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Management of acute cervicofacial infections

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Title: Management of acute cervicofacial infections


1
Management of acute cervicofacial infections
Wednesday, February 29th 2012
Kings College Hospital
2
Management of acute infections
Types of infection
Fungal
3
Management of acute infections
Types of infection
Fungal Viral
4
Management of acute infections
Types of infection
Fungal Viral Bacterial
5
Management of acute infections
Fungal
  • Aspergillosis
  • A. fumigatus, A. niger, A. flavus
  • Granulomatous inflammation of the sinuses which
    may involve the orbit and intracranial
    extensions.

Ref. Maiorano E. Favia G. Capodiferro S.
Montagna MT. Lo Muzio L. Combined mucormycosis
and aspergillosis of the oro-sinonasal region
in a patient affected by Castleman disease.
Virchows Archiv. 446(1)28-33, 2005 Jan
6
Management of acute infections
Fungal
  • 2) Mucormycosis
  • Rhino-orbital-cerebral pulmonary infections are
    the most common form.
  • Survival rate 36-50

Ref. Maiorano E. et al. Combined mucormycosis
and aspergillosis of the oro-sinonasal region in
a patient affected by Castleman disease.
Virchows Archiv. 446(1)28-33, 2005 Jan Chandu
A. et al. A case of mucormycosis limited to the
parotid gland. Head Neck. 2005 Dec27(12)1108-
11.
7
Management of acute infections
Fungal
Ref. Maiorano E. et al. Combined mucormycosis
and aspergillosis of the oro-sinonasal region in
a patient affected by Castleman disease.
Virchows Archiv. 446(1)28-33, 2005 Jan Chandu
A. et al. A case of mucormycosis limited to the
parotid gland. Head Neck. 2005 Dec27(12)1108-
11.
8
Management of acute infections
Viral
  • HSV, EBV, VZV, CMV, Paramyxovirus, Coxsackie
    virus, Picorna virus
  • Mostly symptomatic management, with the exception
    of Herpes zoster (Shingles)

9
Management of acute infections
Viral
  • 15-35 of HZ patients has postherpetic neuralgia
    (PHN)
  • Early antiviral therapy has been found to reduce
    the risk and duration of PHN in elderly patients.

Lilie HM, Wassilew S, The role of antivirals in
the management of neuropathic pain in the older
patient with herpes zoster. Drugs Aging 20 (8)
561-70 2003
10
Management of acute infections
Bacterial
  • Dental infection is the most common cause of deep
    neck abscess.
  • Common acute bacterial infection
  • 1) Cellulitis Ludwigs angina

Parhiscar A., Har-El G. Deep neck abscess a
retrospective review of 210 cases. Annals of
Otology, Rhinology Laryngology.
110(11)1051-4, 2001 Nov.
11
Management of acute infections
Bacterial
  • Dental infection is the most common cause of deep
    neck abscess.
  • Common acute bacterial infection
  • 1) Cellulitis Ludwigs angina
  • 2) Abscess - Parapharyngeal/tonsillar, dental

Parhiscar A., Har-El G. Deep neck abscess a
retrospective review of 210 cases. Annals of
Otology, Rhinology Laryngology.
110(11)1051-4, 2001 Nov.
12
Management of acute infections
Bacterial
  • Dental infection is the most common cause of deep
    neck abscess.
  • Common acute bacterial infection
  • 1) Cellulitis Ludwigs angina
  • 2) Abscess - Parapharyngeal/tonsillar, dental
  • 3) Necrotising fasciitis

Parhiscar A., Har-El G. Deep neck abscess a
retrospective review of 210 cases. Annals of
Otology, Rhinology Laryngology.
110(11)1051-4, 2001 Nov.
13
Management of acute infections
14
Management of acute infections
15
Signs of Infection
  • Local
  • Redness, pain, swelling, heat, /- pus (abscess)
  • Loss of function
  • Systemic
  • Temperature gt 37C (or spikes), malaise, pallor,
    irritability, fatigue, dehydration
  • lymphadenopathy
  • Severe signs dysphagia (sublingual,submandibular
    ), drooling, dysphonia, stridor (airway
    compromise),trismus

16
Management of acute infections
Bacterial
Taken from Petersons Principles of Oral and
Maxilofacial Surgery Chapter 15
17
Management of acute infections
Bacterial
  • Erysipelas
  • Cellulitis of the skin with lymphatic involvement
  • Mainly involves leg but often occurs on the face
  • Strep. Pyogenes S. aureus main pathogen

Lazarini L et al, Erysipelas and cellulitis
clinical and microbiological spectrum in an
Italian tertiary care hospital. Jour. of
Infection, 2005(51) 383-389
18
Management of acute infections
Bacterial
  • Erysipelas
  • Area of erythema and swelling has sharp
    demarcation
  • Treatment Augmentin or Penicillin Clindamycin

Lazarini L et al, Erysipelas and cellulitis
clinical and microbiological spectrum in an
Italian tertiary care hospital. Jour. of
Infection, 2005(51) 383-389
19
Management of acute infections
Bacterial
  • Management
  • Assess for potential airway compromise

20
Management of acute infections
Bacterial
  • Management
  • Assess for potential airway compromise
  • Tracheostomy Gold standard
  • Awake fibreoptic intubation - 1st choice

Reference Ovassapian A, Airway management
in adult patients with deep neck infections a
case series and review of the literature,
Anesth Analg. 2005 Feb100(2)585-9
21
Management of acute infections
Bacterial
  • Management
  • Assess for potential airway compromise
  • Administration of broad spectrum antibiotics
  • References
  • Kuriyama T et al, Bacteriologic features and
    antimicrobial susceptibility in isolates from
    orofacial odontogenic infections,
    Oral Surg Oral Med Oral Pathol Oral Radiol
    Endod. 2000 90(5)600-8.
  • Kuriyama T et al An outcome audit of the
    treatment of acute dentoalveolar infection
    impact of penicillin resistance.Br Dent J. 2005
    Jun 25198(12)759-63
  • Stefanopoulos PK et al, The clinical significance
    of anaerobic bacteria in acute orofacial
    odontogenic infections. Oral Surg Oral Med
    Oral Pathol Oral Radiol Endod. 2004 98398-408.

22
Management of acute infections
Bacterial
Taken from Stefanopoulos PK et al, The
clinical significance of anaerobic bacteria in
acute orofacial odontogenic infections. Oral
Surg Oral Med Oral Pathol Oral Radiol Endod.
2004 98398-408.
23
Management of acute infections
Bacterial
  • Management
  • Assess for potential airway compromise
  • Administration of broad spectrum antibiotics

24
Management of acute infections
Bacterial
  • Management
  • Assess for potential airway compromise
  • Administration of broad spectrum antibiotics
  • Investigations
  • FBE, UE, CRP, ESR, Blood cultures

25
Management of acute infections
Bacterial
  • Management
  • Assess for potential airway compromise
  • Administration of broad spectrum antibiotics
  • Investigations
  • CT scan vs. MRI vs. USS

26
Management of acute infections
Bacterial
  • Management
  • Assess for potential airway compromise
  • Administration of broad spectrum antibiotics
  • Investigations
  • Contrast enhanced CT scan clinical exam
  • Sens 95
  • Spec 80

Ref Miller WD et al, A prospective, blinded
comparison of clinical examination and computed
tomography in deep neck infections.Laryngoscope.
109(11)1873-9, 1999 Nov.
27
Management of acute infections
Bacterial
  • Management
  • Assess for potential airway compromise
  • Administration of broad spectrum antibiotics
  • Investigations
  • Remove source of infection and establish surgical
    drainage

28
Warning Signs
  • Rapid onset.
  • Progressive trismus.
  • Painful trismus that is out of keeping with with
    the clinical picture should raise your suspicion
    regarding a submasseteric/pterygoid space
    infection.

28
29
Management of acute infections
Bacterial
30
Management of acute infections
Bacterial
31
Management of acute infections
32
Management of acute infections
33
Reasons for Admission
  • Rapidly progressing infection
  • Difficulty breathing
  • Difficulty Swallowing
  • Fascial space involvement
  • Elevated temperature - gt38
  • Severe jaw trismus lt 10mm
  • Toxic appearance
  • Compromised host defences

33
34
Investigations
  • Bloods inc glucose and CRP.
  • Consider blood cultures if appropiate
  • If pus, send swab and pus for gram stain
  • Radiological investigations, but these shoudl not
    defer treatment.
  • WARN THE ANAESTHETIST EARLY

34
35
Access
  • Submandibular/sublingual space
  • Parapharyngeal
  • Buccal
  • Submassteric

36
Management of acute infections
Bacterial
  • Management
  • Assess for potential airway compromise
  • Administration of broad spectrum antibiotics
  • Investigations
  • Remove source of infection and establish surgical
    drainage

37
Management of acute infections
Bacterial
  • Management
  • Assess for potential airway compromise
  • Administration of broad spectrum antibiotics
  • Investigations
  • Remove source of infection and establish surgical
    drainage
  • Close evaluation in the immediate post-op phase

38
Management of acute infections
Bacterial
  • Recurrent deep neck infections
  • Consider congenital abnormalities
  • Proper imaging aids in diagnosis
  • Most common cause
  • Branchial cleft cyst
  • Lymphangioma, thyroglossal duct cyst

Ref Nusbaum AO et al, Recurrence of a deep neck
infection a clinical indication of an underlying
congenital lesion. Arch Otolaryngol Head Neck
Surg 125 (12) 1379-82 1999 Dec
39
Salivary Gland Infections
  • Salivary Gland Infections
  • Bacterial ascending infections especially with
    xerostomia, in the presence of salivary calculi.
    Painful, swelling in F.O.M or as an acute
    pre-auricular swelling.
  • Treatment involves giving patient fluids to
    increase saliva flow, antibiotics and /-
    drainage depending on the presence of a
    collection.
  • Amoxycillin metronidazole flucloxacillin
    (staph)
  • Think of and exclude viral infection eg mumps
    most often bilateral parotid swellings

39
40
Ludwigs Angina
  • (Spreading Cellulitis in the FOM)
  • Potentially life threatening, a cellulitis
    starting in the floor of the mouth and often
    arising from a mandibular molar
  • Bilateral submandibular and sublingual space
    infection
  • Clinical signs
  • Oedema on both sides of the floor of the mouth
  • Raised tongue
  • Bilateral submandibular space involvement
  • Oedema spreading down the neck often with loss
    of definition of anatomical structures
  • Progressive trismus, pain, dysphagia, dysphonia
  • For hospital admission

40
41
Complications
  • Trismus (Classically sub masseteric space/lateral
    pharyngeal space infections)
  • Extra-oral incisions CNVII marginal mandibular
    branch, scarring, drains and ascending infection

41
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