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Deep neck infections

Deep neck infections. 가천의과대학 길병원 구강악안면외과 김 현민. 차례. 1) facial spaces 2) each spaces ; buccal masticator sublingual & submandibular parapharyngeal retropharyngeal 3) case report 1.2

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Deep neck infections

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  1. Deep neck infections 가천의과대학 길병원 구강악안면외과 김 현민

  2. 차례 1) facial spaces 2) each spaces ; buccal masticator sublingual & submandibular parapharyngeal retropharyngeal 3) case report 1.2 4) summary 5) references

  3. Fascial spaces of clinical significance Face ; buccal canine masticator – masseter , pterygoid , zygomaticotemporal parotid Suprahyoid ; sublingual submandibular – submaxillary , submental lateral pharyngeal(pharyngomaxillary) peritonsillar Infrahyoid ; pretracheal (anterovisceral) Spaces of total neck ; retropharyngeal danger space space of carotid sheath by Topazian & Goldberg

  4. Fascial anatomy

  5. Fascial anatomy 1

  6. Fascial anatomy 2

  7. Fascial anatomy 3

  8. Fascial anatomy 4

  9. Fascial anatomy 5

  10. Fascial anatomy 6

  11. Cellulitis versus abscess on CT imagies • Abscess ; single or multilocated low density masses, peripheral irregular rim enhancement, fluid collections contrast injections (a)before (b)after on RPA/PPA • Cellulitis ; without a low density collection, no fluid collections hypodensity with(a),without(b) complete ring enhancement

  12. Buccal space infections • Symptoms ; round dome shape swelling, trismus, 원인치의 동요 및 타진 반응, 상하안검 swelling • Anatomy ;

  13. Masticator space infections • Symptoms; trismus, painful swelling, dysphagia etc • Anatomy ;

  14. Masticator space infections • * Mn 에서 야기된 odontogenic infections은 upward 되며 masseter m 감염은 PS , temporalis, lat.pterygoid m로 spread , med. Pterygoid m 감염은 PPS , lat. Pterygoid m로 spread된다. Downward 되어 sublingual, submn spaces로 spread 된다. • * Mx에서 야기된 inf 은 downward 되지 않고 superficially temporal, MS, deeply lat. / med. Pterygoid m을 involve 한다. • MS 는 mn inf. 의 primary site 이고 PS & pharyngeal space는 MS의 2nd site 이며 mn inf. 은 sublingual & submn으로 직접 전파된다. By Koichi Yonetsu

  15. Submandibular space infections • Symptoms ; neck rigidity, trismus, dysphagia, respiratory distress, sialorrhea, pyrexia, • Anatomy ;

  16. Submandibular space infections *Schematic drawing of the 3 types of pathways type 1; beyond mylohyoid ridge & posterioly from adjacent sublingual space ; with mylohyoid m enlarge type 2 ; from inflammatory periostitis of mn ; no or rare PPS,MS involvement mild symptoms without trismus & dysphagia

  17. Submandibular space infections • * 만약 감염이 PPS로 spread 되면 dysphagia 발생되며 PPS는 med. Pterygoid m 같은 MS 감염시 자주 spread 된다. 그런데,Submn space inf 시 PPS 사이에 fasciaL barrier 가 얇아서 전이가 용이하다. 이는 med. Pterygoid m involvment 없이도 동시에 감염이 일어나는 것으로 확인 될 수 있다. • type 3 ; downward from MS • Type1(57.6%) > type2(15.2%) > type3(12.1%) by Y.Ariji et al

  18. Parapharyngeal space infections • Symptoms ; fever(38.5), chill, throat swelling, odynophagia, dysphagia, neck pain & stiffness, respiratory distress, sialorrhea, trismus ( PPS swelling+ & trismus- = peritonsillar abscess) • Cause ; most common cause - peritonsillar abscess odontogenic sourse(20-39%) by Larry J. Peterson • Anatomy ; ant prestyloid compartment- fat filled post retrostyloid compartment-major neurovascular bundle (hard palate- upper PPS, lower PPS)

  19. Parapharyngeal space infections • Anatomy – MS,PS(lateral) , CS(post) , RPS(posteromedial) • PPS의 displacement direction 은 origin of lesion 을 suggest 한다. By VFH Chong et al

  20. Parapharyngeal space infections imagies

  21. Retropharyngeal space infections • Symptoms ; fever, decrease oral intake, odynophagia, malaise, torticollis, neck pain, trismus, otalgia, headache, neck swelling, • Anatomy ;

  22. Retrppharyngeal space infections • Lateral neck x-ray 는 first imaging test 되어야 한다. Air sign이 보이는 경우 specific하다. CT scan은 RPS abscess manage 시 중요하지만 cellulitis 와 abscess를 구분하는 데 한계가 있다. by Carl Boucher • RPS abscess – lat. Neck x-ray – air sign+- drainage (with CT) air sign—IV anti –no improvement-CT scan improvement-IV continue • Young children에서 neck plain films는 true lat, orientation(neck extension, full inspiration, swallowing& expiratory crying 을 avoid 하여야 RPS thicken 을 방지할 수 있다.by P.Bradley Brechtelsbauer • Lat. Neck x-ray diagnosis ; 1)smooth lordotic curve of cervical vertebra-C2,C3 7mm wide적어야, 평균3mm, C6 14mm소아, 22mm성인 soft tissue shadow가 정상

  23. Retropharyngeal space infections • 2) presence of gas • 3) straight cervical spine or reversed kyphotic curve • loss of the lordotic curve by Larry J. Peterson

  24. Retropharyngeal space infections

  25. Case report 1 Pt ; 38/F • CC ; 내원 5일 전 개인치과 발치 후 우측 swelling으로 내원 • PI ; mouth opening limitation, dysphagia, Rt buccal & sub mn swelling / Td/ redness • Dx ; masticatory spce, lat. Pharyngeal space abscess • Tx ; I & D X 2 • (submn & submental, deep neck carotid sheath area) • anti theraphy ( aug + micronomycin + flagyl) • fluid etc supplementary tx (O2 etc) • 초진 lab ; WBC 30260, segmental neutrophil 85.9%, CRP 36.5

  26. 초진 모습

  27. 치료 임상 사진 • 1) 초기 I&D (02.9.13), 2차 I&D(02.9.14) • 2)3차 I&D(02,9.17)

  28. 치료 후 사진 • 02. 9.27

  29. 초진 CT (02.9.14)

  30. 2회 CT(02.9.17)

  31. 3회 CT(02.9.19)

  32. 4회 CT(02.9.25)

  33. Case report 2 • Pt ; 30/M • CC ;transfer from ENT d/t deep neck infection from dental origin • Hx ; 02.5.20 #38 ext 후 ENT로 입원 • PI ; both submn swelling & Td mouth opening limit, dysphagia, dyspnea, neck Td & redness, #38 area pus • DX ; submn & mental space abscess pretracheal space abscess descending necrotizing mediastinitis • Tx ; I & D 3회 (local 1, general 2 with TS)

  34. 초진모습 • 초진 lab ; WBC 16120, segmental neut92.7%, ESR119, CRP25.1

  35. 치료 임상 사진

  36. 치료 후 사진

  37. 초진 CT(02.5.25)

  38. 2회 CT(02.5.29)

  39. 3회 CT(02.6.3)

  40. 4회 CT(02.6.12)

  41. Summary • Deep neck infections 의 치료는 early radiologic Dx, medical management(effective antitherapy), intensive surgical management & airway control 등 요소가 필수적이다. • Culture를 시행하는 것이 중요하지만 감수성검사가 시행되기 전까지 penicillin derivatives & clindamycin과 같은 항생제로 early intervention을 시행하여야 하고 cellulitic stage에서는 항생제만으로도 가능하지만 abscess가 확진 되면 surgical intervention이 시행되어야 한다. CT 및 MRI 등의 이용은 임상증상의 한계를 보이는 deep neck infection 시 고려되어야 한다. • 만약 초기 항생제 치료 48시간내 증상의 호전이 보이지 않거나 abscess가 임상적으로 확인가능 하다면 I & D는 충분히 고려되어야 한다. • AIR way 확보는 RPA, Submn A 시 tracheostomy가 필요로 하는 경우도 있으므로 충분한 환자의 monitoring이 중요하다고 하겠다.

  42. References • 1.Y.Ariji et al.odontogenic inf. Pathway to the submn space; imaging assessment.Int.J.Oral Maxillofac.Surg.2002;31;165 • 2.VHF Chong & YF Fan. Radiology of the PPS.Australasian radiology.1998;42;278 • 3.Larry J. Peterson.L.contemporary management of deep infections of the neck.J.Oral Maxillofac.Surg.1993;51;226-231 • 4.Carl Boucher et al.RPS abscess; a clinical & radiologic correction;J.of Otolaryngology,1999;28;134 • 5. Per-Lennart Westesson; contemporary maxillofacial imaging OMFS clinics of noth america,1992 • 6. Topazian & Goldberg; oral & maxillofacial infections, 3rd edition • 7. 김여갑; 임상구강악안면감염학,1995 • 8. Koichi Yonetsu et al; deep fascial inf. Of odontogenic origin: CT assessment of pathways of space involvment. AM J Neuroradiology,1998;19;123

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