5/2/2012

HOSSAM THABET, M.D.

Otolaryngology - Head & Neck Surgery Department Alexandria University

1 5/2/2012

Pediatric Deep Neck Space Suppuration

Neck Infections

Superficial Deep SNSI DNSI

 Infection involving the  Infections that spread along the superficial neck space deep fascial planes & neck spaces between superficial cervical  Difficult to diagnose & treat fascia & SLDCF  Fascial planes can confine & limit  Easy to diagnose & treat spread of suppuration, but they are imperfect barriers.

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DNSI Is a challenging problem

1.Complex anatomy 2.Deep location 3.Difficult surgical access, 4. Proximity to great vs & ns 5.Communication- between spaces & outside the neck  life-threatening complications

The knowledge of the anatomy of fascial planes, spaces, & lymphatic drainage is the basis for understanding the pathology of DNSI

Deep Neck Spaces

 Anatomy of the Cervical Fascia  Anatomy of the Deep Neck Spaces

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Middle Cervical Fascia

Deep

Superficial L. of D.C.F.Middle L. of D.C.F. Middle Layer of D.C. F. Alar Layer of D.C. F. Muscular D. (Pink) Visceral D. Yellow (Investing Layer)

Prevertebral Layer of Middle, Alar,& Prevertebral L. of D.C.F. Superficial, Middle, & D.C. F. Brown Deep Cervical fascia

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Deep Neck Spaces

I. Spaces involving the II. Suprahyoid Spaces entire length of the neck  Sumandibular  Superficial space (Sublingual & Submaxillary)   Masticator space   Temporal space   Peritonsillar space  Vascular space   Parotid space III. Infrahyoid Spaces  Visceral space

Cervical Fascia Visceral Space

Vascular Space

Retropharyngeal Space

Alar Space

Prevertebral Space

Perivertebral Space

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C1 Mucosal Space

Buccal Space

Masticator Space

Parotid Space

Parapharygeal Spase

Carotid Space

Perivertebral Space Retropharyngeal Space

Etiology

 Adenotonsillitis & pharyngitis (Most Common)

 Odontogenic infections (Common in adults)

 Cervical lymphadenitis

 Traumatic Infections

1. Oral surgical procedures

2. Oropharyngeal injuries (gun shot, falls onto pencils or sticks)

3. F.B. ingestion; fish bones or other sharp objects

4. Instrumentation, (Esophagoscopy or Bronchoscopy)

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Etiology

infection  Congenital cervical Lesions 1. Branchial cleft anomalies 2. Thyroglossal duct cysts 3. Laryngopyocele  Mastoiditis with petrous apicitis & Bezold abscess  Immunosuppression (HIV infection, chemotherapy, or immunosuppressant drugs)

Pathophysiology

DNSI proceeds by one of several paths:  Lymphatic spread of infection from oropharynx, oral cavity, or superficial neck  Suppurative Lymphadenitis  Direct spread 1. Odontogenic abscess 2. Penetrating trauma 3. Sialadenitis  Via communication between spaces.  Hematogenous infection

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Epidemiology

 Most Common Site  Peritonsillar abscess (Ungkanont et al 1995)  Submandibular space infections & Ludwig’s angina (Larawin V et al 2006)  Retropharyngeal & parapharyngeal abscesses. (Flanary VA, Conley SF 1997, Nagy M et al 1997, & Broughton RA 1992)  Pediatric pts  Infants to teens / Most common: 3-5 years  Male predilection

Epidemiology

 Peritonsillar infections (49%)  Retropharyngeal infections (22%)  Submandibular infections (14%)  Buccal infections (11%)  Parapharyngeal space infections (2%)  Canine space infections (2%) (Ungkanont et al 1995)

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LYMPHATIC SPREAD OF INFECTION FROM , ORAL CAVITY, OR SUPERFICIAL NECK

Cervical Suppurative Lymphadenitis

3Y/O Male with suppurated Cervical Lymphadenitis

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Cervical Suppurative Lymphadenitis

3Y/O Male with suppurated Cervical Lymphadenitis

Cervical Suppurative Lymphadenitis

1.5Y/O Male with suppurated Cervical Lymphadenitis

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Cervical Suppurative Lymphadenitis

11 month male with L.N. Suppuration (MRSA)

Cervical Suppurative Lymphadenitis

11 month male with L.N. Suppuration (MRSA)

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Cervical Suppurative Lymphadenitis

Submandibular Space Infection

S.M.G S.M.G

Suppurative Lymphadenitis with Abscess Formation

Cervical Suppurative Lymphadenitis Submental Space Infection

Submntal Cellulitis & Lymphadenitis

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Cervical Suppurative Lymphadenitis Submental Space Infection

Lt Submandibular Lymphadenitis & Submental Abscess

Retopharyngeal Abscess

5 Y/O female child with torticollis to left side, fever , dysphagia, neck pain.

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Plain. X-ray neck shows widening of the prevertebral CECT shows enlarged adenoid space, loss of lordosis, with rim enhancement due to reversed lordosis, suppurative adenoiditis

  

Lt > Rt RP suppurative lymphadenitis with lucent central Lt RPA extending into the area of breakdown. Rt mucosal PPS with rim enhancement & space abscess & a Rt PPh. lucent central area of lymphadenitis (white arrows) breakdown.

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   Th.G

Lt multiloculated RPA extending Extension of the Lt RPA &PP into the PPS with rim abscess into the to the visceral enhancement & lucent central space & left thyroid region (Th.G) area of breakdown. Lt ICA is with lucent area of breakdown pushed laterally with? spasm

Diagnosis 1.Complicated Acute Adenoiditis 2.Retropharyngeal Abscess 3.Lt Parapharyngeal Space Abscess 4.Visceral Space Abscess RPA 5.VascularRPA Space Involvement

MR T2WI showing widening of the retropharyngeal space with hyperintense signal due to Lt retropaharyngeal abscess (RPA)

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Retropharyngeal Abscess

Management

 High risk airway!

 Admit to ICU

 IV antibiotics

 Aspiration/Surgical drainage

 Neck immobilization

Parapharyngeal Abscess

Pathogenesis  Odontogenic & Pharyngotonsillar infections  Other DNSI (PPS communicates with Parotid, Masticator, Peritonsillar, Submandibular, & RP, & vascular spaces)  Parotitis, Sinusitis  Infected neck tumors  Infected brachial cleft cysts  Chronic otitis, mastoiditis

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Parapharyngeal Abscess

Clinical Presentation  Fever, Trismus, & Neck swelling  Torticollis  Dysphagia or odynophagia  Signs of acute tonsillitis or pharyngitis  Neck pain  Medial displacement (tonsil /lateral ph. Wall)  Cervical lymphadenopathy

Parapharyngeal Abscess

Management

 IV abx : 10-15% cure

 Airway management

 Surgical drainage

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Parapharyngeal Abscess

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Nodes Of Rouviere (Lateral Retropharyngeal L.N.)

Lateral Ph.L.Ns lies between the ICA & prevertebral muscles at the upper neck. The most cephalad are known as the nodes of Rouviere

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Peritonsillar Abscess

 Most common DNSI in adults  Result of acute tonsillitis/ 2-5 days from onset  15 - 25% Recurrence in children  Predisposing factors:

 Chronic tonsillitis

 Multiple trials of oral Abx

 Incomplete tonsillectomies

 Tonsilloliths

 Dental infection

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Tonsillitis Vs Quincy

 No trismus/drooling  Trismus & drooling  Bilateral  Unilateral  Tonsils inflammed  Peritonsillar swelling  No peritonsillar swelling  Tonsil pushed medial  Uvula central  Uvula deviated  Aspiration- No pus  Aspiration- pus  Imaging  Imaging  Respond to medical tx  No response to tx

Peritonsillar Abscess

 CT (Sensitivity= 100% & Specificity = 75%)

 Suspicious PE & exclude retroph. abscess

 Inadequate visualization

 Young children

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Peritonsillar Abscess

Medical Management  Hydration  Analgesia 3 point aspiration –  Antibiotics begin in superior-medial pole & advance 0.5 cm Surgical Management more inferior & lateral

 Needle aspiration

 I & D - Confirm diagnosis & definitive drainage  Tonsillectomy

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ODONTOGENIC DNSI

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Odontogenic DNSI Peri-apical abscess

 Most common cause of DNSI in adults  Peri-apical abscess is the most common source  Prior to the use of antibiotics 70-80% of DNSI were 2ry to pharyngeal infection The following structures play a role in determining the location of an abscess 2ry to a mandibular tooth infection? A. Mylohyoid line B. Buccinator muscle insertion C. Location of the tooth apex

Apex Location Space Incisors

Premolars above mylohyoid line Sublingual space 1st molar

2nd and 3rd molar below mylohyoid line Submandibular space Yonetsu K, Izumi M, Nakamura. Deep facial infections of odontogenic origin: CT assessment of pathways of space involvement. Am J Neuroradiol January 1998, 19:123-128.

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Buccinator Muscle Insertion

Intra-oral abscess Abscess

Buccinator Muscle

The buccinator muscle inserts on the maxilla superiorly and the mandible inferiorly. The location of an abscess secondary to a dental infection depends on where the break in the cortex occurs with reference to the insertion of the buccinator muscle. Intra-oral abscess – cortical break below the insertion on the maxilla and above the insertion on the mandible Buccal space abscess – cortical break above the insertion on the maxilla and below the insertion on the mandible.

Submandibular Space Infection

a. Sublingual Space b. Submaxillary Space (Supramyelohyoid) (Inframyelohyoid)  Superficial - FOM m.m.  Superior & Lateral - the mandible  Medial- the genial muscles &  Inferior - the hyoid bone (The two subdivisions freely  Anterior/posterior - digastric ms communicate around the posterior  Lateral - deep cervical fascia border of the mylohyoid)  Medial - hyoglossus, styloglossus, & mylohyoid ms.

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Sublingual Space Infection

 Etiology: Infection of lower premolars & 1st molar with supramylohyoid perforation of the lingual cortex.  Symptoms: FOM swelling with tongue elevation  Extension to  Submandibular, Submental, & Lateral pharyngeal spaces

Drainage via incision of the floor parallel to Wharton's duct

Submandibular Space Infection

 Odontogenic (70%-85%)  Sialadenitis, lymphadenitis, FOM lacerations or mandible fractures, & Bezold abscess.  The mylohyoid insertion dictates the space affected by odontogenic infection. 1. The apices of 1st molar & ant.teeth (supramylohyoid) - Sublingual space involvement 2. The apices of the 2nd & 3rd molars (submylohyoid) - Submaxillary space involvement

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Submandibular Space Infection

Odontogenic Submandibular abscess

(amultiloculated low- attenuation mass with peripheral rim enhancement ).

Submandibular Space Infection

 Symptoms: Swelling inferior to the mandible, between the digastric bellies down to the hyoid bone level.  Treatment:  Antibiotics  Surgical Extraoral Drainage

an incision below & parallel to the inferior border of the mandible in the region of the angle, blunt dissection to explore the space for loculations of pus

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Submental Space Infection

 Occurs to due to: 1. Lower incisor infection (Thinner buccolabial alveolar plate with leak outside below the myelohyoid) 2. Submental suppurative lymphadenitis  Marked external induration  No internal swelling of the FOM  Moderate Odynophagia & no resp. distress

Submental Space Infection Submental Abscess

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Ludwig’s Angina

 Acute, progressive cellulitis of the sublingual & submaxillary spaces (mandibular dental infection 90%)

 50% mortality in the preantibiotic era, 10% in well- managed patients  Common in young adults, M:F= 2:1 or 3:1 ratio

Ludwig’s Angina Clinical Picture  Dysphagia/Odynophagia/Drooling

 Neck Pain/Swelling/Fever

 Throat & FOM Pain

 Dysphonia/Dysarthria

 Hot Pottato Voice

 Airway Obstruction

 Tongue swelling

 Restricted neck movement

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Ludwig’s Angina Clinical Picture

 Submandibular & Submental swelling

 Elevated Woody Tongue & FOM

 Suprhyoid edema & brawny induration “bull neck”

 Tenderness over neck

 Trismus & Fever

 No fluctuance/lymphadenopathy

 Percussion tenderness over involved teeth

Ludwig’s Angina

 Infection can easily spread to other deep spaces of the neck and thoracic cavity if diagnosis is delayed

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Ludwig’s Angina

Management  Continuous close monitoring  Airway management  IV antibiotic therapy (especially for anaerobes)  Surgical Drainage if not responsive to abx

Masticator Space

Infection from Lower 2nd & 3rd molars & extension from contiguous fascial spaces

SLDCF

Superior Spread of Infection P Parotid Space Firm attachment to the mandible There is no fascial separation between the the location of the SLDCF with reference to the medial projection of the and the inferior aspect of the mandible and the muscles MS. Therefore, tumors and infection can spread in the MS. Note: V3 travels through the MS. freely between the buccal & MS.

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Masticator Space Abscess Infection usually spreads superiorly

A B A B

CECT (A and B) show a low attenuation Post contrast axial T1WI (A) & coronal mass with peripheral rim enhancement in (B) demonstrate a low signal intensity the right MS consist with an abscess, with mass with peripheral enhancement inflammatory changes in and surrounding (abscess) in the right MS. There is the parotid. Bone erosion is noted in the superior extension along the temporalis ascending ramus of the mandible (B), muscle, which is enlarged & enhancing. consistent with osteomyelitis.

Masticator Space Abscess nd rd  Infection source: Lower 2 & 3 molarS & from contiguous fascial spaces (from buccal space 1ry involvement)  Extend superiorly , SLDCF is firmly attached to mandible.

 Communication with the buccal & parotid spaces  Symptoms: trismus, posterior-inferior face swelling

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Masticator Space Abscess

Masticator Space Abscess

Submasseteric & parotid infection Masticator space infection

Masticator space infection, lateral Lt masticator space abscess (arrow), pterygoid muscle swelling from a molar abscess (arrowhead).

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Masticator Space Abscess

Treatment:

 Extraoral or Intraoral Drainage along the or the angle of mandible for submassetric or pterygomandibular abscess

 External Drainage for temporal abscess

TRAUMATIC DNSI

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Retropharyngeal Abscess

•18 Y/O male with post traumatic retropharyngeal abscess & Surgical emphysema. Notice the A/F level & loss of cervical lordosis. How would you drain this RPA? (Exteranl Approach)

Retropharyngeal Abscess

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Retropharyngeal Abscess

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Post.Ph.W

Prevertebral Ms

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3Y/O Female

 Plain Xray neck lateral view showed widening of the prevertebral space at C6 level  CT was ordered  Tracheotomy has been performed

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Th.G Th.G Th.G Th.G

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5 Y/O Male

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1.Pharyngoesophegeal perforation 2.Surgical Emphysema 3.Retropharyngeal Abscess 4.Visceral Abscess 5.Mediastinitis & Mediastinal Collection 6.Empyema

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“MISTAKES IN MEDICINE ARE MADE BY THOSE WHO DO NOT CARE, MORE THAN THOSE WHO DO NOT KNOW.”

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IT IS GOOD TO LEARN FROM YOUR MISTAKES. IT IS EVEN BETTER TO LEARN FROM SOMEBODY ELSE’S!

LEARN FROM THE MISTAKES OF OTHERS. YOU CAN’T LIVE LONG ENOUGH TO MAKE THEM ALL YOURSELF

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DNSI DUE TO SIALADENITIS

Parotid space infection

Cause —Bad oral hygiene, sialolithiasis, stomatitis, dehydration, rdiotherapy, Sjogren’s syndrome, severe external otitis, & immune deficincy Tense painful parotid swelling  Fever  No trismus  No fluctuation (dense fascia)  Turbid fluid may be expressed from the duct 

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Parotid space infection

Left parotid Abscess

Lt Suppurative parotitis with localized abscess formation in parotid L.N.

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Parotid space infection

Acute bacterial suppurative parotitis in a neonate

Rt. Submandibular cellulitis due to Rt Suppurative submandibular Sialadenitis

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DNSI of Congenital Origin

 Infected TGDC  Infected Bronchogenic

 Infected BCC Cyst rd th  3 & 4 branchial sinus  Laryngopyocele

 Infected Thymic Cyst  Infected Dermoid Cyst

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Visceral Space Abscess

 Neck induration, tenderness , & edema  Spiking fevers, sepsis  Cause:

 Extension from other spaces rd th  3 & 4 branchial pouch sinus

 Infected BCC

 Infected thymic cysts

 Infected TGDC

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Infected TGDC

Branchial Arch Anomalies Cyst External Internal Fistula Sinus Sinus Pharynx Skin

BCC with external openings are associated with the 1st & 2nd arches, whereas the 3rd & 4th arches cysts are associated with internal openings

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 Type I

 Extremely rare,

 Ectodermal Duplication anomaly of EAC

 Parallel to the EAC

 Pretragal, post auricular cyst or fistula posterior to the pinna or concha.

 Superior to the main trunk of VII n.

 Ends in a cul-de- sac on or near a bony plate at the level of the mesotympanum.

 Surgical Excision  Type II

 A duplication anomaly of membranes & cartilaginous EAC.(ectodermal & mesodermal).

 Sinus tract extends medial, inferior,& anterior to the EAC and may extend deep to VII n.

 Fistula in the concha or EAC & in the neck

 Fistula opens below the angle of mandible at the anterior border of SCM, & superior to hyoid bone.

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Coronal T2 FSE F.D

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Second Branchial Cleft Cysts

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Third Branchial Cleft Cyst

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3rd arch Rt. branchial cyst

Fourth Branchial Cleft Cysts

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Th.G

Th.G

Th.G

AEF

Fistula, Methylene Blue

Arytenoid Pyriform Fossa Pyriform Fossa

Pus

Esophagus

Esophagus

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4th branchial pouch sinus

Fourth branchial pouch sinus originating in Translaryngeal course of a fourth the piriform apex (dashed lines), caudal to branchial pouch sinus. the SLN and terminating as a small cyst in the superior pole of the thyroid gland. The sinus tract is near the RLN at the cricothyroid joint.

2Y/O M

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2Y/O M

2Y/O M

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2Y/O M

2Y/O M

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2Y/O M

2Y/O M

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2Y/O M

2Y/O M

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Bronchogenic Cysts

4th branchial arch cyst & sinus

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Imaging OF DNSI

 Plain x-Ray 1. Lateral neck plain film 2. Chest X-Ray  High-resolution Ultrasound

 CT

 MRI

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Management Of DNSI Four keys to successful management  Airway Control 1. Observation 2. Intubation (Flexible fiberoptic guided intubation) 3. Tracheostomy  Antibiotic Therapy  Surgical Drainage 1. External Drainage 2. Transoral Drainage 3. Image Guided Aspiration  Treatment Of The Primary Cause (Dental Infection)

Management Of DNSI Antibiotic Therapy

 Choice of antibiotics:

 Amoxicillin/clavulanate + Metronidazole

 Ampicillin/Sulbactam (Unasyn) + Metronidazole

 Ticarcillin/Clauvulate (Timentin) + Metronidazole

 Piperacillin/Tazobactam (Zosyn) + Metronidazole

 Other alternatives

 Clindamycin + Cipro (PCN allergy) - Adults nd  2 gen cephalosporin + Metronidazole (B. Fragilis)

 Penicillin, gentamicin & flagyl - developing nations

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 External Surgical  Transoral Surgical Drainage Drainage

Complications Of DNSI

 Airway obstruction  Ruptured abscess & Aspiration  Lung abscess, Pneumonia & Embyema  Vascular complications - CA rupture - IJ thrombophlebitis - thrombosis  Neurologic deficits V.C. paralysis- X involvement Horner’s syndrome –Sympath. chain involvement Transverse Myelitis

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Complications Of DNSI

 Mediastinitis (Descending Necrotizing Mediastinitis)  Septicemia  Septic emboli  Osteomyelitis of cervical vertebrae  Atlantoaxial sublaxation (Griesel's syndrome)  Necrotizing cervical fasciitis  Recurrent Deep Neck Space Infection

Conclusion

 DNSI are potentially lethal infections if they are not diagnosed early and treated properly.

 DNSI exert fatal effect by causing local airway obstruction or extension to vital areas, such as the mediastinum or carotid sheath.

 Good knowledge of the anatomy of H & N fascial planes, spaces, & lymphatic drainage are the basis for understanding the pathology of DNSI.

 Recurrent DNSIs in children are usually due to congenital anomalies, commonly branchial remnants

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