Head and Neck Infections.docx
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Head and Neck Infections.docx
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HeadandNeckInfections
HeadandNeckInfections
Infectionsoftheheadandneckfrombothodontogenicandothercausesareanimportantpartofdailypatientmanagementfororalandmaxillofacialsurgeonsandotherpractitionersinvolvedwiththisanatomicarea.Inmostinstances,infectionsareeasilydealtwithbyproperdiagnosis,removaloftheetiologicfactor,incisionanddrainage,appropriateantibiotictherapy,andsupportivecare.Life-threateninginfectionsarerare,butsuccessfultreatmentdemandsearlyrecognition,propermedicalandsurgicalmanagement,constantvigilance,appreciationofsurgicalanatomy,andunderstandingofpossiblecatastrophicsequelae.
Thischapterdealsprimarilywiththesurgicalmanagementofinfectionsoftheheadandneck,includingprinciplesofassessment,anesthesiaconsiderations,perioperativemanagement,andsurgicalanatomy.Specificanatomiccomplicationsofinfectionsandtheirdiagnosisandmanagementareincluded.
PrinciplesofPatientManagement
MICROBIOLOGYANDPRINCIPLESOFANTIBIOTICTHERAPY
Theoralcavitysupportsthemostcomplexpopulationofbacteriaintheheadandneck.Thisisbecauseofthemultiplemicrosystemsofmicroorganismsfoundintheoralrarityandonandwithintheoralmucosa,toothsurfaces,andgingivalcrevice.Thenasalcavity,sinuses,andtonsillarcryptsalsocontributetothiswidearrayofbacteriaandfungi.
Most(95%)infectionsoftheheadandneckareduetomixedaerobic-anaerobicorganisms,primarilyaerobicandanaerobicgram-positivecocciandanaerobicgramnegativerods.Althoughbeta-lactamantibioticssuchaspenicillinarestilltheprimaryagentsfortreatinginfectionsoftheoralandfacialregions,anaerobessuchasPrevotellaspp.andPorphyromonasspp.seemtobedevelopinganincreasingbeta-lactamresistance.
Itisunderstoodthatathoroughknowledgeofthemicrobiologyofthisareaandoftheprinciplesofappropriateantibiotictherapyarevitaltothesuccessfulmanagementoftheseinfections.Thischapter,however,addressesmainlythesurgicalmanagementofthesepatients.
PATIENTASSESSMENT
Patientspresentingwithheadandneckinfectionsgenerallyhavesignssuggestiveoftheunderlyingprocess.Theseinitialfindingsmayincludepain,swelling,lossoffunction,suppuration,orerythemaoftheaffectedarea.Thesignsandsymptomsmaybeobviousortrivial,orthepatientmaybeextremelyill.Properpatientevaluationisbasedonathoroughhistory,reviewofsystems,andphysicalexamination,andonappropriatelaboratorytestsandimagingstudies,whichmakeuptheinitialdatabase.
HistoryandPhysicalExamination
Adirectedhistoryofthedurationandprogressionofsymptomsshouldbeobtained.Previoustherapyorsurgicalproceduresandinterventionsandtheireffectareimportant.Knowledgeofthepatient'spastmedicalhistoryandareviewofsystemswithanemphasisonunderlyingsystemicdiseases(e.g.,diabetes,renaldisorders,autoimmunedisorders),drugandalcoholabuse,andtheuseofimmunosuppressivemedications,areessential.
Physicalexaminationbeginswithanoverallassessmentofthepatient.Isthepatientalert,lucid,indistressbecauseofpainorpotentialairwayembarrassment?
Whatisthequalityofphonation?
Doesthepatientappearhydratedorabletotakefluids?
Istheretrismusorextensionoftheneckforairwaymaintenance?
Theanswerstothesequestionsallowthecliniciantoassessthe
severityofthepatient'scondition.Amoredirectedexaminationoftheheadandneckcanbeperformedwithinspection,palpation,andpercussion.Areasoferythema,swelling,ordrainageshouldbeappreciated.Palpationtoassessareasofinduration,fluctuance,andtendernessisimportant.Regionallymphadenopathyandtendernessshouldbeassessed.Bimanualpalpationofthefloorofthemouth,lateralpharyngealwall,submandibulartriangle,andmandibularangleareaprovidesinformationabouttheanatomicspacesinvolvedandsuggestsacelluliticprocessversusabscessformation.Thepresenceofparatrachealswellingandinduration,mobilityofthetongue,andtrismus,alongwithheadposture,mayprovideimportantinformationaboutairwaymanagement.Tendernessandswellingoftheinferiorcervicaltrianglesorsupraclavicularareamaysuggestsignificantextensionoftheinfectionorinvolvementofthemediastinum.Obviously,acompleteandcomprehensiveoralexaminationisimportant,withanemphasisoncaries,periodontaldisease,andtheamountandnatureofexpressedsaliva.Attentiontothesoftpalate,tonsillarfossae,andoro-andhypo-pharynxisimportant,notingswelling,deviation,anddisplacementoftissuesorpurulentdrainage.
Ophthalmologicexaminationisimportant,includingassessmentofperiorbitaloreyelidswelling.Conjunctivitis,epiphora,andptosisofthelidswithproptosisoftheglobearesignificant.Assessmentofextraocularmusclefunctionandpupillaryresponseandfunduscopicexaminationarenecessary.Basicvisualacuitytestsandcranialnerveexamination,includingnervesIII,IV,andVI,mayuncoverorbitalapexextension.
Acompletephysicalassessmentshouldincludepulmonary,cardiovascular,andgeneralizedneurologicexaminations.Specificpositivechestfindingsmayincludetachypnea,decreasedbreathsounds,suprasternalandsupraclavicularretraction(suggestiveofairwaycompromise),ormediastinalextension.Tachycardiacanbeseeninahyperpyrexic,dehydratedpatient.Thepresenceofmurmurs,valvulardisease,orprostheticimplantsmaybehighlysignificantformanagementofasepticemicpatient.Extremeweakness,hemiplegia,aphasia,orotherlateralizingneurologicsignsmaysuggestintracranialextensionoftheinfectiousprocess.
LaboratoryandImagingStudies
Apatientwithsevereordeepspaceinfectionshouldhavearoutinecompletebloodcountwithadifferentialwhitebloodcellcount.Asedimentationratemaybeinformative.Otherstudiessuchasbloodglucose,liverfunction,electrolytes,totalproteinandalbumin,renalfunction,andhumanimmunodeficiencyvirus(HIV)statusmaybeimportantintheperioperativemanagementofdiabetic,malnourished,dehydratedpatientsorthosewithspecificunderlyingdiseasesorimmunocompromisedstates.PositiveC-reactiveproteinmaybeusefulinchronicinfections,suchasosteomyelitis.
Diagnosticimagingisusedtodiagnose,confirm,andanatomicallydelineateheadandneckinfection.Panoramicradiographsgenerallyassistindeterminingtheetiologyofanodontogenicinfection.Otherplainradiographs,suchasaWaters'vieworposteroanteriorsofttissueandlateralneckviews,provideinformationregardingsinusdisease,airwaydisplacement,andperitrachealandretropharyngealextensionoftheprocess.Themosthelpfuldiagnostictoolsforanacutelyinfectedpatientarecomputedtomography(CT)andmagneticresonanceimaging(MRI).
Currently,contrastmedium-enhancedandcost-effectivestudy.MRIisconsideredtobeassensitiveasCTforabscessdetection,butnotasspecific.UltrasonographyhasshownsomeapplicationforabscesslocationbutisstillconsideredinferiortoCT.ScintigraphyusingtechnetiumTc99mmethylenediphosphonateandgalliumcitrateGa67scansarehelpfulinthediagnosisandmanagementofosteomyelitisbutprobablyplaynosignificantroleinacutesofttissueinfections.However,anaerobicodontogenicinfectionshavebeendetectedwiththeuseoffluorine-18fluoromisonidazolewithpositronemissiontomography.
ANESTHESIAANDAIRWAYCONSIDERATIONS
Inevaluatingapatientwithafascialspaceinfection,patencyoftheairwayandanesthesiaconsiderationsareoftheutmostconcern.Apatientwhopresentswithahyper-extendedneckandexhibitsopen-mouthednasalbreathingortheinabilitytomaintainanairwayinasupinepositionshouldcauseimmediateconcern.Difficultywiththemanagementoforalsecretions,sorethroat,laboredbreathing,tachypnea,andchangesinvoicequalityaresignsofpartialairwayobstruction.
Trismusandimmobilityofthetongueandfloorofmouth,aswellastonsillar,lateral,andhypopharyngealswelling,mayinterferewiththeabilitytointubatetheairway.Twosimplepreoperativebedsidetestshavebeenusedtopredictadifficultintubation.Inthefirstone,thepatientisseatedateyelevelandaskedtoprotrudethetongue.Iftheuvula,posteriorpharyngealwall,or,worse,softpalateisnotvisualized,adifficultintubationcanbepredicted.Inthesecondtest,ifthedistancefromthethyroidcartilageprominencetothementonislessthan7cm,intubationwillbedifficult.
Otherclinicalmeasurementsofadequateairwayandrespiratoryexchangearepulseoximetryandmeasurementofarterialbloodgases.
Lateralcervicalsofttissuefilmsandachestradiographcanbeusedtoevaluatethepatencyoftheaircolumnintheneckandchest.Narrowinganddeviationoftheaircolumnmaybeseen.Retropharyngealtissuesonanormallateralfilmshouldbe2to7mmatC2and14to22mmatC6.Acommonlyusedmnemonicis"6at2and22at6".Abnormalfindingsinclude
(1)increasedprevertebralsofttissuethicknessofgreaterthan6mmintheretropharyngealarea,orincreasedsofttissuethicknessofgreaterthan14mmforchildrenand22mmforadultsintheretrotrachealarea;
(2)presenceofairintheprevertebralsofttissues;(3)lossofnormallordoticcurvatureofthespine;(4)presenceofaforeignbody;and(5)displacementorlossoftheprevertebralfatline.ApositivefindinginalateralneckfilmshouldbefollowedbyaCTscantoconfirmthediagnosis.
AusefulalgorithmformanagementoftheairwaywaspublishedbyZideandLimchayseng(Fig.4-4).Ifthecordscanbevisualized,thenoralintubation,eveninalateralposition,canb
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