Case Presentation and Discussion on Posterior Neck Mass. Martin Joseph S. Cabahug

Transcription

1 Case Presentation and Discussion on Posterior Neck Mass Martin Joseph S. Cabahug

2 General Data: C.A, 60 y/o male Sta. Ana, Mla

3 Chief Complaint: Posterior Neck Mass

4 History and Physical Exam 2 wks PTA mass, 1 x 1 cm, soft, erythematous, tender no consult done no meds taken 1 wk PTA mass 6 x 4 cms, no consult done self medicated with Amox 500mg tid ADMISSION

5 Physical History General Survey: conscious, coherent, not in cardiorespiratory distress Vital Signs: BP= 120/80 CR= 85 RR= 23 T = 37.5 c

6 6 x 4 cms mass, soft, erythematous, tender, fluctuant,

7 Chest & Lungs: symmetrical chest expansion, no retractions, clear breath sounds Abdomen: flat, NABS, soft, non tender Extremities: grossly normal

8 Salient Features - 60 y/o - male - mass posterior neck 6 x 4 cms, erythematous, tender, fluctuant, warm to touch -DM

9 posterior neck mass skin soft tissue bone

10 posterior neck mass soft tissue Inflammatory Non inflammatory

11 posterior neck mass soft tissue Non inflammatory benign malignant

12 posterior neck mass soft tissue Inflammatory TB Abscess

13 posterior neck mass skin, soft tissue Inflammatory Abscess

14 percent of certainty Primary diagnosis Abscess, posterior neck area Secondary diagnosis TB 95% 5%

15 Do I need a Paraclinical Diagnostic procedure? -NO

16 Treatment Goal drainage of abscess resolution of infection

17 Treatment options Benefit Risk Cost Availability Incision and drainage + antibiotic ++++ bleeding +++ Aspiration + antibiotic ++ Incomplete resolution recurrence +

18 PRE OPERATIVE EVALUATION Optimize patient Secure informed consent Screen for medical problems Prepare materials for operation

19 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

20 OPERATIVE MANAGEMENT Intra-op findings: drained about 50 ml of purulent, non foul smell material

21 OPERATIVE MANAGEMENT Copious washing with nss with H2O2 Hemostasis DSD

22 POST OPERATIVE MANAGEMENT Diabetic Diet Adequate analgesia Adequate antibiotic coverage Daily wound flushing Control of blood sugar

23 Final Daignosis Abscess, posterior neck area

24 Discussion Neck 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.

25

26 Discussion NECK ABSCESS 1. Superficial neck abscesses The most common cause of these abscesses are Staphylococcus or Streptococcus bacteria.

27 Discussion NECK ABSCESS 2. Deep neck Abscess infection that is located in various spaces in the deep layer of the neck.

28 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.

29 Discussion PERITONSILLAR SPACE Located 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.

30 Discussion PARAPHARYNGEAL SPACE It 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.

31 Discussion SUBMANDIBULAR SPACE This 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

32 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.

33 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.

34 Discussion Other etiologies include upper respiratory tract infections, trauma, foreign bodies, instrumentation, spread of localized infection, and congenital deformities (e.g. brachial cleft sinuses).

35 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)

36 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

37 Discussion BACTERIA ISOLATED FROM NECK ABSCESSES Aerobes Anaerobes Streptococci 32 Alpha not group D 13 Beta group A 7 Bacteroides 11 Staphylococcus 9 Aureus 6 Epidermidis 3 *Tom and Rice, 1988, Univ. of Southern California

38 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)

39 Discussion Needle aspiration a. Therapeutic - Herzon patients - 83% resolved without surgery - 58% needed multiple aspirations - none required surgery) - Better cosmetic result, eliminates major surgical procedure, decreased cost

40 Discussion b. Used to confirm diagnosis - Obtain material for culture c. CT - guided needle aspiration