Chapter 3 - Deep Neck Infxn Flashcards
Signs of airway compromise
Trismus, dysphonia, “hot potato voice,” stridor, stertor
Tachypnea and O2 desats are late manifestations
When to just use IV ABx for deep neck infxn
Stable, antibiotic-naive patients, w/out clinical or radio graphic signs of abscess
Source of DNSI adult vs child
Adult- teeth (enamel eroded by plaque bacteria —> periapical abscess —> mandible/maxilla/deep neck
Also cellulitis, trauma, FB, IVDU, congenital lesions
Kid- bacterial pharyngotonsillitis —> para/retro/LN 2-4
Classic PTA signs
Trismus, uvula devation, muffled voice, soft palatal edema
RF for DNSI
Low education, live >1 hr from tertiary care center, tonsils present, Strep infxn, substance abuse, poor dental hygiene
Describe Fascial Planes
SCF: SQ, expression, involves SMAS, platysma
SDCF: parotid and SM gland, masticate, trap, SCM, forms stylomandibular ligament
MDCF: organs (larynx, pharynx, trachea, esophagus, thyroid, para), straps
DDCF: alar (SNS trunk), prevert (paraspinal, vert), layers coalesce to form carotid sheath
Retropharyngeal, Danger Space
Anterior to Posterior: BP Fascia (visceral) RP Space (ends @ mediastinum, T1-6) Alar fascia Danger Space (SB to diaphragm) Prevertebral Fascia Prevertebral Space
What’s in prevertebral Space
prevertebral muscles (longus colli and longus capitis), vertebral artery, vertebral vein, scalene muscles, phrenic nerve and part of the brachial plexus.
Trapezius
O: EOP, SP C7-T12
I: NL, lateral 1/3 posterior clavicle, acromion process, spine scapula
A: transverse cervical (sup br)
N: IX (m), ventral rami c3-4 (s)
A: rotate, retract, elevate, depress scapula
SCM
O: manubrium, medial clavicle
I: mastoid process, SNL
A: occipital, superior thyroid
N: IX, C2-3 ventral rami
A: u/l- c/l rotation, I/l flexion
B/l- flexion, elevate sternum, forced inhalationLongus colli
O: TP C5-T3 I: ant arch atlas A: ascending pharyngeal, vertebral arteries N: C2-6 A: flex neck and head
Longus capitis
O: TP C3-6
I: Occip Bone
N: C1-3/4
A: flex neck at Atlanto-Occ Joint
Erector Spinae
O: SP T9-12, Iliac Crest I: SP cerv, T1-2 A: lateral sacral artery N: spinal A: extend vertebral column
Levator Scapulae
O: TP C1-4 I: medial border scapula A: dorsal scapular N: C3-4, C5 (dorsal scapular) A: elevate, rotate scapula
Splenius
O: NL, SP C7-T3 I: mastoid, occip A: aorta br N: post ramus C3-4 A: Ext, Rot, Lat flex head
Scalenes
O: c2-7 I: Ribs 1-2 A: Asc Cerv (off ITA) N: C3-6 A: elevate ribs 1-2
Source of infections:
Peritonsillar
Parapharyngeal
SubM/L
Tonsil
Tonsil/pharynx
Gingiva, teeth, gland
Source of infections: Retropharyngeal Prevertebral Danger Carotid sheath
- Nose/Sinus, NP, vert bodies
- heme/ contig from vert/discs (S Aureus, not usually anaerobes)
- Para or retropharyngeal
- “
Note: prevertebral Space infections can also spread to danger space
Diseases that masquerade as DNSI
Thyroglossal duct cyst, lymphatic malformations, Branchial cleft cyst
Neoplasm
Symptoms, Workup, Treatment of mediastinitis
Tachycardia, dyspnea, pleuritic chest pain
CXR widening mediastinum
Get contrast chest CT
IV ABx, thoracic c/s, ICU, May need drainage per thoracics
DNSI Bacteria
Oral flora
Strep, peptostrep, actinomyces, fusobact, prevotella
Immunocomp/DM/Postop: S Aureus, Pseudo, GNR
Symptoms of DNSI
Neck pain, fever, dysphagia, neck swell, odynophagia
If dysphonia, eval with laryngoscopy
Key PE steps with DNSI
Size/induration/swell/fluctuance, color change (mark cellulitic area) Feel for crepitus (gas bact) Cranial neuropathies (valve ext with nasal or midface soft tissue infxn)
Cause of trismus with DNSI
Inflamed parapharyngeal, masseteric, pterygoid, temporal spaces
May lead to difficulty manage secretions, airway compromise
Muscles that open jaw
Lateral pterygoid, digastric (when mass/temp relaxed), mylohyoid
DNSI Workup
CBC Diff
XR (if retropharyngeal)
U/S (differ cellulitic vs abscess, guidance)
CT w Con (abscess is hypodense focus centrally with peripheral enhance)
Differentiate SM space vs SL Space
SL: Sup to mylo, from infxn incisors
SM: Inf to mylo, 2/3 molars
Signs of carotid sheath infection
Horners
Pulsatile mass with ecchymosis
BRB nose/mouth/EAC
Cranial nerve palsy, septic phlebitis jug
When to do surgery DNSI
no marked improve 24-72 hr with IV ABx
Airway compromise
Signs of abscess (Clin or Rad)
Remove packing gradually
Symptoms, Workup, treatment Lemierres
Thrombophlebitis IJV (from tonsillar) Fever, lethargy, neck swell/pain Septic emboli in lungs Contrast CT 90% Fusobacterium necrophorum Flagyl
Actinomyces
Infection crosses fascial planes, sinus tracts, grainy
Non-tender, hard, slow grow perimandibular mass
Penicillin/Amoxicillin
Gm+, Branch, facult anaerobe
Ludwig Angina: Signs, Tx
Rapid spread SM/SL, teeth
Trismus, fever, drool, dysphonia, dysphagia
Tense swell FOM, tongue protrusion
ABx, poss drain, poss tube/trach
Empiric ABx for DNSI
Strep plus oral anaerobes Penn G plus Flagyl Unasyn Clinda Moxifloxacin Levoflox plus flagyl Cipro plus flagyl 10-14 d, once marked improvement —> oral
Cat scratch disease: bug, tx
Barro ella Several wk after inoculate Unilateral LAD, resolves 2 mo (maybe 1 yr) Azithro early (w/in 5d) Surg if persist discomfort, suppuration
Atypical DNSI
Painless, slow, WL/night sweats
Consider PPD, HIV, Bartonella, cancer
Scrofula
TB cervical lymphadenitis
Painless, firm, no fever
Biopsy Cx
Excuse, ABx
Classic sign of Necrotizing Fasciitis
Pain OOP to PE
Immunosuppressed
Crepitus
