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 Entire length of the neck 1. Retropharyngeal Space 2. Danger Space 3. Prevertebral Space 4. Visceral Vascular Space Suprahyoid 5. Submandibular Space 6. Lateral Pharyngeal Space 7. Masticator/Temporal Space 8. Parotid Space 9. Peritonsillar Space 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

Network of patterns of infectious extension DEEP NECK SPACES Network of patterns of infectious extension Submandibular Masticator Temporal Peritonsillar Lateral Pharyngeal Parotid Vascular Retropharyngeal Danger Prevertebral Anterior Visceral Mediastinum

CAUSES OF DEEP NECK INFECTIONS (ENT Department, Treviso Regional Hospital) 151 cases (1991-2003)

AGE DISTRIBUTION (ENT Department, Treviso Regional Hospital) 151 cases (1991-2003)

CLINICAL PRESENTATION (ENT Department, Treviso Regional Hospital) 151 cases (1991-2003)

DISTRIBUTION OF CASES (ENT Department, Treviso Regional Hospital)

DEEP NECK SPACE INFECTIONS Origin and clinical presentation of infection Retropharyngeal Infections Pediatrics Suppurative process in retropharyngeal nodes from nose, adenoids, nasopharynx or sinuses infections Fever, irritability, lymphadenopathy, torticollis, poor oral intake, sore throat, drooling Adults Trauma Instrumentation; extension from adjoining deep neck space 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 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 Anaerobes are understimated (>35%) widespread antibiotic use prior to collection of cultures poor sample collection techniques fragility of anaerobes Anaerobes product b-lactamase

BATTERIOLOGY Gold Standard: Empirical Treatment To initiate antibiotic treatment after appropiate cultures are obtained Empirical Treatment

(+/- cefuroxime 0.75-1.5gr tid) BATTERIOLOGY Empirical Treatment First-line Clindamycin 600-900mg tid (+/- cefuroxime 0.75-1.5gr tid) or Penicillin G 24 million units/day + Metronidazole 1gr bid Alternatives AMX/CL 1.5-3gr qid or PIP/TZ 2.25gr qid - 4.5 gr tid

through intact skin or mucosal surface cleaned with antiseptic 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 “rim-enhancing 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

History + Physical examination MANAGEMENT History + Physical examination Culture, IV antibiotics, Airway control, Chest RX cellulitis CT large abscess small abscess W&W 24-48h needle aspiration for culture e drainage improvement? complications? No Yes surgical incision and drainage Continue AB