Anatomy

Question 1

Primary maxillary spaces

Answer 1

Canine space
Buccal space

Question 2

Apical infection of the root of maxillary canine almost exclusively infects what space

Answer 2

Canine space

Question 3

Common manifestation pf canine space infection

Answer 3

Swelling lateral to the nose and loss of ipsilateral nasolabial fold

Question 4

Location of canine space

Answer 4

Between the anterior surface of maxilla and the levator labii superioris

Question 5

Infection of what tooth/teeth will involve the buccal space

Answer 5

Maxillary molars

Question 6

Buccal space becomes involved when?

Answer 6

When infection of maxillary molars break out superior to the attachment of buccinator

Question 7

Buccal space boundaries

Answer 7

It lies between the buccinator muscle and the skin
Ovoid space below the zygomatic arch and above the inferior border of mandible

Question 8

Infection of this space is dramatic in appearance and causes trismus

Answer 8

Buccal space

Question 9

Primary mandibular spaces

Answer 9

Submental space,
Sublingual space
Submandibular space

Question 10

Submental space boundaries

Answer 10

Between anterior bellies of digastric
Between mylohyoid muscle and skin

Question 11

This space is involved when the mandibular incisors, whose roots are long enough to erode the attachment of mentalis muscle, are infected

Answer 11

Submental space

Question 12

This space is involved when the mandibular premolars or molars are infected

Answer 12

Sublingual or submandibular space

Question 13

This determines whether SL or SM space is involved

Answer 13

Location of perforation relative to the mylohyoid attachment or the mylohyoid line.

Question 14

Infection of the premolars and first molar will involve what space?

Answer 14

Sublingual space
-apices of premolars and 1st molar is superior to the mylohyoid line

Question 15

The submandibular space is affected when the following tooth are infected

Answer 15

2nd and 3rd molar
Apices are inferior to the mylohyoid line

Question 16

Boundaries of sublingual space

Answer 16

Between the lingual oral mucosa and mylohyoid muscle

It is open posteriorly and communicates freely with the submandibular space and secondary spaces located posteriorly and superiorly

Question 17

Clinical picture of patients with sublingual space infection

Answer 17

Marked intraoral lingual swelling of the FOM.

If bilaterally involved, tongue is elevated and dysphagia

Question 18

Submandibular space boundaries

Answer 18

Between the mylohyoid and skin
Open posteriorly and communicates with secondary spaces easily

Question 19

Clinical picture of submandibular neck space infection

Answer 19

Swelling of inferior lateral border of mandible extending medially to digastric area and posteriorly to the hyoid bone

Question 20

Infection of all (3) mandibular spaces bilaterally will cause what infection

Answer 20

Ludwig’s angina

Question 21

Characterized by rapid, BILATERAL gangrenous cellulitis of all 3 primary mandibular spaces, manifesting as gross swelling, elevation, displacement of tongue, and tense BRAWNY induration of the submandibular region superior to the hyoid bone and inability to tolerate supine position, severe trismus, drooling, inability to swallow, tachypnea and dyspnea.

Answer 21

Ludwig angina

Question 22

What is the usual cause of ludwig angina?

Answer 22

Ondontogenic infection from mandibular molar,

Streptococci then becomes mixed

Question 23

Known microorganisms that produce tissue destroying enzymes that help spread and infect neck fascial planes

Answer 23

Streptococcus anginosus (S.milleri grp)

Question 24

What does anaerobes produce that helps destroy and spread infection along neck fascial planes?

Answer 24

Hyaluronidase
Collagenase
Fibrinolysin

Question 25

Neck space that is a common site for DNI that subsequently spreads easily to connected spaces. It is an inverted pyramid extending from the skullbase to the hyoid bone. It is divided into two compartments that contains vascular and nervous structures

Answer 25

Parapharyngeal space

Question 26

This structure divides the parapharyngeal space into two compartments

Answer 26

Styloid and its muscular attachments (Pre and poststyloid compartments)

Question 27

What structures are contained in the post styloid compartment?

Answer 27

Sympathetic chain Cranial Nerves: IX, X, XI, XII

Question 28

Infection of the poststyloid compartment may lead to an infected thrombus of the internal jugular vein, also known as

Answer 28

Lemierre syndrome

Question 29

Infection of the poststyloid compartment may lead to:

Answer 29

Lemierre syndrome Carotid aneurysm Horner syndrome CN Palsies

Question 30

Horner syndrome triad

Answer 30

Ptosis Miosis Hemifacial Anhydrosis (aka oculosympathetic paresis)

Question 31

This is characterized by thrombophlebitis of the internal jugular vein and bacteremia caused by primarily anaerobic organisms, following a recent oropharyngeal infection (pharyngitis, tonsillitis,w/w/o peritonsillar or retropharyngeal abscess)

Answer 31

Lemierre syndrome

Question 32

Lemierre syndrome

Answer 32

Invasive infection of Fusobacterium necrophorum Extracellular leucocidin - plt aggregate w/o lysis which results in intravascular coagulation - septic thrombophlebitis

Question 33

Parapharyngeal neck compartment with higher potential for spread to other neck spaces

Answer 33

Prestyloid space (more likely to liquefy fat)

Question 34

Boundaries, contents, and communicating spaces of Peritonsillar space

Answer 34

Boundaries: Palatine tonsil medially Sup constrictor muscle laterally Contents: LCT, tonsillar branches of lingual, facial ascending pharyngeal vessels CS - parapharyngeal space

Question 35

Boundaries, contents, and communicating spaces of Parapharyngeal space

Answer 35

Boundaries: S- mid fossa base I- Hyoid bone A- Pterygomandibular raphe P- Prevertebral fascia M- Sup Constri L- Parotid deep lobe, med pterygoid Contents: Prestyloid- fat, LN, IMA, auriculotemporal lingual inf alveolar nerves, pterygoids, deep lobe parotid Poststyloid- IJV, sup sympathetic chain, CN IX-XII CS - periton, subman, visceral, retrophar, carotid, masticator, parotid spaces

Question 36

Space located in the kidline, posterior to the pharynx and esophagus, extending from the skull base to T2 vertebra

Answer 36

Retropharyngeal space

Question 37

Boundaries, contents, and communicating spaces of Retropharyngeal space

Answer 37

Boundaries: S- Base of skull I- Sup Mediastinum A- Pharynx & esophagus P- Alar fascia M- Midline raphe of sup constri L- Carotid sheath Contents: LCT and Lymph nodes (draining np, and waldeyer ring) CS - carotid sheath, sup mediastinum, parapharyngeal space, danger space

Question 38

This is the only barrier that prevents spread of retropharyngeal space infection to the danger space that will allow spread to the diaphragm and access to the superior mediastinum

Answer 38

Alar fascia

Question 39

Boundaries, contents, and communicating spaces of Danger space

Answer 39

Boundaries: S- base of skull I- diaphragm A- alar fascia of deep layer pf deep cervical fascia P- prevertebral fascia of deep layer pf deep cervical fascia Contents: Loose areolar tissue CS- regropharyngeal, prevertebral spaces, mediastinum

Question 40

Spread along the vasculature from superior mediastinum to the aortic arch is also known as

Answer 40

Lincoln highway

Question 41

Difficulty with mouth opening indicates that inflammation has already spread to what space/s?

Answer 41

Parapharyngeal, pterygoid and masseteric spaces

Question 42

Unilateral pharyngeal swelling without inflammatory symptoms

Answer 42

Parapharyngeal tumors (No biopsy or incision without further evaluation)

Question 43

Unilaterally enlarged irregular or ulcerated tonsil with prolonged exposure to tobacco and alcohol

Answer 43

Tonsillar malignancy

Question 44

Plain radiography identifies dental sources of infection and salivary stones of what size

Answer 44

>5mm

Question 45

Neck STL finding in retropharyngeal infection

Answer 45

(+) Air fluid level (+) greater than 5mm (pedia) or greater than 7mm (adult) thickening of prevertebral tissue at C2

Question 46

Supraglottitis radiographic findings

Answer 46

Thickening of epiglottis or thumbprint sign and/or arytenoids

Question 47

Standard radiographic technique for evaluation of DNI

Answer 47

CT scan of head and neck CT with contrast - bony and soft tissues , visualization of vessels and enhancement of areas of inflammation. Determines if infection is confined within the LN or has spread beyond into fascial planes Low dose for pedia - 80kVP vs 120kVP (traditional)

Question 48

Role of Ultrasonography in DNI

Answer 48

Attractive imaging for pedia d/t noninvasive nature and lack of radiation exposure For FNA to obtain culture or for therapeutic drainage

Question 49

Initial management of patient suspected of DNI

Answer 49

Secure the airway Airway management - Fiberoptic eval of Upper airway at initial evaluation *pulse Oximetry may provide false security

Question 50

First line airway therapy

Answer 50

Oxygenated face tent with cool mist humidity IV steroids Epinephrine nebulizers Mild airway S/Sx, <50% obstruction at glottic or supraglottic level - usually responds to med therapy alone while at the ER suite or ICU

Question 51

Urgent airway management

Answer 51

(+) Greater level of stridor and dyspnea (+) Airway obstruction >50% Awake fiberoptic intubation (airway large enough to allow passage of ave flexible bronchoscope (5-6mm) -airway prep with lido nebulization lido lubricated nasal trumpet, w/w/o light sedation Elective tracheotomy (if extubation is not anticipated within 24-48hrs, idlf surg drainage are likely to result in significant or prolonged airway edema

Question 52

Antibiotic therapy

Answer 52

Broad spectum coverage is mandatory <2yo - CLINDAMYCIN is initial therapy of choice - shift to TMP/SMX or vancomycin (clinda resistance or no improvement in 2 days) Ampicillin-Sulbactam - FIRST LINE DRUG 1.5-3g TIV Q6

Question 53

First line antibiotic for DNI [Community acquired (+ cocci, -rods, anaerobes]

Answer 53

1. Ampicillin Sulbactam 1.5-3g TIV Q6 2. Clindamycin (pen allergy) 600-900mg TIV Q8 3. Ampi 1-2g Q6 PLUS Metro 500mg TIV Q6

Question 54

First line antibiotic for DNI [Compromised pt/Nosocomial (Pseudomonas;MRSA) pseudomonal and g-]

Answer 54

1. Pip-Tazo 3g TIV Q6 2. Imipinem-Cilastatin 500mg TUV Q6 3. Levoflox (Pen allergy) 750mg TIV Q24 4. Ciprofloxacin 400mg TIV Q12

Question 55

First line antibiotic for DNI [MRSA]

Answer 55

1. Clindamycin 600-900mg TIV Q8 PLUS Vancomycin 1g TIV Q12 2. TMP/SMZ (if Clinda resistant) 10m/k/d ➗Q8 PLUS Vancomycin 1g TIV Q12

Question 56

First line antibiotic for Necrotizing Fasciitis [Mixed positive and anaerobes]

Answer 56

Ceftriaxone 2g TIV Q8 PLUS Clindamycin 600-900mg TIV Q8, PLUS Metronidazole 500mg TIV Q6

Question 57

Antibiotic regimen

Answer 57

Clinical improvement after 48-72 hrs, extend for 24hrs after normalization of symptoms then 2 weeks equivalent of oral antibiotics

Question 58

Principles in considering SURGICAL management of DNI

Answer 58

- Antibiotic availability in pus filled spaces is limited - Treatment of fascial space infection depends on open incision and dependent drainage - Fascial planes are contiguous (should open all primary and secondary spaces, drain and possibly irrigation catheters placed) - involved teeth should be extracted ideally at time of I&D

Question 59

Absolute indications for surgical drainage

Answer 59

Surgical drainage is necessary when: - Air fluid level in the neck or evidence of gas producing organisms - airway compromise from abscess or phlegmon - Failure to respond to 48-72 hrs empiric antibiotics - Presence of complications

Question 60

Needle aspiration

Answer 60

Use of G16-18 IV cannula Done for small abscess comtained within the confines of the LN or acute infection of suspected congenital cyst or fibrotic pseudocyst

Question 61

Procedures that promote high likelihood for success of peritonsillar I&D

Answer 61

IVF rehydration, Pain meds, Antibiotics and steroids administered at least 1 hour before procedure.

Question 62

Steps in doing peritonsillar I&D

Answer 62

- Topical anesthetic spray - Lido epi 1:100,000 - 1-2 cc injected into mucosa of soft palate - Initial attempt of aspiration - 1-2cm mucosa & submucosa incision along normal curvature 1cm behind the edge of anterior pillar - Vertical spreading - Irrigation with NSS thru the incision using G18 angiocatheter - Discharged and ff up after 48-72hrs Tonsillectomy at a later date(periton abscess hx, recurrent/chronic tonsillitis, obstructive sx d/t tonsillar hypertrophy)

Question 63

Quinsy Tonsillectomy

Answer 63

Acute tonsillectomy done at time of presentation in cases of recurrent periton abscess, tonsillitis or if GA is needed due to patient discomfort and or poor exposure - more difficult and bloody d/t surrounding inflamm

Question 64

Surgical Incision & drainage of Ludwig angina

Answer 64

Neck incision with dependent drainage in bilateral FOM thru the mylohyoid muscle 1/2 inch Penrose drain or gauze wick secured with silk

Question 65

Surgical Incision & drainage of buccal space involvement

Answer 65

Transoral incision of buccal mucosa and blunt dissection parallel to CN VII through the buccinator 1/2 inch Penrose drain or gauze wick secured with silk

Question 66

Surgical Incision & drainage of masticator space involvement

Answer 66

Incision of retromolar trigone bwith blunt dissection through the masseter 1/2 inch Penrose drain or gauze wick secured with silk

Question 67

Surgical Incision & drainage of retropharyngeal space involvement

Answer 67

Transoral - transmucosal aspiration after securing airway and use of tonsil gag

Question 68

What are the 4 transcervical incisions for DNI?

Answer 68

Preauricular parotid incision with neck extension (parotid & temporal abscess) Horizontal neck incision ( masticator, parapharyngeal, pterygoid, submandibular, prevertebral, retropharyngeal, carotid, lateral neck space) Midline horizontal neck incision ( strap muscles, thyroid & trachea) Horizontal submental incision (bilateral submandibular space, FOM)

Question 69

Thrombophlebitis of internal jugular vein

Answer 69

Lemierre Syndrome

Question 70

Common course of disease in Lemierre syndrome

Answer 70

Period of pharyngitis before progression to fever, lethargy, lateral neck tenderness and edema, occasional trismus, septic emboli commonly seen as bilateral nodular infiltrates on chest xray

Question 71

Confirmatory imaging for Lemierre syndrome

Answer 71

Neck CT with contrast - filling defect in the IJV

Question 72

Management of Lemierre Syndrome

Answer 72

IV B lactamase resistant IV antibiotics w/w/o heparin Surgical excision of IJV if with worsening clinical course

Question 73

Cavernous sinus thrombosis Signs and symptoms

Answer 73

FEVER LETHARGY ORBITAL PAIN PROPTOSIS REDUCED EOM DILATED PUPIL SLUGGISH PUPILLARY LIGHT REFLEX

Question 74

Mechanism of infection in CST

Answer 74

Retrograde spread from upper dentition or PNS via the VALVELESS OPHTHALMIC VENOUS SYSTEM to the cavernous sinus

Question 75

Carotid artery pseudoaneurysm or rupture hallmarks

Answer 75

Pulsatile neck mass, Horner syndrome CN palsies 9-12 Expanding hematoma or neck ecchymosis Bright red blood from the nose or mouth in the setting of DNI

Question 76

Mediastinitis presentation

Answer 76

Diffuse neck edema Dyapnea Pleuritic pain Tachycardia Hypoxia Pleural effusion Mediastina widening on cxr (Pedia <2yo, MRSA, retropharyngeal space involvement)

Question 77

Rapidly progressive cellulitis with pitting edema and peau d’ orange with or without subcutaneous crepitus

Answer 77

Necrotizing fasciitis