INFECTIONS OF THE DEEP SPACES OF THE NECK. Anatomy of the Cervical Fascia Anatomy of the Cervical...

INFECTIONS OF THE DEEP INFECTIONS OF THE DEEP

SPACES OF THE NECKSPACES OF THE NECK

• Anatomy of the Cervical FasciaAnatomy of the Cervical Fascia

• Anatomy of the Deep Neck SpacesAnatomy of the Deep Neck Spaces

• Deep Neck Space InfectionsDeep Neck Space Infections

DEEP NECK SPACES AND DEEP NECK SPACES AND

INFECTIONSINFECTIONS

• Superficial fasciaSuperficial fascia

• DeepDeep fasciafascia

Superficial layerSuperficial layer

Middle layer Middle layer

Deep layerDeep layer

CERVICAL FASCIACERVICAL FASCIA

…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

Superficial layer of the deep cervical fasciaSuperficial layer of the deep cervical fascia

““the enveloping layer”the enveloping layer”

MusclesMuscles

SternocleidomastoidSternocleidomastoid

TrapeziusTrapezius

GlandsGlands

SubmandibularSubmandibular

ParotidParotid

SpacesSpaces

Subvaginal space Subvaginal space

Suprasternal space of BurnsSuprasternal space of Burns

DEEP CERVICAL FASCIADEEP CERVICAL FASCIA

Middle layer of the deep cervical fasciaMiddle layer of the deep cervical fascia

Muscular DivisionMuscular Division

Infrahyoid Strap MusclesInfrahyoid Strap Muscles

Visceral DivisionVisceral Division

Pharynx, Larynx,Pharynx, Larynx,

Esophagus, Trachea,Esophagus, Trachea,

ThyroidThyroid

Buccopharyngeal FasciaBuccopharyngeal Fascia


Deep Layer of Deep Cervical FasciaDeep Layer of Deep Cervical Fascia

Alar LayerAlar Layer

Posterior to visceral layer Posterior to visceral layer

of middle fasciaof middle fascia

Anterior to prevertebral layerAnterior to prevertebral layer

Prevertebral LayerPrevertebral Layer

Vertebral bodiesVertebral bodies

Deep muscles of the neckDeep muscles of the neck


Carotid SheathCarotid Sheath

Formed by all three layers of deep fasciaFormed by all three layers of deep fascia

Contains carotid artery, internal jugular vein, and Contains carotid artery, internal jugular vein, and vagus nervevagus nerve

Runs from the skull through the lateral pharyngeal Runs from the skull through the lateral pharyngeal space into the chestspace into the chest

SPECIAL FASCIAL SHEATHSPECIAL FASCIAL SHEATH

A. Entire length of the neck

1. Retropharyngeal Space

2. Danger Space

3. Prevertebral Space

4. Visceral Vascular Space

Described in relation to the hyoid

B. Suprahyoid

5. Submandibular Space

6. Lateral Pharyngeal Space

7. Masticator/Temporal Space

8. Parotid Space

9. Peritonsillar Space

C. Infrahyoid

10. Anterior Visceral Space

Levitt, 1968

DEEP NECK SPACESDEEP NECK SPACES

Entire Length of Neck:Entire Length of Neck:

1. Prevertebral Space1. Prevertebral Space

Anterior border is prevertebral Anterior border is prevertebral

fascia, posterior border is vertebral fascia, posterior border is vertebral

bodies and deep neck muscles.bodies and deep neck muscles.

Extends along entire length Extends along entire length

of vertebral column.of vertebral column.

Conteins very compact tissueConteins very compact tissue


Entire Length of Neck:Entire Length of Neck:

2. Danger Space2. Danger Space

Anterior border is alar layer Anterior border is alar layer

of deep fascia, posterior border of deep fascia, posterior border

is prevertebral layer.is prevertebral layer.

Extends from skull throughExtends from skull through

posterior mediastinum to posterior mediastinum to

diaphragm.diaphragm.

Conteins very loose Conteins very loose

areolar tissue offeringareolar tissue offering

little resistance to the spreadlittle resistance to the spread

of infection to the mediastinumof infection to the mediastinum


Entire Length of Neck:

3. Retropharyngeal 3. Retropharyngeal

SpaceSpace

Posterior to pharynxPosterior to pharynx

and esophagus, anterior and esophagus, anterior

to alar layer of deep fasciato alar layer of deep fascia

Extends from skull base Extends from skull base

to T1-T2to T1-T2

Two chains of nodes on Two chains of nodes on

either side of the midlineeither side of the midline


InfrahyoidInfrahyoid

3. Anterior Visceral 3. Anterior Visceral

SpaceSpaceMiddle layer of deep fasciaMiddle layer of deep fascia

Contains thyroid,Contains thyroid,

trachea, esophagustrachea, esophagus

Extends from thyroidExtends from thyroid

cartilage into superiorcartilage into superior

mediastinummediastinum


Suprahyoid:Suprahyoid:

4. Lateral Pharyngeal 4. Lateral Pharyngeal

SpaceSpaceSuperior: Superior: skull baseskull base

Inferior: Inferior: hyoidhyoid


PrestyloidPrestyloid

Contains fat, connectiveContains fat, connective

tissue, nodestissue, nodes

PoststyloidPoststyloid

Carotid sheathCarotid sheath

Cranial nerves IX, X, XIICranial nerves IX, X, XII

Suprahyoid: Suprahyoid:

5. Submandibular Space5. Submandibular SpaceAnterior/Lateral: Anterior/Lateral: mandiblemandible

Superior: Superior: oral mucosaoral mucosa

Inferior: Inferior: superficial layer of deep fasciasuperficial layer of deep fascia

Posterior/Inferior: Posterior/Inferior: hyoidhyoid


Supramylohyoid portionSupramylohyoid portion

Sublingual glandSublingual gland

Hypoglossal and lingualHypoglossal and lingual

nervesnerves

Portion of Submandibular glandPortion of Submandibular gland

Inframylohyoid portionInframylohyoid portion

Submandibular gland Submandibular gland

Wharton’s ductWharton’s duct

Anterior bellies of digastricsAnterior bellies of digastrics


6. Masticator and 6. Masticator and

Temporal SpacesTemporal SpacesBounded by theBounded by the

superficial layer of deepsuperficial layer of deep

cervical fasciacervical fascia

Contains masseter, pterygoids,Contains masseter, pterygoids,

temporalis, ramus and temporalis, ramus and

posterior portions of the bodyposterior portions of the body

of mandible, inferior alveolar of mandible, inferior alveolar

vessels and nervesvessels and nerves



7. Parotid Space7. Parotid Space

Superficial layer Superficial layer

of deep fasciaof deep fascia

Dense septa from Dense septa from

capsule into glandcapsule into gland

Relationship Relationship

to parapharyngeal spaceto parapharyngeal space


Network of patterns of infectious extensionNetwork of patterns of infectious extension

MasticatorMasticator

LateralLateral

PharyngealPharyngeal

DangerDanger

MediastinumMediastinum

TemporalTemporal

ParotidParotid

RetropharyngealRetropharyngeal

SubmandibularSubmandibular

PeritonsillarPeritonsillar

VascularVascular

Anterior Anterior VisceralVisceral

PrevertebralPrevertebral


CAUSES OF DEEP NECK INFECTIONSCAUSES OF DEEP NECK INFECTIONS(ENT Department, Treviso Regional Hospital)(ENT Department, Treviso Regional Hospital)

0 10 20 30 40 50 60

Miscellaneous

Lymphadenitis

Dental

Sialadenitis

Pharyngitis

Unknown

151 cases (1991-2003)

AGE DISTRIBUTIONAGE DISTRIBUTION(ENT Department, Treviso Regional Hospital)(ENT Department, Treviso Regional Hospital)

151 cases (1991-2003)

0

5

10

15

20

25

30

35

0-5 10-20 20-30 30-40 40-50 50-60 60-70 70-80 80-90 >90

CLINICAL PRESENTATIONCLINICAL PRESENTATION(ENT Department, Treviso Regional Hospital)(ENT Department, Treviso Regional Hospital)

151 cases (1991-2003)

0 10 20 30 40 50 60 70 80 90 100

OTALGIA

DYSPHONIA

TRISMA

DYSPNEA

ODYNOPHAGIA

PHARYNGODYNIA

DYSPHAGIA

FEVER

DISTRIBUTION OF CASESDISTRIBUTION OF CASES(ENT Department, Treviso Regional Hospital)(ENT Department, Treviso Regional Hospital)

151 cases (1991-2003)

0 10 20 30 40 50 60

Retropharyngeal

Parotid/Masticatory

Ludwig's angina

Lateral pharyngeal

Submandibular

DEEP NECK SPACE INFECTIONSDEEP NECK SPACE INFECTIONS

PediatricsPediatrics

Suppurative process in Suppurative process in retropharyngeal nodes from retropharyngeal nodes from

nose, adenoids, nasopharynx nose, adenoids, nasopharynx or sinuses infectionsor sinuses infections

Fever, irritability, Fever, irritability, lymphadenopathy, torticollis, lymphadenopathy, torticollis, poor oral intake, sore throat, poor oral intake, sore throat,

droolingdrooling

AdultsAdults

Trauma Instrumentation; extension from Trauma Instrumentation; extension from adjoining deep neck spaceadjoining deep neck space

Pain, dysphagia, anorexia, snoring, nasal Pain, dysphagia, anorexia, snoring, nasal obstruction, nasal regurgitation. obstruction, nasal regurgitation.

Origin and clinical presentation of infectionOrigin and clinical presentation of infection

Retropharyngeal InfectionsRetropharyngeal Infections

Dyspnea and respiratory distressDyspnea and respiratory distress

UnilateralUnilateral posterior pharyngeal swelling posterior pharyngeal swelling (the buccopharyngeal fascia (the buccopharyngeal fascia is adherent to the alar fascia in the medline)is adherent to the alar fascia in the medline)


Retropharyngeal InfectionsRetropharyngeal Infections

AdultAdult ChildChild


Clinical Presentation and Origin of infectionClinical Presentation and Origin of infection

Danger Space InfectionsDanger Space Infections

• Presentation and exam nearly identical to retropharyngeal Presentation and exam nearly identical to retropharyngeal

space infection but the infection spreads rapidly through space infection but the infection spreads rapidly through

the loose areolar tissue within this space to the posteriorthe loose areolar tissue within this space to the posterior

mediastinummediastinum

• Extension from retropharyngeal, prevertebral or lateral Extension from retropharyngeal, prevertebral or lateral

pharyngeal spacepharyngeal space


• Back, shoulder, neck pain made worse by deglutitionBack, shoulder, neck pain made worse by deglutition

Dysphagia or dyspneaDysphagia or dyspnea

Bulding mass in the Bulding mass in the midlinemidline of the pharynx of the pharynx

• Extension from retropharyngeal and danger spaces,Extension from retropharyngeal and danger spaces,

Pott’s abscess, iatrogenic trauma, osteomyelitisPott’s abscess, iatrogenic trauma, osteomyelitis


Prevertebral Space InfectionsPrevertebral Space Infections


Prevertebral Space InfectionsPrevertebral Space Infections



Anterior Visceral SpaceAnterior Visceral Space

• Dysphagia, odynophagia, hoarseness, dyspneaDysphagia, odynophagia, hoarseness, dyspnea

Edema of hypopharynxEdema of hypopharynx

Anterior neck edema with subcutaneous emphysemaAnterior neck edema with subcutaneous emphysema

• Extension from retropharyngeal, perforation of anterior Extension from retropharyngeal, perforation of anterior

esophageal wall, foreign body, external trauma, esophageal wall, foreign body, external trauma,

extension of infection in thyroidextension of infection in thyroid


Anterior Visceral SpaceAnterior Visceral Space


• Induration and tenderness deep to the SCMInduration and tenderness deep to the SCM

Torticollis toward opposite sideTorticollis toward opposite side

Septicemia, spiking feversSepticemia, spiking fevers

• Intravenous drug abuse, Intravenous drug abuse,

extension from other deep neck spacesextension from other deep neck spaces


Visceral Vascular Space Infections Visceral Vascular Space Infections


Visceral Vascular Space Infections:Visceral Vascular Space Infections:Lemierre Syndrome Lemierre Syndrome


• Pain, drooling, dysphagia, neck stiffnessPain, drooling, dysphagia, neck stiffness

Anterior neck swelling, floor of mouth edemaAnterior neck swelling, floor of mouth edema

• 70% have odontogenic origin70% have odontogenic origin

First molar: First molar: supramylohyoid spacespace

Second and third molars: Second and third molars: inframylohyoid space space

Sialadenitis, lymphadenitisSialadenitis, lymphadenitis

Lacerations of the floor of mouth, mandible fracturesLacerations of the floor of mouth, mandible fractures

Tonsillar diseaseTonsillar disease

Ludwig’s anginaLudwig’s angina


Submandibular Space InfectionsSubmandibular Space Infections


Particular Clinical PresentationParticular Clinical Presentation

Ludwig’s anginaLudwig’s angina (Morbus Strangolatorius)(Morbus Strangolatorius)

Grodinsky’s criteria (1939):

1.1. 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


Clinical PresentationClinical Presentation


““Woody” hardness with well defined border. Woody” hardness with well defined border.

Comparative slight inflammation of throat and absence of Comparative slight inflammation of throat and absence of infection in regional lymph nodesinfection in regional lymph nodes

““Hot potato” voice, drooling, tachypnea, dyspnea, stridorHot potato” voice, drooling, tachypnea, dyspnea, stridor

Complications:Complications:

1. Spread along the styloglossus muscle back into the 1. Spread along the styloglossus muscle back into the parapharyngeal spaceparapharyngeal space retropharyngeal space retropharyngeal space superior mediastinum superior mediastinum

2. Tongue displacement posteriorly and superiorly against the 2. Tongue displacement posteriorly and superiorly against the palate with respiratory embarrassment palate with respiratory embarrassment (Morbus strangolatorius)(Morbus strangolatorius)

DENTALSCANDENTALSCAN

DENTALSCAN DENTALSCAN


• Sore throat, dysphagia, odynophagia, otalgia, trismus Sore throat, dysphagia, odynophagia, otalgia, trismus

Medial bulge of lateral pharyngeal wallMedial bulge of lateral pharyngeal wall

• Infection of pharynx, tonsil, adenoids, teeth,Infection of pharynx, tonsil, adenoids, teeth,

parotid, mastoid (parotid, mastoid (Bezold’s abscessBezold’s abscess), suppurative lymphadenitis,), suppurative lymphadenitis,

extension from other deep neck spacesextension from other deep neck spaces


Lateral Pharyngeal Space Infections Lateral Pharyngeal Space Infections


Lateral Pharyngeal Space Infections Lateral Pharyngeal Space Infections



Parotid Space infectionsParotid Space infections

• Pain, swelling of the angle of jaw, medial bulge Pain, swelling of the angle of jaw, medial bulge

of posterior lateral pharyngeal wall, of posterior lateral pharyngeal wall,

• Parotitis, sialolithiasis, Sjogren’s syndromeParotitis, sialolithiasis, Sjogren’s syndrome


Parotid Space infectionsParotid Space infections

1.1. Most abscesses contained mixed bacterial flora Most abscesses contained mixed bacterial flora

Aerobes: Aerobes: Streptococci Streptococci -hemolytic (Strept. viridans)-hemolytic (Strept. viridans)

Staphylococci, Neisseria, Klebsiella, HaemophilusStaphylococci, Neisseria, Klebsiella, Haemophilus

(Decresed role of (Decresed role of -hemolytic -hemolytic Streptococci)Streptococci)

Anaerobes:Anaerobes: Bacteroides, Peptostreptococcus Bacteroides, Peptostreptococcus

2.2. Anaerobes are understimated (>35%)Anaerobes are understimated (>35%)

widespread antibiotic use prior to collection of cultureswidespread antibiotic use prior to collection of cultures

poor sample collection techniquespoor sample collection techniques

fragility of anaerobesfragility of anaerobes

3.3. Anaerobes product Anaerobes product -lactamase-lactamase

BACTERIOLOGYBACTERIOLOGY

Gold Standard:Gold Standard:

To initiate antibiotic treatment To initiate antibiotic treatment

after appropiate cultures are obtainedafter appropiate cultures are obtained

BATTERIOLOGYBATTERIOLOGY

Empirical TreatmentEmpirical Treatment


Empirical TreatmentEmpirical Treatment

First-lineFirst-line

Clindamycin 600-900mg tidClindamycin 600-900mg tid

(+/- cefuroxime 0.75-1.5gr tid)(+/- cefuroxime 0.75-1.5gr tid)

oror

Penicillin G Penicillin G

24 million units/day 24 million units/day

++

Metronidazole 1gr bidMetronidazole 1gr bid

AlternativesAlternatives

AMX/CL 1.5-3gr qidAMX/CL 1.5-3gr qid

oror

PIP/TZ 2.25gr qid - 4.5 gr tid PIP/TZ 2.25gr qid - 4.5 gr tid

BATTERIOLOGYBATTERIOLOGY CultureCulture

Needle Aspiration Needle Aspiration

through intact skin or mucosal surface cleaned with antiseptic 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


Two to Three Blood CultureTwo to Three Blood Culture

Blood culture bottle for aerobes

Blood culture bottle for anaerobes


Diagnostic StudiesDiagnostic Studies

Radiographs of the chestRadiographs of the chest

Lateral soft tissue radiographsLateral soft tissue radiographs

UltrasonographyUltrasonography

Contrast Enhanced CTContrast Enhanced CT

MRI MRI


Diagnostic StudiesDiagnostic Studies

Contrast Enhanced Computer TomographyContrast Enhanced Computer Tomography

Intravenous contrast may help identify an abscess as a “rim-Intravenous contrast may help identify an abscess as a “rim-enhancing lesion” with a low-density center.enhancing lesion” with a low-density center.

A gas-fluid level or gas bubbles are also diagnostic of an A gas-fluid level or gas bubbles are also diagnostic of an abscessabscess

Intravenous contrast also helps delineate vascular structures Intravenous contrast also helps delineate vascular structures (e.g. trombosis of the jugular vein)(e.g. trombosis of the jugular vein)

MANAGEMENTMANAGEMENT

History + Physical examination

Culture, IV antibiotics, Airway control, Chest RX

CTcellulitis

small abscess

large abscess

needle aspirationfor culture e drainage

surgical incisionand drainage

W&W24-48h

improvement?

Continue AB

YesNo

complications?

INFECTIONS OF THE DEEP SPACES OF THE NECK. Anatomy of the Cervical Fascia Anatomy of the Cervical...

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Transcript of INFECTIONS OF THE DEEP SPACES OF THE NECK. Anatomy of the Cervical Fascia Anatomy of the Cervical...