martin joseph s. cabahug - tripod.commembers.tripod.com/m_cabahug_gsj/s/posterior neck...ludwig’s...
TRANSCRIPT
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Case Presentation and
Discussion on
Posterior Neck Mass
Martin Joseph S. Cabahug
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General Data:C.A , 60 y/o maleSta. Ana, Mla
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Chief Complaint:Posterior Neck Mass
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History and Physical Exam
2 wks PTA mass, 1 x 1 cm, soft, erythematous, tenderno consult doneno meds taken
1 wk PTA mass 6 x 4 cms, no consult doneself medicated withAmox 500mg tid
ADMISSION
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Physical History
General Survey:conscious, coherent, not in
cardiorespiratory distressVital Signs:
BP= 120/80 CR= 85RR= 23 T = 37.5 c
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6 x 4 cms mass, soft, erythematous, tender, fluctuant,
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Chest & Lungs: symmetrical chest expansion, no retractions, clear breath sounds Abdomen: flat, NABS, soft, non tenderExtremities: grossly normal
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Salient Features
- 60 y/o- male- mass posterior neck
6 x 4 cms, erythematous, tender, fluctuant, warm to touch
- DM
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posterior neck mass
skin bonesoft tissue
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posterior neck mass
soft tissue
Inflammatory Non inflammatory
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posterior neck mass
soft tissue
Non inflammatory
benign malignant
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posterior neck mass
soft tissue
Inflammatory
TB Abscess
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posterior neck mass
skin, soft tissue
Inflammatory
Abscess
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5%Secondary diagnosis
TB
95%Primary diagnosis
Abscess, posterior neck area
percent of certainty
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� Do I need a Paraclinical Diagnostic procedure?
-NO
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Treatment
Goaldrainage of abscessresolution of infection
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Treatment options
√+
Incomplete resolutionrecurrence
++Aspiration + antibiotic
√+++bleeding++++
Incision and drainage + antibiotic
AvailabilityCostRiskBenefit
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PRE OPERATIVE EVALUATION
� Optimize patient� Secure informed consent� Screen for medical problems� Prepare materials for operation
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OPERATIVE MANAGEMENT
� Patient on R lateral position under GA� Asepsis and Antisepsis done� Sterile drapes placed� Cruciate Incision done over the fluctuant
area� Intra-op findings noted
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OPERATIVE MANAGEMENT
� Intra-op findings:drained about 50 ml of purulent , non
foul smell material
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OPERATIVE MANAGEMENT
� Copious washing with nss with H2O2� Hemostasis� DSD
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POST OPERATIVE MANAGEMENT
� Diabetic Diet� Adequate analgesia� Adequate antibiotic coverage� Daily wound flushing � Control of blood sugar
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Final Daignosis
Abscess, posterior neck area
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DiscussionNeck
There is a band of tissue in the neck called the cervical fascia, which divides the neck into superficial (just under the skin) and deep layers.
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DiscussionNECK ABSCESS
1. Superficial neck abscesses The most common cause of these
abscesses are Staphylococcus or Streptococcus bacteria.
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Discussion
NECK ABSCESS 2. Deep neck Abscess
infection that is located in various spaces in the deep layer of the neck.
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Discussion� RETROPHARYNGEAL SPACE
This space is located directly behind the mouth.
The lymph nodes that drain the ADENOIDS, SINUSES, nose, and pharynx are located in this space.
Infections in any of these areas can result in spread of infection to these lymph nodes, resulting in lymphadenitis and abscess formation.
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Discussion
� PERITONSILLAR SPACELocated in the tissue around the tonsil in the
back of the throat.Infection in this space usually results from an untreated infection of the tonsils
This type of infection is known as a peritonsillar abscess or quinsy and is probably the most common type of deep neck infection.
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Discussion
� PARAPHARYNGEAL SPACEIt is located just behind the carotid artery Infections in this area are due to common
upper respiratory infections that spread to the lymph nodes located in this space. If an infection in this area remains untreated, the neck swells and the patient stops moving the neck, indicating pain.
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Discussion
� SUBMANDIBULAR SPACEThis space is located under the jaw on
each side. Infection in this space is usually the result of a dental infection and is known as Ludwig's angina. It is more commonly seen in adolescents
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Discussion
� In the pre-antibiotic era, 70% of neck infections resulted from infections of the pharynx and tonsils, and approximately 20% were of dental origin.
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Discussion
� In the post-antibiotic era, an increasing percentage secondary to dental infections (generally considered #1 cause currently) and salivary gland infections. Overall incidence has decreased.
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Discussion
� Other etiologies include upper respiratory tract infections, trauma, foreign bodies, instrumentation, spread of localized infection, and congenital deformities (e.g. brachial cleft sinuses).
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Discussion� Source remains unknown in significant number
of patients (22% unknown etiology, USC Study)
� Pediatric Population - Most common source is acute tonsillitis (peritonsillar space abscess)
- Second most common source is dental(submandibular - submental space
abscess)
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Discussion
Bacteriology 1. Most abscesses with mixed bacteria.
Rare fungal etiology. 2. Anaerobics most likely underrepresented
by bacteriology studies, higher percent in abscesses of odontogenic origin
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DiscussionBACTERIA ISOLATED FROM NECK ABSCESSES
� Aerobes Anaerobes � Streptococci 32 � Alpha not group D 13� Beta group A 7 � Bacteroides 11 � Staphylococcus 9
Aureus 6Epidermidis 3
*Tom and Rice, 1988, Univ. of Southern California
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Discussion� Surgical drainage
- Gold standard - "Treatment is dependent upon the principle
of proper drainage of abscess cavities...Both the primary space involved and any secondary compartments where infection have spread must be properly drained...Surgery of the neck is not primarily cosmetic. A large incision with well loosened and well retracted flaps is essential."
(Levitt, 1970)
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DiscussionNeedle aspiration
� a. Therapeutic � - Herzon 1988 - 24 patients � - 83% resolved without surgery � - 58% needed multiple aspirations � - none required surgery) � - Better cosmetic result, eliminates major
surgical procedure, decreased cost
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Discussion
b. Used to confirm diagnosis - Obtain material for culture
c. CT - guided needle aspiration