampi 1-2g Q6 PLUS Metro 500mg TIV Q6
First line antibiotic for DNI [Compromised pt/Nosocomial (Pseudomonas;MRSA) pseudomonal and g-]
- Pip-Tazo 3g TIV Q6
- Imipinem-Cilastatin 500mg TUV Q6
- Levoflox (Pen allergy) 750mg TIV Q24
- Ciprofloxacin 400mg TIV Q12
First line antibiotic for DNI [MRSA]
- Clindamycin 600-900mg TIV Q8 PLUS Vancomycin 1g TIV Q12
- TMP/SMZ (if Clinda resistant) 10m/k/d ➗Q8 PLUS Vancomycin 1g TIV Q12
First line antibiotic for Necrotizing Fasciitis [Mixed positive and anaerobes]
Ceftriaxone 2g TIV Q8 PLUS Clindamycin 600-900mg TIV Q8, PLUS Metronidazole 500mg TIV Q6
Antibiotic regimen
Clinical improvement after 48-72 hrs, extend for 24hrs after normalization of symptoms then 2 weeks equivalent of oral antibiotics
Principles in considering SURGICAL management of DNI
- 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
Absolute indications for surgical drainage
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
Needle aspiration
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
Procedures that promote high likelihood for success of peritonsillar I&D
IVF rehydration, Pain meds, Antibiotics and steroids administered at least 1 hour before procedure.
Steps in doing peritonsillar I&D
- 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)
Quinsy Tonsillectomy
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
Surgical Incision & drainage of Ludwig angina
Neck incision with dependent drainage in bilateral FOM thru the mylohyoid muscle
1/2 inch Penrose drain or gauze wick secured with silk
Surgical Incision & drainage of buccal space involvement
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
Surgical Incision & drainage of masticator space involvement
Incision of retromolar trigone bwith blunt dissection through the masseter
1/2 inch Penrose drain or gauze wick secured with silk
Surgical Incision & drainage of retropharyngeal space involvement
Transoral - transmucosal aspiration after securing airway and use of tonsil gag
What are the 4 transcervical incisions for DNI?
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)
Thrombophlebitis of internal jugular vein
Lemierre Syndrome
Common course of disease in Lemierre syndrome
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
Confirmatory imaging for Lemierre syndrome
Neck CT with contrast
- filling defect in the IJV
Management of Lemierre Syndrome
IV B lactamase resistant IV antibiotics w/w/o heparin
Surgical excision of IJV if with worsening clinical course
Cavernous sinus thrombosis Signs and symptoms
FEVER
LETHARGY
ORBITAL PAIN
PROPTOSIS
REDUCED EOM
DILATED PUPIL
SLUGGISH PUPILLARY LIGHT REFLEX
Mechanism of infection in CST
Retrograde spread from upper dentition or PNS via the VALVELESS OPHTHALMIC VENOUS SYSTEM to the cavernous sinus
Carotid artery pseudoaneurysm or rupture hallmarks
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
Mediastinitis presentation
Diffuse neck edema
Dyapnea
Pleuritic pain
Tachycardia
Hypoxia
Pleural effusion
Mediastina widening on cxr
(Pedia <2yo, MRSA, retropharyngeal space involvement)
Rapidly progressive cellulitis with pitting edema and peau d’ orange with or without subcutaneous crepitus
Necrotizing fasciitis
