infectious & inflammatory disorders
DESCRIPTION
Infectious & Inflammatory Disorders. The lymphatic tissue in the neck accounts for 1/3 of all nodal tissue in the entire body Most cervical LN are located in the anterior triangle. Infectious lymphadenitis → extracapsular extension → neck space infection → frank neck abscess. - PowerPoint PPT PresentationTRANSCRIPT
Infectious & Infectious & Inflammatory Inflammatory
DisordersDisorders
Infectious & Infectious & Inflammatory Inflammatory
DisordersDisorders
• The lymphatic tissue in the neck accounts for 1/3 of all nodal tissue in the entire body
• Most cervical LN are located in the anterior triangle
Infectious lymphadenitis → extracapsular extension → neck space infection → frank neck abscess
Acute bacterial lymphadenitis :
Group A ß hemolytic strepococcus Staphylococcus aureus
Chronic form of lymphadenitis: Mycobacterium tuberculosis
Atypical mycobacterium Cat-scratch disease
Viral involvement Toxoplasmosis
Previous History • Age • Duration of symptom• Possible infectious contact• Animal exposure• Recent travel• Co-existing conditions
Physical inspection• Site • Size • Inflammatory characteristics :
Tenderness Fluctuation
Redness Warmness
Diagnostic Test• Needle aspiration• Excisional biopsy• Incision & drainage• Gram stain • Acid fast bacterial stain • Culture for aerobic & anaerobic
bacteria• Viral ,fungal & unusual bacterial culture
Diagnostic test (cont.)
• CBC• ESR• Serum Ig titer• TB skin test
Radiologic examination
• Lateral neck X-ray• CXR• Axial CT scanning with IV contrast
Treatment
Treatment for suppurative lymphadenitis is oral or IV broad-spectrum antibiotic with surgery reserved for refractory cases
Bacterial infection
Penicillin
First& second generation cephalosporinclindamycin
Viral infection
Most common cause of cervical lymphadenitisRSV , parainfluenza , adenovirus ,HIV entrovirus, HSV , EBVGeneralized LAP , Exanthems
Group A β hemolytic strep. & staph
Unilateral cervical lymphadenitis1-3 duration
Level I & IIOral antibiotic
Cat-scratch diseaselast fall & winter
90% cat exposure ( Bartonella henselae )Axillary LAP → Cervical LAPSkin lesion after 7-14 →1-2 weeks later tender lymphadenitis
Can remain enlarged up to 4 monthNeedle aspiration may relieve acute pain
Drainage should be avoidedNo treatment unless toxic symptom → Azithromycin
Mycobacterium species• The most common cause of chronic
unilateral , suppurative cervical lymphadenitis
• Positve tuberculin test will differentiated M. tuberculosis from atypical form .
• Minimally tender , spontaneous rupture • Atypical form is rarely associated with
pulmonary disease
Treatment
• M. tuberculosis :six month rifampin,
isoniazide ,pyrazinamide
Atypical mycobacterium : Surgical excision with oral clarithromycin
Toxoplasmosis gondii
• Infection via undercooked meat & unpasteurized milk
• Immunocompetent → IM like viral infection
• Immunocompromised → CNS infection
• Oocytes in cat feces
Kawasaki disease • Fever • Rash • Mucositis • Nonpurulant conjunctivitis• Cervical lymphadenopathy• Common under 4 years • Toxin of S, aureous implicated as a
possible etiology
Dental caries & gingivitis
• Anaerobic species • Actinomycosis • Fungal• HSV
Fascial space infection• Submandibular space • Peritonsillar • Masticator space • Parotid space • Parapharyngeal space• retropharyngeal space
Pathophysiology of neck space infection
• Pre-antibiotic era : tonsil & pharynx (70% ) , dentition
( 20% )
• Antibiotic era : Tonsil & pharynx (30%) , dental (30%) ,
cervical adenitis , trauma , IV drug abuser
Bacteriology• Mixed flora ( anaerobic abscesses
predominating over aerobic abscesses)
• Anaerobe : peptosterp. , Bacteriod , Anaerobic staph.
• Aerobic : S. aureus , Strep. H. influ. E. coli , Klebsiella
Management of neck spaces infection
• History of : • Recent dental work • Dental pain • IV drug abuse • URT infection • Recent surgery • Trauma
Management ( cont.)
Physical examination : Inspection of dentition Palpation of the soft tissue of
the H&N Vital sign
Radiologic study• Lateral neck film : may show increased prevertebral
width : > 7 mm at C2 > 20 mm at C6 Presence of gas
Radiology ( cont.)
• In patients who are initially managed with IV antibiotics , a CT scan should be used only when the patient is not progressing as expected .
• Axial Ct with IV contrast
Wound cultures are not routinely obtained unless the patient is immunocompromised or the infection is unresponsive or life-threatening .
12-24 h of antibiotic therapy can differ cellulitis versus abcess .
Airway control is the first priority when the submandibular , parapharyngeal and retropharyngeal spaces are involved .
• Severe trismus or Ludwig`s angina : Tracheostomy
• Retropharyngeal abscess : Intubation in Trendelenburg
position
Antibiotic
• Clindamycin as a first – line coverage
• Penicillin• Cefuroxime
Surgical drainage
• Wide exposure , vascular identification
• Drainage• Copious irrigation • Placement of drains ( 3-5 days )
Drainage (cont.)• Canine & sublingual space : intraorally• Buccal space : intra or extra oral• Masticator , submandibular ,submental : Extraoral parallel to the lower border of
mandibule• Peritonsillar : aspiration & incision
transorally
Drainage (cont.)
• Parapharyngeal space : Transcervical
• Retropharyngeal : transorally or transcervical• Parotid :standard parotidectomy
incision
Necrotizing Fasciitis • Usually in trunk , extremity or perineum • Dental abscess , trauma , peritonsillar
abscess , osteoradionecrosis , inset bite , burn , laceration , needle puncture
• Predisposing factor : DM , peripheral vascular disease ,
cirrhosis , malignancy , alcoholism, immunosuppression
• Progress over a few hours or a few days • Central zone of necrosis → tender
purplish area → wide peripheral zone of erythema
• Lack of frank purulence , thin gray exudate
• Subcutaneous emphysema• Toxic state : hyperpyrexia , tachypnea ,
tachcardia , lethargy
Treatment • Correction of electrolyte
imbalance , anemia , hypovolemia• Wide surgical debridement • Broad spectrum antibiotic • Aggressive bedside dressing • Frequent debridement under GA • Hyper baric oxygen