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General OTOHNS > Deep Neck Space + Odontogenic Infections > Flashcards

Deep Neck Space + Odontogenic Infections Flashcards

1
Q

What is the bacteria that make up normal oral flora?

A
  1. GRAM POSITIVE COCCI
    - Aerobic: Streptococcus, Staphylococcus aureus
    - Anaerobic: Streptococcus, Peptococcus, Peptostreptococcus
  2. GRAM NEGATIVE COCCI
    - Aerobic: Neisseria
    - Anaerobic: Veillionella
  3. GRAM POSITIVE BACILLI
    - Aerobic: Diphtheroids
    - Anaerobic: Clostridium, actinomycese, eubacterium, lactobacillus
  4. GRAM NEGATIVE BACILLI
    - Aerobic: Haemophilus, Eikenella
    - Anaerobic: Prevotella, Bacteroides, Fusobacterium, Porphyromonas
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2
Q

What are the risk factors for deep neck space infections? List 13 risks.

A
  1. Poor dental hygiene
  2. 3-4th decade of life
  3. Pericoronitis (dental term) - inflammatory reaction in 3rd molar
  4. Diabetic
  5. Low SES
  6. Acute rhinosinusitis in children (retropharyngeal nodes that necrose)
  7. Penetrating neck trauma
  8. Salivary gland infections
  9. Mastoiditis (Bezold’s abscess)
  10. Superficial skin infections
  11. Surgical instrumentation
  12. IVDU (IJV)
  13. TGDC/Branchial cleft cyst in pediatrics
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3
Q

What are 8 etiologies for deep neck space infections? What are the most common in adults vs. children?

A
  1. URTI/Pharyngitis/tonsillitis (most common in chidlren)
  2. Dental (most common in adults)
  3. Salivary infection (second most common for adults)
  4. Trauma/Surgery/Instrumentation
  5. Foreign bodies
  6. Spread of localized/superficial infection
  7. IV drug abuse
  8. Congenital/branchial anomalies
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4
Q

Label the following teeth:
1. Incisors
2. Canines
3. Premolars
4. Molars

A

Vancouver Page 60

Vancouver page 60

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5
Q

Define the following dental terms and label them on a tooth:
1. Cusp
2. Groove
3. Mesial
4. Distal
5. Lingual
6. Buccal

A
  1. Cusp - tooth eminence
  2. Groove - area between cusps
  3. Mesial - toward the incisor (ie. more anterior)
  4. Distal - towards posterior mandible or maxilla (ie. more posterior)
  5. Lingual - towards the tongue
  6. Buccal - towards the cheek

Vancouver FP 327

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6
Q

What are the layers of the tooth?

A

CROWN:
1. Enamel
2. Dentin
3. Pulp

ROOT:
1. Gum
2. Periodontal ligament
3. Cementum
4. Dentin
5. Lateral canals (inferiorly, within dentin) )
6. Blood vessels and nerves (within pulp)

Vancouver Page 60

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7
Q

Describe the anatomy and configuration of the teeth, in both children and adults

A

All teeth have “roots” and “cusps”

ROOTS:
- Mandibular molars = 2 roots
- Maxillary molars = 3 roots

CUSPS:
- Molars have 4 cusps
- Premolars have 2 cusps

CHILDREN:
- 5 teeth per quadrant: central incisor, lateral incisor, canine, premolar, and molar
- Teeth erupt ~6 months, complete by 2-2.5 years

ADULTS:
- 8 teeth per quadrant: central incisor, lateral incisor, canine, premolars x2, molars x 3

https://i0.wp.com/pocketdentistry.com/wp-content/uploads/2021/09/9781284222913_CH01_FIGF21.png?w=960

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8
Q

Describe the FDI 2-digit tooth-numbering system

A
  • Each quadrant is labelled 1-4 (starting at patient’s right upper, going clockwise)
  • Each tooth is labelled 1-8 (starting from midline and working laterally)
  • Each tooth = 2 digits = (quadrant #) (tooth #)
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9
Q

Describe Angle’s classification of dental occlusion

A

ANGLE CLASSIFICATION:
- Defines position of maxillary 1st molar’s mesial-buccal cusps relation to the buccal groove of the mandibular 1st molar (#6)

  1. Class 1 = neutral (mesiobuccal cusp fits into groove)
  2. Class 2 = overbite/retrognathism (mesiobuccal cusp is anterior to groove)
  3. Class 3 = underbite/prognathism (mesiobuccal cusp is posterior to groove)

Vancouver FP 327

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10
Q

What is the normal transverse dental relationship?

A

Mandibular molar buccal cusps sit between maxillary molar buccal and lingual cusps

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11
Q

Describe the pathophysiology of odontogenic infections

A
  • Necrosis of dental pulp from deep caries –> necrosis enters into bone and soft tissues through path of least resistance –> leads to inflammatory response (vasodilation, edema causing pain), and ischemia (necrosis)
  • Bacteria also spreads endotoxin to initiate infection
  • Inoculation phase Day 1-3, Cellulitis phase Day 3-5, Abscess day 4-10
  • Periapical bony changes not seen initially, periapical cysts in chronic infections
  • 100% have pain before presentation in chronic infections - pain from pulp compression and soft tissue/periosteum over cortical bone becomes distended
  • Pain drops when spreads through bone and periosteum into soft tissues

Common locations:
1. Mandibular 1, 2, and 3rd molars
2. Pediatrics: Maxillary teeth

Associated trismus:
1. Mild 20-30mm
2. Moderate 10-20mm
3. Severe < 10mm

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12
Q

Describe the bacterial flora and organisms commonly seen in deep space neck and odontogenic oral infections?

A

Usually due to mixed flora

AEROBES:
1. Streptococcus (Viridans group, pyogenes)
2. Staph aureus
3. Neisseria
4. Klebsiella
5. Haemophilus
6. Fusobacterium

ANAEROBES:
1. Peptostreptococcus
2. Peptococcus
3. Eubacterium
4. Veionella
5. Eikenella
6. Bacteroides

Antibiotics should cover strep + anaerobes

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13
Q

What spaces can a tooth infection spread? List 3 maxillary teeth and 3 mandibular teeth that can spread to varying locations

A

MAXILLARY:
1. Maxillary tooth = vestibular space
2. 1st and 2nd maxillar molar = buccal, palate
3. Canine tooth = Canine, maxillary sinus

MANDIBULAR:
1. Mandibular incisor = Submental and sublingual space
2. Mandibular tooth anterior to 2nd molar (mylohyoid line) = sublingual
3. Mandibular tooth posterior to 2nd molar (mylohyoid line) = submandibular
4. Secondary spread from mandibular spaces = masticator space (Masseteric, pterygomandibular, and temporal spaces)
5. Tertiary spread from secondary spaces = cervical spaces (parapharyngeal, retropharyngeal, danger, prevertebral)

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14
Q

What are the CT characteristics of deep space neck infections or abscesses?

A
  1. Low attenuation
  2. Contrast enhancement of abscess wall
  3. Tissue edema/fat stranding
  4. Cystic/loculated appearance
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15
Q

What is a Pott’s abscess?

A

Tuberculous osteomyelitis of the spine

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16
Q

Describe 5 causes for a false positive retropharyngeal abscess appearance on lateral neck x-ray

A
  1. Swallowing
  2. Crying
  3. Oblique view
  4. Neck flexion
  5. Expiration

“SCONE”

17
Q

What are Mosher’s 5 landmarks for surgical approaches to the infected neck?

A
  1. Cricoid cartilage
  2. Hyoid: Lateral tip of the greater cornu of hyoid
  3. Anterior border of SCM
  4. Posterior belly of digastric
  5. Styloid process

“CHAPS”

Retropharynx approach:
- Oral if only retropharyngeal collection
- External if any other neck spaces are involved

18
Q

What are 5 pathways of spread to the orbit by dental infections?

A
  1. Teeth infect maxillary sinus, which can track posterior to infratemporal fossa/pterygomaxillary fossa to inferior orbital fissure
  2. Teeth infect maxillary sinus, which can track into ethmoids, then through lamina papyracea
  3. Venous spread along facial, angular, and ophthalmic veins
  4. Lymphatic seeding
  5. Traumatic/congenital dehiscence
19
Q

What is Ludwig’s angina? How is this treated?

A

Ludwig’s Angina = Infection of bilateral sublingual, submandibular, and submental spaces
- Usually mixed flora
- Usually secondary to dental infection
- Presentation - airway distress secondary to posteriorly displaced tongue; woody floor of mouth on exam
- Treatment: Airway control, I&D of abscess/phlegmon

20
Q

What are 8 predisposing factors for osteomyelitis of the maxilla and mandible?

A

“OSTEITIS”

O: Osteodystrophies (Paget’s, fibrous dysplasia)
S: Systemic (e.g. steroids, bisphosphonates)
T: Trauma
E: Endosteal lesions (e.g. Cementoma)
I: Immunocompromised (e.g. HIV, DM, leukemia, chemo)
T: RadioTherapy
I: Implants (dental implants - plates, and other foreign bodies)
S: Surgery

21
Q

Describe the treatment strategy for osteomyelitis of the mandible/maxilla

A
  1. Appropriate culture-directed antibiotics
  2. Debridement of foreign bodies/sequestra/necrotic tissue
  3. Adjuncts to increase oxygenation (e.g. trephination, decortication, HBO)
  4. Reconstruction after infection clears
  5. Resection and osteomyocutaneous free flap reconstruction
22
Q

What is Horner’s syndrome? What are 5 signs?

A

Horner’s Syndrome: Secondary to injury to the sympathetic chain

SIGNS: “AMPLE”
A: Anhidrosis (inability to sweat)
M: Meiosis (constricted pupile - dilator iris)
P: Ptosis (Muller’s muscle)
L: Loss of Ciliospinal reflex (therefore absence of dilation of the ipsilateral pupil to a pain stimulus applied to the face)
E: Enopthalmos (apparent due to ptosis)

23
Q

Regarding Lemierre’s syndrome, discuss:
1. What is it?
2. Cause and Pathophysiology?
3. Investigations?
4. Clinical presentation?
5. Complications?
6. Treatment?

A

LEMIERRE’S SYNDROME:
- Internal Jugular Vein thrombophlebitis, usually due to dental or pharyngeal infections

CAUSE:
1. Fusobacterium Necrophorum (Gram negative, obligate anaerobe) - most common

PATHOPHYSIOLOGY:
- Throat infection –> PTA –> spread to internal jugular vein through tonsil veins –> thrombosis (from bacterial endotoxin that induces platelet aggregation) –> septic emboli, septicemia

INVESTIGATIONS:
1. CT Neck / Angio / Venogram - ring enhancement and filling defect of IJV (secondary to clot or purulence)
2. CT PE protocol
3. U/S of neck
4. Blood cultures
5. Toby-Ayer/Queckenstadt test
6. MR Venogram is the best imaging to follow resolution of clot

CLINICAL PRESENTATION:
1. Spiking fever
2. Engorged optic disks
3. Increased CSF pressure
4. SCM tenderness
5. Neck stiffness
6. Metastatic lung abscesses
7. Septic arthritis
8. Griesinger’s sign
9. SOB and chest pain (pulmonary and systemic emboli)

COMPLICATIONS:
1. Retrograde spread of thrombus –> Cavernous sinus thrombosis (IV abx + ICU support)
2. Intracranial hypertension

TREATMENT:
1. Drainage of infection
2. Beta-lactamase-resistant antibiotics (Ceftriaxone, Clindamycin/Flagyl)
3. Anticoagulation for thrombus progression or septic emboli (controversial) - Heparin
4. Ligation of IJV

24
Q

Regarding Cavernous sinus thrombosis, discuss:
1. What is the pathophysiology and cause?
2. Clinical presentation?
3. Diagnosis

A

PATHOPHYSIOLOGY:
- Retrograde spread via valveless ophthalmic vein or pterygoid plexus system

CAUSE/SOURCES:
1. Facial veins (central midface) –> angular veins –> nasofrontal vein –> superior ophthalmic vein –> cavernous sinus
2. Orbital: Superior/inferior ophthalmic veins –> Cavernous sinus
3. Dental: Pterygoid plexus –> Cavernous sinus
4. Parapharyngeal/temporal/paranasal sinus/neck spaces: Pterygoid plexus –> Cavernous sinus

25
Q

What is Griesinger’s sign?

A
  • Edema at the mastoid tip due to thrombus of the sigmoid sinus
  • Can also occur in mastoiditis
  • Secondary to mastoid emissary veins
26
Q

What is the Toby-Ayer Queckenstadt test?

A
  • Compression of the IJV has no effect on CSF pressure in the presence of ipsilateral lateral sinus thrombosis
  • Performed while monitoring CSF pressure during a LP
27
Q

Discuss carotid pseudoaneurysm as a complication of neck infection:
1. Definition
2. Epidemiology
3. Causes
4. Clinical presentation
5. Diagnosis findings
6. Treatment options

A

CAROTID PSEUDOANEURYSM:
- False aneurysm with loss of integrity of the 3 layers of the arterial wall, resulting in a contained rupture of the blood vessel
- Compared with a true anerusm - vascular wall is intact but dilated

EPIDEMIOLOGY:
- Can present in children as a complication of cervical adenitis
- IVDU

CAUSE:
1. Historically: Arteritis by syphillis or TB
2. Bacterial deep neck infections (esp. children and IVDU)
3. IVDU: Salmonella and Klebsiella is more frequent in these patients, and has elastase that dissolves the artery

CLINICAL PRESENTATION: (4 signs)
1. Protracted clinical course of parapharyngeal/retropharyngeal infection (untreated or undertreated)
2. Recurrent small pharyngeal hemorrhages (presenting in ear/nose or throat)
3. Possible Shock
4. Neurological abnormalities: Horner’s, CN VII, IX, XI and XII

DIAGNOSIS:
1. CT Angiography; or
2. Duplex ultrasound

TREATMENT OPTIONS:
1. Reconstruction of carotid with autologous graft
2. Endovascular coiling
3. Open ligation especially if hemorrhaging

https://www.drugs.com/cg/images/en3686288.jpg

https://www.criticalcare-sonography.com/wp-content/uploads/2021/08/pseudoaneurysm-e1630387647786.png

28
Q

Regarding Eagle Syndrome, discuss:
1. Definition
2. Pathophysiology
3. Clinical presentation
4. Diagnosis
5. Treatment options

A

EAGLES SYNDROME:
- Myriad of symptoms, but most commonly defined by pain due to abnormal styloid process

PATHOPHYSIOLOGY (many possibilities):
1. Retained embryologic cartilage tissue from Reichert’s cartilage
2. Calcification of the stylohyoid ligament
3. Expansion of osseous tissue at the origin of the stylohyoid ligament

CLINICAL PRESENTATION:
1. Pain (most common): Tonsil/anterior neck that radiates to ear/jaw, pain with jawning or turning head, and Carotidynia (tenderness of the carotid artery)
2. Dysphagia, odynophagia
3. Foreign body sensation
4. Neurologic complaints/complications: Horner’s syndrome, TIAs, stroke, carotid artery dissection

DIAGNOSIS:
1. Pharyngeal palpation (tonsil and tonsillar fossa)
2. Relief of symptoms upon infiltration of lidocaine into anterior tonsillar pillar
3. CT Neck (gold standard)

TREATMENT:
1. Conservative: NSAIDs, anticonvulsants (carbamazepine), gabapentin, stellate ganglion block
2. Surgical: Excision of styloid (intraoral approach, transcervical)

Vancouver Page 62

29
Q

A patient presents with trismus, neck pain, and dysphagia. You suspect retropharyngeal abscess, but the WBC is normal and no abscess on CT. What are other possible diagnoses?

A

Calcific Tendonitis of Longus Coli
- Calcium crystal accummulation in the prevertebral soft tissues at the C1-2 level
- Most commonly in 20-50 years of age
- Accompanied with surrounding hypoattenuation from muscular edema
- Treatment: anti-inflammatories

Vancouver Page 62

30
Q

What are indications for surgical management of a deep head/neck space infection?

A
  1. Gas
  2. Fluid filled > 2cm
  3. Threatening airway
  4. Failure to respond to medical management after 48-72 hours
  5. C+S to guide treatment
  6. Irrigation, reduce infection load
  7. Provide external route for drainage to prevent reaccumulation and spread
  8. Mediastinal extension
31
Q

What bacteria are most commonly implicated in Necrotizing Fasciitis?

A
  1. Strep pyogenes (Group A hemolytic)
  2. Staph aureus
  3. Clostridium perfringens

General OTOHNS (9 decks)

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