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Deep Neck Space Infections
Jeffrey Buyten, MD
Faculty Advisor: Francis B. Quinn, Jr., MD
The University of Texas Medical Branch
Department of Otolaryngology
Grand Rounds Presentation
October 5, 2005
Outline
Anatomy
Fascial planes
Spaces
Epidemiology
Etiology
Clinical presentation
Imaging
Bacteriology
Therapy
Medical
Surgical
Complications
Mediastinitis
ανατομία
Cervical Fascia
Superficial Layer
Deep Layer Subdivisions not
histologically separate
Superficial Enveloping layer
Investing layer
Middle Visceral fascia
Prethyroid fascia
Pretracheal fascia
Deep
Superficial Layer
Superior attachment – zygomatic process
Inferior attachment – thorax, axilla.
Similar to subcutaneous tissue
Ensheathes platysma and muscles of facial expression
Superficial Layer of the Deep Cervical Fascia
Completely surrounds the neck.
Arises from spinous processes.
Superior border – nuchal line, skull base, zygoma, mandible.
Inferior border – chest and axilla
Splits at mandible and covers the masseter laterally and the medial surface of the medial pterygoid.
Envelopes
SCM
Trapezius
Submandibular
Parotid
Forms floor of submandibular space
Superficial Layer of the Deep Cervical Fascia
Middle Layer of the Deep Cervical Fascia
Muscular Division Superior border – hyoid and
thyroid cartilage Inferior border – sternum, clavicle
and scapula Envelopes infrahyoid strap
muscles
Visceral Division Superior border
Anterior – hyoid and thyroid cartilage Posterior – skull base
Inferior border – continuous with fibrous pericardium in the upper mediastinum.
Buccopharyngeal fascia Name for portion that covers the
pharyngeal constrictors and buccinator.
Envelopes Thyroid Trachea Esophagus Pharynx Larynx
Middle Layer of the Deep Cervical Fascia
Deep Layer of Deep Cervical Fascia
Arises from spinous processes and ligamentum nuchae.
Splits into two layers at the transverse processes: Alar layer
Superior border – skull base Inferior border – upper mediastinum at T1-T2
Prevertebral layer Superior border – skull base Inferior border – coccyx Envelopes vertebral bodies and deep muscles of the neck. Extends laterally as the axillary sheath.
Deep Layer of Deep Cervical Fascia
Carotid Sheath
Formed by all three layers of deep fascia
Anatomically separate from all layers.
Contains carotid artery, internal jugular vein, and vagus nerve
“Lincoln’s Highway”
Travels through pharyngomaxillary space.
Extends from skull base to thorax.
Deep Neck Spaces
Described in relation to the hyoid. Entire length of neck
Superficial space Retropharyngeal Danger Prevertebral Vascular visceral
Suprahyoid Submandibular Pharyngomaxillary (Parapharyngeal) Parotid Peritonsillar Temporal Masticator
Infrahyoid Anterior visceral
Superficial Space
Entire length of neck
Surrounds platysma
Contains areolar tissue, nodes, nerves and vessels
Subplatysmal Flaps
Involved with cellulitis and superficial abscesses
Treat with incision along Langer’s lines, drainage and antibiotics
Retropharyngeal Space
Entire length of neck.
Anterior border - pharynx and esophagus (buccopharyngeal fascia)
Posterior border - alar layer of deep fascia
Superior border - skull base Inferior border – superior
mediastinum Combines with buccopharyngeal
fascia at level of T1-T2
Midline raphe connects superior
constrictor to the deep layer of deep cervical fascia.
Contains retropharyngeal nodes.
Space
Entire length of neck
Anterior border - alar layer of deep fascia
Posterior border - prevertebral layer
Extends from skull base to diaphragm
Contains loose areolar tissue.
Prevertebral Space
Entire length of neck
Anterior border - prevertebral fascia
Posterior border - vertebral bodies and deep neck muscles
Lateral border – transverse processes
Extends along entire length of vertebral column
Visceral Vascular Space
Entire length of neck
Carotid Sheath
“Lincoln Highway”
Lymphatic vessels can receive drainage from most of lymphatic vessels in head and neck.
Submandibular Space
Suprahyoid
Superior – oral mucosa Inferior - superficial layer
of deep fascia Anterior border –
mandible Lateral border - mandible Posterior - hyoid and
base of tongue musculature
2 compartments Sublingual space
Areolar tissue Hypoglossal and lingual
nerves Sublingual gland Wharton’s duct
Submaxillary space Anterior bellies of digastrics
Submental compartment Submaxillary
compartments
Submandibular gland
Submandibular Space
Pharyngomaxillary space
Suprahyoid
aka – Parapharyngeal space
Superior—skull base Inferior—hyoid Anterior—ptyergomandibular
raphe Posterior—prevertebral fascia Medial—buccopharyngeal
fascia Lateral—superficial layer of
deep fascia
Pharyngomaxillary space
Prestyloid Muscular compartment Medial—tonsillar fossa Lateral—medial pterygoid Contains fat, connective
tissue, nodes
Poststyloid Neurovascular compartment Carotid sheath Cranial nerves IX, X, XI, XII Sympathetic chain
Stylopharyngeal aponeurosis of Zuckerkandel and Testut Alar, buccopharyngeal and
stylomuscular fascia. Prevents infectious spread
from anterior to posterior.
Pharyngomaxillary Space
Communicates with several deep neck spaces. Parotid
Masticator
Peritonsillar
Submandibular
Retropharyngeal
Peritonsillar Space
Suprahyoid
Medial—capsule of palatine tonsil
Lateral—superior pharyngeal constrictor
Superior—anterior tonsil pillar
Inferior—posterior tonsil pillar
Masticator and Temporal Spaces Suprahyoid
Formed by superficial layer of deep
cervical fascia
Masticator space Antero-lateral to pharyngomaxillary
space. Contains
Masseter Pterygoids Body and ramus of the mandible Inferior alveolar nerves and vessels Tendon of the temporalis muscle
Temporal space
Continuous with masticator space. Lateral border – temporalis fascia Medial border – periosteum of
temporal bone Superficial and deep spaces divided
by temporalis muscle
Parotid Space Suprahyoid
Superficial layer of deep fascia Dense septa from capsule into
gland
Direct communication to parapharyngeal space
Contains External carotid artery
Posterior facial vein
Facial nerve
Lymph nodes
Anterior Visceral Space
Infrahyoid
aka – pretracheal space
Enclosed by visceral division of middle layer of deep fascia
Contains thyroid Surrounds trachea
Superior border - thyroid cartilage
Inferior border - anterior superior mediastinum down to the arch of the aorta.
Posterior border – anterior wall of esophagus
Communicates laterally with the retropharyngeal space below the thyroid gland.
Epidemiology
All patients
Avg age b/w 40-50.
More predominant in patients over 50 years.
Pediatric patrents
Infants to teens.
Male predilection in some case series.
Most common age group: 3-5 years.
Etiology Odontogenic
Tonsillitis
IV drug injection
Trauma
Foreign body
Sialoadenitis
Parotitis
Osteomyelitis
Epiglottitis
URI
Iatrogenic
Congenital anomalies
Idiopathic
Clinical presentation Most common symptoms
Sore throat (72%) Odynophagia (63%)
Most common symptoms (exluding peritonsillar abscesses)
Neck swelling (70%) Neck Pain (63%)
Pediatric
Fever Decreased PO Odynophagia Malaise Torticollis Neck pain Otalgia HA Trismus Neck swelling Vocal quality change Worsening of snoring, sleep apnea
Imaging
Lateral neck plain film Screening exam No benefit in pts with
DNI based on strong clinical suspicion.
Normal: 7mm at C-2 14mm at C-6 for kids 22mm at C-6 for adults
Technique dependent Extension Inspiration
Sensitivity 83%, compared to CT 100%
Imaging CT with contrast
Pros Widely available Faster (5-15 minutes) Abscess vs cellulitis Less expensive
Cons Contrast Radiation Uniplanar Dental artifacts
MRI Pros
MRI superior to CT in initial assessment
More precise identification of space involvement (multiplanar)
Better detection of underlying lesion
Less dental artifact Better for floor of mouth No radiation Non iodine contrast
Cons Cost Pt cooperation Slower (19 to 35 minutes)
Imaging
Regular cavity wall with ring enhancement (RE)
Sensitivity - 89%
Specificity - 0%
Irregular wall (scalloped)
Sensitivity - 64%
Specificity - 82%
PPV - 94%
Modified and combined data from 738 patients (1, 2, 3, 4, 5, 6, 7).
Bacteriology Aerobic Anaerobic
G (+) n % G (-) n % n %
Total 645 87.40 Total 137 18.56 Total 201 27.24
Strep sp. 229 31.03 Klebsiella sp. 90 12.20 Peptostreptococcus 43 5.83
Staph sp. 112 15.18 Neisseria sp. 20 2.71 Bacteroides sp. 50 6.78
B-hemolytic Strep 80 10.84 Acinebacter sp. 7 0.95 Unidentified 46 6.23
Strep viridans 71 9.62 Enterobacter sp. 7 0.95 Bacteroides melaninogenicus 13 1.76
Staph aureus 57 7.72 Proteus sp. 4 0.54 Propionibacterium 9 1.22
Coagulase neg. Staph sp. 55 7.45 E coli 3 0.41 Provotella sp. 7 0.95
Strep pneum 13 1.76 Citrobacter sp 2 0.27 Fusobacterium 7 0.95
Enterococcus 10 1.36 M. Catarrhalis 2 0.27 Bacteroidies fragilis 6 0.81
Mycobacterium tub.* 10 1.36 Pseudomonas sp. 1 0.14 Eubacterium 6 0.81
Micrococcus 8 1.08 H. Parainfluenza 1 0.14 Peptococcus 6 0.81
Diptheroids 7 0.95 H influenzae 1 0.14 Veillonella parvula 5 0.68
Bacillus sp. 6 0.81 Salmonella sp. 1 0.14 Clostridium sp. 4 0.54
Actinomycosis israelii 3 0.41 Lactobacillus 4 0.54
Bifidobacterium sp. 3 0.41
Polymicrobial 181 24.53 Sterile 71 9.62
Antibiotic Therapy
Initial therapy Cover Gram positive cocci and anaerobes If pt is diabetic, should consider covering
gram negatives empirically. Unasyn, Clindamycin, 2nd generation
cephalosporin. PCN, gentamicin and flagyl - developing
nations.
IV abx alone (based on retro and
parapharyngeal infections) Patient stability and nature of lesion. Cellulitis/phlegmon by CT. Abscesses in clinically stable patient. If no clinical improvement in 24 - 48
hours proceed to surgical intervention.
Surgery
External drainage Landmarks
Tip of greater horn of hyoid Cricoid cartilage Styloid process SCM
Transoral drainage
Parapharyngeal, retropharyngeal abscesses
Great vessels lateral to abscess
Tonsillectomy for exposure
Needle aspiration
Complications
Airway obstruction Trach 10 – 20%
Ludwig’s angina - 75%
Mediastinitis – 2.7% UGI bleeding Sepsis Pneumonia IJV thrombosis Skin defect Vocal cord palsy Pleural effusion Hemorrhage
20 - 80% mortality
Multiple space involvement
Who gets complications?
Older pts Systemic dz
Immunodeficient pts HIV Myelodysplasia
Cirrhosis DM
Most common systemic Mbio – Klebsiella pneum. (56%) 33% with complications Higher mortality rate Prolonged hospital stay
20 days vs. 10 days
Descending Necrotizing Mediastinitis
Definition – mediastinal infection in which pathology originates in
fascial spaces of head and neck and extends down. Retropharyngeal and Danger Space – 71% Visceral vascular – 20% Anterior visceral – 7-8%
Criteria for diagnosis 1. Clinical manifestation of severe infection. 2. Demonstration of the characteristic imaging features of mediastinitis. 3. Features of necrotizing mediastinal infection at surgery.
1960-89 – 43 published cases Mortality rate 14-40%
Clinical Presentation
Symptoms
Respiratory difficulty
Tachycardia
Erythema/edema
Skin necrosis
Crepitus
Chest pain
Back pain
Shock
Important to have a low threshold for further workup
Mediastinitis Imaging
Plain films Widened mediastinum
(superiorly) Mediastinal emphysema Pleural effusions Changes appear late in the
disease.
CT neck and thorax.
Esophageal thickening Obliterated normal fat planes Air fluid levels Pleural effusions CT helps establish dx and
surgical plan
Treatment
IV antibiotics
Cervical drainage
Cervical abscesses
Superior mediastinal abscesses above T4 (tracheal bifurcation)
Transthoracic drainage
Abscesses below T4
Subxyphoid approach
Anterior mediastinal drainage
Thoracostomy tubes
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