1. No category

INFECTIONS OF THE DEEP
SPACES OF THE NECK
DEEP NECK SPACES AND
INFECTIONS
• Anatomy of the Cervical Fascia
• Anatomy of the Deep Neck Spaces
• Deep Neck Space Infections
CERVICAL FASCIA
• Superficial fascia
• Deep fascia
Superficial layer
Middle layer
Deep layer
…This division… must be considered arbitrary and created by man rather
than nature in order to convert an anatomical thought into a verbal picture…
Levitt, 1968
DEEP CERVICAL FASCIA
Superficial layer of the deep cervical fascia
“the enveloping layer”
Muscles
Sternocleidomastoid
Trapezius
Glands
Submandibular
Parotid
Spaces
Subvaginal space
Suprasternal space of Burns
DEEP CERVICAL FASCIA
Middle layer of the deep cervical fascia
Muscular Division
Infrahyoid Strap Muscles
Visceral Division
Pharynx, Larynx,
Esophagus, Trachea,
Thyroid
Buccopharyngeal Fascia
DEEP CERVICAL FASCIA
Deep Layer of Deep Cervical Fascia
Alar Layer
Posterior to visceral layer
of middle fascia
Anterior to prevertebral layer
Prevertebral Layer
Vertebral bodies
Deep muscles of the neck
SPECIAL FASCIAL SHEATH
Carotid Sheath
Formed by all three layers of deep fascia
Contains carotid artery, internal jugular vein, and
vagus nerve
Runs from the skull through the lateral pharyngeal
space into the chest
DEEP NECK SPACES
Described in relation to the hyoid
A. Entire length of the neck
B. Suprahyoid
1. Retropharyngeal Space
5. Submandibular Space
2. Danger Space
6. Lateral Pharyngeal Space
3. Prevertebral Space
7. Masticator/Temporal Space
4. Visceral Vascular Space
8. Parotid Space
9. Peritonsillar Space
C.
Infrahyoid
10. Anterior Visceral Space
Levitt, 1968
DEEP NECK SPACES
Entire Length of Neck:
1. Prevertebral Space
Anterior border is prevertebral
fascia, posterior border is vertebral
bodies and deep neck muscles.
Extends along entire length
of vertebral column.
Conteins very compact tissue
DEEP NECK SPACES
Entire Length of Neck:
2. Danger Space
Anterior border is alar layer
of deep fascia, posterior border
is prevertebral layer.
Extends from skull through
posterior mediastinum to
diaphragm.
Conteins very loose
areolar tissue offering
little resistance to the spread
of infection to the mediastinum
DEEP NECK SPACES
Entire Length of Neck:
3. Retropharyngeal
Space
Posterior to pharynx
and esophagus, anterior
to alar layer of deep fascia
Extends from skull base
to T1-T2
Two chains of nodes on
either side of the midline
DEEP NECK SPACES
Infrahyoid
3. Anterior Visceral
Space
Middle layer of deep fascia
Contains thyroid,
trachea, esophagus
Extends from thyroid
cartilage into superior
mediastinum
DEEP NECK SPACES
Suprahyoid:
4. Lateral Pharyngeal
Space
Superior: skull base
Inferior: hyoid
Prestyloid
Contains fat, connective
tissue, nodes
Poststyloid
Carotid sheath
Cranial nerves IX, X, XII
DEEP NECK SPACES
Suprahyoid:
5. Submandibular Space
Anterior/Lateral: mandible
Superior: oral mucosa
Inferior: superficial layer of deep fascia
Posterior/Inferior: hyoid
Supramylohyoid portion
Sublingual gland
Hypoglossal and lingual
nerves
Portion of Submandibular gland
Inframylohyoid portion
Submandibular gland
Wharton’s duct
Anterior bellies of digastrics
DEEP NECK SPACES
Suprahyoid:
6. Masticator and
Temporal Spaces
Bounded by the
superficial layer of deep
cervical fascia
Contains masseter, pterygoids,
temporalis, ramus and
posterior portions of the body
of mandible, inferior alveolar
vessels and nerves
DEEP NECK SPACES
Suprahyoid:
7. Parotid Space
Superficial layer
of deep fascia
Dense septa from
capsule into gland
Relationship
to parapharyngeal space
DEEP NECK SPACES
DEEP NECK SPACES
DEEP NECK SPACES
DEEP NECK SPACES
DEEP NECK SPACES
DEEP NECK SPACES
DEEP NECK SPACES
Network of patterns of infectious extension
Submandibular
Masticator
Temporal
Peritonsillar
Lateral
Pharyngeal
Parotid
Vascular
Danger
Retropharyngeal
Prevertebral
Mediastinum
Anterior
Visceral
CAUSES OF DEEP NECK INFECTIONS
(ENT Department, Treviso Regional Hospital)
Unknown
Pharyngitis
Sialadenitis
Dental
Lymphadenitis
Miscellaneous
0
151 cases (1991-2003)
10
20
30
40
50
60
AGE DISTRIBUTION
(ENT Department, Treviso Regional Hospital)
35
30
25
20
15
10
5
0
0-5
10-20
20-30
30-40
151 cases (1991-2003)
40-50
50-60
60-70
70-80
80-90
>90
CLINICAL PRESENTATION
(ENT Department, Treviso Regional Hospital)
FEVER
DYSPHAGIA
PHARYNGODYNIA
ODYNOPHAGIA
DYSPNEA
TRISMA
DYSPHONIA
OTALGIA
0
10
151 cases (1991-2003)
20
30
40
50
60
70
80
90
100
DISTRIBUTION OF CASES
(ENT Department, Treviso Regional Hospital)
Submandibular
Lateral pharyngeal
Ludwig's angina
Parotid/Masticatory
Retropharyngeal
0
10
151 cases (1991-2003)
20
30
40
50
60
DEEP NECK SPACE INFECTIONS
Origin and clinical presentation of infection
Retropharyngeal Infections
Pediatrics
Adults
Suppurative process in
retropharyngeal nodes from
nose, adenoids, nasopharynx
or sinuses infections
Trauma Instrumentation; extension from
adjoining deep neck space
Fever, irritability,
lymphadenopathy, torticollis,
poor oral intake, sore throat,
drooling
Pain, dysphagia, anorexia, snoring, nasal
obstruction, nasal regurgitation.
Dyspnea and respiratory distress
Unilateral posterior pharyngeal swelling (the buccopharyngeal fascia
is adherent to the alar fascia in the medline)
DEEP NECK SPACE INFECTIONS
Retropharyngeal Infections
Adult
Child
DEEP NECK SPACE INFECTIONS
Clinical Presentation and Origin of infection
Danger Space Infections
• Presentation and exam nearly identical to retropharyngeal
space infection but the infection spreads rapidly through
the loose areolar tissue within this space to the posterior
mediastinum
• Extension from retropharyngeal, prevertebral or lateral
pharyngeal space
DEEP NECK SPACE INFECTIONS
Clinical Presentation and Origin of infection
Prevertebral Space Infections
• Back, shoulder, neck pain made worse by deglutition
Dysphagia or dyspnea
Bulding mass in the midline of the pharynx
• Extension from retropharyngeal and danger spaces,
Pott’s abscess, iatrogenic trauma, osteomyelitis
DEEP NECK SPACE INFECTIONS
Prevertebral Space Infections
DEEP NECK SPACE INFECTIONS
Clinical Presentation and Origin of infection
Anterior Visceral Space
• Dysphagia, odynophagia, hoarseness, dyspnea
Edema of hypopharynx
Anterior neck edema with subcutaneous emphysema
• Extension from retropharyngeal, perforation of anterior
esophageal wall, foreign body, external trauma,
extension of infection in thyroid
DEEP NECK SPACE INFECTIONS
Anterior Visceral Space
DEEP NECK SPACE INFECTIONS
Clinical Presentation and Origin of infection
Visceral Vascular Space Infections
• Induration and tenderness deep to the SCM
Torticollis toward opposite side
Septicemia, spiking fevers
• Intravenous drug abuse,
extension from other deep neck spaces
DEEP NECK SPACE INFECTIONS
Visceral Vascular Space Infections:
Lemierre Syndrome
DEEP NECK SPACE INFECTIONS
Clinical Presentation and Origin of infection
Submandibular Space Infections
• Pain, drooling, dysphagia, neck stiffness
Anterior neck swelling, floor of mouth edema
• 70% have odontogenic origin
First molar: supramylohyoid space
Second and third molars: inframylohyoid space
Sialadenitis, lymphadenitis
Lacerations of the floor of mouth, mandible fractures
Tonsillar disease
Ludwig’s angina
DEEP NECK SPACE INFECTIONS
Particular Clinical Presentation
Ludwig’s angina (Morbus Strangolatorius)
Grodinsky’s criteria (1939):
1. A cellulitis, not an abscess of submandibular space
2. The cellulitis involves all the sublingual and bilateral submaxillary
spaces
3. The cellulitis produces a serosanguineous putrid infiltration
but very little or no frank pus
4. Fascia, muscle, connective tissue involvement, sparing glands
5. The cellulitis is spread by continuity and not by lymphatics
DEEP NECK SPACE INFECTIONS
Clinical Presentation
Ludwig’s angina
“Woody” hardness with well defined border.
Comparative slight inflammation of throat and absence of
infection in regional lymph nodes
“Hot potato” voice, drooling, tachypnea, dyspnea, stridor
Complications:
1. Spread along the styloglossus muscle back into the
parapharyngeal space
retropharyngeal space
superior mediastinum
2. Tongue displacement posteriorly and superiorly against the
palate with respiratory embarrassment (Morbus strangolatorius)
DEEP NECK SPACE INFECTIONS
Ludwig’s angina
DENTALSCAN
DENTALSCAN
DEEP NECK SPACE INFECTIONS
Clinical Presentation and Origin of infection
Lateral Pharyngeal Space Infections
• Sore throat, dysphagia, odynophagia, otalgia, trismus
Medial bulge of lateral pharyngeal wall
• Infection of pharynx, tonsil, adenoids, teeth,
parotid, mastoid (Bezold’s abscess), suppurative lymphadenitis,
extension from other deep neck spaces
DEEP NECK SPACE INFECTIONS
Lateral Pharyngeal Space Infections
DEEP NECK SPACE INFECTIONS
Clinical Presentation and Origin of infection
Parotid Space infections
• Pain, swelling of the angle of jaw, medial bulge
of posterior lateral pharyngeal wall,
• Parotitis, sialolithiasis, Sjogren’s syndrome
DEEP NECK SPACE INFECTIONS
Parotid Space infections
BACTERIOLOGY
1. Most abscesses contained mixed bacterial flora
Aerobes:
Streptococci a-hemolytic (Strept. viridans)
Staphylococci, Neisseria, Klebsiella, Haemophilus
(Decresed role of b-hemolytic Streptococci)
Anaerobes: Bacteroides, Peptostreptococcus
2. Anaerobes are understimated (>35%)
widespread antibiotic use prior to collection of cultures
poor sample collection techniques
fragility of anaerobes
3. Anaerobes product b-lactamase
BATTERIOLOGY
Gold Standard:
To initiate antibiotic treatment
after appropiate cultures are obtained
Empirical Treatment
BATTERIOLOGY
Empirical Treatment
First-line
Alternatives
Clindamycin 600-900mg tid
(+/- cefuroxime 0.75-1.5gr tid)
AMX/CL 1.5-3gr qid
or
or
Penicillin G
PIP/TZ 2.25gr qid - 4.5 gr tid
24 million units/day
+
Metronidazole 1gr bid
BATTERIOLOGY
Culture
Needle Aspiration
through intact skin or mucosal surface cleaned with antiseptic
Blood culture bottle
for aerobes
Blood culture bottle
for anaerobes
Sterile container for
Gram and
Ziehl-Nielsen Stain
BATTERIOLOGY
Two to Three Blood Culture
Blood culture bottle
for aerobes
Blood culture bottle
for anaerobes
DEEP NECK SPACE INFECTIONS
Diagnostic Studies
Radiographs of the chest
Lateral soft tissue radiographs
Ultrasonography
Contrast Enhanced CT
MRI
DEEP NECK SPACE INFECTIONS
Diagnostic Studies
Contrast Enhanced Computer Tomography
Intravenous contrast may help identify an abscess as a “rimenhancing lesion” with a low-density center.
A gas-fluid level or gas bubbles are also diagnostic of an
abscess
Intravenous contrast also helps delineate vascular structures
(e.g. trombosis of the jugular vein)
DEEP NECK SPACE INFECTIONS
MANAGEMENT
History + Physical examination
Culture, IV antibiotics, Airway control, Chest RX
cellulitis
CT
small abscess
needle aspiration
for culture e drainage
W&W
24-48h
complications?
improvement?
No
Yes
Continue AB
surgical incision
and drainage
large abscess