10. Management of Dna Sarangan

8/13/2019 10. Management of Dna Sarangan

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Dr. Made Jeren, SpTHT

Lahir : 23 Maret 1962

Pend idikan :

1. Lulus FK UNUD : Pebruari 1988

2. Th. 1988

1993 : RSUD Anutapura Palu &

RSUD Parigi Sulawesi Tengah

3. Th. 1994 1998 : PPDS THT FK UNDIP

4. Th. 1998 - 2001 : PNS RSUD Magetan

5. Th. 2002

sekarang : PNS RSUD Dr. Harjono PonorogoPangkat/ Gol. IV/C


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Made Jeren

Bagian THT RSUD Dr. Harjono

Ponorogo


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Remain an important health problem in ENT Dep. Significant risk of morbidity and mortality

The complication rate has been reduced :

1. advant of modern microbiology

2. shopisticated diagnostic procedure(CT Scan, MRI)

3. development of management

(medical and surgical)

4. effectiveness of modern Antibiotics


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COMPLEX ANATOMY

DEEP LOCATION

ACCESS PROBLEM

COMMUNICATION OF THE DEEP NECKSPACES


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Huang (185 cases): th 1997 - 2002

Abses Parafaring (38,4 %)

Abses submandibula (15,7 %)

Ludwig Angina (12,4 %)

Abses Parotis (7 %)

Abses Retrofaring (5,9 %)

Yang (100 cases) : th 2001 -

2006

ring (20 %)

Abses submandibula (35 %)

Abses infrahioid (26 %)

Abses Mastikator (13 %)

Abses Retrofaring (13 %)

Abses Ruang karotis (11 %)

Abses Peritonsil (9 %)Abses sublingual (7 %)

Abses Parotis (3 %)


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Bagian THT UNAND(33 kasus ) :

Th 2009/2010

Abses Peri ton si l (32 %)

Abses submandibu la (26 %)

Abses Parafaring (18 %)

Abses Retrofaring (12 %)

Abses Mastikator (9 %)

Abses Pretrakea (3 %)


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1) Superficial cervical fascia

2) Deep cervical fascia :

Superficial layer(Investing layer)

Midd le layer

(Viseral layer )

Deep layer

(Prevertebral &

A lar layer)


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1. Length of the Neck

2. Above the Hyoid bone

3. Below the Hyoid bone


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1. Retropharyngeal Space

2. Danger Space

(Prevertebral Space)

3. Paravertebral Space4. Carotid Sheath Space


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1. Parapharyngeal Space

2. Submandibular Space

3. Masticator Space

4. Temporal Space

5. Parotid Space


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ETIOLOGY OF DNI

1. Tonsillar and Pharyngealinfection

2. Dental infection

3. Oral surgical procedure

4. Salivary gland infection

5. Trauma oral cavity and pharynx

6. Cervical lymphadenitis

7. Infection of a malignant cervicallymph node

8. Mastoiditis with Bezold abscess

In fact 2050% no identi f iable source


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MICROBIOLOGY

Mixed organisms (aerobic and anaerobic)

Aerobic organisms :

Group A beta-hemolytic streptococcal species (Streptococcus

pyogenes)

Streptococcus viridans, Streptococcus pneumoniae),Staphylococcus aureus, Moraxtella catarrhalis, Neisseriasp,

Klebsiella sp ; Haemophilus influenzae.

Anaerobic o rganisms :

Fusobacterium nucleatum, Bacteroides melaninogenicus,

Bacteroides oralisand Prevotella


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SPREAD MECHANISM

Mandibula periapikal abcess

Submandibula

Parafaring

Mastikator

Carotid SheathRetrofaring

CraniumMediastinum


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History + Physical ex.

Culture, IV Antibiotic, Airway control, Chest Rx

CT Scan

CellulitisSmall Abcess Large Abcess

Wait 24 48 h

Improvement

Ab

Needle aspiration for

culture and draenase

Complication

Surgical Inc ision

yes

no


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1. Streptococcus

pyogenes

Ampicillin-sulbactam 1.5-3 g IV q6h ,

Clindamycin 600 mg IV q8h

2. anaerobes Clindamycin 600 mg IV q8h ,

metronidazole 500 mg IV q8h

3. Methicillin-susceptible

Staphylococcus aureus

(MSSA)

Clindamycin 600 mg, Nafcillin 1.5 g IV q4h,

Ceftriaxone 1-2 g or

Ampicillin-sulbactam 1.5-3 g

4. Methicillin-resistantStaphylococcus aureus

(MRSA)

Vancomycin 1000 mg (15 mg/kg) orLinezolid 600 mg,Daptomycin 4-6 mg/kg,

Telavancin 10 mg/kg IV

5. Haemophilus

influenzae

Ceftriaxone 1-2 g or Ampicillin-sulbactam

IV Ant ib iot ic Treatment


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Wit ing b i la i amarga tuna pangerten(mendapat celaka karena kurangnya

pengetahuan).

Wit ing kalantur amarga tanpa pitutur(kesalahan yang berkelanjutan karena

tidak adanya tuntunan)


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PERITONSILLAR ABSCESS

Cellulitis of the space behind tonsillar capsuleextending Into soft palate leading to abscess.

The pus is located between the tonsillar bed and thecapsule anterosuperior to the anterior pillar.

Complication from acute/chronic tonsillitis

Microbiology : Streptococcus, Staphyllococcus,anaerobic.

Unilateral

Most common 10-30 years old


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Inflamation of tonsil peritonsillar space

Supero-lateral of tonsillar fossa (tonsillar bed)


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MANAGEMENT

Antibiotic therapy

Surgical drainage

COMPLICATION

Spontaneus rupture aspiration

Direct spread :

Parapharyngeal spaceMediastinum

Intracranial complication


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Wit ing luput saka kal imput (penyebab salah karena tertutupi).

Weruh in g sis ip sayekt i sul i t (menyadari kekeliruan benar-benar sulit).


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ETIOLOGY

PediatricsSuppurative process in

retropharyngeal nodes

(more than 50% due to

lymphadinitis) from nose,adenoids , nasopharynx or

sinuses infect ions

Adults

Trauma Instrumentation;

Trauma foreign body.

from contiguous spaces, suchas the parapharyngeal space,submandibular space (Ludwigangina), or prevertebral space( osteomyelitis).


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Pediatrics

History of upper Resp. track infection,

Fever, irritability, torticollis, poor oral

intake, sore throat, drooling, hot potato

voice, posterior pharyngeal swelling,

lymphadenopathy,

Adults

History of trauma, Slow onset

Severe case :

Dyspnea and respiratory d istress


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Lateral soft t issu e radiograph s

Ult rasonography

Contrast Enhanced CT

MRI


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Antibiotic therapy

Surgical drainage :

1. Trans oral approach

2. External approach

MANAGEMENT


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Parapharyng abscess

Laryngeal inflammation

Rupture with aspiration

Mediastinitis


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Boundary

o Superiorly : Skull baseo Inferiorly : submandibullar glando Laterally : Medial pterygoid m,

Parotis, Mandibulao Medially : Pharynx

(sup. Constrictor pharynx m.)o Anteriorly : Submandibular spaceo

Posterior : Prevertebral fascia,retrophryngeal space

Connections to other deep spaces:

posteromedially: retropharyngeal space

inferiorly: submandibular space

laterally: masticator space

medially: peritonsillar space


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1. Trauma :

Post Tonsilectomy, others trauma

2. Spread in fect ion from :

Cervical lymphadenitis, Dentalinfection, Parotitis, Tonsilitis,

Pharyngitis, Nasal / Sinus,

Mastoiditis

3. Compl icat ion from others space

Retropharinx, Peritonsillar,

Submandibula


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Trismus , spasm of pterygoids m.

Pyrexia,malaise,

Pain throat,difficult swallowing (Disphagy / Odinophagy

Painful external swelling in neck ( angle mandible,

lateral pharynx )

Medial displacement of lateral pharyngeal wall (Tonsil

pushed medially )


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PARAPHARYNGEAL SPACE INFECTIONTreatment

1. Evaluate and maintain

airway & fluid hydration

2. Parenteral antibiotic highdose 24-48 hrs.

3. If not improve, considere

surgical drainage

MANAGEMENT

Surgical drainage

1. Intraoral approch

(peritonsillar abscess only)

2. External approach

-transverse submandibularincision

-T. shape incision (Mosher)


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Routh of complication1. Limphatic system

2. Hematogen

3. Direct spread

1. Intracranial complication

2. Caroted artery rupture3. Internal jugular vein thrombosis

4. Septecimia

5. Mediastinitis

6. Spread to other spaces of theneck


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Bud i hayu mangg ih rahayu (budi mulia menemukan kerahayuan).

Durangkara manggih sangsara (angkara murka menemukan sengsara).


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The submandibular space :

hyoid bone to the mucosa of the

floor of the mouth.

anteriorly- laterally : mandible

inferiorly : superficial layer of thedeep cervical fascia.

by m ylohyo id m.

1. Sublingual space (above

mylohyoid m.)

2. Submaxillaly space (below

mylohyiod m.)


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Gangren Pulpa Molar

Apicalis Periodontitis

Periostitis

Deep Neck Space


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Dysphagia, OdynophagiaHypersalivasi / Drolling

Hot potato voice

Febrile

Trismus

Stiff neck

Stridor

Woody inflammation,

Protruding tongue

Torax Photo

CT Scan

MRI


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Grodinskys criteria (1939):

1. A cellulitis, not an abscess2. The cellulitis involves all the

sublingual and bilateral

submaxillary spaces

3. The cellulitis produces a sero-

sanguineous infiltration butvery little or no pus

4. Fascia, muscle, connective tissue

involvement, sparing glands

5. The cellulitis is spread bycontinuity and not by lymphatics

Ludwigs anginaby Ludwig in 1836.


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Ludwigs anginaby Ludwig in 1836.

Rapid spread to :lateral pharyngeal / retropharyngeal space

Rapidly obstruct upper airway :

Tachypnea, dyspnea, stridor


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An t ib iot ic therapy

Patients with cellulitis can betreated with parenteral

antibiotics alone. Closely

observe these patients for

development of an abscess.

Surgical

Tracheotomy for airway control

Surgical Drainage

Surgical Drainage


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Surgical Drainage

Transoral

Cruciate mucosal incision, blunt spreading through

superior pharyngeal constrictor.For : retro-, parapharyngeal.

External

Levitt: anterior vs. posterior approachSubmandibular incision

Submental incision

T-incision


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1. Airway obstruction

2. Ruptured abscess

Pneumonia

Lung Abscess

3. Carotid Artery Rupture

Mortality of 20-40%Sentinel bleeds from ear, nose, mouth

Treatment

Proximal and distal control

Ligation


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4. Internal Jugular Vein ThrombosisTreatment IV antibiotic therapy

Anticoagulation? Ligation and excision

5. Mediastinitis

Mortality of 40%

Increasing dyspnea, chest pain

Treatment

Aggressive IV antibiotic therapy

Surgical drainage

Transcervical approach

Chest tube vs. Thoracotomy

6. Sepsis


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10. Management of Dna Sarangan

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