Deep Neck Space + Odontogenic Infections Flashcards
What is the bacteria that make up normal oral flora?
- GRAM POSITIVE COCCI
- Aerobic: Streptococcus, Staphylococcus aureus
- Anaerobic: Streptococcus, Peptococcus, Peptostreptococcus - GRAM NEGATIVE COCCI
- Aerobic: Neisseria
- Anaerobic: Veillionella - GRAM POSITIVE BACILLI
- Aerobic: Diphtheroids
- Anaerobic: Clostridium, actinomycese, eubacterium, lactobacillus - GRAM NEGATIVE BACILLI
- Aerobic: Haemophilus, Eikenella
- Anaerobic: Prevotella, Bacteroides, Fusobacterium, Porphyromonas
What are the risk factors for deep neck space infections? List 13 risks.
- Poor dental hygiene
- 3-4th decade of life
- Pericoronitis (dental term) - inflammatory reaction in 3rd molar
- Diabetic
- Low SES
- Acute rhinosinusitis in children (retropharyngeal nodes that necrose)
- Penetrating neck trauma
- Salivary gland infections
- Mastoiditis (Bezold’s abscess)
- Superficial skin infections
- Surgical instrumentation
- IVDU (IJV)
- TGDC/Branchial cleft cyst in pediatrics
What are 8 etiologies for deep neck space infections? What are the most common in adults vs. children?
- URTI/Pharyngitis/tonsillitis (most common in chidlren)
- Dental (most common in adults)
- Salivary infection (second most common for adults)
- Trauma/Surgery/Instrumentation
- Foreign bodies
- Spread of localized/superficial infection
- IV drug abuse
- Congenital/branchial anomalies
Label the following teeth:
1. Incisors
2. Canines
3. Premolars
4. Molars
Vancouver Page 60
Vancouver page 60
Define the following dental terms and label them on a tooth:
1. Cusp
2. Groove
3. Mesial
4. Distal
5. Lingual
6. Buccal
- Cusp - tooth eminence
- Groove - area between cusps
- Mesial - toward the incisor (ie. more anterior)
- Distal - towards posterior mandible or maxilla (ie. more posterior)
- Lingual (or palatal) - towards the tongue
- Buccal (or facial) - towards the cheek
Vancouver FP 327
What are the layers of the tooth?
CROWN:
1. Enamel
2. Dentin
3. Pulp
ROOT:
1. Gum
2. Periodontal ligament
3. Cementum
4. Dentin
5. Lateral canals (inferiorly, within dentin) )
6. Blood vessels and nerves (within pulp)
Vancouver Page 60
Describe the anatomy and configuration of the teeth, in both children and adults.
How many roots for molars mandible and maxilla?
How many cusps for premolar vs molar?
All teeth have “roots” and “cusps”
ROOTS:
- Mandibular molars = 2 roots
- Maxillary molars = 3 roots
CUSPS:
- Molars have 4 cusps
- Premolars have 2 cusps
CHILDREN:
- 5 teeth per quadrant: central incisor, lateral incisor, canine, premolar, and molar
- Teeth erupt ~6 months, complete by 2-2.5 years
ADULTS:
- 8 teeth per quadrant: central incisor, lateral incisor, canine, premolars x2, molars x 3
https://i0.wp.com/pocketdentistry.com/wp-content/uploads/2021/09/9781284222913_CH01_FIGF21.png?w=960
Describe the FDI 2-digit tooth-numbering system
- Each quadrant is labelled 1-4 (starting at patient’s right upper, going clockwise)
- Each tooth is labelled 1-8 (starting from midline and working laterally)
- Each tooth = 2 digits = (quadrant #) (tooth #)
Describe Angle’s classification of dental occlusion
ANGLE CLASSIFICATION:
- Defines position of maxillary 1st permanent molar’s mesial-buccal cusps relation to the buccal groove of the mandibular 1st molar (#6)
- Can use a Canine tooth if you don’t have a 1st maxillar molar (but hopefully don’t need to know this)
- Class 1 = neutral (mesiobuccal cusp fits into groove)
- Class 2 = overbite/retrognathism (mesiobuccal cusp is anterior to groove); divided based on how the anterior teeth are aligned
- Division 1: Proclined anterior teeth (ie. overjet of teeth), usually developmental abnormality where the mandible is smaller
- Division 2: Typically mandible is normal sized; Anterior maxillary teeth are retroclined inward like a “deep overbite (cuz a small overbite can be normal)” - Class 3 = underbite/prognathism (mesiobuccal cusp is posterior to groove) - usually genetic cause (if it’s not a genetic cause, some call it a “pseudo” class 3).
Vancouver FP 327
What is the anterior teeth vs. posterior teeth?
Anterior teeth up to the canines
Posterior teeth is behind the canines (anything with cusp is a posterior tooth)
What is the name of teeth in children?
Deciduous teeth
What is the normal transverse dental relationship?
Mandibular molar buccal cusps sit between maxillary molar buccal and lingual cusps
Describe the pathophysiology of odontogenic infections
- Necrosis of dental pulp from deep caries –> necrosis enters into bone and soft tissues through path of least resistance –> leads to inflammatory response (vasodilation, edema causing pain), and ischemia (necrosis)
- Bacteria also spreads endotoxin to initiate infection
- Inoculation phase Day 1-3, Cellulitis phase Day 3-5, Abscess day 4-10
- Periapical bony changes not seen initially, periapical cysts in chronic infections
- 100% have pain before presentation in chronic infections - pain from pulp compression and soft tissue/periosteum over cortical bone becomes distended
- Pain drops when spreads through bone and periosteum into soft tissues
Common locations:
1. Mandibular 1, 2, and 3rd molars
2. Pediatrics: Maxillary teeth
Associated trismus:
1. Mild 20-30mm
2. Moderate 10-20mm
3. Severe < 10mm
Describe the bacterial flora and organisms commonly seen in deep space neck and odontogenic oral infections?
Usually due to mixed flora
AEROBES:
1. Streptococcus (Viridans group, pyogenes)
2. Staph aureus
3. Neisseria
4. Klebsiella
5. Haemophilus
6. Fusobacterium
ANAEROBES:
1. Peptostreptococcus
2. Peptococcus
3. Eubacterium
4. Veionella
5. Eikenella
6. Bacteroides
Antibiotics should cover strep + anaerobes
What spaces can a tooth infection spread? List 3 maxillary teeth and 3 mandibular teeth that can spread to varying locations
MAXILLARY:
1. Maxillary tooth = vestibular space
2. 1st and 2nd maxillar molar = buccal, palate
3. Canine tooth = Canine, maxillary sinus
MANDIBULAR:
1. Mandibular incisor = Submental and sublingual space
2. Mandibular tooth anterior to 2nd molar (mylohyoid line) = sublingual
3. Mandibular tooth posterior to 2nd molar (mylohyoid line) = submandibular
4. Secondary spread from mandibular spaces = masticator space (Masseteric, pterygomandibular, and temporal spaces)
5. Tertiary spread from secondary spaces = cervical spaces (parapharyngeal, retropharyngeal, danger, prevertebral)
What are the CT characteristics of deep space neck infections or abscesses? 4
- Low attenuation
- Contrast enhancement of abscess wall
- Tissue edema/fat stranding
- Cystic/loculated appearance
What is a Pott’s abscess?
Tuberculous osteomyelitis of the spine
Describe 5 causes for a false positive retropharyngeal abscess appearance on lateral neck x-ray
- Swallowing
- Crying
- Oblique view
- Neck flexion
- Expiration
“SCONE”
What are Mosher’s 5 landmarks for surgical approaches to the infected neck?
- Cricoid cartilage
- Hyoid: Lateral tip of the greater cornu of hyoid
- Anterior border of SCM
- Posterior belly of digastric
- Styloid process
“CHAPS”
Retropharynx approach:
- Oral if only retropharyngeal collection
- External if any other neck spaces are involved
What are 5 pathways of spread to the orbit by dental infections?
- Teeth infect maxillary sinus, which can track posterior to infratemporal fossa/pterygomaxillary fossa to inferior orbital fissure
- Teeth infect maxillary sinus, which can track into ethmoids, then through lamina papyracea
- Venous spread along facial, angular, and ophthalmic veins
- Lymphatic seeding
- Traumatic/congenital dehiscence
What is Ludwig’s angina? How is this treated?
Ludwig’s Angina = Infection of bilateral sublingual, submandibular, and submental spaces
- Usually mixed flora
- Usually secondary to dental infection
- Presentation - airway distress secondary to posteriorly displaced tongue; woody floor of mouth on exam
- Treatment: Airway control, I&D of abscess/phlegmon
What are 8 predisposing factors for osteomyelitis of the maxilla and mandible?
“OSTEITIS”
O: Osteodystrophies (Paget’s, fibrous dysplasia)
S: Systemic (e.g. steroids, bisphosphonates)
T: Trauma
E: Endosteal lesions (e.g. Cementoma)
I: Immunocompromised (e.g. HIV, DM, leukemia, chemo)
T: RadioTherapy
I: Implants (dental implants - plates, and other foreign bodies)
S: Surgery
Describe the treatment strategy for osteomyelitis of the mandible/maxilla - 5
- Appropriate culture-directed antibiotics
- Debridement of foreign bodies/sequestra/necrotic tissue
- Adjuncts to increase oxygenation (e.g. trephination, decortication, HBO)
- Reconstruction after infection clears
- Resection and osteomyocutaneous free flap reconstruction
What is Horner’s syndrome? What are 5 signs?
Horner’s Syndrome: Secondary to injury to the sympathetic chain
SIGNS: “AMPLE”
A: Anhidrosis (inability to sweat)
M: Meiosis (constricted pupile - dilator iris)
P: Ptosis (Muller’s muscle)
L: Loss of Ciliospinal reflex (therefore absence of dilation of the ipsilateral pupil to a pain stimulus applied to the face)
E: Enopthalmos (apparent due to ptosis)
Regarding Lemierre’s syndrome, discuss:
1. What is it?
2. Cause and Pathophysiology?
3. Investigations?
4. Clinical presentation?
5. Complications?
6. Treatment? 4
LEMIERRE’S SYNDROME:
- Internal Jugular Vein thrombophlebitis, usually due to dental or pharyngeal infections
CAUSE:
1. Fusobacterium Necrophorum (Gram negative, obligate anaerobe) - most common
PATHOPHYSIOLOGY:
- Throat infection –> PTA –> spread to internal jugular vein through tonsil veins –> thrombosis (from bacterial endotoxin that induces platelet aggregation) –> septic emboli, septicemia
INVESTIGATIONS:
1. CT Neck / Angio / Venogram - ring enhancement and filling defect of IJV (secondary to clot or purulence)
2. CT PE protocol
3. U/S of neck
4. Blood cultures
5. Toby-Ayer/Queckenstadt test
6. MR Venogram is the best imaging to follow resolution of clot
CLINICAL PRESENTATION:
1. Spiking fever
2. Engorged optic disks
3. Increased CSF pressure
4. SCM tenderness
5. Neck stiffness
6. Metastatic lung abscesses
7. Septic arthritis
8. Griesinger’s sign
9. SOB and chest pain (pulmonary and systemic emboli)
COMPLICATIONS:
1. Retrograde spread of thrombus –> Cavernous sinus thrombosis (IV abx + ICU support)
2. Intracranial hypertension
TREATMENT:
1. Drainage of infection
2. Beta-lactamase-resistant antibiotics (Ceftriaxone, Clindamycin/Flagyl)
3. Anticoagulation for thrombus progression or septic emboli (controversial) - Heparin
4. Ligation of IJV
Regarding Cavernous sinus thrombosis, discuss:
1. What is the pathophysiology and cause? Name 4 different pathophysiologies
2. Clinical presentation?
3. Diagnosis
PATHOPHYSIOLOGY:
- Retrograde spread via valveless ophthalmic vein or pterygoid plexus system
CAUSE/SOURCES:
1. Facial veins (central midface) –> angular veins –> nasofrontal vein –> superior ophthalmic vein –> cavernous sinus
2. Orbital: Superior/inferior ophthalmic veins –> Cavernous sinus
3. Dental: Pterygoid plexus –> Cavernous sinus
4. Parapharyngeal/temporal/paranasal sinus/neck spaces: Pterygoid plexus –> Cavernous sinus
What is Griesinger’s sign?
- Edema at the mastoid tip due to thrombus of the sigmoid sinus
- Can also occur in mastoiditis
- Secondary to mastoid emissary veins
What is the Toby-Ayer Queckenstadt test?
- Compression of the IJV has no effect on CSF pressure in the presence of ipsilateral lateral sinus thrombosis
- Performed while monitoring CSF pressure during a LP
Discuss carotid pseudoaneurysm as a complication of neck infection:
1. Definition
2. Epidemiology
3. Causes / risks - 3
4. Clinical presentation
5. Diagnosis findings
6. Treatment options
CAROTID PSEUDOANEURYSM:
- False aneurysm with loss of integrity of the 3 layers of the arterial wall, resulting in a contained rupture of the blood vessel
- Compared with a true anerusm - vascular wall is intact but dilated
EPIDEMIOLOGY:
- Can present in children as a complication of cervical adenitis
- IVDU
CAUSE:
1. Historically: Arteritis by syphillis or TB
2. Bacterial deep neck infections (esp. children and IVDU)
3. IVDU: Salmonella and Klebsiella is more frequent in these patients, and has elastase that dissolves the artery
CLINICAL PRESENTATION: (4 signs)
1. Protracted clinical course of parapharyngeal/retropharyngeal infection (untreated or undertreated)
2. Recurrent small pharyngeal hemorrhages (presenting in ear/nose or throat)
3. Possible Shock
4. Neurological abnormalities: Horner’s, CN VII, IX, XI and XII
DIAGNOSIS:
1. CT Angiography; or
2. Duplex ultrasound
TREATMENT OPTIONS:
1. Reconstruction of carotid with autologous graft
2. Endovascular coiling
3. Open ligation especially if hemorrhaging
https://www.drugs.com/cg/images/en3686288.jpg
https://www.criticalcare-sonography.com/wp-content/uploads/2021/08/pseudoaneurysm-e1630387647786.png
Regarding Eagle Syndrome, discuss:
1. Definition
2. Pathophysiology - 3
3. Clinical presentation
4. Diagnosis 3
5. Treatment options 3
EAGLES SYNDROME:
- Myriad of symptoms, but most commonly defined by pain due to abnormal styloid process
PATHOPHYSIOLOGY (many possibilities):
1. Retained embryologic cartilage tissue from Reichert’s cartilage
2. Calcification of the stylohyoid ligament
3. Expansion of osseous tissue at the origin of the stylohyoid ligament
CLINICAL PRESENTATION:
1. Pain (most common): Tonsil/anterior neck that radiates to ear/jaw, pain with jawning or turning head, and Carotidynia (tenderness of the carotid artery)
2. Dysphagia, odynophagia
3. Foreign body sensation
4. Neurologic complaints/complications: Horner’s syndrome, TIAs, stroke, carotid artery dissection
DIAGNOSIS:
1. Pharyngeal palpation (tonsil and tonsillar fossa)
2. Relief of symptoms upon infiltration of lidocaine into anterior tonsillar pillar
3. CT Neck (gold standard)
TREATMENT:
1. Conservative: NSAIDs, anticonvulsants (carbamazepine), gabapentin, stellate ganglion block
2. Surgical: Excision of styloid (intraoral approach, transcervical)
Vancouver Page 62
A patient presents with trismus, neck pain, and dysphagia. You suspect retropharyngeal abscess, but the WBC is normal and no abscess on CT. What are other possible diagnoses?
Calcific Tendonitis of Longus Coli
- Calcium crystal accummulation in the prevertebral soft tissues at the C1-2 level
- Most commonly in 20-50 years of age
- Accompanied with surrounding hypoattenuation from muscular edema
- Treatment: anti-inflammatories
Vancouver Page 62
What are indications for surgical management of a deep head/neck space infection? 8
- Gas
- Fluid filled > 2cm
- Threatening airway
- Failure to respond to medical management after 48-72 hours
- C+S to guide treatment
- Irrigation, reduce infection load
- Provide external route for drainage to prevent reaccumulation and spread
- Mediastinal extension
What bacteria are most commonly implicated in Necrotizing Fasciitis? 3
- Strep pyogenes (Group A hemolytic)
- Staph aureus
- Clostridium perfringens
What is a cross bite
Can occur with any teeth.
In normal occlusion, lateral aspect of maxillary teeth are more lateral than the mandibular teeth (overbite and overjet, the anterior teeth are all lateral/over)
If the maxillary teeth are inside the mandibular teeth, this is considered a cross bite
How can you feel your alignment?
Periodontal ligament has sensation
What does the inferior alveolar nerve give sensation to? 3
- Lower teeth
- Gums
- Lower chin and lower lip (mental nerve)
