PROLOGUE: A MYSTERY CASE
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Transcript of PROLOGUE: A MYSTERY CASE
PROLOGUE: A MYSTERY CASE
CASE: HPI BV. 14 year old F Remote tonsillectomy and ESS x 2 In the ED with 9 d h/o sore throat and
odynophagia. Antecedent ‘head cold’ 4 d prior, has since resolved with conservative measures.
Developed intense L otalgia 2 d ago. Treated with amoxicillin for putative AOM → no improvement.
Last night, spiked fevers to 101. 5 F. Had emesis. Not tolerating PO.
Courtesy of BCM Dept. OTO-HNS. Grand Rounds Archives. 16 Sept 2010
CASE: PHYSICAL VITALS: T 102.5 | BP 138/66 | HR 116 | R 24 | SpO2
97% RA GEN: Sitting comfortably. Phonation is normal. No
drooling. EARS: L pre-auricular tenderness. External ears normal.
TMs quiet bilaterally. NOSE: Normal nares, septum, and turbinates. MOUTH: Mandible centered. Moderate trismus.
Tonsils surgically absent. Posterior pharynx with L > R fullness, no erythema or exudates.
NECK: No meningismus. Mildly restricted active ROM to L. Tenderness at Level II on L > R.
PULM:Respirations relaxed. No stridor. Lung fields clear throughout.
NEURO: Mental status is clear. No lateralizing deficits.
CASE: LABS and STUDIES CBC: WBC 21,000 with 85% PMNs, 15% band
forms BMP: Na 149, K 5.1, Cr 1.4, BUN: 30 Rapid Strep: Non-reactive AP Neck Film: Unremarkable CXR: Unremarkable
Common Infections of the Deep Neck Spaces: An Overview
Victor Tseng, MS-3OTO-HNS Subrotation
DEEP NECK SPACES: Eleven anatomic or potential compartments created by interfascial planes within the neck
DEEP NECK INFECTION: A supperative (usually bacterial) infection within the deep neck spaces of the deep cervical fascia
DEFINITIONS
AXIAL ANATOMY
SAGITTAL ANATOMY
SAGITTAL ANATOMY
RADIOLOGIC ANATOMY
HEAD AND NECK AXIAL MRI
FLYTHROUGH (LINK)
A MENU OF SPACES: PEARLSSUPRAHYOID
PARAPHARYNGEAL (PP): A major nexus of contiguous spread. Transmits the carotid sheath. Isolated involvement is uncommon.
SUBMANDIBULAR (SM): Infection may lead to upper airway obstruction MASTICATOR: Most closely associated with trismus. Almost exclusively
secondary to odontogenic causes. PAROTID: Most likely seen in dehydrated and decrepit patients with poor
dentition TEMPORAL: Between temporalis fascia and temporal bone periostium PERITONSILLAR (PTS): Most common site overall, but not aknowledged as a
true DNI, since it is not defined by fascial apposition
INFRAHYOID RETROPHARYNGEAL (RPA): Extends from skull base to level of carina (T2).
Does not communicate with the pleural space. DANGER: Infection easily escapes into the mediastinum and pleural space PREVERTEBRAL (PV): Extends to coccyx and may develop into psoas absess. CAROTID: Associated with IVDA and septic thromboembolism PRETRACHEAL (PT): Associated with anterior perforation of the esophageal
wall
HOOFBEATS: COMMONS
PERITONSILLAR (49%) RETROPHARYNGEAL (22%, 43% non-
PTS) Most common DNI across all age groups But it is predominantly a pediatric
infection SUBMANDIBULAR (14%, 27% non-PTS) PAROTID (11%)
RETROPHARYNGEAL ABSCESS (RPA) EPIDEMIOLOGY
> 75% of cases occur < 6 years old. 50% of cases occur by 12 mos. Overall (treated) mortality approximately 1%
ETIOLOGY Children (< 18 years): 60% related to supperative LAD due to URI,
AOM, acute sinusitis Adults: Mostly due to trauma, foreign body, instrumentation, or
contiguous extension from primary DNI MICROBIOLOGY
>90% are polymicrobial. Average n = 5 microbes isolated from culture.
>50% of isolates grow anerobes S. pyogenes > S. aureus > oropharyngeal anaerobes > H. influenzae
PATHOPHYSIOLOGY supperative lymphadenitis → organized phlegmon → mature abscess Morbidty and mortality is due to development of complications
RETROPHARYNGEAL ABSCESS (RPA) CLINICAL PRESENTATION
Adults: Sore Throat > Fever > Dysphagia > Odynophagia > Nuchal Pain > Dyspnea > Hoarseness
Children: Sore Throa (84%) > Fever (64%) > Odynophagia (55%) > Cough
Infants: Neck Fullness (97%) > Fever (85%) > Poor PO (55%) DIFFERENTIAL DIAGNOSIS
Epiglottitis, PTA, Croup, Diphtheria Angioedema Respiratory lymphagiomas or hemangiomas Traumatic esophagus or airway, foreign body impaction
COMPLICATIONS Acute Mediastinitis: very high (>50%) mortality Empyema Pericardial effusion with tamponade physiology Mass effect: supraglottic airway obstruction (anterior) or epidural
abscess (posterior)
RETROPHARYNGEAL ABSCESS (RPA) PHYSICAL FINDINGS
Adults: pharyngeal edema > cervical LAD > nuchal rigidity > drooling > stridor
Children: fever and nuchal rigidity (64%) > retropharyngeal bulge and neck mass (55%) > agitation or lethargy > drooling (22%) > respiratory distress or stridor
Other: dystonic reactions (torticollis), dysphonia (‘hot potato’ voice), trismus
In a drooling or stridorous patient, be minimally invasive when examining the pharynx
LABORATORY CBC: 20% of cases may not show leukocytosis or relative left shift Standard GAS rapid throat swab and culture Blood cultures: rarely return positive growth Wound culture: 91% sensitivity for polymicrobial infection CRP and ESR to follow baseline. CRP is actually prognostic of
hospitalization legnth. Pre-operative labs in anticipation of surgical intervention (coagulation
panel, metabolic panel, type and cross)
RETROPHARYNGEAL ABSCESS (RPA) IMAGING
Lateral Neck Film: look for widened AP diameter of retropharyngeal tissue. Maximal reported sensitivity of 88%.
CT Neck with Contrast Most important imaging test to consider Hypodense lesion of retropharyngeal space with rim enhancement Absolute Indications: equivocal LNF, negative LNF with high clinical
suspicion Sensitivity 77 – 100% , Specificity 95%
High-Resolution U/S Maybe used to track abscess during hospitalization. Some anatomic
insight into surrounding vascular structures. Proof of concept. No data to support routine use.
MRI: Not recommended for initial evaluation due to untimeliness
Flexible Endoscopy: not recommended
RETROPHARYNGEAL ABSCESS (RPA)
RETROPHARYNGEAL ABSCESS (RPA) MEDICAL MANAGEMENT PARENTERAL ANTIBIOTIC THERAPY is guided by suspected source of infection!
Must have MRSA coverage if strain is endemic, poor clinical response to clindamycin, or in patients with very severe disease
SUSPECTED SOURCE
FIRST-LINE THERAPY ALTERNATIVE
Odontogenic Ampicillin-Sulbactam 3 g IV q6h
Penicillin G 2-4 MU IV q4-6h + Metronidazole 500 mg IV q6-8h
Clindamycin 600 mg IV q6-8h
Imipenem 500 mg IV q6h
Meropenem 1 g IV q8h
Rhinogenic and Otogenic
Ampicillin-sulbactam 3 g IV q6h
Ceftriaxone 1 g IV q24h +Metronidazole 500 mg IV q6-8h
Ciprofloxacin 400 mg q12h + Clindamycin 600 mg IV q6-8h
As above
Immuncompromised Cefipime 2 g IV q12h + Metronidazoole 500 g IV q6h
Piperacillin-Tazobactam 4.5 g IV q6h
As above
RETROPHARYNGEAL ABSCESS (RPA) SURGICAL INDICATIONSImportant: > 50% of patients with uncomplicated RPA
achieve spontaneous resolution with medical therapy alone
Respiratory distress Urgent complication of RPA (e.g. mediastinitis,
empeyema, septic thrombophlebitis) Diameter of abscess > 2 cm on CT Neck No response to ABx therapy at 48 hrs
SURGICAL APPROACH U/S guided FNA: preferred in hemodynamically unstable
patients, or those with small and accessible loculations I/D: Usually requires trans-cervical entry. Small abscesses may
be drained via trans-oral aspiration.
QUESTIONS