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8/13/2019 10. Management of Dna Sarangan
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Dr. Made Jeren, SpTHT
Lahir : 23 Maret 1962
Pend idikan :
1. Lulus FK UNUD : Pebruari 1988
2. Th. 1988
1993 : RSUD Anutapura Palu &
RSUD Parigi Sulawesi Tengah
3. Th. 1994 1998 : PPDS THT FK UNDIP
4. Th. 1998 - 2001 : PNS RSUD Magetan
5. Th. 2002
sekarang : PNS RSUD Dr. Harjono PonorogoPangkat/ Gol. IV/C
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Made Jeren
Bagian THT RSUD Dr. Harjono
Ponorogo
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Remain an important health problem in ENT Dep. Significant risk of morbidity and mortality
The complication rate has been reduced :
1. advant of modern microbiology
2. shopisticated diagnostic procedure(CT Scan, MRI)
3. development of management
(medical and surgical)
4. effectiveness of modern Antibiotics
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COMPLEX ANATOMY
DEEP LOCATION
ACCESS PROBLEM
COMMUNICATION OF THE DEEP NECKSPACES
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Huang (185 cases): th 1997 - 2002
Abses Parafaring (38,4 %)
Abses submandibula (15,7 %)
Ludwig Angina (12,4 %)
Abses Parotis (7 %)
Abses Retrofaring (5,9 %)
Yang (100 cases) : th 2001 -
2006
ring (20 %)
Abses submandibula (35 %)
Abses infrahioid (26 %)
Abses Mastikator (13 %)
Abses Retrofaring (13 %)
Abses Ruang karotis (11 %)
Abses Peritonsil (9 %)Abses sublingual (7 %)
Abses Parotis (3 %)
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Bagian THT UNAND(33 kasus ) :
Th 2009/2010
Abses Peri ton si l (32 %)
Abses submandibu la (26 %)
Abses Parafaring (18 %)
Abses Retrofaring (12 %)
Abses Mastikator (9 %)
Abses Pretrakea (3 %)
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1) Superficial cervical fascia
2) Deep cervical fascia :
Superficial layer(Investing layer)
Midd le layer
(Viseral layer )
Deep layer
(Prevertebral &
A lar layer)
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1. Length of the Neck
2. Above the Hyoid bone
3. Below the Hyoid bone
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1. Retropharyngeal Space
2. Danger Space
(Prevertebral Space)
3. Paravertebral Space4. Carotid Sheath Space
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1. Parapharyngeal Space
2. Submandibular Space
3. Masticator Space
4. Temporal Space
5. Parotid Space
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ETIOLOGY OF DNI
1. Tonsillar and Pharyngealinfection
2. Dental infection
3. Oral surgical procedure
4. Salivary gland infection
5. Trauma oral cavity and pharynx
6. Cervical lymphadenitis
7. Infection of a malignant cervicallymph node
8. Mastoiditis with Bezold abscess
In fact 2050% no identi f iable source
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MICROBIOLOGY
Mixed organisms (aerobic and anaerobic)
Aerobic organisms :
Group A beta-hemolytic streptococcal species (Streptococcus
pyogenes)
Streptococcus viridans, Streptococcus pneumoniae),Staphylococcus aureus, Moraxtella catarrhalis, Neisseriasp,
Klebsiella sp ; Haemophilus influenzae.
Anaerobic o rganisms :
Fusobacterium nucleatum, Bacteroides melaninogenicus,
Bacteroides oralisand Prevotella
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SPREAD MECHANISM
Mandibula periapikal abcess
Submandibula
Parafaring
Mastikator
Carotid SheathRetrofaring
CraniumMediastinum
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History + Physical ex.
Culture, IV Antibiotic, Airway control, Chest Rx
CT Scan
CellulitisSmall Abcess Large Abcess
Wait 24 48 h
Improvement
Ab
Needle aspiration for
culture and draenase
Complication
Surgical Inc ision
yes
no
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1. Streptococcus
pyogenes
Ampicillin-sulbactam 1.5-3 g IV q6h ,
Clindamycin 600 mg IV q8h
2. anaerobes Clindamycin 600 mg IV q8h ,
metronidazole 500 mg IV q8h
3. Methicillin-susceptible
Staphylococcus aureus
(MSSA)
Clindamycin 600 mg, Nafcillin 1.5 g IV q4h,
Ceftriaxone 1-2 g or
Ampicillin-sulbactam 1.5-3 g
4. Methicillin-resistantStaphylococcus aureus
(MRSA)
Vancomycin 1000 mg (15 mg/kg) orLinezolid 600 mg,Daptomycin 4-6 mg/kg,
Telavancin 10 mg/kg IV
5. Haemophilus
influenzae
Ceftriaxone 1-2 g or Ampicillin-sulbactam
IV Ant ib iot ic Treatment
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Wit ing b i la i amarga tuna pangerten(mendapat celaka karena kurangnya
pengetahuan).
Wit ing kalantur amarga tanpa pitutur(kesalahan yang berkelanjutan karena
tidak adanya tuntunan)
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PERITONSILLAR ABSCESS
Cellulitis of the space behind tonsillar capsuleextending Into soft palate leading to abscess.
The pus is located between the tonsillar bed and thecapsule anterosuperior to the anterior pillar.
Complication from acute/chronic tonsillitis
Microbiology : Streptococcus, Staphyllococcus,anaerobic.
Unilateral
Most common 10-30 years old
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Inflamation of tonsil peritonsillar space
Supero-lateral of tonsillar fossa (tonsillar bed)
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MANAGEMENT
Antibiotic therapy
Surgical drainage
COMPLICATION
Spontaneus rupture aspiration
Direct spread :
Parapharyngeal spaceMediastinum
Intracranial complication
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Wit ing luput saka kal imput (penyebab salah karena tertutupi).
Weruh in g sis ip sayekt i sul i t (menyadari kekeliruan benar-benar sulit).
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ETIOLOGY
PediatricsSuppurative process in
retropharyngeal nodes
(more than 50% due to
lymphadinitis) from nose,adenoids , nasopharynx or
sinuses infect ions
Adults
Trauma Instrumentation;
Trauma foreign body.
from contiguous spaces, suchas the parapharyngeal space,submandibular space (Ludwigangina), or prevertebral space( osteomyelitis).
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Pediatrics
History of upper Resp. track infection,
Fever, irritability, torticollis, poor oral
intake, sore throat, drooling, hot potato
voice, posterior pharyngeal swelling,
lymphadenopathy,
Adults
History of trauma, Slow onset
Severe case :
Dyspnea and respiratory d istress
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Lateral soft t issu e radiograph s
Ult rasonography
Contrast Enhanced CT
MRI
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Antibiotic therapy
Surgical drainage :
1. Trans oral approach
2. External approach
MANAGEMENT
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Parapharyng abscess
Laryngeal inflammation
Rupture with aspiration
Mediastinitis
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Boundary
o Superiorly : Skull baseo Inferiorly : submandibullar glando Laterally : Medial pterygoid m,
Parotis, Mandibulao Medially : Pharynx
(sup. Constrictor pharynx m.)o Anteriorly : Submandibular spaceo
Posterior : Prevertebral fascia,retrophryngeal space
Connections to other deep spaces:
posteromedially: retropharyngeal space
inferiorly: submandibular space
laterally: masticator space
medially: peritonsillar space
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1. Trauma :
Post Tonsilectomy, others trauma
2. Spread in fect ion from :
Cervical lymphadenitis, Dentalinfection, Parotitis, Tonsilitis,
Pharyngitis, Nasal / Sinus,
Mastoiditis
3. Compl icat ion from others space
Retropharinx, Peritonsillar,
Submandibula
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Trismus , spasm of pterygoids m.
Pyrexia,malaise,
Pain throat,difficult swallowing (Disphagy / Odinophagy
Painful external swelling in neck ( angle mandible,
lateral pharynx )
Medial displacement of lateral pharyngeal wall (Tonsil
pushed medially )
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PARAPHARYNGEAL SPACE INFECTIONTreatment
1. Evaluate and maintain
airway & fluid hydration
2. Parenteral antibiotic highdose 24-48 hrs.
3. If not improve, considere
surgical drainage
MANAGEMENT
Surgical drainage
1. Intraoral approch
(peritonsillar abscess only)
2. External approach
-transverse submandibularincision
-T. shape incision (Mosher)
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Routh of complication1. Limphatic system
2. Hematogen
3. Direct spread
1. Intracranial complication
2. Caroted artery rupture3. Internal jugular vein thrombosis
4. Septecimia
5. Mediastinitis
6. Spread to other spaces of theneck
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Bud i hayu mangg ih rahayu (budi mulia menemukan kerahayuan).
Durangkara manggih sangsara (angkara murka menemukan sengsara).
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The submandibular space :
hyoid bone to the mucosa of the
floor of the mouth.
anteriorly- laterally : mandible
inferiorly : superficial layer of thedeep cervical fascia.
by m ylohyo id m.
1. Sublingual space (above
mylohyoid m.)
2. Submaxillaly space (below
mylohyiod m.)
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Gangren Pulpa Molar
Apicalis Periodontitis
Periostitis
Deep Neck Space
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Dysphagia, OdynophagiaHypersalivasi / Drolling
Hot potato voice
Febrile
Trismus
Stiff neck
Stridor
Woody inflammation,
Protruding tongue
Torax Photo
CT Scan
MRI
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Grodinskys criteria (1939):
1. A cellulitis, not an abscess2. The cellulitis involves all the
sublingual and bilateral
submaxillary spaces
3. The cellulitis produces a sero-
sanguineous infiltration butvery little or no pus
4. Fascia, muscle, connective tissue
involvement, sparing glands
5. The cellulitis is spread bycontinuity and not by lymphatics
Ludwigs anginaby Ludwig in 1836.
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Ludwigs anginaby Ludwig in 1836.
Rapid spread to :lateral pharyngeal / retropharyngeal space
Rapidly obstruct upper airway :
Tachypnea, dyspnea, stridor
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An t ib iot ic therapy
Patients with cellulitis can betreated with parenteral
antibiotics alone. Closely
observe these patients for
development of an abscess.
Surgical
Tracheotomy for airway control
Surgical Drainage
Surgical Drainage
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Surgical Drainage
Transoral
Cruciate mucosal incision, blunt spreading through
superior pharyngeal constrictor.For : retro-, parapharyngeal.
External
Levitt: anterior vs. posterior approachSubmandibular incision
Submental incision
T-incision
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1. Airway obstruction
2. Ruptured abscess
Pneumonia
Lung Abscess
3. Carotid Artery Rupture
Mortality of 20-40%Sentinel bleeds from ear, nose, mouth
Treatment
Proximal and distal control
Ligation
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4. Internal Jugular Vein ThrombosisTreatment IV antibiotic therapy
Anticoagulation? Ligation and excision
5. Mediastinitis
Mortality of 40%
Increasing dyspnea, chest pain
Treatment
Aggressive IV antibiotic therapy
Surgical drainage
Transcervical approach
Chest tube vs. Thoracotomy
6. Sepsis
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