Deep Neck Space Infections

1.

What is the predominant organism in children younger than 9 months of age according to the studies provided?
- A.
  
  Streptococcus viridans
- B.
  
  β-hemolytic streptococci
- C.
  
  Bacteroides sp.
- D.
  
  Staphylococcus aureus
Correct Answer
D. Staphylococcus aureus

Explanation
It appears that in infants younger than 9 months of age, Staphylococcus aureus is the predominant organism when abscesses that involve the anterior and posterior triangles of the neck are involved. They constituted 80% of cases in one study. S. aureus was found to be a predominant isolate, albeit at a lower rate of 56% in a study reported by Brook. This organism along with β-hemolytic streptococci was also reported by Ungkanont and colleagues, although the incidence was smaller.

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2.

A patient presents with ipsilateral ptosis, facial anhydrosis, and miosis, what space could be involved?
- A.
  
  Prevertebral space
- B.
  
  Visceral vascular space
- C.
  
  Parotid space
- D.
  
  Temporal space
Correct Answer
B. Visceral vascular space

Explanation
In cases where the visceral vascular space or the parapharyngeal space is involved, the astute physician may pick up the signs of Horner syndrome, which is characterized by ipsilateral ptosis, facial anhydrosis, and miosis due to the proximity of the sympathetic chain.

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3.

What is a possible complication with the use of steroid in a especially in a child with an evolving neck abcess?
- A.
  
  Masking of fever
- B.
  
  Progression of edema
- C.
  
  Adrenal suppression
- D.
  
  Masking of WBC
Correct Answer
D. Masking of WBC

Explanation
In infants and children, rapidly progressive airway compromise is usually present along with fever and neck mass. In infants in particular, a high index of suspicion is important, because complaints such as sore throat, voice changes, and odynophagia may not be forthcoming as they are in older children. In this series, 21 of 22 patients had an elevated white blood cell (WBC) count. Serial WBC counts are a good way to monitor response to antibiotic therapy, and consequently, it is the preference of these authors that steroids not be used unless airway compromise is impending or present.

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4.

What is the recommended time to take a patient to the OR for I&D of a neck abcess if there is failure to progress?
- A.
  
  24 hrs
- B.
  
  48 hrs
- C.
  
  72 hrs
- D.
  
  96 hrs
Correct Answer
B. 48 hrs

Explanation
The recommended time to take a patient to the OR for I&D (incision and drainage) of a neck abscess if there is failure to progress is 48 hours. This means that if there is no improvement in the patient's condition within 48 hours of initiating treatment, it is recommended to perform the surgical procedure to drain the abscess. This timeframe allows for a sufficient period of observation and conservative management before deciding on surgical intervention.

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5.

A patient presents with spiking fevers, tenderness along the sternocleidomastoid muscle, neck stiffness, and septic arthritis. CT scan shows ring enhancement with a central area of lucency of the IJV, what is the diagnosis?
- A.
  
  Cavernous sinus syndrome
- B.
  
  Carotid artery erosion
- C.
  
  Lemierre syndrome
- D.
  
  Branchial cleft cyst
Correct Answer
C. Lemierre syndrome

Explanation
The patient's presentation of spiking fevers, tenderness along the sternocleidomastoid muscle, neck stiffness, and septic arthritis, along with the CT scan findings of ring enhancement with a central area of lucency of the IJV, are consistent with Lemierre syndrome. This syndrome is characterized by septic thrombophlebitis of the internal jugular vein (IJV) following an oropharyngeal infection. It typically presents with fever, neck pain, and swelling, and can progress to septic emboli and abscess formation. The CT scan findings of ring enhancement with a central area of lucency of the IJV is a characteristic feature of septic thrombophlebitis in Lemierre syndrome.

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6.

A 4y/o child with a Hx of previous URI, present with fever, dysphagia, odynophagia, nuchal rigidity, and mild airway compromise. What is the first space that may be affected with abcess?
- A.
  
  Retropharyngeal
- B.
  
  Prevertebral
- C.
  
  Submandibular
- D.
  
  Parapharyngeal
Correct Answer
A. Retropharyngeal

Explanation
Most abscesses of the retropharyngeal space occur in children. This is due to the fact that retropharyngeal nodes disappear by about the age of 5 years. Most infections begin in the nose or nasopharynx and adenoids, and paranasal sinuses and drain to these nodes which go on to suppurate. There is consequently a history of an upper respiratory tract infection. Fever, dysphagia, odynophagia, nuchal rigidity, and airway compromise may occur.

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7.

Dental infections occurring anterior to the second molar involve which space?
- A.
  
  Submandibular
- B.
  
  Masseteric
- C.
  
  Sublingual
- D.
  
  Parapharyngeal
Correct Answer
C. Sublingual

Explanation
Dental infections occurring anterior to the second molar involve the sublingual space. This space is located under the tongue and extends from the midline to the mandibular symphysis. It is a potential space that can become infected due to the spread of dental infections.

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8.

Dental infections occurring posterior to the second molar involve which space?
- A.
  
  Submandibular
- B.
  
  Masseteric
- C.
  
  Sublingual
- D.
  
  Parapharyngeal
Correct Answer
A. Submandibular

Explanation
Dental infections occurring posterior to the second molar involve the submandibular space. This space is located beneath the mandible and contains the submandibular gland and lymph nodes. Infections in this area can cause swelling, pain, and difficulty in opening the mouth. Treatment usually involves antibiotics and drainage of the abscess if necessary. The other options, masseteric, sublingual, and parapharyngeal spaces, are not typically involved in dental infections occurring posterior to the second molar.

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9.

What complication still has a high rate of mortality despite antibiotic therapy?
- A.
  
  Carotid artery erosion and hemorrhage
- B.
  
  Osteomyelitis of the spine
- C.
  
  Pulmonary edema
- D.
  
  Mediastinitis
Correct Answer
D. Mediastinitis

Explanation
Mediastinitis is an inflammation of the tissues in the mediastinum, the area between the lungs. Despite antibiotic therapy, it still has a high rate of mortality. This could be due to several reasons, such as delayed diagnosis, difficulty in treating the infection due to the complex anatomy of the mediastinum, or the presence of underlying health conditions that make the infection harder to manage. The high mortality rate highlights the need for early recognition and aggressive treatment of mediastinitis.

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10.

A patient has a supperative thyroiditis infection, what space would most likely be involved?
- A.
  
  Temporal space
- B.
  
  Anterior visceral space
- C.
  
  Suprasternal space
- D.
  
  Visceral vascular space
Correct Answer
B. Anterior visceral space

Explanation
Anterior visceral space infections are usually the result of perforations of the esophagus, due to instrumentation, foreign body, or external trauma. A suppurative thyroiditis may also be a source of infection. Laryngeal necrosis following radiation and infection can also be a potential source for such an infection.

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Deep Neck Space Infections

What is the predominant organism in children younger than 9 months of age according to the studies provided?

A patient presents with ipsilateral ptosis, facial anhydrosis, and miosis, what space could be involved?

What is a possible complication with the use of steroid in a especially in a child with an evolving neck abcess?

What is the recommended time to take a patient to the OR for I&D of a neck abcess if there is failure to progress?

A patient presents with spiking fevers, tenderness along the sternocleidomastoid muscle, neck stiffness, and septic arthritis. CT scan shows ring enhancement with a central area of lucency of the IJV, what is the diagnosis?

A 4y/o child with a Hx of previous URI, present with fever, dysphagia, odynophagia, nuchal rigidity, and mild airway compromise. What is the first space that may be affected with abcess?

Dental infections occurring anterior to the second molar involve which space?

Dental infections occurring posterior to the second molar involve which space?

What complication still has a high rate of mortality despite antibiotic therapy?

A patient has a supperative thyroiditis infection, what space would most likely be involved?