Emergency lectures - Head neck infection

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  • The cause of cavernous sinus thrombosis is usually a bacterial infection that has spread from the sinuses, teeth, ears, eyes, nose, or skin of the face. Persons with conditions that cause an increased risk of blood clots may also develop cavernous sinus thrombosis. Symptoms Bulging eyeballs Ocular palsy Ptosis Headaches Visual loss
  • Superficial Layer Deep Layer Subdivisions not histologically separate Superficial Enveloping layer Investing layer Middle Visceral fascia Prethyroid fascia Pretracheal fascia Deep
  • Emergency lectures - Head neck infection

    1. 1. + Head and Neck Infections Jonathan Fleurat, MD Emergency Medicine, PGY-2 Boston Medical Center
    2. 2. + Outline  Facial Infections Introduction  Common etiology  Odontogenic infections  Parotiditis  Sinusitis  Orbital Infections  Deep Neck Space Infections  Complications  Summary
    3. 3. + Some History  Pre-antibiotic era:  31 case Ludwig’s angina, 54% died 1940 Ashbel Williams  The antibiotic era:  reduced to 4%. 1979 Hought RT
    4. 4. + Facial Infections
    5. 5. + Abscess vs. Cellulites
    6. 6. + Etiology  Odontogenic  Osteomyelitis  Tonsillitis  Epiglottitis  IV drug injection  URI  Trauma  Iatrogenic  Foreign body  Congenital anomalies  Sialoadenitis  Idiopathic  Parotitis
    7. 7. + Odontogenic Infections: Anatomy
    8. 8. + Odontogenic Infections: Microbiology  Multiple bacteria anaerobic vs aerobic vs mixed 35% 5% 60% Aerobic G(+) streptococci Anaerobic G(+) cocci G(+) rods
    9. 9. + Odontogenic Infections: Management  History Taking  Physical Exam  When, Where, How,  Vital signs, palpation, Why, Duration teeth, x-ray  Signs and symptoms:  pain  Abscess vs. Cellulitis  swelling  warmth  redness  Immunocompromised  trismus
    10. 10. + 11 Odontogenic Infections: Treatment  Indications for antibiotics  Rapid, diffuse or progressive swelling  Immunocompromised  Involvement of facial spaces  Severe pericoronitis/abscess  Osteomyelitis  Situations in which use of antibiotics is not necessary  Dry socket  Mild pericoronitis/chronic or vestibular abscess
    11. 11. Odontogenic Infections: Treatment
    12. 12. 13When to refer Rapid infection spread Breathing or swallowing difficulties Facial space infection Fever Trismus (<10mm) Toxic appearance Compromised State
    13. 13. + Facial Infections: Parotiditis• Usually viral: Paramyxovirus• Bacterial:elderlyimmunohigher risk with dehydration• Treatment:lemon dropsmassagehydrationwarmth•If purulent- IV antibioticsCompetent: for oral bacteriaImmunocompromised: broad spectrum
    14. 14. + Facial Infections: Sinusitis  Signs and symptoms  H/A, facial pain in sinus distribution  purulent yellow-green rhinorrhea  Fever  CT more sensitive than plain films
    15. 15. + Facial Infections: Sinusitis Continued  Complications  ethmoid sinusitis: orbital cellulits and abscess  frontal sinusitis: may erode bone (Potts Puffy Tumor, Brain Abscess)  Orbital Cellulitis  Cavernous Sinus Thrombosis
    16. 16. + At Risk: Cavernous sinus thrombosis
    17. 17. + Deep Neck Infections
    18. 18. +ef ee cp t Noencs k: D In i C lin ic a l P r e s e n t a t io nMos t C ommonS ym p to m s :  Pediatric Symptoms: - Sore throat (72%) - Fever - HA - Odynophagia (63%) - Decreased PO - Trismus - Neck swelling (70%) (excluding - Odynophagia - Neck swellingperitonsillar abscesses) - Malaise - Vocal quality chang - Neck pain (63%) - Torticollis - Worsening of snorin - Neck pain - Sleep apnea - Otalgia
    19. 19. + Deep Neck Infections: Imaging  Lateral neck plain film  Normal:  7mm at C-2  14mm at C-6 for kids  22mm at C-6 for adults  Technique dependent  Extension  Inspiration  Sensitivity 83% compared to CT 100%
    20. 20. + Imaging
    21. 21. + Mediastinitis Imaging Plain films  Widened mediastinum (superiorly)  Mediastinal emphysema  Pleural effusions  Changes appear late in the disease CT neck and thorax  Esophageal thickening  Obliterated normal fat planes  Air fluid levels  Pleural effusions  CT helps establish dx and surgical plan
    22. 22. + Deep Neck Infections: Imaging  MRI  CT with contrast  Pros  Pros  More precise  Widely available  Less dental artifact  Faster (5-15 minutes)  Better for floor of mouth  Abscess vs cellulitis  No radiation  Non iodine contrast  Less expensive  Cons  Cons  Cost  Contrast  Pt cooperation  Radiation  Slower (19 to 35 minutes)  Uniplanar  Dental artifacts
    23. 23. + Deep Neck Infections: Antibiotic Therapy  Initial Therapy  Admit  Antibiotics: Gm+ and anaerobes  If diabetic: also Gm-  IV abx only  If no clinical improvement in 24-48 hours, proceed to surgical intervention
    24. 24. + LUDWIG’S ANGINAu b lin g u a l s p a c e S u b m a x illa r y s p a c e
    25. 25. + Deep Neck Infections: Ludwig’s Angina  Inflammation and cellulitis of the submandibular space.  Tongue causes airway obstruction.  +/- abscess  Symptoms:  drooling  trismus  pain  submandibular mass  dyspnea  Most require tracheostomy for airway control.
    26. 26. + Deep Neck Infections: Complications  Airway obstruction  Vocal cord palsy  Trach: 10-20%  Hemorrhage  Ludwig’s angina: 75%  20-80% mortality  Mediastinitis – 2.7%  Multiple space involvement  UGI bleeding  Sepsis  Pneumonia  IJV thrombosis  Skin defect
    27. 27. +  Older ptsWho Gets  Immunodeficient ptsComplications?  Cirrhosis  DM  33% with complications  Higher mortality rate  Prolonged hospital stay  20 days vs. 10 days
    28. 28. + Key Points  Anatomy can help predict spread and complications  Can be life threatening: recognize and consult early  Airway in very sick patients
    29. 29. + Bibliography• The Treatment Principle of Head & Neck Infection.• ENT Emergencies, Division of Emergency Medicine, Stanford University-slides.• Buyten, J, Francis, QB, Deep Neck Space Infections, Department ofOtolaryngology, The University of Texas Medical Branch at Galveston, 2005.-slides• Emedicine.com•Herr RD, Serious Soft Tissue Infections of the Head and Neck, American FamilyPhysician, September 1991, Vol 44, no 3, 878-888

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