Infectious & Infectious & Inflammatory Inflammatory

DisordersDisorders

Infectious & Infectious & Inflammatory Inflammatory

DisordersDisorders

• 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

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

Acute bacterial lymphadenitis :

Group A ß hemolytic strepococcus Staphylococcus aureus

Chronic form of lymphadenitis: Mycobacterium tuberculosis

Atypical mycobacterium Cat-scratch disease

Viral involvement Toxoplasmosis

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

Physical inspection• Site • Size • Inflammatory characteristics :

Tenderness Fluctuation

Redness Warmness

Diagnostic Test• Needle aspiration• Excisional biopsy• Incision & drainage• Gram stain • Acid fast bacterial stain • Culture for aerobic & anaerobic

bacteria• Viral ,fungal & unusual bacterial culture

Diagnostic test (cont.)

• CBC• ESR• Serum Ig titer• TB skin test

Radiologic examination

• Lateral neck X-ray• CXR• Axial CT scanning with IV contrast

Treatment

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

Bacterial infection

Penicillin

First& second generation cephalosporinclindamycin

Viral infection

Most common cause of cervical lymphadenitisRSV , parainfluenza , adenovirus ,HIV entrovirus, HSV , EBVGeneralized LAP , Exanthems

Group A β hemolytic strep. & staph

Unilateral cervical lymphadenitis1-3 duration

Level I & IIOral antibiotic

Cat-scratch diseaselast fall & winter

90% cat exposure ( Bartonella henselae )Axillary LAP → Cervical LAPSkin lesion after 7-14 →1-2 weeks later tender lymphadenitis

Can remain enlarged up to 4 monthNeedle aspiration may relieve acute pain

Drainage should be avoidedNo treatment unless toxic symptom → Azithromycin

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

Treatment

• M. tuberculosis :six month rifampin,

isoniazide ,pyrazinamide

Atypical mycobacterium : Surgical excision with oral clarithromycin

Toxoplasmosis gondii

• Infection via undercooked meat & unpasteurized milk

• Immunocompetent → IM like viral infection

• Immunocompromised → CNS infection

• Oocytes in cat feces

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

possible etiology

Dental caries & gingivitis

• Anaerobic species • Actinomycosis • Fungal• HSV

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

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

Bacteriology• Mixed flora ( anaerobic abscesses

predominating over aerobic abscesses)

• Anaerobe : peptosterp. , Bacteriod , Anaerobic staph.

• Aerobic : S. aureus , Strep. H. influ. E. coli , Klebsiella

Management of neck spaces infection

• History of : • Recent dental work • Dental pain • IV drug abuse • URT infection • Recent surgery • Trauma

Management ( cont.)

Physical examination : Inspection of dentition Palpation of the soft tissue of

the H&N Vital sign

Radiologic study• Lateral neck film : may show increased prevertebral

width : > 7 mm at C2 > 20 mm at C6 Presence of gas

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

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 .

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

• Severe trismus or Ludwig`s angina : Tracheostomy

• Retropharyngeal abscess : Intubation in Trendelenburg

position

Antibiotic

• Clindamycin as a first – line coverage

• Penicillin• Cefuroxime

Surgical drainage

• Wide exposure , vascular identification

• Drainage• Copious irrigation • Placement of drains ( 3-5 days )

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

Drainage (cont.)

• Parapharyngeal space : Transcervical

• Retropharyngeal : transorally or transcervical• Parotid :standard parotidectomy

incision

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

• 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

Treatment • Correction of electrolyte

imbalance , anemia , hypovolemia• Wide surgical debridement • Broad spectrum antibiotic • Aggressive bedside dressing • Frequent debridement under GA • Hyper baric oxygen