Infectious & Inflammatory Disorders

1. Infectious & Inflammatory Disorders

2. 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

3. Infectious lymphadenitis → extracapsular extension → neck space infection → frank neck abscess

4. Acute bacterial lymphadenitis : Group A ß hemolytic strepococcus Staphylococcus aureus

5. Chronic form of lymphadenitis : Mycobacterium tuberculosis Atypical mycobacterium Cat-scratch disease Viral involvement Toxoplasmosis

6. Previous History • Age • Duration of symptom • Possible infectious contact • Animal exposure • Recent travel • Co-existing conditions

7. Physical inspection • Site • Size • Inflammatory characteristics : Tenderness Fluctuation Redness Warmness

8. Diagnostic Test • Needle aspiration • Excisional biopsy • Incision & drainage • Gram stain • Acid fast bacterial stain • Culture for aerobic & anaerobic bacteria • Viral ,fungal & unusual bacterial culture

9. Diagnostic test (cont.) • CBC • ESR • Serum Ig titer • TB skin test

10. Radiologic examination • Lateral neck X-ray • CXR • Axial CT scanning with IV contrast

11. Treatment Treatment for suppurative lymphadenitis is oral or IV broad-spectrum antibiotic with surgery reserved for refractory cases

12. Bacterial infection Penicillin First& second generation cephalosporin clindamycin

13. Viral infection Most common cause of cervical lymphadenitis RSV , parainfluenza , adenovirus ,HIV entrovirus, HSV , EBV Generalized LAP , Exanthems

14. Group A β hemolytic strep. & staph Unilateral cervical lymphadenitis 1-3 duration Level I & II Oral antibiotic

15. 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

16. 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

17. Treatment • M. tuberculosis : six month rifampin, isoniazide ,pyrazinamide Atypical mycobacterium : Surgical excision with oral clarithromycin

18. Toxoplasmosis gondii • Infection via undercooked meat & unpasteurized milk • Immunocompetent → IM like viral infection • Immunocompromised → CNS infection • Oocytes in cat feces

19. Kawasaki disease • Fever • Rash • Mucositis • Nonpurulant conjunctivitis • Cervical lymphadenopathy • Common under 4 years • Toxin of S, aureous implicated as a possible etiology

20. Dental caries & gingivitis • Anaerobic species • Actinomycosis • Fungal • HSV

21. Fascial space infection • Submandibular space • Peritonsillar • Masticator space • Parotid space • Parapharyngeal space • retropharyngeal space

22. 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

23. Bacteriology • Mixed flora ( anaerobic abscesses predominating over aerobic abscesses) • Anaerobe : peptosterp. , Bacteriod , Anaerobic staph. • Aerobic : S. aureus , Strep. H. influ. E. coli , Klebsiella

24. Management of neck spaces infection • History of : • Recent dental work • Dental pain • IV drug abuse • URT infection • Recent surgery • Trauma

25. Management ( cont.) Physical examination : Inspection of dentition Palpation of the soft tissue of the H&N Vital sign

26. Radiologic study • Lateral neck film : may show increased prevertebral width : > 7 mm at C2 > 20 mm at C6 Presence of gas

27. 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

28. 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 .

29. Airway control is the first priority when the submandibular , parapharyngeal and retropharyngeal spaces are involved .

30. Severe trismus or Ludwig`s angina : Tracheostomy • Retropharyngeal abscess : Intubation in Trendelenburg position

31. Antibiotic • Clindamycin as a first – line coverage • Penicillin • Cefuroxime

32. Surgical drainage • Wide exposure , vascular identification • Drainage • Copious irrigation • Placement of drains ( 3-5 days )

33. 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

34. Drainage (cont.) • Parapharyngeal space : Transcervical • Retropharyngeal : transorally or transcervical • Parotid :standard parotidectomy incision

35. 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

36. 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

37. Treatment • Correction of electrolyte imbalance , anemia , hypovolemia • Wide surgical debridement • Broad spectrum antibiotic • Aggressive bedside dressing • Frequent debridement under GA • Hyper baric oxygen