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GENERAL OTOLARYNGOLOGY > CHAPTER 9: Deep Neck and Odontogenic Infections > Flashcards

CHAPTER 9: Deep Neck and Odontogenic Infections Flashcards

1
Q

Remains a frequent, potentially life threatening condition in both children and adults

A

Deep neck infection (DNI)

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2
Q

Primary cause of DNIs

A

INFECTIOUS and INFLAMMATORY conditions of the upper aerodigestive tract

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3
Q

MOST COMMON etiology of DNI in adults

A

Dental infections

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4
Q

MOST COMMON etiology of DNI in children

A

Waldeyer ring infections

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5
Q

Estimated to cause 65% to 80% of human infections and

Play a key role in the cause of odontogenic infections

A

Bacterial biofilms

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6
Q

TRUE or FALSE

Most dental-related infections are localized, minor exacerbations from long standing decay or periodontal disease

A

True

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7
Q

A chronic inflammatory disease of the tooth-supporting structures- as a potential risk factor in the morbidity and mortality of systemic conditions such as cardiovascular disease, DM and premature birth

A

Periodontitis

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8
Q

Common causes of retropharyngeal lymphadenitis in pediatric population

A
  1. Acute rhinosinusitis
  2. Tonsillitis
  3. Pharyngitis
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9
Q

May iatrogenically incite an upper airway infection or traumatize the pharyngoesophageal lumen

A

Oral surgical procedures

Endoscopic instrumentation

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10
Q

TRUE or FALSE

Sialadenitis, with or without ductal obstruction, can precipitate infectious spread

A

TRUE

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11
Q

TRUE or FALSE

Foreign bodies trapped within the upper aerodigestive tract may initiate infections that spread to the deep neck

A

TRUE

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12
Q

TRUE or FALSE

Superficial infections, such as skin cellulitis, may spread along fascial planes into deeper neck compartments

A

TRUE

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13
Q

TRUE or FALSE

Penetrating trauma including needle injection associated with IV drug use may introduce pathogens into the fascial planes

A

TRUE

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14
Q

TRUE or FALSE

Congenital or acquired lesions, such as branchial cleft cysts, TGDC, or laryngoceles may become infected with resulting spread

A

TRUE

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15
Q

Congenital cysts account for ______ of DNI in the pediatric population and should be suspected especially in the setting of recurrent DNI

A

10% to 15%

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16
Q

Microbiology of DNI

A

Mixture of aerobic and anaerobic organism

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17
Q

Normal oral bacteria that is more common in the nose and throat and may participate in mixed odontogenic infections

A

Staphylococcus aureus

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18
Q

Comprise much of the rest of the mouth’s normal flora, and these organisms can increase in numbers, especially in patients with chronic periodontal disease

A

Gram-negative anaerobes

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19
Q

Species associated with odontogenic infections

A

Streptococcus milleri group
Prevotella (Bacteroides)
Peptostreptococcus
Staphylococci

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20
Q

Associated with neck space infections that increasingly worldwide, especially among the pediatric population

A

Community acquired MRSA

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21
Q

Aerobic bacteria (gram-positive cocci)

A 
Streptococcus
Staphylococcus aureus (faciltative anaerobe)
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22
Q

Aerobic bacteria (gram-negative cocci)

A

Neisseria

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23
Q

Aerobic bacteria (gram-positive bacilli)

A

Diphtheroids

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24
Q

Aerobic bacteria (gram-negative bacilli)

A

Haemophilus

Eikenella

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25
Q

Anaerobic bacteria (gram-positive cocci)

A

Streptococcus
Peptococcus
Peptostreptococcus

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26
Q

Anaerobic bacteria (gram-negative cocci)

A

Veillonella

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27
Q

Anaerobic bacteria (gram-positive bacilli)

A

Clostridium
Actinomyces
Eubacterium
Lactobacillus

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28
Q

Anaerobic bacteria (gram-negative bacilli)

A

Prevotella
Fusobacterium
Porphyromonas

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29
Q

Atypicsl and endogenous saprophytic organisms of the oral cavity and tonsil

A

Actinomyces

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30
Q

Most common site of cervicofacial actinomycosis

A

Vicinity of the angle of the mandible (may cross fascial planes in its route of spread)

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31
Q

Characteristic of Actinomycosis

A

Granulomatous reaction with central abscess formation and necrosis with “sulfur granules”

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32
Q

Infection of the head and neck most commonly presents with cervical lymphadenopathy, often with adherence and ulceration of overlying skin

A

Tuberculous and nontuberculous infection

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33
Q

Histopathology of atypical infection of the head and neck

A

Caseating necrotizing granulomatous inflammation

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34
Q

Etiologic agent of cat scratch disease

A

Bartonella henselae

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35
Q

Disease caused by the pelomorphic gram-negative bacillus Bartonella henselae

A

Cat scratch disease

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36
Q

Manifestation of cat scratch disease

A

Large, tender cervical lymph nodes (late lesion may form abscess)

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37
Q

Management of atypical neck space infections

A

Nonsurgical

Incision and drainage procedures may result in a chronic wound or fistulous tract

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38
Q

2 spaces involved in maxillary space

A
  1. Canine

2. Buccal

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39
Q

Becomes infected almost exclusively as a result of apical infection of the ROOT of the MAXILLARY CANINE TOOTH

A

Canine space

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40
Q

Location of canine space

A

Between the ANTERIOR SURFACE of the MAXILLA and the LEVATOR LABII SUPERIORIS

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41
Q

Manifestation of infected canine space

A

Swelling lateral to the nose and loss of the ipsilateral nasolabial fold

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42
Q

Drainage of infected canine space

A

Intraoral stab incision

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43
Q

Involved when the infection of maxillary molar teeth breaks out superior to the attachment of the buccinator muscle

A

Buccal space

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44
Q

Space between the buccinator muscle and the skin

A

Buccal space

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45
Q

TRUE or FALSE

All three maxillary molars may cause infection in buccal space

A

TRUE

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46
Q

It is an ovoid space, below the zygomatic arch and above the inferior border of the mandible

A

Buccal space

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47
Q

TRUE or FALSE

Infections in buccal space may cause trismus

A

TRUE

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48
Q

Primary mandibular spaces include

A
  1. Submental
  2. Sublingual
  3. Submandibular
49
Q

TRUE or FALSE

The primary spaces are those into which infection spreads directly from the teeth through bone

50
Q

Lies between the anterior bellies of the digastric muscles and between the mylohyoid muscle and the skin

A

Submental space

51
Q

This space is involved with infected mandibular incisors, whose roots are long enough to allow erosion apically to the attachment of the mentalis muscle

A

Submental space

52
Q

Exit on the medial aspect of the mandible

A

Sublingual and submandibular spaces

53
Q

TRUE or FALSE
The factor that determines whether the sublingual or submandibular space is involved is the location of the perforation relative to the mylohyoid muscle attachment

54
Q

Sublingual space is involved…

A

Location of the apex of the tooth is superior (premolars, first molar)

55
Q

Submandibular space is involved…

A

The location of the apices are inferior to the mylohyoid (second, third molar)

56
Q

Space between the lingual oral mucosa and mylohyoid muscle

A

Sublingual space

57
Q

Its posterior boundary is open, so it communicates freely with the submandibular space and the secondary spaces located more posteriorly and superiorly

A

Sublingual space

58
Q

Clinical manifestation of sublingual space infection

A
  1. Little extraoral swelling
  2. Marked intraoral lingual swelling in the FOM
  3. Bilateral: tongue will be elevated and swallowing becomes difficult
59
Q

Lies between the mylohyoid muscle and the skin

A

Submandibular space

60
Q

It has an open posterior boundary, so it can communicate easilty with the secondary spaces

A

Submandibular space

61
Q

Infection of submandibular space

A

Swelling begins at the inferior lateral border of the mandible and extends medially to the digastric area and posteriorly to the hyoid bone

62
Q

If all three primary mandibular spaces bilaterally become infected, the infection is known as…

A

Ludwig angina

63
Q

Ludwig angina is described by_______ in 1836

A

Wilhelm Friedrich von Ludwig

64
Q

Character of Ludwig angina

A

Rapid, bilateral gangrenous cellulitis of all three primary spaces

65
Q

Manifestation of Ludwig angina

A
  1. Gross swelling
  2. Elevation and displacement of the tongue
  3. Tense brawny induration of the submandibular region superior to the hyoid bone
66
Q

TRUE or FALSE
Ludwig angina is a clinical diagnosis not requiring advanced imaging, and patients may not tolerate lying supine for a scan due to swelling and oral secretions

67
Q

Signs and symptoms of Ludwig angina

A
  1. Severe trismus
  2. Drooling
  3. Inability to swallow
  4. Tachypnea
  5. Dyspnea
68
Q

Usual cause of Ludwig angina

A

Due to odontogenic infection from a mandibular molar

69
Q

Are known to produce tissue-destroying enzymes that can help them to spread and infect along these planes, similar with anerobic bacteria that produce hyaluronidase, collagenase, and fibrinolysin

A

Streptococcus anginosus (S. milleri group)

70
Q

Is an inverted pyramid in shape extending superiorly from the skull base inferiorly to the hyoid

A

Parapharyngeal space

71
Q

Common site for a DNI

A

Parapharyngeal space

72
Q

Contents of postsyloid compartment

A
  1. Sympathetic chain

2. CN IX, X, XI, XII

73
Q

Infection to the poststyloid compartment that may lead to an infected thrombus in the internal jugular vein

A

Lemierre syndrome

74
Q

One of the main sites for spread of abscess

A

Retropharyngeal space

75
Q

Location of retropharyngeal space

A

Midline posterior to the pharynx and esophagus, extending supoeriorly from the skull base to the level of the 2nd thoracic vertebrae

76
Q

Lymph nodes in the retropharyngeal space drain the…

A
  1. Sinuses
  2. Nasopharynx
  3. Waldeyer ring
77
Q

TRUE or FALSE
Infections in the retropharyngeal space are primarily seen in children secondary to regression of lymphoid tissue in adult

78
Q

Posterior to the retropharyngeal space and the only barrier from spread to the danger space

A

Alar fascia

79
Q

TRUE or FALSE
Communication into the danger space allows spread to the diaphragm and access to the superior mediastinum, which can lead to intrathoracic extension of an infection and mediastinitis

80
Q

A separate access site to the mediastinum is via the…

A

Carotid sheath

81
Q

Spread along the vasculature can go to the superior mediastinum at the aortic arch

A

“Lincoln highway” by H.P Mosher (1929)

82
Q

Indicates orbital inflammation/abscess

A
  1. Reduced mobility of the globe

2. Absent papillary light reflex

83
Q

Retropharyngeal in children (measurement) of thr prevertebral tissue at C2

A

Greater than 5mm

84
Q

Retropharyngeal in adult (measurement) of thr prevertebral tissue at C2

A

Greater than 7mm

85
Q

“Thumb print sign”

A

Thickening of the epiglottis and/or arytenoids

86
Q

Remains the standard radiographic technique for the evaluation of DNI

A

CT of the head and neck

87
Q

TRUE or FALSE
CT scan is excellent for identifying the presence of DNI, it cannot reliably differentiate betwen the generalized edema of phlegmon versus purulent abscess, since both often commonly appear as hypodense collections with peripheral enhancement

88
Q

Initial management of any patient with known or suspected DNI

A

Securing the airway

89
Q

Major source of mortality from DNI

A

Loss of airway

90
Q

Signs of fluid deficit

A
  1. Tachycardia
  2. Dry and pasty mucous membranes
  3. Decreased skin turgor
91
Q

Recommended as a 1st-line drug, given the up to 20% resistance rate to penicillin G and clindamycin in DNI

A

Ampicillin-sulbactam

92
Q

Surgical drainage is necessary under the following circumstances:

A
  1. Air-fluid level in the neck or evidence of gas-producing organisms
  2. Threatened airway compromise
  3. Failure to respond to 48-72 hours of empiric IV antibiotic therapy
  4. Presence of complications of DNI
93
Q

Main goals of surgical intervention

A
  1. Providing a fluid or tissue sample for tissue staiming and culture and sensitivity testing
  2. Providing therapeutic irrigation of the infected body cavity (to prevent reaccumulation of abscess)
94
Q

Preauricular parotid incision

A

Allows access to the parotid and temporal spaces

95
Q

Horizontal neck incision

A

Access to the masticator, parapharyngeal, pterygoid, submandibular, prevertebral, retropharyngeal, carotid and lateral neck spaces

96
Q

Parapharyngeal and pterygoid spaces are entered by…

A

Retracting the submandibular gland anteriorly while dissecting superior and medial to the posterior belly of the digastric muscle along the medial surface of the mandibular ramus

97
Q

Prevertebral and retropharyngeal spaces are entered by…

A

Identifying the prevertebral fascia by retracting the strap muscles medially and the carotid sheath laterally at the level of inferior to the carotid bifurcation

98
Q

Horizontal submental incision

A

Provides a direct route to the bilateral submandibular spaces and FOM

99
Q

A rare thrombophlebitis of the internal jugular vein

A

Lemierre syndrome

100
Q

Lemierre syndrome is most often caused by the anaerobic, gram-negative bacillus

A

Fusobacterium necrophorum

101
Q

Follows a period of pharyngitis before progressing to fever, lethargy, lateral neck tenderness and edema, occasional trismus and septic emboli

A

Lemierre syndrome

102
Q

Diagnosis of Lemierre syndrome is confirmed by…

A

CT with IV contrast (filling defect in the internal jugular system)

103
Q

TRUE or FALSE
Surgery to excise the jugular vein may be indicated in patients with a worsening clinical course, despite appropriate medical therapy, or in the event of neck abscess formation

104
Q

Is a life-threatening infection with a mortality rate of 30% to 40% caused by retrograde spread of infection from the upper dentition or paranasal sinuses via the valveless ophthalmic venous system to the cavernous sinus

A

Cavernous sinus thrombosis

105
Q

Symptoms of cavernous sinus thrombosis

A
  1. Fever
  2. Lethargy
  3. Orbital pain
  4. Proptosis
  5. Reduced extraocular mobility
  6. Dilated pupil with sluggish papillary light reflex
106
Q

Diagnosis of cavernous sinus thrombosis is best confirmed by…

A

MRI of the brain with contrast (dural enhancement in the region of the cavernous sinus)

107
Q

Hallmarks of carotid artery pseudoaneurysm/rupture

A
  1. Pulsatile neck mass
  2. Horner syndrome
  3. Palsies of CN IX-XII
  4. Expanding hematoma
  5. Neck ecchymosis
  6. Bright red blood from the nose or mouth (DNI)
108
Q

Treatment of carotid artery pseudoaneurysm/rupture

A

Immediate surgical ligation of the carotid artery

109
Q

Mortality rate of mediastinitis

A

30% to 40%

110
Q

Caused by spread of infection along the retropharyngeal and prevertebral planes of the neck into the upper mediastinum

A

Mediastinitis

111
Q

Presentation of mediastinitis

A
  1. Diffuse neck edema
  2. Dyspnea
  3. Pleuritic pain with deep breathing
  4. Tachycardia
  5. Hypoxia
  6. Pleural effusion
  7. Mediastinal widening
112
Q

Treatment of mediastinitis limited to the anterior-superior mediastinum above the carina

A

Transcervical drainage via a bilateral cervicotomy with blunt dissection along the prevertebral plane

113
Q

Surgical treatment in case that the mediastinitis extend beyond the upper mediatinum or that involve more than one mediastinal compartment

A

Thoracotomy

114
Q

Risk factors for mediastinitis in the pediatric population

A
  1. Age less than 2 years
  2. Retropharyngeal space involvement
  3. MRSA
115
Q

A severe form of DNI thst occurs more often in older age groups (age >60 years) and immunocompromised patients, especially poorly controlled diabetics

A

Necrotizing fascitis

116
Q

Clinical presentation of necrotizing fascitis

A
  1. Rapidly progressive cellulitis with pitting neck edema

2. Orange-peel appearance from obstructed dermal lymphatics with or without subcutaneous crepitus

117
Q

Neck CT with IV contrast findings in necrotizing fascitis

A

Tissue gas and widespread, nonloculated hypodense areas without peripheral enhancement, consistent with liquefaction necrosis

118
Q

Findings at surgery consistent with necrotizing fascitis

A
  1. Foul odor
  2. Brown, watery fluid collections
  3. Liquefied and grayish fat
  4. Muscle that pulls apart with minimal finger pressure

GENERAL OTOLARYNGOLOGY (12 decks)

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