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Head and Neck InfectionsJonathan Fleurat, MD
Emergency Medicine, PGY-2Boston Medical Center
+Outline
Facial Infections Introduction
Common etiology Odontogenic infections Parotiditis Sinusitis Orbital Infections
Deep Neck Space Infections
Complications
Summary
+Some History
Pre-antibiotic era: 31 case Ludwig’s angina, 54% died
1940 Ashbel Williams
The antibiotic era: reduced to 4%.
1979 Hought RT
+Facial Infections
+Abscess vs. Cellulites
+Etiology
Odontogenic
Tonsillitis
IV drug injection
Trauma
Foreign body
Sialoadenitis
Parotitis
Osteomyelitis
Epiglottitis
URI
Iatrogenic
Congenital anomalies
Idiopathic
+Odontogenic Infections: Anatomy
+Odontogenic Infections: Microbiology
Multiple bacteria
anaerobic vs aerobic vs mixed
35% 5% 60%
Aerobic G(+) streptococci
Anaerobic G(+) cocci G(+) rods
+Odontogenic Infections: Management
Physical Exam Vital signs, palpation,
teeth, x-ray
History Taking When, Where, How,
Why, Duration
Signs and symptoms: pain swelling warmth redness trismus
Abscess vs. Cellulitis
Immunocompromised
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
Odontogenic Infections: Treatment
13
When to refer
Rapid infection spread
Breathing or swallowing difficulties
Facial space infection
Fever
Trismus (<10mm)
Toxic appearance
Compromised State
+Facial Infections: Parotiditis
• Usually viral: Paramyxovirus• Bacterial: elderlyimmunohigher risk with dehydration• Treatment: lemon dropsmassagehydrationwarmth
•If purulent- IV antibioticsCompetent: for oral bacteriaImmunocompromised: broad spectrum
+Facial Infections: Sinusitis
Signs and symptoms H/A, facial pain in sinus
distribution purulent yellow-green
rhinorrhea Fever CT more sensitive than
plain films
+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
+At Risk: Cavernous sinus thrombosis
+Deep Neck Infections
+Deep Neck Infections: Clinical Presentation
Pediatric Symptoms:
- Fever
- Decreased PO
- Odynophagia
- Malaise
- Torticollis
- Neck pain
- Otalgia
Most Common Symptoms:
- Sore throat (72%)
- Odynophagia (63%)
- Neck swelling (70%) (excluding peritonsillar abscesses)
- Neck pain (63%)
- HA
- Trismus
- Neck swelling
- Vocal quality change
- Worsening of snoring
- Sleep apnea
+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%
+ Imaging
+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
+Deep Neck Infections: Imaging MRI
Pros More precise Less dental artifact Better for floor of mouth No radiation Non iodine contrast
Cons Cost Pt cooperation Slower (19 to 35 minutes)
CT with contrast Pros
Widely available Faster (5-15 minutes) Abscess vs cellulitis Less expensive
Cons Contrast Radiation Uniplanar Dental artifacts
+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
+LUDWIG’S ANGINA
Sublingual space
Submaxillary space
+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.
+Deep Neck Infections: Complications
Airway obstruction Trach: 10-20% Ludwig’s angina: 75%
Mediastinitis – 2.7%
UGI bleeding
Sepsis
Pneumonia
IJV thrombosis
Skin defect
Vocal cord palsy
Hemorrhage 20-80% mortality
Multiple space involvement
+Who Gets Complications?
Older pts
Immunodeficient pts
Cirrhosis
DM 33% with complications Higher mortality rate Prolonged hospital stay
20 days vs. 10 days
+Key Points
Anatomy can help predict spread and complications
Can be life threatening: recognize and consult early
Airway in very sick patients
+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 of Otolaryngology, The University of Texas Medical Branch at Galveston, 2005.- slides• Emedicine.com •Herr RD, Serious Soft Tissue Infections of the Head and Neck, American Family Physician, September 1991, Vol 44, no 3, 878-888