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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.

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slide2

CASE: HPI

  • BV. 14 year old F
  • Remote tonsillectomy and ESS x2
  • 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

slide3

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.
slide4

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

Common Infections of the Deep Neck Spaces: An Overview

Victor Tseng, MS-3

OTO-HNS Subrotation

slide6

DEFINITIONS

  • 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
slide10

RADIOLOGIC ANATOMY

HEAD AND NECK AXIAL MRI FLYTHROUGH (LINK)

slide11

A MENU OF SPACES: PEARLS

  • SUPRAHYOID
    • 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 psoasabsess.
    • CAROTID: Associated with IVDA and septic thromboembolism
    • PRETRACHEAL (PT): Associated with anterior perforation of the esophageal wall
slide12

HOOFBEATS: COMMONS

  • PERITONSILLAR (49%)
  • RETROPHARYNGEAL(22%, 43% non-PTS)
    • Most common DNIacross all age groups
    • But it is predominantly a pediatric infection
  • SUBMANDIBULAR(14%, 27% non-PTS)
  • PAROTID (11%)
slide13

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
slide14

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)
slide15

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)
slide16

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
slide18

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
slide19

RETROPHARYNGEAL ABSCESS (RPA)

  • SURGICAL INDICATIONS

Important: > 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.