Deep Neck Infections Roop/Jaffe Flashcards
What is Keflex? What type of bacteria does it work best with (gram pos or neg?) What generation is it?
a cephalosporin antibiotic that works best with gram positive bacteria
cephalexin is a class of meds called cephalosporin
its a 1st gen antibiotic
How many generations are there of cephalosporin?
5
How many generations are there of cephalosporin against MRSA?
5
What is inspiratory stridor and what does it most likely indicate?
test q!!!!!!
-an abnormal, high-pitched respiratory sound
-noisy breathing usually due to obstructed airflow through narrowed airway
-most commonly caused by
1) an object blocking the airway
2) swelling in throat or upper airway
3) trauma to the airway
-indicates airway obstruction above the glottis
Define dyspnea
difficulty breathing
define dysphagia
difficulty swallowing
What is trismus?
-jaw muscles become so tight that you cannot open mouth
-muscle spasms in temporomandibular joint (TMJ)
-commonly referred to as “lockjaw”
-normal motion of the mandible is reduced as a result of sustained, tetanic spasm of the masticatory muscles mediated by the trigeminal nerve
Erythema, edema, and pain- what do they indicate?
inflammation!
Pt had an infected tooth which turned into an abscess. It has progressed to the soft tissue. What is this known as?
cellulitis!
The submandibular space extends from….
hyoid bone up to the floor of the mouth
The submandibular space is bound by what?
-anteriorly and laterally by the mandible
-inferiorly by superficial layer of deep cervical fascia
-medially by the anterior belly of the digastric muscle
-posteriorly by submandibular gland
-superiorly by the mylohyoid muscle
The three paired neck triangles are the…… and the unpaired triangle is the…..
paired=
-submandibular (digastric) triangle
-carotid triangle
-muscular triangle
unpaired= submental triangle
The submandibular space communicates with what spaces?
-Lateral pharyngeal space (also known as parapharyngeal space)
-Pterygomandibular space
-Retropharyngeal space
-Sublingual space
What caused deviation of the trachea for the pt with the infected tooth that got abscess and spread? What would show this in tests?
the deviated trachea indicates a compression or blockage
the infection that formed the abscess, spread and compressed the trachea, causing it to deviate
will be seen in x-ray and stridor breath sounds
Deep neck problems fall into 4 major categories. What are they?
1) congenital
2) vascular
3) infectious (pt case study had this one)
4) neoplastic
Congenital deep neck problems can lead to what 2 things?
1) aphasia/hypoplasia of salivary glands
2) dermoid/epidermoid cyst
Vascular deep neck problems will lead to what?
low or high blood flow, which will have its own set of issues
Low blood flow vascular deep neck problems will lead to what 2 things?
venous or lymphatic malformations
High blood flow vascular deep neck problems will lead to what?
arterial malformations
Infection/inflammation deep neck problems will lead to what?
-cellulitis
-ludwig angina
-abscess ranula
-sialadenitis
What are the 2 types of neoplastic deep neck problems?
benign or malignant
What are the types of benign neoplasms in the deep neck?
-lipoma
-primary salivary gland tumors
-neurogenic tumors
What are the types of malignant neoplasms in the deep neck?
-squamous cell carcinoma
-primary salivary gland tumors
-lymphoma
What is sialadenitis? What is it caused by?
-refers to a swollen salivary gland
-salivary infection most commonly affecting the parotid glands or submandibular salivary glands
-can spread to the deep tissues of the head and neck
-caused by bacteria or viruses
What are the symptoms of sialadenitis?
-Pain, tenderness and redness
-Hard swelling of the salivary gland and the tissues around it
-Fever and chills
-Drainage of infectious fluid from the gland
What is ludwig angina?
-type of bacterial infection that occurs in the floor of the mouth, under the tongue
-often develops after an infection of the roots of the teeth (such as tooth abscess) or a mouth injury
-most commonly affected space= submandibular
-uncommon in children
-chest pain
What are the symptoms of ludwig angina?
1) swelling of the tongue
2) neck pain
3) breathing problems
4) chest pain
What is abscess ranula?
-clear or bluish cysts caused by a blocked salivary gland in the mouth
-slow-growing benign growths found on the floor of the mouth and can vary in size (some cysts remain small, whereas others enlarge and cause problems)
-saliva-filled cyst due to leakage from a damaged salivary gland
-can be due to trauma, injury, or spontaneous
What are the symptoms of abscess ranula?
-clear or bluish lump on the floor of mouth (most common symptom of a ranula under tongue)
-swelling that goes up and down
-usually start out around 2-3 inches in diameter (sometimes they empty, but then fill up again and they can grow larger over time)
What is the first priority in management of the pt with tooth abscess/deep neck infection?
-Make sure pt has an airway (avoid doing intubation bc you can rupture the abscess)
-treatment= tracheostomy and extraction
What is the full treatment plan for the pt with tooth abscess/deep neck infection?
1) tracheostomy
2) tooth extraction
3) incision and drainage
4) penrose drain placement
5) antibiotics and/or steroids
What is a penrose drain?
-surgical incision is made to keep area open (cannot close it because pt has infection)
-its a soft, flat, flexible tube
-penrose drain allows any unwanted bodily fluids to drain/come out (like blood)
What are the boundaries of the oral cavity?
oral labia to oropharynx
(oropharynx is separated from oral cavity by palatopharyngeal arches)
What oral cavity structures are implicated in a tooth abscess infection?
upper (maxilla) and lower jaw (mandible) bones
What is the normal dentition for an adult? Child?
adult= 32 teeth
child= 20 primary teeth by 3 y/o
What are the 4 different types of teeth?
1) incisors
2) canines
3) premolars
4) molars
The three main parts or regions of a tooth include the…
1) crown
2) neck
3) root
Teeth are composed of 4 tissues. Name them
1) enamel
2) dentin
3) pulp cavity (the center of the tooth that contains nerves, blood vessels and connective tissue)
4) apical foramen (connects the nerves and blood vessels from the pulp cavity to join the gingiva)
What is the nerve supply to the gingiva and teeth?
all the nerves supplying the gingival mucosa originate from the mandibular and maxillary branches of the trigeminal nerve (CN V)
What is the blood supply to the gingiva and teeth?
branches of the maxillary artery:
-posterior superior alveolar artery (upper posterior teeth and upper molars)
-inferior alveolar artery
-buccal artery
-greater and lesser palatine arteries
-sphenopalatine arteries
What is the lymphatic drainage of the gingiva and teeth?
-lymph vessels from the teeth usually run directly into the submandibular nodes on the same side
-lymph from the mandibular incisors drains into the submental nodes
-occasionally, lymph from the molars passes directly into the jugulodigastric group of nodes
Is the mandible or maxilla fixed in place?
maxilla
What is a useful landmark on the mandible for palpation?
brim of mandible
Is a tooth in its socket considered a joint?
yes
What are the 3 functional classifications of joints? Which one is teeth?
1) synarthrosis (immovable), ex: teeth
2) amphiarthrosis (slightly moveable)
3) diarthrosis (freely moveable)
What is gomphoses?
a fibrous mobile peg-and-socket joint
The roots of the teeth (the pegs) fit into their sockets in the mandible and maxilla and are the only examples of this type of joint
What is cementum?
connective tissue holding tooth to the gum line (periodontal ligament is what attaches to tooth)
What is the normal gum color/texture?
pinkish and typically contain a textured surface which is referred to as being “stippled”. This can be thought of as resembling a texture similar to an orange peel
Do children have wisdom teeth?
no
How would a posterior superior alveolar nerve block be administered?
enter just posterior to the root of the 2nd molar
How would a middle superior alveolar nerve block be administered?
enter between the 1st molar and 2nd premolar
How would an anterior superior alveolar nerve block be administered?
enter just above the canine tooth
What divides the anterior and posterior neck triangles?
SCM
What are the 3 major salivary glands?
1) parotid
2) sublingual
3) submandibular
Facial veins are ______________ compared to peripheral veins
VALVELESS
What are the nodes for lymphatic drainage of the face?
-submental nodes
-submandibular nodes
-parotid nodes
-mastoid nodes
-occipital nodes
What are the boundaries of the anterior triangle?
-mandible
-midline of neck
-SCM
What are the 4 neck triangles a part of the anterior triangle?
-submental triangle
-digastric triangle
-muscular triangle
-carotid triangle
What is the roof of the anterior triangle?
platysma
What is the floor of the anterior triangle?
-pharynx
-larynx
-thyroid
What are the boundaries of the submental triangle?
-anterior belly of digastric m. (1)
-body of the hyoid bone
-midline of the neck
What is the floor of the submental triangle?
mylohyoid m. (2)
What are the contents in the submental triangle?
anterior jugular vein and submental lymph nodes
What are the boundaries of the digastric triangle?
-2 bellies of digastric m.
-lower border of the mandible
What is the floor of the digastric triangle?
-mylohyoid m. (2)
-hyoglossus m.
-middle constrictor
What are the contents of the digastric triangle?
-submandibular gland and lymph nodes
-parotid gland
-facial artery and vein
-submental vessels
-carotid sheath (posteriorly)
What are the boundaries of the muscular triangle?
-SCM
-superior belly of omohyoid m. (1)
-midline of the neck
What is the floor of the muscular triangle?
-sternothyroid m. (2)
-sternohyoid m. (3)
What are the contents of the muscular triangle (beneath the floor)?
-thyroid gland
-larynx
-trachea
-esophagus
What are the boundaries of the carotid triangle?
-SCM
-posterior belly of digastric m.
-superior belly of omohyoid m.
What is the floor of the carotid triangle?
-thyrohyoid m.
-hyoglossus m.
-middle and inferior constrictors
What are the contents of the carotid triangle (beneath the floor)?
-bifurcation of the common carotid artery
-superior thyroid a.
-inguinal a.
-facial a.
-occipital and ascending pharyngeal branches of the external carotid artery
-hypoglossal nerve and its 2 branches (nerve to thyrohyoid and superior root of ansa cervicalis, internal and external laryngeal nerves)
What is a high rectal temp for infant?
100.4 F or higher
What is torticollis?
-also known as wryneck
-a twisting of the neck that causes the head to rotate and tilt at an odd angle. The top of their head may be tilted to one side and their chin may be tilted to the other side
-contraction of the neck muscles causing the odd angle
-spasms of the neck muscles
What is cervical lymphadenopathy?
abnormal enlargement of lymph nodes in the head and neck
Is 17.4x10^3/mm^3 high WBC count for an infant? Is so, what is the normal range?
yes this is high!!!! It indicates infection
normal range= 5000 - 10,000 mm3
How does acute bronchitis begin?
as common cold
What are 2 common symptoms w/ acute bronchitis?
fever + cough that may progress from non-productive to productive
How does epiglotitis begin?
sudden onset of high fever and severe sore throat
What are the common S&S of epiglottis?
there’s a lot!!!!!!
-fever and chills
-sore throat
-malaise (general feeling of discomfort)
-decreased appetite
-irritability
-dysphagia (difficulty swallowing)
-odynophagia (painful swallowing)
-drooling
-cyanosis
-sniffling or tripod
-cherry red epiglottis
What are the common S&S of retropharyngeal abscess?
There’s a lot!!!!!
-fever and chills
-sore throat
-malaise (general feeling of discomfort)
-decreased appetite
-irritability
-dysphagia (difficulty swallowing)
-odynophagia (painful swallowing)
-trismus (TMJ spasm)
-torticollis (head at weird angle)
-cervical lymphadenopathy (enlarged lymph)
-lateral x-ray demonstrating abscess (trachea out of alignment)
What are retropharyngeal lymph nodes (RLNs)?
-known as Rouviere nodes
-located medially to the internal carotid artery
-enlarged retropharyngeal nodes can be the result of inflammatory diseases or malignancy
What happens to retropharyngeal lymph nodes (RLNs) during puberty/adulthood?
-most of them will atrophy by puberty
-it is very rare to be an adult and have RLNs
2 y/o was diagnosed with retropharyngeal abscess (RPA). What is the treatment?
Airway! → make sure pt has airway and airway is stable
Broad-spectrum antibiotic coverage is typically indicated in the initial management of RPA.
Surgical intervention is often indicated if the clinical picture does not improve with antibiotic therapy.
In children, retropharyngeal abscess (RPA) is usually caused by an infection which spreads to the retropharyngeal lymph nodes, with subsequent…..
cellulitis and abscess formation
The most urgent complication in retropharyngeal abscess (RPA) is RPA expansion against the __________ or ___________, leading to airway compression.
pharynx, trachea
The first priority in treating a patient with a suspected retropharyngeal abscess (RPA) is to determine what?
airway stability
What are the cardinal signs of inflammation?
-erythema
-edema
-localized pain
-localized warmth
The submandibular space is a ________________ deep compartment of the head and neck that encompasses the submandibular gland
suprahyoid
Posteriorly, the submandibular space freely communicates with pterygomandibular, ______________, lateral pharyngeal, and ___________________ spaces
sublingual, retropharyngeal
The digastric muscle is made up of _____ bellies. What are they?
2, anterior and posterior
The digastric muscle is made up of 2 bellies. One of them is the anterior belly, which has branchiomotor innervation from CN ____
V3 (trigeminal)
The digastric muscle is made up of 2 bellies. One of them is the posterior belly, which has branchiomotor innervation from CN ____
VII (facial n.)
What does the posterior belly of the digastric muscle assist with?
assists in steadying the hyoid bone during swallowing and speech, as well as depress mandible against resistance
The hypoglossal nerve (CN XII) passes posterior to the posterior belly of the ____________ muscle to enter triangle and oral cavity
digastric
_______________ muscle is associated with the posterior belly of digastric muscle
stylohyoid
The stylohyoid muscle is innervated by __________ nerve and assists digastric muscles in elevating hyoid bone during swallowing
facial (CN VII)
The pterygomandibular space is triangular in shape and is bounded by the…..
medial surfaces of the mandibular ramus laterally
The sublingual space is located below the mouth and above the ____________ muscle
mylohyoid
The retropharyngeal space is the ___________ space between fascial layers in the neck
largest
The retropharyngeal space is found anterior to the ________________ _____________ and posterior to the buccopharyngeal fascia
prevertebral fascia
The retropharyngeal space spans the _______ of skull to the __________
base, mediastinum
The retropharyngeal space is located anterior to _______________ muscles and posterior to ___________ and ___________
prevertebral, pharynx, esophagus
Children do not have ___________ 1 and 2
premolars
Adults have _________ 1-3
molars
A tooth abscess would drain through where in the mouth?
apical foramen
The oral cavity (teeth and gingiva) has lymphatic drainage to where?
deep cervical trunk
What does thumb palpation of the inferior alveolar coronoid notch do to pt?
distracts them from needle pain when getting a nerve block
maxillary nerve block via the ___________________ technique will anesthetize all the terminal branches of the maxillary nerve with a single injection
greater palatine canal
Mandibular nerve block involves blockage of the auriculotemporal, _______________, buccal, mental, incisive, mylohyoid, and lingual nerves
inferior alveolar
Vascular supply of the oral cavity has 3 divisions. What are they?
1) mandibular division
2) pterygoid division
3) pterygopalatine division
What are the fascial planes of the neck?
-investing fascia
-pretracheal fascia
-carotid sheath
-buccopharyngeal
-prevertebral sheath
-platysma
What is the primary venous drainage in the neck?
internal jugular vein
What arteries are in charge of primary blood flow in the head/neck?
internal and external carotid arteries
Cervical plexus forms from ________ rami C1-C4 within prevertebral fascia in posterior triangle of neck
anterior
What are the cervical lymph nodes?
-prelaryngeal nodes
-thyroid nodes
-paratracheal nodes
-pretracheal nodes
Pretracheal lymph nodes drain lymph from….
-larynx
-trachea
-thyroid to deep lateral cervical lymph nodes
Neck region drains into circulation via….
right lymphatic duct
The muscular triangle contains the infrahyoid muscles. It’s a group of 4 pairs in the anterior part of neck. Name them
1) sternohyoid
2) sternothyroid
3) thyrohyoid
4) omohyoid
