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Deep Neck Infections

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Deep Neck Infections

  1. 1. Deep neck infections 가천의과대학 길병원 구강악안면외과 김 현민
  2. 2. 차례 <ul><li>1) facial spaces </li></ul><ul><li>2) each spaces ; buccal </li></ul><ul><li>masticator </li></ul><ul><li>sublingual & submandibular </li></ul><ul><li>parapharyngeal </li></ul><ul><li>retropharyngeal </li></ul><ul><li>3) case report 1.2 </li></ul><ul><li>4) summary </li></ul><ul><li>5) references </li></ul>
  3. 3. Fascial spaces of clinical significance <ul><li>Face ; buccal </li></ul><ul><li>canine </li></ul><ul><li>masticator – masseter , pterygoid , zygomaticotemporal </li></ul><ul><li>parotid </li></ul><ul><li>Suprahyoid ; sublingual </li></ul><ul><li>submandibular – submaxillary , submental </li></ul><ul><li>lateral pharyngeal(pharyngomaxillary) </li></ul><ul><li>peritonsillar </li></ul><ul><li>Infrahyoid ; pretracheal (anterovisceral) </li></ul><ul><li>Spaces of total neck ; retropharyngeal </li></ul><ul><li>danger space </li></ul><ul><li>space of carotid sheath </li></ul><ul><li>by Topazian & Goldberg </li></ul>
  4. 4. Fascial anatomy
  5. 5. Fascial anatomy 1
  6. 6. Fascial anatomy 2
  7. 7. Fascial anatomy 3
  8. 8. Fascial anatomy 4
  9. 9. Fascial anatomy 5
  10. 10. Fascial anatomy 6
  11. 11. Cellulitis versus abscess on CT imagies <ul><li>Abscess ; single or multilocated low density masses, peripheral irregular rim enhancement, fluid collections </li></ul><ul><li>contrast injections (a)before </li></ul><ul><li>(b)after on RPA/PPA </li></ul><ul><li>Cellulitis ; without a low density collection, no fluid collections </li></ul><ul><li>hypodensity with(a),without(b) </li></ul><ul><li>complete ring enhancement </li></ul>
  12. 12. Buccal space infections <ul><li>Symptoms ; round dome shape swelling, trismus, 원인치의 동요 및 타진 반응 , 상하안검 swelling </li></ul><ul><li>Anatomy ; </li></ul>
  13. 13. Masticator space infections <ul><li>Symptoms; trismus, painful swelling, dysphagia etc </li></ul><ul><li>Anatomy ; </li></ul>
  14. 14. Masticator space infections <ul><li>* Mn 에서 야기된 odontogenic infections 은 upward 되며 masseter m 감염은 PS , temporalis, lat.pterygoid m 로 spread , </li></ul><ul><li>med. Pterygoid m 감염은 PPS , lat. Pterygoid m 로 spread 된다 . </li></ul><ul><li>Downward 되어 sublingual, submn spaces 로 spread 된다 . </li></ul><ul><li>* Mx 에서 야기된 inf 은 downward 되지 않고 superficially temporal, MS, deeply lat. / med. Pterygoid m 을 involve 한다 . </li></ul><ul><li>MS 는 mn inf. 의 primary site 이고 PS & pharyngeal space 는 MS 의 2nd site 이며 mn inf. 은 sublingual & submn 으로 직접 전파된다 . </li></ul><ul><li>By Koichi Yonetsu </li></ul>
  15. 15. Submandibular space infections <ul><li>Symptoms ; neck rigidity, trismus, dysphagia, respiratory distress, sialorrhea, pyrexia, </li></ul><ul><li>Anatomy ; </li></ul>
  16. 16. Submandibular space infections <ul><li>*Schematic drawing of the 3 types of pathways </li></ul><ul><li>type 1; beyond mylohyoid ridge & </li></ul><ul><li>posterioly from adjacent sublingual space </li></ul><ul><li>; with mylohyoid m enlarge </li></ul><ul><li>type 2 ; from inflammatory periostitis of mn </li></ul><ul><li>; no or rare PPS,MS involvement </li></ul><ul><li>mild symptoms without trismus & dysphagia </li></ul>
  17. 17. Submandibular space infections <ul><li>* 만약 감염이 PPS 로 spread 되면 dysphagia 발생되며 PPS 는 med. Pterygoid m 같은 MS 감염시 자주 spread 된다 . 그런데 ,Submn space inf 시 PPS 사이에 fasciaL barrier 가 얇아서 전이가 용이하다 . 이는 med. Pterygoid m involvment 없이도 동시에 감염이 일어나는 것으로 확인 될 수 있다 . </li></ul><ul><li>type 3 ; downward from MS </li></ul><ul><li>Type1(57.6%) > type2(15.2%) > type3(12.1%) by Y.Ariji et al </li></ul>
  18. 18. Parapharyngeal space infections <ul><li>Symptoms ; fever(38.5), chill, throat swelling, odynophagia, dysphagia, neck pain & stiffness, respiratory distress, sialorrhea, trismus ( PPS swelling+ & trismus- = peritonsillar abscess) </li></ul><ul><li>Cause ; most common cause - peritonsillar abscess </li></ul><ul><li>odontogenic sourse(20-39%) by Larry J. Peterson </li></ul><ul><li>Anatomy ; ant prestyloid compartment- fat filled </li></ul><ul><li>post retrostyloid compartment-major neurovascular bundle (hard palate- upper PPS, lower PPS) </li></ul>
  19. 19. Parapharyngeal space infections <ul><li>Anatomy – MS,PS(lateral) , CS(post) , RPS(posteromedial) </li></ul><ul><li>PPS 의 displacement direction 은 origin of lesion 을 suggest 한다 . By VFH Chong et al </li></ul>
  20. 20. Parapharyngeal space infections imagies
  21. 21. Retropharyngeal space infections <ul><li>Symptoms ; fever, decrease oral intake, odynophagia, malaise, torticollis, neck pain, trismus, otalgia, headache, neck swelling, </li></ul><ul><li>Anatomy ; </li></ul>
  22. 22. Retrppharyngeal space infections <ul><li>Lateral neck x-ray 는 first imaging test 되어야 한다 . Air sign 이 보이는 경우 specific 하다 . CT scan 은 RPS abscess manage 시 중요하지만 cellulitis 와 abscess 를 구분하는 데 한계가 있다 . </li></ul><ul><li>by Carl Boucher </li></ul><ul><li>RPS abscess – lat. Neck x-ray – air sign+- drainage (with CT) </li></ul><ul><li>air sign—IV anti –no improvement-CT scan </li></ul><ul><li>improvement-IV continue </li></ul><ul><li>Young children 에서 neck plain films 는 true lat, orientation(neck extension, full inspiration, swallowing& expiratory crying 을 avoid 하여야 RPS thicken 을 방지할 수 있다 . by P.Bradley Brechtelsbauer </li></ul><ul><li>Lat. Neck x-ray diagnosis ; 1)smooth lordotic curve of cervical vertebra-C2,C3 7mm wide 적어야 , 평균 3mm, C6 14mm 소아 , 22mm 성인 soft tissue shadow 가 정상 </li></ul>
  23. 23. Retropharyngeal space infections <ul><li>2) presence of gas </li></ul><ul><li>3) straight cervical spine or reversed kyphotic curve </li></ul><ul><li>loss of the lordotic curve by Larry J. Peterson </li></ul>
  24. 24. Retropharyngeal space infections
  25. 25. Case report 1 <ul><ul><ul><li>Pt ; 38/F </li></ul></ul></ul><ul><li>CC ; 내원 5 일 전 개인치과 발치 후 우측 swelling 으로 내원 </li></ul><ul><li>PI ; mouth opening limitation, dysphagia, Rt buccal & sub mn swelling / Td/ redness </li></ul><ul><li>Dx ; masticatory spce, lat. Pharyngeal space abscess </li></ul><ul><li>Tx ; I & D X 2 </li></ul><ul><li>(submn & submental, deep neck carotid sheath area) </li></ul><ul><li>anti theraphy ( aug + micronomycin + flagyl) </li></ul><ul><li>fluid etc supplementary tx (O2 etc) </li></ul><ul><li>초진 lab ; WBC 30260, segmental neutrophil 85.9%, CRP 36.5 </li></ul>
  26. 26. 초진 모습
  27. 27. 치료 임상 사진 <ul><li>1) 초기 I&D (02.9.13), 2 차 I&D(02.9.14) </li></ul><ul><li>2)3 차 I&D(02,9.17) </li></ul>
  28. 28. 치료 후 사진 <ul><li>02. 9.27 </li></ul>
  29. 29. 초진 CT (02.9.14)
  30. 30. 2회 CT(02.9.17)
  31. 31. 3회 CT(02.9.19)
  32. 32. 4회 CT(02.9.25)
  33. 33. Case report 2 <ul><li>Pt ; 30/M </li></ul><ul><li>CC ;transfer from ENT d/t deep neck infection from dental origin </li></ul><ul><li>Hx ; 02.5.20 #38 ext 후 ENT 로 입원 </li></ul><ul><li>PI ; both submn swelling & Td </li></ul><ul><li>mouth opening limit, dysphagia, dyspnea, </li></ul><ul><li>neck Td & redness, #38 area pus </li></ul><ul><li>DX ; submn & mental space abscess </li></ul><ul><li>pretracheal space abscess </li></ul><ul><li>descending necrotizing mediastinitis </li></ul><ul><li>Tx ; I & D 3 회 (local 1, general 2 with TS) </li></ul>
  34. 34. 초진모습 <ul><li>초진 lab ; WBC 16120, segmental neut92.7%, ESR119, CRP25.1 </li></ul>
  35. 35. 치료 임상 사진
  36. 36. 치료 후 사진
  37. 37. 초진 CT(02.5.25)
  38. 38. 2회 CT(02.5.29)
  39. 39. 3회 CT(02.6.3)
  40. 40. 4회 CT(02.6.12)
  41. 41. Summary <ul><li>Deep neck infections 의 치료는 early radiologic Dx, medical management(effective antitherapy), intensive surgical management & airway control 등 요소가 필수적이다 . </li></ul><ul><li>Culture 를 시행하는 것이 중요하지만 감수성검사가 시행되기 전까지 penicillin derivatives & clindamycin 과 같은 항생제로 early intervention 을 시행하여야 하고 cellulitic stage 에서는 항생제만으로도 가능하지만 abscess 가 확진 되면 surgical intervention 이 시행되어야 한다 . CT 및 MRI 등의 이용은 임상증상의 한계를 보이는 deep neck infection 시 고려되어야 한다 . </li></ul><ul><li>만약 초기 항생제 치료 48 시간내 증상의 호전이 보이지 않거나 abscess 가 임상적으로 확인가능 하다면 I & D 는 충분히 고려되어야 한다 . </li></ul><ul><li>AIR way 확보는 RPA, Submn A 시 tracheostomy 가 필요로 하는 경우도 있으므로 충분한 환자의 monitoring 이 중요하다고 하겠다 . </li></ul>
  42. 42. References <ul><li>1.Y.Ariji et al.odontogenic inf. Pathway to the submn space; imaging assessment.Int.J.Oral Maxillofac.Surg.2002;31;165 </li></ul><ul><li>2.VHF Chong & YF Fan. Radiology of the PPS.Australasian radiology.1998;42;278 </li></ul><ul><li>3.Larry J. Peterson.L.contemporary management of deep infections of the neck.J.Oral Maxillofac.Surg.1993;51;226-231 </li></ul><ul><li>4.Carl Boucher et al.RPS abscess; a clinical & radiologic correction;J.of Otolaryngology,1999;28;134 </li></ul><ul><li>5. Per-Lennart Westesson; contemporary maxillofacial imaging OMFS clinics of noth america,1992 </li></ul><ul><li>6. Topazian & Goldberg; oral & maxillofacial infections, 3rd edition </li></ul><ul><li>7. 김여갑 ; 임상구강악안면감염학 ,1995 </li></ul><ul><li>8. Koichi Yonetsu et al; deep fascial inf. Of odontogenic origin: CT assessment of pathways of space involvment. </li></ul><ul><li>AM J Neuroradiology,1998;19;123 </li></ul>

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