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

Ranetta Putri


Gabriella Sabrina


Cintyadewi W


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

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

: appear ill


: compos mentis

Pulse rate

: 100x/minute

Respiration rate

: 27x/minute


: 37,4oC

Lymph node


ii. ENT examination

Auris dextra et sinistra


External auditory canal:

: normal




fluctuation (+)




: 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
- Retropharynx
: hiperemic (-), granule (-)
- Arcus pharynx
: symmetrical, hiperemic (-/-)
: Symmetrical

: mass (+), lymphadenopathy (+)

D. Work Ups
1. Laboratory Examination:

Bleeding time
Clotting time

: 10,4 g/dL
: 9.600/L
: 213.000/ L
: 2
: 6

2. Radiography
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

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.
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.

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.

Penetrating trauma

Trauma from surgical instrumentation

Retained foreign bodies

Congenital deformities : branchial cleft cysts and fistulae

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.
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).

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.
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.

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.
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.


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.