Deep-neck-infection-051005.doc

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TITLE: Deep Neck Spaces and Infections

SOURCE: Grand Rounds Presentation, UTM, Dept! of Oto"ar#n$o"o$#

D%TE: Octo&er ', ())'

RESIDENT P*+SICI%N: effre# u#ten, MD

-%CULT+ P*+SICI%N: -rancis ! .uinn, r!, MD

SERIES EDITORS: -rancis ! .uinn, r!, MD and Matt/e0 1! R#an, MD

"This material was prepared by resident physicians in partial fulfillment of educationalrequirements established for the Postgraduate Training Program of the UTMB Department of

Otolaryngology/ead and !ec #urgery and was not intended for clinical use in its present form$

%t was prepared for the purpose of stimulating group discussion in a conference setting$ !owarranties either e&press or implied' are made with respect to its accuracy' completeness' or

timeliness$ The material does not necessarily reflect the current or past opinions of members of

the UTMB faculty and should not be used for purposes of diagnosis or treatment without

consulting appropriate literature sources and informed professional opinion$"

ANATOMY OF THE CERVICAL FASCIA

The nec can be di(ided into se(eral layers and potential spaces$ #ome anatomists ha(edi(ided the nec into (isceral and somatic portions$ Others ha(e di(ided the nec into triangles

in order to help organi)e the crowded and complicated anatomy$ *nowledge of the fascial layers

and the potential spaces of the nec are important to clinical practice because of the potentialcomplications that arise from spread of infection$

Despite the constant nature of human anatomy there ha(e been many permutations of thecer(ical fascial layers$ +ach anatomist that has charged themsel(es with describing the layers

has used different terminology which has ultimately muddled an already complicated sub,ect$ %t

seems that each time you learn the nomenclature- you encounter yet another set of synonyms$.e(itt summari)es it best when he said %t is essentially the terminology which is confusing' not

the basic anatomy$0 12

The ma,ority of otolaryngology papers addressing the sub,ect ha(e accepted the

nomenclature re(iewed by Paonessa et al$ Papers from other surgical and radiology ,ournals

continue to use different terms' so there is no uni(ersally accepted standard across differentfields$

There are two main di(isions of the cer(ical fascia3 the superficial layer and the deep

layer$ The superficial cer(ical fascia does not ha(e any subdi(isions$ The deep layer has

multiple subdi(isions$ 4ll three di(isions of the deep layer contribute to formation of the carotidsheath$

The superficial cer(ical fascia e&tends from the )ygoma and mimetic muscles of the facedown to the chest' shoulder and a&illa$ %t is similar to subcutaneous tissue and is di(ided into

two potential compartments by the platysma muscle$ 12

The superficial layer of the deep cer(ical fascia 5#.D678 surrounds the nec and

encloses two glands 5parotid and submandibular8' two muscles 5sternocleidomastoid and


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trape)ius8 and two spaces 5suprasternal space of Burns and #pace of the posterior triangle8 59ule

of Twos8$ %t is a sheet of fibrous tissue that attaches to the nuchal line' )ygoma' mandible andsull base superiorly$ %nferiorly it e&tends to the sternum and cla(icles laterally to the acromion

processes$ %t attaches to the body of the hyoid bone and e&tends to the mandible to form the

floor of the submandibular space$ 4s the fascia encounters the mandible' it splits into two

portions which co(er the masseter laterally and the pterygoids medially$ 12

The middle layer of the deep cer(ical fascia 5M.D678 is also referred to as the (isceralfascia because it encloses the aerodigesti(e tract and thyroid gland$ #uperiorly it e&tends from

the sull base posteriorly and the hyoid bone anteriorly$ %nferiorly the fascia is continuous with

the fibrous pericardium in the upper mediastinum$ The posterior portion of the fascia is alsocalled the buccopharyngeal fascia$ The fascia has two di(isions3 the muscular di(ision which

encloses the infrahyoid strap muscles and the (isceral di(ision$ 12

The deep layer of the deep cer(ical fascia 5D.D678 has two di(isions3 the alar and the

pre(ertebral layer$ Both layers e&tend from the sull base superiorly but the alar layer fuses with

the M.D67 in the upper mediastinum at T1:T;$ The pre(ertebral layer e&tends down to thecoccy&$ The alar layer is only present in the anterior midline between the (ertebral trans(erse

processes$ The layers fuse then into one fascial layer that surrounds the deep nec musculature'(ertebral bodies' phrenic ner(es' and brachial ple&us$ %t also e&tends laterally and becomes thea&illary sheath$ 12

ANATOMY OF THE DEEP NECK SPACES

The potential spaces of the nec can be di(ided into groups in relation to the hyoid bone$There are si& suprahyoid spaces' one infrahyoid space and fi(e spaces that span the length of the

nec$

SP%CES SP%NNING T*E ENTIRE NEC2

The superficial space can be di(ided into two parts by the platysma muscle$ This space is

similar to subcutaneous tissue and contains lymphatic channels$ The deep portion contains the

e&ternal ,ugular (ain and lymph nodes$ 4bscesses that present in this space can be drained byincising along .anger


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processes of the (ertebral bodies$ 12

The (isceral (ascular space is the potential space within the carotid sheath$ %t e&tends

from the sull base to the mediastinum$ %t contains the carotid artery' internal ,ugular (ein and

(agus ner(e$ %t also recei(es lymphatic drainage from all the lymphatic (essels in the head andnec$ 12

SUPR%*+OID SP%CES

The submandibular space is bounded by the mandible anteriorly and laterally' the lingualmucosa superiorly' the hyoid postero:inferiorly and the superficial layer of the deep cer(ical

fascia inferiorly$ The mylohyoid muscle di(ides this space into a superior sublingual space and

an inferior submylohyoid space$ The sublingual space contains loose areolar tissue' thehypoglossal and lingual ner(es' the sublingual gland and ?harton


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surrounds the masseter laterally and the pterygoid muscles medially$ This space contains these

muscles as well as the body and ramus of the mandible' the inferior al(eolar ner(es and (esselsand the tendon of the temporalis muscle$ The masticator space is in direct communication with

the temporal space superiorly deep to the )ygoma$ This space is antero:lateral to the

pharyngoma&illary space$ 1' 12' 1@

The temporal space has as its lateral boundary the superficial layer of deep fascia as it

attaches to the )ygoma and temporal ridge and its medial boundary the periosteum of thetemporal bone$ %t is subdi(ided into superficial and deep spaces by the body of the temporalis

muscle$ This space contains the internal ma&illary artery and the mandibular ner(e$ 1' 12' 1@

IN-R%*+OID SP%CES

The anterior (isceral space is a potential space within the middle layer of deep cer(ical

fascia$ %t also referred to as the pretracheal space$ %t is continuous with the retropharyngeal

space laterally$ %t is bounded by the thyroid cartilage superiorly and the anterior superiormediastinum down to the aortic arch inferiorly$ Posteriorly it is limited by the anterior

esophageal wall$ %t contains the thyroid and parathyroid glands and surrounds the trachea$ 1' 12' 1@

DEEP NECK INFECTIONS (DNI)

PRESENT%TION

?hen considering both adult and pediatric patients' the a(erage age of patients presenting

with D!% is between C to E years$ #ome papers site a higher incidence in patients in their

twenties as well$ O(erall there is a predominance in patients o(er E$ 9e(iews from %ndia point

to a higher pre(alence in the lower socioeconomic groups mainly due to poor oral hygiene andlac of dental care$ %n pediatric patients' these infections can occur at any age$ The most

common age group is between three to fi(e years of age with a slight male predominance$

9etropharyngeal abscesses are more common in the pediatric population because of the presenceof lymph nodes that atrophy with age$ ;' F' C' E' G' 2' 1@

Patients with deep nec infections can present in a (ariety of ways$ uang et al$ found

that the two most common symptoms were sore throat and odynophagia$ ?hen disregarding all

patients with peritonsillar abscesses' the most common symptoms were nec swelling and nec

pain$ %n pediatric patients' the most common presenting symptoms are fe(er' decreased oralintae' odynophagia and malaise$ Depending on the location of the D!%' trismus may be present

but o(erall it was only present in up to ;H of patients in multiple re(iews$ Patients may present

in respiratory distress and may ha(e impending upper airway obstruction or concomitantpneumonia$ Dehydration from lac of oral intae and intolerance of their own secretions are also

common symptoms$ Other clinical signs include torticollis from #6M inflammation' nec painwith nec mo(ement' otalgia' headache' and (ocal quality changes$ Parents and spouses maynote worsening snoring and sleep apnea$ ;' F' C' E' G' 2' 1@

ETIOLOG+

?hen considering all deep nec infections' the most common etiology is probablypharyngitis or tonsillitis$ ?hen e&cluding peritonsillar abscesses' the most common etiology is

odontogenic infection$ These infections occur in patients who ha(e had recent dental e&tractions

and in patients in lower socioeconomic groups who ha(e no access to dental health care$ %n


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pediatric patients' these infections are usually a result of suppurati(e lymph node following

upper respiratory infections' pharyngitis' otitis media' and tonsillitis$ %n areas where intra(enousdrug abuse is pre(alent' these infections can result from contaminated in,ections into the ,ugular

(eins$ Traumatic in,ury to the pharyn& and nec' including iatrogenic trauma' is also a potential

source of infection$ Other less common causes include foreign bodies' sialoadenitis' parotitis'

osteomyelitis' and epiglottitis$ %n patients with recurrent deep nec infections' you should ha(e a

high suspicion for underlying congenital anomalies 5second branchial cleft cyst' first' third andfourth branchial cleft cysts' lymphangiomas' thyroglossal duct cysts and cer(ical thymic cysts8$ ;'F' C' E' G' 2' 1@

MICROIOLOG+

The a(ailable culture data for 2F> patients from se(eral re(iews were combined to mae

the following tables$ The most commonly isolated organisms in these infections are grampositi(e aerobes followed by anaerobes' gram negati(e aerobes and fungi$ Polymicrobial

infections are common 5;EH8 with some series indicating an incidence of up to GEH$ The

estimation of anaerobic infections may be low because of the difficulty in growing theseorganisms$ =ram negati(e aerobes were found in 1@H of patients$ uang et al found that EGH

of diabetic patients in their series grewKlebsiella pneumonia$ #terile pus was noted in @$GH ofpatients$ 7ungal species were isolated in less than 1H of patients$ 1' ;' F' C' E' G' 2

The most common gram positi(e aerobes were #treptococcal species followed by

#taphylococcal species$ Beta hemolytic streptococci were the predominant subgroup followedby Streptococcus viridansand Staphylococcus aureus$ The predominant gram negati(e aerobes

wereKlebsiellaspecies andNeisseriaspecies$ PeptostreptococcusandBacteroidesspecies were

the most common anaerobic isolates$ 1' ;' F' C' E' G' 2

4erobic

= 5I8 n H = 5:8 n H

Total GCE >2 Total 1F2 1@

#trep sp$ ;;@ F1 *lebsiella sp$ @ 1;$;

#taph sp$ 11; 1E$; !eisseria sp$ ; ;$21

B:hemolytic #trep > 1$> 4cinebacter sp$ 2 $@E

#trep (iridans 21 @$G; +nterobacter sp$ 2 $@E

#taph aureus E2 2$2; Proteus sp$ C $EC

6oagulase neg$ #taph sp$ EE 2$CE + coli F $C1

#trep pneum 1F 1$2G 6itrobacter sp ; $;2

+nterococcus 1 1$FG M$ 6atarrhalis ; $;2

Mycobacterium tub$J 1 1$FG Pseudomonas sp$ 1 $1C

Micrococcus > 1$> $ Parainfluen)a 1 $1CDiptheroids 2 $@E influen)ae 1 $1C

Bacillus sp$ G $>1 #almonella sp$ 1 $1C

4ctinomycosis israelii F $C1

Table 13 4erobic isolates- Modified and combined data from 2F> patients 51' ;' F' C' E' G' and 28

4naerobic n H

Total ;1 ;2$;C

Peptostreptococcus CF E$>F


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Bacteroides sp$ E G$2>

Unidentified CG G$;F

Bacteroidesmelaninogenicus 1F 1$2G

Propionibacterium @ 1$;;

Pro(otella sp$ 2 $@E

7usobacterium 2 $@EBacteroidies fragilis G $>1

+ubacterium G $>1

Peptococcus G $>1

Keillonella par(ula E $G>

6lostridium sp$ C $EC

.actobacillus C $EC

Bifidobacterium sp$ F $C1

Table ;3 4naerobic %solates3 Modified and combined data from 2F> patients 51' ;' F' C' E' G' and

28$

n H

Polymicrobial 1>1 ;E

#terile 21 @$G

Table F3 Polymicrobial and #terile 6ultures3 Modified and combined data from 2F> patients 51';' F' C' E' G' and 28$

TRE%TMENT

Patients with suspected deep nec infections should be started on antibiotic therapy$

Most patients are gi(en %K antibiotics targeting gram positi(e cocci and anaerobes$ Diabeticpatients should recei(e antibiotics that co(er gram negati(e aerobes as well$ 6ommon regimens

include Unasyn 54mpicillin / #ulbactam8' 6lindamycin or second generation cephalosporins lie

6efuro&ime$ %n the de(eloping world' Meher et al found that empiric therapy with penicillin'gentamycin and metronida)ole was an effecti(e therapy$ Once culture results can be obtained'

antibiotic therapy can be tailored to the organism in question$ Once the patient is able to tolerate

oral antibiotics then they are switched o(er$ There is no concensus on duration of oral antibiotic

therapy$ 1' ;' C' E' 1

Patients should undergo imaging studies to determine if there is an abscess of phlegmonpresent$ !agy et al found that lateral nec films were not useful in patients in which there was a

high suspicion of deep nec infection$ 6T of the nec with contrast is the most used imaging

modality because of its ability to delineate cellulites (ersus abscesses and also because it can be

used for surgical planning$ ?hen compared to M9%' 6T if faster' cheaper and more widelya(ailable but M9% decreases to&ic e&posure to radiation and iodine based contrast$ M9% is

superior in assessing the origin of infection and also has decreased interference from dental

artifacts$ 9oberson et al found that lesions with regular ca(ity walls and ring enhancement on6T with contrast were >@H sensiti(e but H specific in identifying abscess ca(ities$ %rregular

5scalloped8' ring enhancing lesions on 6T were GCH sensiti(e' >;H specific and had a positi(e

predicti(e (alue of @CH in identifying abscess ca(ities$ 1' ;' E' @' 11

#urgical therapy and approaches can be determined by e(aluating the 6T nec of the


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patient$ %n patients with definiti(e abscesses by 6T drainage was the usual treatment choice$

Patients with e(idence of cellulites or phlegmon by 6T but no definiti(e abscess' %K antibioticsalone ha(e been shown to be effecti(e$ Mc6lay et al showed that use of %K antibiotics alone in

pediatric patients with a definiti(e abscess by 6T scan was reported to be effecti(e in clinically

stable patients$ %n patients recei(ing %K antibiotics that show no clinical impro(ement 5febrile'

not tolerating po intae8 then repeat imaging and surgical drainage should be pursued$ +&ternal

approaches are widely used and transoral approaches ha(e been contro(ersial depending on thesite of the infection$ Transoral approaches ha(e been shown to be safe in patients with

retropharyngeal' pharyngoma&illary and pre(ertebral abscesses that are medial to the great(essels$ #ome patients may need a tonsillectomy to facilitate e&posure to the abscess$ .esions

that e&tend lateral to the great (essels should be approached e&ternally$ 7or e&ternal drainage'

incisions can be made anterior or posterior to the #6M and may be carried trans(ersely as asubma&illary or submental incision$ #ince the infection may distort normal anatomy' useful

landmars include the3 tip of greater horn of hyoid' cricoid cartilage' styloid process' and #6M$

9epeated needle aspiration is also used to drain these abscesses$ 1' ;' F' C' E' G' 2' 1

COMPLIC%TIONS

The incidence of complications from deep nec space infections has remarablydecreased since the ad(ent of antibiotic therapy$ Despite this' the potentially de(astatingoutcomes associated with these complications remind the physician to remain (igilant for their

signs$ 4irway obstruction and asphy&ia is a potential complication of any deep nec infection'

but has been most commonly associated with .udwigH$ This

can occur when infection in(ol(ing the carotid sheath leads to arterial wall weaening' erosion

and e(entual hemorrhage$ #alinger and Pearlman' in a re(iew of ;;2 cases of deep nec abscesscomplicated by hemorrhage' found that G;H of ruptures occur from the internal carotid artery'

;EH in(ol(e the e&ternal carotid and 1FH in(ol(e the common carotid$ %n their series' of the 2F

patients who were treated with artery ligation' GCH sur(i(ed$ 4rtery rupture may be heralded byrecurrent small bleeds from the ear' nose or mouth' the onset of shoc' a protracted clinical

course' and hematoma in the nearby tissue' orner


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MEDI%STINITIS

By definition descending necroti)ing mediastinitis is a mediastinal infection in which the

pathology originates in fascial spaces of head and nec and e&tends down$ The most commoncer(ical spaces that spread to the mediastinum are the retropharyngeal and danger space 521H8'

(isceral (ascular space 5;H8 and the anterior (isceral space 52:>H8$ +strera et al@$ The mortality rate ranges between 1C to CH indifferent re(iews$ 1;' 1F' 1C' 1E' 1G

6linically' these patients are usually diagnosed with a deep nec infection and are alreadyundergoing antibiotic therapy$ #ome reports of patients presenting to the emergency room with

this condition ha(e been reported as well$ #ymptoms include increased respiratory difficulty'tachycardia' chest pain' bac pain' erythema/edema of the nec and chest' crepitus and shoc$ %t

is important to ha(e a low threshold for further worup in patients with these symptoms$

Unstable patients should be mo(ed to an %6U setting and imaging studies and an +6= should be

obtained$ Plain chest films do not show changes until late in the course of the disease$ Patientswith mediastinitis will ha(e a widened mediastinum superiorly' mediastinal emphysema' and

pleural effusions$ 6T of the nec and thora& are the best modalities to determine if there is a

descending infection$ 7indings on 6T thora& include esophageal thicening' air fluid le(els'pleural effusions and obliterated normal fat planes$ The 6T thora& establishes the diagnosis and

aids in the surgical planning$ 1;' 1F' 1C' 1E' 1G

Treatment for descending necroti)ing mediastinitis should include some sort of drainage

procedure along with %K antibiotics$ 6onsultation with thoracic surgeons should be obtained$

4ccess to the superior mediastinum from a cer(ical incision is adequate for fluid collectionsabo(e the tracheal bifurcation 5TC8$ Transthoracic drainage should be performed for abscesses

that e&tend below TC$ 4bscesses in the anterior mediastinum may be approached by a

sub&yphoid incision$ Thoracostomy tubes should be placed for pleural effusions$ 1;' 1F' 1C' 1E' 1G


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BIBLIOGRAPHY

1$ #cott' B4' #tiernberg' 6M' Driscoll' BP$ Deep !ec #pace %nfections$ %n3 ead and

!ec #urgeryLOtolaryngology' Frd ed$' Bailey' B +d$ Philadelphia' .ippincott:9a(en

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spaces:;;:C$doc

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