Deep Neck Space Infections — MCQs

10 questions

Most common cause of retropharyngeal abscess in adults?

Middle age diabetic with tooth extraction with ipsilateral swelling over middle one-third of sternocleidomastoid & displacement of tonsils towards contralateral -

Which muscle is the deepest in the anterior neck region?

In which body site do health workers commonly carry microbes causing healthcare-associated infections (haemolytic Streptococcus)?

First step taken in a case of multiple injuries of face and neck?

Ludwig angina is usually caused by

38 year old male underwent a tooth extraction at a local dental camp. After few days he develops fever and trismus. On local examination, there is a swelling at the angle of jaw . He has a poor oral hygiene and tonsils were pushed medially .No membranous covering or discharging sinus were seen around tonsils. Most likely diagnosis in this condition would be ?

Which of the following bacteria is the most likely cause of toxic shock syndrome?

Which of the following statements about Ludwig's angina is true?

Q10

A 15 years old Male presented with history of fever since 2 days, unable to swallow the food with muffled voice. On examination it is noted right tonsil is shifted to midline. What is the diagnosis:

Deep Neck Space Infections Indian Medical PG Practice Questions and MCQs

Question 1: Most common cause of retropharyngeal abscess in adults?

A. Tonsillitis
B. Lymphadenitis (Correct Answer)
C. Tooth extraction
D. TB

Explanation: ***Lymphadenitis*** - **Lymphadenitis** in the retropharyngeal space, often secondary to an upper respiratory tract infection, is the most common cause of retropharyngeal abscesses in adults. - The infection spreads from inflamed lymph nodes to form a **purulent collection** in the potential space behind the pharynx. *TB* - **Tuberculosis (TB)** can cause retropharyngeal abscesses, particularly in immunocompromised individuals or endemic areas, but it is less common than pyogenic infections [1]. - TB abscesses tend to be more **chronic** and may be associated with vertebral involvement (Pott's disease) [1]. *Tooth extraction* - While dental infections, including complications from **tooth extraction**, can lead to deep neck space infections, they are not the most common cause of retropharyngeal abscess specifically. - Infections from teeth more often spread to the **submandibular** or **parapharyngeal spaces**. *Tonsillitis* - **Tonsillitis** is a common cause of pharyngeal inflammation and can lead to peritonsillar abscesses, which are distinct from retropharyngeal abscesses. - While severe tonsillitis can occasionally spread to the retropharyngeal space, it is primarily local and less common than direct lymphatic seeding.

Question 2: Middle age diabetic with tooth extraction with ipsilateral swelling over middle one-third of sternocleidomastoid & displacement of tonsils towards contralateral -

A. Ludwigs angina
B. Parapharyngeal abscess (Correct Answer)
C. Retropharyngeal abscess
D. None of the options

Explanation: ***Parapharyngeal abscess*** - The **ipsilateral swelling** over the middle one-third of the sternocleidomastoid and **contralateral tonsil displacement** are classic signs of a parapharyngeal abscess, often secondary to an odontogenic infection. - This location involves the space lateral to the pharynx, which can expand and push structures like the tonsils medially. *Ludwig's angina* - Ludwig's angina is a **rapidly progressive cellulitis** of the submandibular, sublingual, and submental spaces, typically bilateral. - It presents with **brawny induration** of the neck and elevation of the tongue, but usually without a distinct mass displacing the tonsils. *Retropharyngeal abscess* - A retropharyngeal abscess develops in the space behind the posterior pharyngeal wall, usually presenting with **swelling of the posterior pharyngeal wall**. - It more commonly causes **dysphagia**, **stridor**, and neck stiffness, and does not typically result in significant ipsilateral external neck swelling or contralateral tonsil displacement like a parapharyngeal abscess. *None of the options* - The described clinical presentation, with a history of **tooth extraction**, ipsilateral sternocleidomastoid swelling, and contralateral tonsil displacement, is highly specific for a parapharyngeal abscess. - This option is incorrect because there is a clear and well-matched diagnosis among the choices.

Question 3: Which muscle is the deepest in the anterior neck region?

A. Sternocleidomastoid
B. Platysma
C. Longus colli (Correct Answer)
D. Trapezius

Explanation: ***Longus colli*** - The **longus colli** muscle is the **deepest muscle** located in the anterior neck region, running along the front of the cervical vertebral column from C1 to T3. - It lies in the **prevertebral layer**, deep to all other anterior neck structures including the carotid sheath, visceral compartment, and superficial muscles. - Its position directly anterior to the vertebral bodies makes it the deepest anterior neck muscle. *Platysma* - The platysma is the **most superficial muscle** of the neck, located just beneath the skin in the superficial fascia. - It is not a deep muscle and lies superficial to all other neck muscles. *Sternocleidomastoid* - The sternocleidomastoid is enclosed within the **investing layer of deep cervical fascia**, making it relatively superficial. - While prominent in the anterior and lateral neck, it is not the deepest anterior neck muscle. *Trapezius* - The trapezius is a large, **superficial muscle of the back and posterior neck**. - It is not located in the anterior neck and is a superficial, not deep, muscle.

Question 4: In which body site do health workers commonly carry microbes causing healthcare-associated infections (haemolytic Streptococcus)?

A. Nail
B. Skin
C. Hair
D. Throat (Correct Answer)

Explanation: ***Throat*** - The **throat** (pharynx) is a common colonization site for **Streptococcus pyogenes** (Group A Streptococcus), often considered a **hospital-acquired infection** risk if transmitted. - Asymptomatic carriers can harbor these bacteria in their throat, potentially transmitting them to vulnerable patients. *Nail* - While bacteria can accumulate under fingernails, they are not typically a primary or significant reservoir for **haemolytic Streptococcus** colonization in healthcare workers. - Proper hand hygiene, including nail cleaning, is crucial but does not address nasal or throat carriage. *Skin* - The skin can harbor various microbes, but **haemolytic Streptococcus** (like *S. pyogenes*) is more commonly found colonizing mucosal surfaces such as the **throat** rather than being a primary skin colonizer. - Skin colonization with other bacteria, such as *Staphylococcus aureus*, is more common and contributes to healthcare-associated infections. *Hair* - Hair itself is not a significant site for the long-term colonization of **haemolytic Streptococcus**. - While hair can temporarily harbor microorganisms from the environment, it does not serve as a primary reservoir for these pathogens.

Question 5: First step taken in a case of multiple injuries of face and neck?

A. Reconstruction
B. Blood transfusion
C. Maintenance of airways (Correct Answer)
D. IV fluids

Explanation: ***Maintenance of airways*** - In cases of **multiple injuries to the face and neck**, securing the airway is the **absolute priority** due to the high risk of obstruction from edema, hematoma, or displaced structures. Failure to do so can quickly lead to hypoxia and death. - The **"ABCDE" approach (Airway, Breathing, Circulation, Disability, Exposure)** in trauma management emphasizes airway patency as the crucial first step before addressing other issues. *Reconstruction* - **Reconstruction** is a definitive treatment performed after the patient is stable and life-threatening injuries have been addressed. - It is not an initial step in managing **acute trauma** where immediate life support is paramount. *Blood transfusion* - **Blood transfusion** is part of managing **circulation (C in ABCDE)** and addresses significant blood loss. - While critical in hypovolemic shock, ensuring a **patent airway** comes first, as the patient cannot be resuscitated if they cannot breathe. *IV fluids* - Administering **IV fluids** is a component of managing **circulation (C in ABCDE)** to support blood pressure and perfusion. - Similar to blood transfusion, it is secondary to establishing a **secure airway** in the sequence of trauma resuscitation.

Question 6: Ludwig angina is usually caused by

A. Streptococci and various mixed anaerobes (Correct Answer)
B. Anaerobic infection by Prevotella and Fusobacterium
C. Paramyxovirus
D. Candida species

Explanation: ***Streptococci and various mixed anaerobes*** - **Ludwig angina** is a rapidly progressive **cellulitis** of the submandibular and sublingual spaces, predominantly caused by bacteria from the oral flora. - The most common pathogens include **alpha-hemolytic streptococci**, along with various **anaerobes** such as *Bacteroides*, *Peptostreptococcus*, and *Fusobacterium* species, reflecting the polymicrobial nature of dental infections that often precede it. *Anaerobic infection by Prevotella and Fusobacterium* - While *Prevotella* and *Fusobacterium* are important **anaerobic components** of the oral flora and can contribute to Ludwig angina, this option is too restrictive. - It omits the crucial role of **aerobic streptococci** which are frequently isolated alongside anaerobes in this infection. *Paramyxovirus* - **Paramyxoviruses** are a family of RNA viruses that cause diseases such as **mumps**, measles, and respiratory syncytial virus infection. - They are responsible for **viral infections** and do not cause bacterial cellulitis like Ludwig angina. *Candida species* - **Candida species** are yeasts that typically cause **fungal infections**, such as oral thrush or systemic candidiasis. - They are generally not primary causative agents of **bacterial cellulitis** such or severe deep neck infections like Ludwig angina.

Question 7: 38 year old male underwent a tooth extraction at a local dental camp. After few days he develops fever and trismus. On local examination, there is a swelling at the angle of jaw . He has a poor oral hygiene and tonsils were pushed medially .No membranous covering or discharging sinus were seen around tonsils. Most likely diagnosis in this condition would be ?

A. Ludwig's angina
B. Parapharyngeal abscess (Correct Answer)
C. Retropharyngeal abscess
D. Peritonsillar abscess

Explanation: ***Parapharyngeal abscess*** - The patient's history of a recent **tooth extraction** and poor oral hygiene, followed by fever, trismus, swelling at the angle of the jaw, and medially pushed tonsils, are classic symptoms of a **parapharyngeal abscess**. - This type of abscess develops in the **deep neck spaces** and can be caused by odontogenic infections, leading to significant swelling and potential airway compromise. *Ludwig's angina* - While also an odontogenic infection, **Ludwig's angina** primarily affects the **submandibular, sublingual, and submental spaces**, characterized by firm, brawny induration of the floor of the mouth and neck, with less prominent swelling at the angle of the jaw and often **tongue elevation**. - It does not typically present with the tonsils being pushed medially, as it involves spaces anterior to the tonsillar region. *Retropharyngeal abscess* - A **retropharyngeal abscess** typically presents with severe **dysphagia**, odynophagia, fever, and neck stiffness, often resulting from upper respiratory tract infections or trauma. - The swelling would be more prominent in the posterior pharyngeal wall, and would less commonly cause significant swelling at the angle of the jaw or trismus unless extensive. *Peritonsillar abscess* - A **peritonsillar abscess** usually develops due to a complication of tonsillitis, presenting with severe **sore throat**, unilateral tonsillar swelling, and a characteristic deviation of the **uvula** to the opposite side. - While tonsils are affected, they are not typically pushed *medially* from an external deep neck space infection in this manner, and swelling at the angle of the jaw is less pronounced.

Question 8: Which of the following bacteria is the most likely cause of toxic shock syndrome?

A. Clostridium perfringens
B. Streptococcus pyogenes
C. Neisseria meningitidis
D. Staphylococcus aureus (Correct Answer)

Explanation: ***Staphylococcus aureus*** - This bacterium is the most common cause of **toxic shock syndrome (TSS)**, particularly in cases associated with **tampon use** or **surgical wound infections**. - It produces **toxic shock syndrome toxin-1 (TSST-1)**, a superantigen that triggers a massive, systemic inflammatory response. *Clostridium perfringens* - This bacterium is primarily associated with **gas gangrene** (clostridial myonecrosis) and **food poisoning**. - Its toxins cause tissue necrosis and gas production, which are not characteristic features of TSS. *Streptococcus pyogenes* - While *S. pyogenes* can cause a form of **toxic shock-like syndrome (STSS)**, it is distinct from TSS caused by *S. aureus*. - *S. pyogenes* is more commonly known for causing **strep throat**, **scarlet fever**, and **necrotizing fasciitis**. *Neisseria meningitidis* - This bacterium is the primary cause of **meningitis** and **meningococcemia**, a severe systemic infection. - It does not produce the specific toxins associated with TSS or STSS, and its clinical presentation is typically different, involving petechial or purpuric rash and signs of central nervous system infection.

Question 9: Which of the following statements about Ludwig's angina is true?

A. It is usually unilateral.
B. It spreads by lymphatics.
C. It is primarily a viral infection.
D. It involves both submandibular and sublingual spaces. (Correct Answer)

Explanation: ***It involves both submandibular and sublingual spaces.*** - Ludwig's angina is a rapidly spreading, **bilateral cellulitis** involving the **submandibular, sublingual, and submental spaces**. - Its involvement of these spaces can lead to a characteristic **"brawny" induration** of the neck and elevation of the tongue. - This is the defining anatomical characteristic of Ludwig's angina. *It is primarily a viral infection.* - Ludwig's angina is a **bacterial infection**, not viral. - The most common causative organisms are **oral flora**, including Streptococcus, Staphylococcus, and anaerobes. - **Dental infections** (particularly from the second and third mandibular molars) are the most common source (80-90% of cases). *It is usually unilateral.* - Ludwig's angina is characteristically a **bilateral infection** of the floor of the mouth and neck spaces. - Unilateral involvement would suggest a more localized infection, such as an **abscess**, rather than the diffuse cellulitis of Ludwig's angina. *It spreads by lymphatics.* - Ludwig's angina is a **diffuse cellulitis** that spreads via continuity through **fascial planes** and connective tissues, rather than primarily through the lymphatic system. - The absence of significant **lymphadenopathy** is a key differentiating feature from other neck infections.

Question 10: A 15 years old Male presented with history of fever since 2 days, unable to swallow the food with muffled voice. On examination it is noted right tonsil is shifted to midline. What is the diagnosis:

A. Quincy (Correct Answer)
B. Acute tonsillitis
C. Parapharyngeal abscess
D. Acute retropharyngeal abscess

Explanation: ***Quincy (Peritonsillar abscess)*** - This patient's presentation with **fever**, **dysphagia**, **muffled voice** (hot potato voice), and **tonsil shifted to the midline** is classic for a **peritonsillar abscess (Quincy)**. - The affected tonsil is pushed **medially toward the midline** by the collection of pus between the tonsillar capsule and the superior constrictor muscle. - The uvula is typically deviated to the **contralateral side**, and patients often have **trismus** and difficulty opening the mouth. - This is the **most common deep neck space infection** and typically follows acute tonsillitis. *Parapharyngeal abscess* - A **parapharyngeal abscess** would present with **severe trismus**, **neck swelling**, **torticollis**, and **bulging of the lateral pharyngeal wall**. - While it can push the tonsil medially, it more characteristically causes **anterolateral displacement** of the entire pharyngeal wall rather than isolated tonsillar displacement. - Patients typically have more pronounced **systemic toxicity** and **neck involvement** than seen with peritonsillar abscess. *Acute tonsillitis* - **Acute tonsillitis** presents with **bilateral tonsillar enlargement**, exudates, and pharyngeal erythema. - It does not cause **displacement of the tonsil to the midline** or significant **muffled voice**. - While fever and dysphagia are present, the physical examination finding of tonsillar shift indicates a suppurative complication (abscess formation). *Acute retropharyngeal abscess* - An **acute retropharyngeal abscess** occurs in the retropharyngeal space behind the posterior pharyngeal wall. - It presents with **neck stiffness**, **stridor**, **drooling**, **bulging of the posterior pharyngeal wall**, and **reluctance to extend the neck**. - It would **not cause visible displacement of the tonsil to the midline** as the abscess is in a different anatomical space. - More common in **young children** (under 5 years) than adolescents.

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