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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.

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PROLOGUE: A MYSTERY CASE

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  1. PROLOGUE: A MYSTERY CASE

  2. 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

  3. 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.

  4. 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

  5. Common Infections of the Deep Neck Spaces: An Overview Victor Tseng, MS-3 OTO-HNS Subrotation

  6. 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

  7. AXIAL ANATOMY

  8. SAGITTAL ANATOMY

  9. SAGITTAL ANATOMY

  10. RADIOLOGIC ANATOMY HEAD AND NECK AXIAL MRI FLYTHROUGH (LINK)

  11. 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

  12. 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%)

  13. 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

  14. 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)

  15. 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)

  16. 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

  17. RETROPHARYNGEAL ABSCESS (RPA)

  18. 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

  19. 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.

  20. QUESTIONS

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