Deep Neck Infections PDF

Dr. Luqman A. Mustafa M.B.Ch.B, FKBMS (ORL-HNS) UOD/SCHOOL OF MEDICINE 2022-2023  I Peritonsillar Space — Medial—capsule of palatine tonsil — Lateral—superior pharyngeal constrictor — Superior—anterior tonsil pillar — Inferior—posterior tonsil pillar ...

Dr. Luqman A. Mustafa M.B.Ch.B, FKBMS (ORL-HNS) UOD/SCHOOL OF MEDICINE 2022-2023  I Peritonsillar Space — Medial—capsule of palatine tonsil — Lateral—superior pharyngeal constrictor — Superior—anterior tonsil pillar — Inferior—posterior tonsil pillar PERITONSILLAR ABCESS (QUINSY) — Peritonsillar abscess is Q a collection of pus between the fibrous capsule of the tonsil, usually at the upper pole and the superior constrictor muscles of the pharynx. — It usually arises as a complication of tonsillitis. — I t may happen at any age but the majority is in young adults between 20 and 39 years of age Bacteriology — Anaerobic organisms JET — Beta haemolytic streptococcal infection. — Methicillin-resistant Staphylococcus aureus (MRSA) has been identified in a PTA Clinical features — progressive usually unilateral, sore throat over three to four days, o_ — odynophagia, — dysphagia for solids and eventually liquids, — drooling of saliva, — trismus, — ipsilateral otalgia and headache associated with fever lethargy and ipsilateral lymphadenopathy. — The patient often develops a plummy voice secondary to the oropharyngeal swelling.  Signs: — limited mouth opening (trismus) is virtually pathognomonic, — the tonsil is displaced medially by the hyperaemic, bulging mucosa of the anterior pillar over the peritonsillar space — the jugulodigastric nodes are tender and enlarged Differential diagnosis Infectious: peritonsillar cellulitis, parapharyngea abscess. Vascular: post-traumatic internal carotid artery pseudoaneurysms can occasionally cause confusion. Benign lesions: benign lymphoepithelial cyst. Neoplastic: large tonsil tumours with lateral extratonsillar spread, such as squamous cell carcinoma (SCC). Suspicious of SCC Investigation Investigation is not mandatory in clear-cut cases, but may be helpful in less straightforward cases. Needle aspiration of pus. Transoral ultrasound. Computed tomography (CT). Magnetic resonance imaging (MRI) angiography may be suitable for suspected vascular anomalies. Treatment qAdmission + intravenous antibiotics. qDrainage either by — needle aspiration or — using a conventional guarded quinsy knife indicated in: — The presence of an obvious pointing abscess, — clinical deterioration, 8 — failure to respond to i.v. antibiotics, — evidence of pus in the peritonsillar space on an imaging modality — Elective tonsillectomy after recurrent quinsy is recommended after 6-8 weeks. Complications — Mediastinitis is a condition with significant mortality (23 percent). — Necrotizing fasciitis following PTAs has rarely been described.  Parapharyngeal Space The parapharyngeal space lies on either side of the superior part of the pharynx. It is bounded: Laterally by the parotid gland, parotid fascia and medial pterygoid muscle. Medially it is bounded by the superior constrictor muscles. Superiorly it is limited by the skull base Inferiorly by the fascia surrounding the submandibular gland. Posteriorly the space communicates with the retropharyngeal spaceal Parapharyngeal space — Prestyloid — Muscular compartment — Medial—tonsillar fossa — Lateral—medial L pterygoid — Contains fat, connective tissue, nodes — Poststyloid — Neurovascular compartment — Carotid sheath — — Ese Cranial nerves IX, X, XI, XII Sympathetic chain PARAPHARYNGEAL ABSCESS Parapharyngeal abscess can occur in any age group. The most common causes are — tonsillitis, — PTA, — dental infection. Rarely, — elective tonsillectomy, — mastoiditis — pharyngeal foreign body, — trauma from nasotracheal intubation, — internal cysts and fistulae of branchial origin or second pharyngeal pouches. Infection can spread to the parapharyngeal space from any of the other deep neck spaces, i.e. peritonsillar, retropharyngeal and submandibular spaces. Bacteriology — Klebsiella pneumoniae — Streptococcus viridans — Pseudomonas aeruginosa in a patient with HIV disease Clinical features — are very similar to PTA — the maximum swelling in the pharynx is more inferiorly placed and behind the tonsil with less oedema of the palate Clinical features — There is the tender, firm but fluctuant swelling of the abscess to be felt in the neck rather than just LAP. DDx : Infection: PTA and spinal TB. Neoplastic: primary tumours of the parapharyngeal space including deep lobe parotid tumours, local spread from tonsil tumours or lymphoma. Differential diagnosis Vascular lesions: including pseudoaneurysms of the common and internal carotid and lingual arteries. Investigation Plain X-ray , lateral view for soft tissue of the neck can demonstrate foreign body penetration CT and MRI of the head and neck if mastoiditis is suspected and of the chest if mediastinitis is suspected. Investigation Treatment — Admission + i.v. ABx is the baseline Rx. — Failure to respond to conservative treatment or clinical deterioration should prompt surgical abscess drainage. — The traditional site of drainage is through an incision on the side of the neck at the level of the hyoid bone. Complications Carotid sheath involvement. 0 Acute pharyngeal perforation secondary to cervical necrotizing fasciitis. Mediastinitis Descending necrotizing fasciitis of the neck and mediastinum. Upper airways obstruction.  Retropharyngeal Space Anterior border - pharynx and esophagus (buccopharyngeal fascia) Posterior border - alar layer of deep fascia Superior border - skull base Inferior border – superior mediastinum Contains retropharyngeal nodes. Odin RETROPHARYNGEAL ABSCESS — Most commonly occur in children under six years of age, with a peak incidence between 3-5 years, due to a e suppurating retropharyngeal node following a URTI. — In adults and children it may occur very rarely secondary to foreign body penetration. — A tuberculous retropharyngeal abcess is rare even in the presence of tuberculous cervical spondylitis, with an incidence of 0.3-1 percent. Bacteriology — Strept. viridans (39 %) was the most common — Staphylococcus 8 epidermis (22 %) — S. aureus (22 %). — Penicillin-resistant S. pneumoniae has been described as a causative organism in pediatric cases. Clinical features In young children, — neck stiffness associated with fever, — irritability, — dysphagia, — airways obstruction, on examination, the posterior pharyngeal wall bulges forward. Clinical features The diagnosis of RPA in infants and young children is easily overlooked and should be considered in the differential diagnosis of fever and irritability, in particular, when lumbar puncture results are normal. Clinical features In adults, A history of previous TB contact, or pharyngeal trauma by fish or chicken bone must be specifically sought. Pain occurs at a relatively late stage and may be associated with fever. Neurological signs may develop due to cord compression. There may be bulging of the posterior pharyngeal wall on examination. Differential diagnosis — Nasopharyngeal carcinoma, — lipoma, — malignant schwannoma, — sarcoidosis, — aberrant internal carotid artery, — internal carotid artery pseudoaneurysm, — haematoma following whiplash injury. Investigations , plain lateral films in flexion and extension show loss of normal curvature of the cervical spine with a soft tissue bulge in front of it as well as bone destruction. Investigations Both CT and MRI can be used to delineate the abscess in greater detail Treatment Surgical drainage is the norm in paediatric RPAs, probably because of the significant incidence of airway compromise at presentation (29 percent). General anaesthesia is advisable but requires great skill and the abscess is incised through the pharyngeal wall transorally and pus sent for bacteriological examination. Complications Mediastinitis Spinal epidural abscesses Osteomyelitis of the odontoid process Purulent meningitis has been described as a complication of adult RPA ANY QUESTION ?