Download Infectious & Inflammatory Disorders

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
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
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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
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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.)
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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 broadspectrum antibiotic with surgery
reserved for refractory cases
Bacterial infection
Penicillin
First& second generation cephalosporin
clindamycin
Viral infection
Most common cause of cervical
lymphadenitis
RSV , parainfluenza , adenovirus ,HIV
entrovirus, HSV , EBV
Generalized LAP , Exanthems
Group A β hemolytic
strep. & staph
Unilateral cervical lymphadenitis
1-3 duration
Level I & II
Oral antibiotic
Cat-scratch disease
last fall & winter
90% cat exposure ( Bartonella henselae )
Axillary LAP → Cervical LAP
Skin lesion after 7-14 →1-2 weeks later tender
lymphadenitis
Can remain enlarged up to 4 month
Needle aspiration may relieve acute pain
Drainage should be avoided
No 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
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Fever
Rash
Mucositis
Nonpurulant conjunctivitis
Cervical lymphadenopathy
Common under 4 years
Toxin of S, aureous implicated as a
possible etiology
Dental caries & gingivitis
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Anaerobic species
Actinomycosis
Fungal
HSV
Fascial space infection
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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
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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