DanJoo,MD,CCFP,PGY‐3EM May,2011

Facial Infections 1. DEEP NECK INFECTIONS i. Life-threatening infections of the peripharyngeal and deep fascial spaces of the head and neck. Reynolds SC - Infect Dis Clin North Am - 01-JUN-2007; 21(2): 557-76 ii. Deep neck infection. Vieira F - Otolaryngol Clin North Am - 01-JUN-2008; 41(3): 459-83, iii. Chow. 2010. Deep Neck Space Infections. UpToDate v19.1 Accessed May 2011. 3 Life-Threatening Spaces

‐ Submandibular space ‐ Lateral pharyngeal space (a.k.a. parapharyngeal) ‐ Retropharyngeal space

Submandibular Space - Combination of sublingual and submylohyoid spaces - Source of infection: mandibular molar odontogenic >>> direct trauma, spread from other spaces - Micro: mixed infection (aerobes, anaerobes, gram negatives (*Klebsiella in DM) - **Ludwig’s Angina is prototype

‐ Clinical: rapid progression mouth pain, fever ‐ Tongue protrudes anterior and superior ‐ Brawny induration to floor of mouth (raised Wharton’s

Duct) - Complications:

‐ Rapid airway obstruction - Management pearls

‐ Difficult airway – ENT and Anesthesia to bedside ‐ Awake (nasal) fiberoptic vs. awake trach

Lateral Pharyngeal (Parapharyngeal) - Inverted cone bordered by superior constrictor medially and parotid gland / medial pterygoid / mandible laterally - Divided into two communicating compartments: anterior (muscular) and posterior (neurovascular) - The hub of all fascial / deep neck spaces: route of spread to others - Source of infection: PTA, pharyngitis, tonsillitis, odontogenic, spread from other spaces - Clinical: trismus if anterior compartment - Complications - airway obstruction

- neuro: Horner’s, CN 9-12 palsies - vascular: septic thrombophlebitis - Key mgmt points:

-CT needed to delineate anatomy / collections / complications

DanJoo,MD,CCFP,PGY‐3EM May,2011

Retropharyngeal Space - Think of Retropharyngeal / Danger Spaces together - key feature: direct route to mediastinum - Source of infection: suppurative adenitis (children), instrumentation, FB, spread from others - Prevertebral space – NOT odontogenic – hematogenous/osteo – same RFs as epidural abscess - Clinical: stiff neck, fever, muffled voice - Complications: airway obstruction, rupture with aspiration pneumonia, necrotizing mediastinitis

Space Pain Trismus Swelling Dysphagia Dyspnea

Submandibular Yes No Mouth floor Yes if bilat Yes if bilat

Lateral Pharyngeal - Anterior

Yes Yes Lateral anterior pharynx, angle of jaw

Yes Maybe

Lateral Pharyngeal - Posterior

Minimal Minimal Posterolateral pharynx

Yes Severe

Retropharyngeal / Danger

Yes No Posterior pharynx

Yes Yes

DanJoo,MD,CCFP,PGY‐3EM May,2011

2. ERYSEPELAS Key differentiating features c/f cellulitis:

‐ sudden onset, sharper demarcation ‐ fever, chills, constitutional symptoms ‐ superficial dermal involvement ‐ peau d’orange

Key management points:

‐ IV antibiotics until improvement ‐ Cover GABHS and MSSA ‐ Erythema may worsen before improves

3. (PERI)ORBITAL INFECTIONS i. Rudloe et al. 2010. Acute Periorbital Infections: Who Needs Emergency Imaging? Pediatrics 125: e719-726. ii. Periorbital and orbital infections. Wald ER - Infect Dis Clin North Am - 01-JUN-2007; 21(2): 393-408 iii. Hunter and Trucksis. 2010. Preseptal (periorbital) and Orbital Cellulitis. UpToDate v19.1 Accessed May 2011. Epidemiology 9:1 incidence of preseptal v. postseptal Source:

Preseptal: skin barrier breakdown (skin bugs) Postseptal: Sinusitis/Respiratory bugs

Specific features of orbital involvement: ‐ proptosis ‐ EOM limitation/ophthalmoplegia ‐ Vision changes

Orbital involvement = ‐ cellulitis – medical (mx) ‐ subperiosteal abscess – mx +/- sx ‐ orbital abscess – mx +/- sx

Predictors of abscess requiring intervention: ‐ proptosis / ophthalmoplegia / painful EOM

/ vision changes ‐ ANC > 10 ‐ Edema beyond eyelid ‐ Absence of conjunctivitis

CT needed if: ‐ Can’t reliably assess vision ‐ High risk clinical features ‐ Failure of medical tx after 24h ‐ CNS signs/symps

Mgmt tips: ‐ low-risk (preseptal) nontoxic: PO Abx and 24h follow up unless < 12mo age. ‐ Low-risk (preseptal) + unwell: IV Abx, Admit ‐ Med-High Risk for orbital: CT, IV Abx, Admit, Ophtho

DanJoo,MD,CCFP,PGY‐3EM May,2011

4. WOUND PROPHYLAXIS i. Management of facial bite wounds. - Stefanopoulos PK - Dent Clin North Am – Oct 2009; 53(4): 691-705, ii. Use of prophylactic antibiotics in preventing infection of traumatic injuries. - Abubaker AO - Dent Clin North Am - 01-OCT-2009; 53(4): 707-15, iii. Kesting et al. 2006. Animal bite injuries to the head: 132 cases. British Journal of Oral and Maxillofacial Surgery 44: 235–239.

Facial Lacerations Key points for prophylaxis

‐ Good wound irrigation/cleaning/debridement = cornerstone

‐ Remember tetanus ‐ Abx prophylaxis generally not reoommended

unless: o Through and through (weak data) o High risk patient factors:

immunocompromised, DM o High risk wound factors:

• De

layed presentation, large area, gross contamination

Facial Dog bites Key points

‐ Facial wound = good vascularity = no infection o This is now being rethought

‐ Irrigate with soapy water and iodine solution (MOH) ‐ Primary closure is preferred ‐ All facial bites warrant prophylaxis (esp kids)

o Rationale: Poor predictors of infection Risk of poor cosmesis Sutures increase infxn risk Cheek area prone to infection

‐ 1st line should be amox-clav ‐ Treat for 3-5 days

DanJoo,MD,CCFP,PGY‐3EM May,2011

5. PERITONSILLAR ABSCESS I. Cem Ozbek, Erdinc Aygenc, Evrim Unsal Tuna, Adin Selcuk and Cafer Ozdem (2004). Use of steroids in the treatment of peritonsillar abscess. Journal of Laryngology &amp; Otology, 118, pp 439-442 doi:10.1258/002221504323219563 II. Marx et al. 2010. Rosen’s Emergency Medicine. Chapter 73: Upper Respiratory Infections. III. The EDE 2 Course Training Manual, v3.4. 2010. pp. 204-208.

Key Points:

‐ occurs after tonsillitis / pharyngitis ‐ poor clinical accuracy at predicting abscess

vs. cellulitis (73% sensitivity ENT docs) ‐ U/S sensitivity and spec 80-100% ‐ Generally a medical disease – can often treat

with antibiotics even if fluid collection (unlike most other abscesses)

‐ Important aspect is analgesia and hydration ‐ Drainage helps symptoms and resolution ‐ **single dose steroids improves symptoms,

shortens hospiilzation, and no increase in complications

Ultrasound tips:

‐ position patient ‐ analgesia (spray / viscous gargle) ‐ 5cm depth, endocavitary probe marker to

patient’s right ‐ Note position and depth of carotid

(posterolateral location)