CASE PRESENTATION

SUBMENTAL ABSCESS

Supervisor: dr. H. Oscar Djauhari, Sp. THT-KL

Penyusun: Ranetta Putri Gabriella Sabrina Cintyadewi W 2012.061.011 2012.061.012 2012.061.013

Ilmu Kesehatan Telinga Hidung Tenggorok Kepala Leher Fakultas Kedokteran Unika Atma Jaya Jakarta RSUD Syamsudin, S.H., Sukabumi Period 03 June 2013 06 July 2013

BAB I CASE DISCUSSION

A. Patients Identity Name: Nadira Gender: female Age: 3 years old Occupation: B. Complaint Chief complaint: swelling below the chin Additional complaint: fever, tenderness, expand continuously History of Present Illness The patient came with swelling below the chin as chief complain. The swelling started 6 days ago. Initial swelling arised after high fever the day before. The swelling expanded continuously. The swelling appears red with fluctuation. History of sorethroat, cold, dental infection or any trauma was denied. History of dysphagia was denied. The patient can eat and drink normally. C. Physical Examination i. General examination General Condition Awareness Pulse rate Respiration rate Temperature Lymph node ii. ENT examination Auris dextra et sinistra Auricle : normal External auditory canal: : appear ill : compos mentis : 100x/minute : 27x/minute : 37,4oC : swelling tenderness, in submental region, redness, heat, fluctuation (+)

Skin Secretion Serumen Mass -

: hiperemic (-/-), oedema (-/-) : (-/-) : (-/-) : (-/-)

Laceration : (-/-) Timpanic membrane: intact/intact, light reflex (+/+) Retroauricular : normal

Cavum nasii Septum deviation: Mucous: hiperemic (-/-) , oedema (-/-) Concha: (-/-) Secretion: (-/-) Mass : (-/-) Laceration : (-/-)

Nasopharynx and oropharynx - Uvula : middle : hiperemic (-), granule (-) : symmetrical, hiperemic (-/-) : Symmetrical : mass (+), lymphadenopathy (+) - Retropharynx - Arcus pharynx Maxillofacial Neck D. Work Ups 1. Laboratory Examination: Hb Leucocyte : 10,4 g/dL : 9.600/L

Thrombocyte : 213.000/ L Bleeding time : 2 Clotting time : 6

2. Radiography Anteroposterior Lateral

E. Working Diagnosis: Submental Abscess F. Treatment: Paracetamol syr 1x1 cth Cefotaxime 0,5 gr IV 2x1 Metronidazole 500 mg IV 4x1/2 Drainage and curetase

BAB II LITERATURE STUDY

2.1 BACKGROUND The use of antibiotics has decreased the mortality from deep neck space infections, but infections of the deep spaces of the neck still have potential for serious and even life threatening complications. Surgery is still considered the main treatment. However, early infections can be treated with antibiotics. Delay in diagnosis, or a missed diagnosis can lead to serious complication and even death. Even in the antibiotic era, a mortality rate 40% has been reported. It is important to understand the biology of the disease, and understand the anatomic pathways for the spread of infection. The aim is to intervene aggressively, both medically and if indicated, surgically, prior to the onset of complications. 2.2 ANATOMY Submandibular Space The submandibular space is separated superiorly from the sublingual space by the mylohyoid, hyoglossus, and styloglossus muscles medially and by the body of the mandible laterally. The lateral border is the overlying skin, superficial fascia, platysma muscle, and the superficial layer of the deep cervical fascia. Its inferior boundary is formed by the anterior and posterior bellies of the digastric muscle. The space communicates freely with the submental space anteriorly; and posteriorly with the pharyngeal space. This space contains the submaxillary gland, Wharton's duct, the lingual and hypoglossal nerves, the facial artery, and some lymph nodes and fat. Submental Space The submental space is a triangular space in the midline beneath the mandible, with its lateral margins, the anterior bellies of the digastric muscle. The inferior border of the space is the mylohyoid muscles, and the superior border is the overlying skin, superficial fascia, and platysma muscle. It contains a few scattered lymph nodes and fibrofatty tissue.

2.4 ETIOLOGY Most abscess are polymicrobial, such as Staphylococcus aureus, Clostridium clostridiforme, dan Prevotella buccae. In infants younger than 9 months of age, Staphylococcus aureus is the predominant organism. 2.5 RISK FACTOR Penetrating trauma Trauma from surgical instrumentation Retained foreign bodies Congenital deformities : branchial cleft cysts and fistulae

2.6 PATHOPHYSIOLOGY Most of submental space infection source is by drainage from the mandibular incisor teeth as well as their gingival. Because the mylohyoid line obliquely crosses the second molar tooth, dental infections originating anterior to this tooth involve the sublingual space and submental space while those behind it involve the submandibular space. Entry into the space also can occur from an infection in the adjacent sublingual and submandibular space. 2.7 CLINICAL MANIFESTATIONS Patients with submental abcess may show presentations such as fever, pain and swelling in the submental, and may show fluctuation. Depending on the progression of disease, some patients may also have presentations like sore throat, dysphagia, and odynophagia to more serious problems such as airway compromise, septic shock, and mediastinitis. In one series, the duration of symptoms ranged from 12 hours to 28 days (average is 5 days).

2.8 WORK-UPS 1. Serial WBC counts: WBC is commonly elevated in patients with abscess. 2. Radiography: a. Plain lateral and anteroposterior radiographs are useful in the diagnosis of neck space infections. The presence of radio-opaque foreign bodies,

tracheal deviation, subcutaneous air, fluid within the soft tissues, lymphadenopathy, widening of the mediastinum as in mediastinitis, pulmonary edema, and pneumomediastinum may be indicators of abscess formation. b. Contrast-enhanced CT scans: more sensitive in picking up deep neck space infections. It clearly depicts the spaces involved and the superior-inferior extension of the process. CT characteristics of an abscess include low attenuation (low Hounsfield units), contrast enhancement of the abscess wall, tissue edema surrounding the abscess, and a cystic or multiloculated appearance. 3. Blood culture: Performed during incision and drainage. Once the results of cultures are obtained, targeted antibiotic therapy is recommended. 2.9 MANAGEMENTS 1. High dose antibiotics for both aerobic and non-aerobic bacteria parenterally. Most often the infections are polymicrobial (gram positive, gram negative, aerobic, and anaerobic) and -lactamase producing organisms must be anticipated. Therefore, therapy with ampicillin-sulbactam or clindamycin with a third-generation cephalosporin such as cefotaxime is begun while culture results are pending. Once the results of cultures are obtained, targeted antibiotic therapy is recommended. 2. Abscess evacuation: Evacuation of abscess is peformed with needle aspiration under local anasthesia for localized abscess or surgical incision for patients with large or deep abcess. Incision itself is is done in the most fluctuated area of the abcess or at the level of os hyoid. Patients with submandibular or other deep neck abscess need to be hospitalized until 1-2 days after symptoms or infection signs lessen.

2.10 COMPLICATIONS Complications that may occur following submental abscess include: 1. Sepsis 2. Aspiration (due to spontaneous rupture) 3. Osteomyelitis of the mandible 4. Pericarditis 5. Mediastinitis 6. Pulmonary edema 7. Carotid artery erosion and hemorrhage Complications most often occur due to delay in diagnosis or delayed treatment when the infection spreads from one region to another. Host factors such as reduced immunity and systemic diseases such as diabetes also play a role and the medical condition of the patient must also be appropriately managed. Complications are the result of the anatomic proximity of important structures juxtaposed against the deep

spaces of the neck. The carotid arteries, jugular veins, sympathetic chain, and cranial nerves IX through XII are all at risk. 2.11 PROGNOSIS Deep neck space infections can be life-threatening, and once the diagnosis is suspected or made, it is best that the patient be treated on an inpatient basis. However, early diagnosis and adequate treatments can modify the presentation of course or the disease towards a better result and prevent complications.

REFERENCES
Bailey BJ, et al. Head & Neck Surgery: Otolaryngology. 4th ed. Lippincot Williams & Wilkin;2006. - Soepardi EA et al, editor. Buku Ajar Ilmu Kesehatan Telinga Hidung Tenggorok Kepala & Leher. Ed ke-6. Jakarta: Balai Penerbit FKUI; 2008. - Ballenger JJ, et al. Ballengers Otolaryngology Head and Neck Surgery . 16thed. Spain: BC Decker;2003.