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Continuity of physicians in the diagnosis and treatment of deep cellulitis esophageal tissue around the neck, complicated with sepsis, septicemia and purulent pleurisy
A. B. Baizharkinova, N.A. Akatayev, I.R. Khakimov, A.F. Kononenko, Abubakirov G.B., Akhmetkaliyev S.S. Marat Ospanov's chair OVP №2, MC ZKGMU, GP №1, Aktobe city
Annotation. A clinical case of successful treatment of patients with deep phlegmon of the neck, with the help of the continuity of hospital doctors and clinics.
Keywords: Continuity of diagnosis and treatment, deep abscess of the neck, errors and complications diagnostic CT neck surgery.
Hot topics: The problem now timely diagnosis of acute purulent cellulitis of the neck remains relevant.
Introduction
Bearing in mind the anatomical structure of the neck, the topographic classification phlegmons neck is imperfect. Limitation of each layer five fascia of the neck, with penetration of infection in the loose cellular spaces cellulitis is due to the rapid spread of the inflammatory process in the deeper layers. They may have a different location and pose a serious threat to lifes of our patients. The prevalence of inflammatory process depends on a state reactivity of the patient. Between phlegmon and abscess is no possible clear line. Abscess differs from cellulitis only in the presence of pyogenic shell consequently transition to the mechanical limitations of inflammation in diffuse form (phlegmon) often does not exist. On the other hand, even the presence of pyogenic membrane often does not prevent (especially with the delay in the provision of assistance) conversion of an abscess in phlegmon, or vice versa, cellulitis and delimited abscessed. Depending on the localization of abscesses and cellulitis distinguish the neck: superficial and deep, (pre visceral and retrovisce-rale ) unilateral, bilateral and central, lateral surface of cellulitis; upper and Lower rear surface phlegmon etc. Only some of them in the title reflected topographic localization: submandibular, chin and abscess of the vascular space. This is due to a variety of sources occurrence and lack of complete isolation between the fascial spaces neck. Most abscesses localized on the front and side of the neck. Almost half of all abscesses neck up submandibular cellulitis and cellulitis vascular space. Etiology and pathogenesis of occurrence of cellulitis of the neck are extensive, it could be as self-development (with injuries and penetration through the damaged portions pathogens) and complication after an diseases. Suppuration congenital cysts and fistulas side of the neck, all kinds of angina (follicular, catarrhal, lacunar and the like) are also sometimes cause development of cellulitis. Inflammation of the ear (otitis), dental disease (caries, gingivitis, periodontal disease, osteomyelitis), place of opening abscesses, lesions cervical spine or neck can lead to cellulitis neck. For example, children's abscess can be provoked by Haemophilus influenzae. at dog bites, soft tissue penetrates bacteria Pasturella multocida, thereby development of cellulitis with a short incubation period (6-20 hours). But such instances, fortunately are rare. Diagnosis of
deep cellulitis of the neck may be difficult due to the lack of clear signs of disease. For small phlegmons, deep-seated, external cutaneous manifestations in the neck may be absent. The body temperature is low-grade. Manifestations of intoxication syndrome are mild. However, the external or extensive cellulitis of the neck is much easier to reveal, while there is a marked redness, swelling, and soreness fluctuation accompanied tensions of the skin. The general condition of the patient presented in the form of hard or with moderate severity. One of the most difficult diseases, often leading to death can be a deep abscess of the neck.
In symptomatic abscesses and abscesses are acute and subacute stage disease, its main forms: serous, purulent, putrid, necrotic, anaerobic and lightning. Deep abscess develops severe anaerobes: peptococcus, Bacteroides, Clostridium, etc., that can exist without oxygen. It goes beyond the one area, capturing both adjacent and appears Clinic severe intoxication and is malignant character when patients die on the first 2 days.
Pathogens: Staphylococcus aureus, Streptococcus less, and their associations, Proteus, intestinal and Pseudomonas aeruginosa. Often occurrence of abscesses, along with pyogenic cocci involved fusospirillare anaerobic microflora inhabiting in the mouth and throat, as well as E. coli, the causative agent of typhoid and paratyphoid and even Cl.perfringens Cl.oedematiens.
The chronic form of cellulitis can occur at low virulence pathogenic microorganisms and increased resistance of the patient. Accompanied by the development of woody infiltration, dense to the touch. Skin covers in the inflammatory process are cyanotic hue. Most often otorhinolaryngologists have to meet phlegmons vascular space. Diagnosis and treatment of odontogenic abscesses and abscesses in okoloushno-chewing, with the jaw, jaw-Pterygopalatine areas in the area of maxillo-lingual groove, tongue and floor of the mouth are the responsibility of dentists. In such phlegmons there is a danger of Arroz vessels, thrombophlebitis and thrombosis internal jugular vein with septic complications. Deep neck abscess -difficult and dangerous disease according to the literature in 51% of cases of cellulitis "Vascular" space neck occur with no or weak expression local and general symptoms that are characteristic of severe suppurative processes.
The greatest danger is deep cellulitis of the neck - the lower portion of her and the front surface of the vascular space. With their progression as usually develops front or rear mediastinitis. Deep cellulitis of the lower of the front of the neck are usually the result of purulent thyroiditis or strumita, at least - acute lymphadenitis. Marked swelling and tenderness in the the anterior surface of the lower half of the neck. Appears diffuse swelling anterolateral surface of the neck with a voltage of tissues, skin cyanotic - purple.
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Вестник хирургии Казахстана №4, 2014
The patient tries to keep his head still, several tilted toward defeat. The general condition of the patient abruptly broken, body temperature increased, difficult or painful swallowing, there is a pronounced general intoxication, sometimes drooling, trismus and breath. In the most severe cases of inflammation previscerale spaces extend to the other side of the neck.
At the top of cellulitis vascular space maximum swelling is in a sleepy triangle behind the mandibular angle. It applies to submandibular area, the area of the parotid salivary gland and down up to the larynx. Below the level of the hyoid bone are located the so-called anterior neck cellulitis emanating from festering median cyst before-laryngeal lymph nodes or mucous bags Boyer.
However, at first, the swelling of the neck with external examination is often not detected. pain may be strong. Body temperature reaches high numbers. There is a general intoxication, sometimes voice changes and difficulty in breathing due to compression trachea and involvement in recurrent nerves.
Particularly adversely neck abscess occurs in older patients and background related diseases, such as tuberculosis, blood diseases, immunodeficiency status, diabetes, hypertension, coronary artery disease, atherosclerosis, chronic alcoholism, morbid obesity, and others. For the successful treatment of a patient with phlegmon of the neck must work closely otolaryngologist, surgeon, dentist, Anaesthetist.
Phlegmon neck situated at the front, in the region of the pharynx and the esophagus, causing discomfort when swallowing and breathing. There have been a lot of pain, especially when swallowing in the neck (or behind the breastbone with a strong localization process) dysphagia, forced position of the head and pain on her movements, local tenderness lateral and posterior to the larynx and trachea. But swelling of the neck with external examination is often not detected. The general condition of the patient dramatically disrupted, the body temperature increased, swallowing is difficult or painful, there is a pronounced general intoxication, sometimes drooling, trismus and breath mouth.
Cellulitis of the neck occupies a special place, which is developed as a complication of the apical forms of mastoiditis. Pus comes under Sternocleidomastoid muscle or directly into her vagina. On the neck under the mastoid appears tight infiltrate. A break of pus medial digastric formed more deep abscess. These inflammatory processes related to the lateral triangle of the neck. Phlegmon submandibular area usually develops from festering submandibular lymph nodes due to odontogenic infection.
List of complications of cellulitis of the neck: sepsis, abscesses, meningitis - from patient body through the blood, asphyxia - by displacement with purulent airway bag, bleeding - from bursting purulent masses, the penetration of pus in the hollow authorities. Complications of cellulitis of the neck can lead to death, so it is very important to do a timely diagnosis and immediate treatment of disease.
In addition to the above complications, the process may move to the bone, tendons and muscles. The risk of death in phlegmon of the neck increases due anatomic structure, the presence of large blood arteries close to the head brain. Diagnostic errors due to the fact that it is not taken into account the possibility of a diagnosis of abscesses with the absence of severe symptoms. Errors treatment policy is to perform the operation in the later stages of abscesses, as well as sufficient wide drainage of the inflammatory focus. Very valuable method for diagnosing abscesses space is the
method of X-ray of the neck - radiography of the neck in the side projection and CT.
Clinic: in the beginning of disease patients note arching neck pain and swelling, redness of the skin not that difficult to diagnose the process. develop severe intoxication: fever, tachycardia, leukocytosis.
Unrecognized time inflammation leads to the spread of toxins and enzymes, destroying tissue throughout the body. Diagnosis of deep-seated inflammation performed by eliminating streaks tuberculosis, malignant tumors and Hodgkin's disease. The final diagnosis is displayed after the previous history diseases that can cause cellulitis of the neck. Sometimes there development of gas anaerobic infections. This condition is accompanied by high fever, pain in the affected area with a pulsating character pain, nausea and vomiting, pale skin. In the blood is determined elevated levels of C - reactive protein, leukocytosis, increased erythrocyte sedimentation rate increased, reduced levels of hemoglobin and red blood cells. The acute form of inflammatory process leads to intoxication, poor blood speed erythrocyte sedimentation rate reaches 40-50 mm / h. Typically, acute abscesses characterized by rapid onset with a sharp rise in temperature to 40 ° C, and at times the above; general intoxication, which is accompanied by thirst, malaise, headache pain, chills.
Treatment of patients should include extensive surgical treatment of abscesses in as early as possible from the onset. Typically, debridement purulent focus phlegmons "vascular" outer space is carried neck Sharing. Along with the surgical treatment must prescribe antibiotics broad spectrum of action in large doses, antisense drugs and vitamins, infusion therapy.
Operation with phlegmon of the neck - a complex intervention, combined with the emergence of complications. Therefore, to prepare for surgery for cellulitis should always be very thoroughly.
Emergency surgery was immediately after the diagnosis.
The purpose and goal of our work
Based on years of experience of doctors Marat Ospanov named ZKGMU can firmly say that any general surgeon treating cellulitis different parts of the body and face difficulties in the diagnosis of deep issues cellulitis of the neck. We decided to share the experience of physicians in succession timely diagnosis of deep neck space cellulitis in aspect, of interest to all clinicians: otolaryngologists, surgeons, chelyustno- surgeons. Examples for the period of practical work surgeon - a lot, this is one of them.
Example: Sick AG, 1990g.r. asked 11.10.10g. in GP№1 to an ENT - doctor - no pathology. At this consultation assistant chair OVP№2 together with a young surgeon clinics in a quandary when the ENT doctor - finds diseases. Patient complaints of general weakness, high t°, Objectively: tachycardia, No skin changes on the neck, palpation gives no information, so we consider it necessary to mention the difficulties of the doctor responsible for the fate of the patient with vague symptoms of deep cellulitis with 4 days disease. The patient was asked at a time when the R-examination room did not work. Drawing the experience of intuition, it is note that the patient with severe drooling her condition, so the patient was sent to the "fast" to the duty clinic surgery -Medical Center of Marat Ospanov ZKGMU diagnosed with "deep abscess neck sepsis. "
Retrospectively studying the medical history of the patient №11760 A.G.1990 born, duty surgeon put diagnosis on
admission 11.10.10g 16ch.30 "Neck lymphadenitis, abscess of the neck? "
In the surgical ward a patient with phlegmon of neck symptoms were severe intoxication - lethargy, malaise, fever and headache. Marked leukocytosis with a shift to the left, increased erythrocyte sedimentation rate to 40 mm / hour. B Hospital performed R- examination of the chest, examination of the patient on duty surgeon, Associate Professor, Head of the Department of Surgery and Head of the Department of ENT. condition sick of conservative therapy has not improved. In blood cultures for sterility - no growth.
After the telephone assistant chair OVP№2 about the patient's condition, aimed at MC ZKGMU, received information from the professor that the department CT radiology office from 13.10.10. given the conclusion: "CT picture is typical for cellulitis about esophageal tissue "and X-ray of the chest cavity, where identified right-purulent pleurisy. Despite the massive anti-inflammatory, detoxication therapy, symptoms of intoxication grew degree intoxication characterized by high numbers LII (4 to 6 and above), there were no Only symptoms of sepsis, but septicemia. Held 13.10.10. 13ch.15 at m / a 0.25% - 40ml.Sol. Novocaini puncture of the chest on the right, aspiration of pus in the 7th intercostal space Right on the posterior axillary line, drainage on Byullau. On the same day, ie, 13.10.10. in 15ch.10-15ch.50 performed under endotracheal anesthesia Course of autopsy deep cellulitis of the neck. In the longitudinal direction of the front edge of the left rib clavicular muscles to make the cut, the abscess was found in the vascular bundle, where found erosive bleeding internal jugular vein, which is tied below arroz, drainage and deep cellulitis of the neck on the left.
In the intensive care unit for almost 5 days patient had massive antibacterial, allergen, cardiotonic, detoxification, replacement therapy. In the future - transfusions odnogruppnoy ermassy, plasma and p-ry blood substitutes. The wound on his neck daily irrigated with sterile sodium chloride sodium in a concentration of 10% -400 mg / l. And the change of aseptic dressing. drains removed as pus from wounds stopping the neck of the left and right side of the thoracic cavity. Inspection duty surgeons, intensive care specialists, physicians, assistant professor and professor noted that the patient's condition improved, decreased body temperature, decreased amount of purulent discharge from the wound. In the study of stroke in patients with neck injuries with phlegmon was detected Staphylococcus aureus, Pseudomonas aeruginosa, aerobic microflora. In some cases, the growth of flora obtained.
On the 6th day patient was transferred to the surgical ward, where the treatment was continued. After his release
from the wound pus held overlay deferred seams. Patient A.G. on the 32nd day after admission discharged in a satisfactory condition for outpatient follow-up care. there has been a seroma in postoperative scar still weak. After several dressings serous discharge ceased. A scar in the neck on the left front edge Sternocleidomastoid muscle (m.Sternocleidomastoideus), palpation painless. The movement of the neck are not limited. Immediate and long-term results are good.
The young age of the patient and a timely treatment had a significant impact on the nature of the disease and the positive outcome.
In assessing the effectiveness of the treatment into account the clinical course disease, severity of pain, temperature reaction dynamics pulse. Also studied the dynamics of the level of leukocyte intoxication index (LII) Data coagulation, blood biochemistry and its sterility,hematocrit.
Conclusion
The success of the treatment of this patient was on timely diagnosis, particularly in the Prehospital and continuity of physicians, a detailed survey on CT and fluoroscopy with graphite, timely adequate surgery and comprehensive medical treatment.
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