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Insidensi & mortalitas deep neck infections (DNIs) penggunaan
antibiotik & perawatan gigi yang baik
DNIs masih menjadi masalah anatomi yang kompleks & komplikasi fatal
Sebagian besar sumber DNIs infeksi
odontogen, terutama infeksi yang sudah
melibatkan ruang submandibula
Muskulus mylohyoid membagi ruang
submandibula menjadi rongga superior
(sublingual) & rongga inferior (submaksilar)
Rongga submaksilar dibagi dua oleh muskulus
digastrik bagian anterior menjadi rongga
submental sentral dan rongga submaksilar
lateral
Horizontal Section Coronal Section
Infeksi gigi, sialadenitis
kelenjar submandibula, Infeksi rongga Infeksi rongga leher
limfadenitis, trauma & submandibula dalam
tindakan pembedahan
Ludwigs angina selulitis difus gangren bilateral pada rongga submandibular
dan sublingual mengancam jiwa pembengkakan jaringan submandibular
secara cepat elevasi lidah distres pernapasan
SIGNS SYMPTOMS
Bull Neck Appearance Difficulty in Breathing
Swelling & Inflammation Pain Chin & Neck
Swollen Tongue Upwards Difficulty Swallowing
Displacement Speech Difficulties
Tenderness Floor of Mouth Uncontrolled Drooling
Ear Pain
Weakness & Fatigue
Fever & Chills
Mengidentifikasi faktor
Menilai karakteristik
predisposisi yang
klinis dan tatalaksana
dapat mengakibatkan
infeksi rongga
komplikasi kegawat
submandibula
daruratan
Medical Records University of Padua Otolaryngology Clinic at
Treviso Regional Hospital

Diagnosis Submandibular Space Infection 1998-2006

Head & Neck Cancer / post-traumatic submandibular space


infection excluded
Demographic
Data

Complications Pathogenesis

Clinical
Treatment Variables
Presentation

Associated
Imaging Systemic
Diseases
Bacteriology
Patients CECT scan detect abscess

Suspect descending infections extended CECT scan

Confirmed by needle aspiration or surgery


Cellulitis
Character
Abscess

Monolateral
Infection Side
Bilateral

One Space
Involved
Spaces Multiple
Space
Clinically Unstable

Descending
Infection

Anterior Visceral
Space Involvement
Patients IV Immediate Surgical
Antibiotics Drainage
Multiple Space
Infections

Abscess > 3,0 cm


Worsen / No
Clinical Surgical Drainage
Observed for 48 Improvement
All Other Cases
Hours
Clinical
CECT
Improvement
Gender

Leucocytosis Age

Fever
DM
>38,0C
Parameters

Other
Trismus Associated
Diseases

Areas Character of
Involved Infection
Analysis I Analysis II Programs

Fishers Multivariate SPSS


exact test logistic CIA
Chi-square regression
test
Odd ratios
95% CI
Sample

n = 81 42 males (51,9%), 39 females (48,1%)


Age ranging from 12 to 96 year-old

Most common symptoms

Neck swelling (98,8%) and dysphagia (35,8%)

Most common cause

Dental infection (46,9%, n = 38)


Unknown (28,4%, n = 23)
Site of infection

Primary submandibular infection (84%, n = 68)


Secondary submandibular infection (16%, n = 13)

Complication

Abscess (49,4%, n = 40) and cellulitis (50,6%, n = 41)

Systemic disease

Diabetes mellitus was present in 13 patients (16%)


Microbiology diagnosis was successful in 42 patients (51,9%)
Anaerobic cultures were not carried out
Amoxicillin & / clavulanate potassium 56 patients (69,1%)
Cephalosporins (2nd & 3rd gen) 12 patients (14,8%)
Metronidazole 10 patients (12,3%)
Clindamycin 9 patients (11,1%)
Ampicillin/sulbactam 8 patients (9,9%)
Vancomycin A Single Case
25 patients (30,9%) underwent cervical surgical drainage
12 patients (14,8%) developed life-threatening complications
2 patients underwent thoracotomy
4 patients underwent tracheostomy
3 patients underwent fiberoptic intubation
Management of DNIs Troublesome
Inappropriate
Complex Polymicrobial Life Threatening Use of
Anatomy Etiology Complications Antibiotics,
Steroids, & NSAID

Mask signs of infection, change the clinical presentation & slow


course of disease delayed recovery development of
complications
Airway Control Safe & Secure Airway

Antibiotic Medical Treatment

Surgical Drainage
Bilateral Submandibular
Swelling

Tongue Pushing Against Anterior Visceral Space


the Roof of the Mouth and the Involvement with Laryngeal
Posterior Pharyngeal Wall Edema
Most of anterior visceral space involvement occurred in association with an
infection of both the submandibular and lateral pharyngeal space
Both these spaces communicate inferiorly with the anterior visceral space
The anterior visceral space extends from the hyoid bone down to the
superior mediastinum contains the larynx, thyroid gland, trachea, and
cervical esophagus
Awake tracheotomy
under local anesthesia,
Conventional
blind nasal intubation, Fiberoptic guided
endotracheal intubation
and IV / gaseous awake endotracheal
& tracheotomy under
induction followed by intubation
general anesthesia
laryngoscopy and appropriate procedure
Problematic
intubation Possible,
but not risk-free
Most Common

Dental infection

Not identified (28.4% of cases)

Suppuration of the deep lymph nodes ?? not


recognized in clinical & imaging studies
Predominant Organisms
Aerobic: Group A streptococcus,
Anaerobic: Prevotella,
Viridans streptococci,
Porphyromonas, Fusobacterium,
Staphylococcus aureus, and
& Peptostreptococcus spp
Haemophilus influenzae

No correlation usually exists between the anatomical region and


microbiology of neck space infections
The microbiological pattern polymicrobial, including aerobes and
anaerobes Empiric antibiotic therapy
> 2/3 of deep neck infections beta-lactamase producing organisms
The most efficacious antimicrobial agents:
Combination of a penicillin and a beta-lactamase inhibitor
amoxicillin/clavulanate
ticarcillin/clavulanate
piperacillin/tazobactam)
Cefoxitin
Carbapenem
clindamycin
Macrolides or ketolides plus metronidazole patients with a penicillin
allergy
No bacterial growth was observed in 39 patients, and anaerobes were
isolated in only a few cases
Factors may have affected the results of microbiological tests :

Use of antibiotics prior to admission

High-dosage IV antibiotics prior to surgical drainage

Improper collection of specimens

No routine use of anaerobic cultures


Coagulase-negative Staphylococcus MOST COMMON (38,1%)
Consider contaminated specimens only 24% of specimens
were from intra-operative collection

It is essential to decontaminate the mucous membrane before


obtaining material for microbiological culture
Staphylococcus aureus 2nd MOST COMMON
No methicillin-resistant strains (MRSA) were identified
Considering the expanding role of MRSA in suppurative infections, an
increasing rate of MRSA deep neck space infections could be
expected in the future

Vancomycin, trimethoprim/sulfamethoxazole, rifampin, & linezolid


surgical drainage of the abscess
clear differentiation between cellulitis and abscess

CECT

appropriate treatment planning


Identification of DNIs

Differentiate Deep Neck Abscesses from Cellulitis

CECT Delineate the Involved Spaces

Diagnosis of Complications

Checking the Evolution of the Infection


Coronal Axial Bone Window
Axial Bone Window
Characteristics Cellulitis Abscess
Duration Acute Phase Chronic Phase
Pain Severe and Generalized Localized
Size Large Small
Localization Diffuse Borders Well Circumscribed
Palpation Doughy to Indurated Fluctuant
Presence of Pus No Yes
Degree of Seriousness Greater Less
Bacteria Aerobic Anaerobic / Mixed
Intra-operative findings confirmed the CECT diagnosis 68-88% of cases
The differential diagnosis between abscess and cellulitis subjective
findings & dependent on the level of experience of the radiologist
An area of low attenuation with a complete circumferential rim of
enhancement is considered the hallmark of abscess
Unfortunately, CECT findings may be ambiguous in the transition stages
from cellulitis to abscess; specifically, a thin or partial enhanced rim may
be present in cellulitis
Another subjective finding, a scalloped contour of the ring-enhancing, was
recently proved to be highly predictive of the presence of pus (positive
predictive value 94%, sensitivity 64%, and specificity 82%)
Submandibular Space Infections Dental Origin

Acquisition of High-Resolution Axial Scans of the Jaw


Together with Curved and Orthoradial Multiplanar
Reconstructions (Dentalscan) Advisable

Identify Periapical Infections


Open surgical incision and drainage are considered the
mainstay of treatment for submandibular space abscesses and
Ludwigs angina

Treat all patients with large doses of broad-spectrum IV


antibiotics (e.g., amoxicillin/clavulanate potassium) culture
results identify the causative organism

Large abscesses or multiple space involvement open surgical


incision & drainage

Small abscesses watch and wait for 48 hours lack of


response to medical treatment is noted both clinically and by
CECT open surgical drainage
Aggressive approach is justified, even if areas of colliquation are not evident

More at risk for adverse complication

Consistent with our regression results, which showed a significant impact of


bilateral submandibular swelling on the rate of complications
Patients with diabetes mellitus and other comorbidities particularly susceptible
to DNIs and tend to have a higher rate of life-threatening complication

particular attention early surgical drainage

Comorbidities and immunosuppression from polypharmacy in older patients


more severe infections as well as make clinical presentation more elusive
Submandibular space infections potentially
lethal infections aware that the clinical status
may quickly & unexpectedly worsen

Airway obstruction & spread of infection to the


mediastinum the most troublesome complications
secure airway & aggressive treatment

Patients with cellulitis & small abscesses can respond


to antibiotics alone
Surgical drainage larger abscesses,
Ludwigs angina, anterior visceral
space involvement & in those who do
not respond to antibiotic treatment

Each case has to be taken on its merit, specifically,


in patients with DM & other comorbidities
requires a high level of suspicion for potential life-
threatening complications early surgical
drainage should always be considered