Morning Report

Morning Report: 6/29/2015

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Deep Space Neck Infections!

Anatomy

deep neck pic

Image from:

http://www.uptodate.com/contents/image?imageKey=PEDS%2F74998&topicKey=ID%2F3415&rank=1~17&source=see_link&search=deep+neck+infection&utdPopup=true

 

Types

Peritonsillar space (abcess)

Parotid space

Submandibular space (Ludwig’s angina)

Pretracheal space

Prevertebral space

Parapharyngeal space

Retropharyngeal & danger space

 

History & Physical Exam Findings

– Dysphagia                                                                   – Drooling

– Odynophagia                                                               – Paratonsillar or pharyngeal bulge

– Dyspnea +/- stridor if airway obstruction present           – Displaced uvula

-Toxic appearance                                                         – Trismus

– Fever                                                                           – Unilateral tongue paresis

– Muffled or hoarse voice

 

Imaging

Lateral neck XR

  • Prevertebral soft tissue should be less than 5mm or <1/3 the width of C4 vertebral body

Bedside ultrasound

  • Can be used to search for a fluid collection suggesting underlying abcess

CT Neck & Chest

 

Microbiology

Polymicrobial – consider flora from source of infection

  • Anaerobic predominance with anterior soft tissue infections that infiltrate the deep neck space
    • viridians, S. pyogenes, Fusobacterium, Peptostreptococcus, Prevotella
  • Gram + predominance with vertebral infections that advance into prevertebral space
    • aureas most common
  • Immunocompromised (DM, EtOH abuse, IVDA, immunosuppresion tx):
    • Greater risk of S. aureas, Pseudomonas, ESBL-Enterobacteriaceae

 

Management – In general, always consider where infection may have originated from

*IV abx for 2-3 weeks

  • Parapharyngeal/Retropharyngeal source
    • Immunocompetent à Augmentin
    • Immocompromised à Cefepime + Flagyl or Meropenem or Zosyn
  • Prevertebral source
    • Immunocompetent à Nafcillin or Vancomycin + Gentamicin/Ciprofloxacin/Timentin
    • Immunocompromised à Vancomycin/Linezolid + Zosyn/Meropenem/Cefepime & Flagyl

*Image-guided drainage

 

Complications

Carotid sheath involvement – resulting from infections of parapharyngeal space and/or submandibular space

  • Arteritis à be wary of the sick patient with torticollis!!!
  • False aneurysm
  • Rupture

Suppurative jugular thrombophlebitis (Lemierre’s syndrome)

  • Septic pulmonary emboli, persistent fever despite abx

Necrotizing mediastinits – resulting from infections of retropharyngeal and/or danger space

  • Empyema
  • Pleural/pericardial effusion

 

References:

  • Chow, AW. (9/17/13). Deep Space Neck Infections. Up To Date. Retrieved 6/28/15 from http://www.uptodate.com/contents/deep-neck-space-infections?source=search_result&search=deep+neck+space+infections&selectedTitle=1~17
  • Murray, AD. (3/28/14). Deep Neck Infections. Medscape. Retrieved 6/28/15 from http://emedicine.medscape.com/article/837048-overview
The views expressed on this blog are the author's own and do not reflect the views of their employer. Please read our full disclaimer here. Any references to clinical cases refer to patients treated at a virtual hospital, Janus General Hospital.
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