Deep-Neck Spaces Infections

8/2/2019 Deep-Neck Spaces Infections

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Deep Neck Spaces and Infections

Elizabeth J. Rosen, MDByron J. Bailey, MD4/17/02


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Deep Neck Spaces and

InfectionsAnatomy of the Cervical Fascia

Anatomy of the Deep Neck Spaces

Deep Neck Space Infections


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Cervical Fascia

Superficial Layer

Deep LayerSuperficialMiddle

Deep


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Cervical Fascia

Superficial Layer

PlatysmaMuscles of FacialExpression


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Cervical Fascia

Superficial Layer of theDeep Cervical Fascia

MusclesSternocleidomastoidTrapezius

GlandsSubmandibularParotid

SpacesPosterior Triangle

Suprasternal space of Burns


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Cervical Fascia

Middle Layer of theDeep Cervical Fascia

Muscular DivisionInfrahyoid StrapMuscles

Visceral DivisionPharynx, Larynx,

Esophagus, Trachea,ThyroidBuccopharyngealFascia


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Cervical Fascia

Deep Layer of DeepCervical Fascia

Alar LayerPosterior to viscerallayer of middle fasciaAnterior to

prevertebral layerPrevertebral Layer

Vertebral bodiesDeep muscles of theneck


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Cervical Fascia

Carotid SheathFormed by all threelayers of deep fasciaContains carotidartery, internal

jugular vein, and

vagus nerveLincolnsHighway


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Deep Neck Spaces

Described in relation to the hyoid

Entire length of theneck SuprahyoidInfrahyoid


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Deep Neck Spaces

Entire Length of Neck:Superficial Space

Surrounds platysmaContains areolar tissue,nodes, nerves and vesselsSubplatysmal FlapsInvolved with cellulitisand superficial abscessesTreat with incision alongLangers lines, drainageand antibiotics


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Deep Neck Spaces

Entire Length of Neck:RetropharyngealSpace

Posterior to pharynxand esophagusAnterior to alar layerof deep fasciaExtends from skullbase to T1-T2


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Deep Neck Spaces

Entire Length of Neck:Danger Space

Anterior border is alarlayer of deep fasciaPosterior border isprevertebral layerExtends from skull baseto diaphragm


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Deep Neck Spaces

Entire Length of Neck:Prevertebral Space

Anterior border isprevertebral fasciaPosterior border isvertebral bodies anddeep neck musclesExtends along entirelength of vertebralcolumn


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Deep Neck Spaces

Entire Length of Neck: VisceralVascular Space

Carotid SheathLincolns Highway

Can becomesecondarily involvedwith any other deepneck space infection bydirect spread


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Deep Neck Spaces

Suprahyoid:Submandibular Space

Anterior/Lateral mandibleSuperior mucosaInferior superficial layerof deep fasciaPosterior/Inferior--hyoid


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Deep Neck Spaces

Suprahyoid:Submandibular Space

Sublingual SpaceAreolar tissueHypoglossal and lingualnerves

Sublingual glandWhartons duct

Submylohyoid SpaceAnterior bellies of digastrics

Submandibular gland


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Deep Neck Spaces

Suprahyoid:Parapharyngeal Space

Superior skull baseInferior hyoidAnterior ptyergomandibular raphe

Posterior prevertebralfasciaMedial

buccopharyngeal fasciaLateral superficial layerof deep fascia


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Deep Neck Spaces

Suprahyoid:Parapharyngeal Space

PrestyloidMedial tonsillar fossaLateral medial pterygoidContains fat, connective

tissue, nodesPoststyloid

Carotid sheathCranial nerves IX, X, XII


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Deep Neck Spaces

Suprahyoid:Peritonsillar Space

Medial capsule of palatine tonsilLateral superiorpharyngeal constrictorSuperior anteriortonsil pillarInferior posteriortonsil pillar


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Deep Neck Spaces

Suprahyoid: Masticatorand Temporal Spaces

Formed by thesuperficial layer of deepcervical fascia

Masseter and pterygoids

Temporalis


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Deep Neck Spaces

Suprahyoid: ParotidSpace

Superficial layer of deepfasciaDense septa fromcapsule into glandDirect communication toparapharyngeal space


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Deep Neck Spaces

Infrahyoid: AnteriorVisceral Space

Middle layer of deepfasciaContains thyroid,trachea, esophagusExtends from thyroidcartilage into superiormediastinum


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Deep Neck Space Infections

Presentation/Origin of Infection

MicrobiologyImagingTreatment

ComplicationsSpecial Consideration


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Presentation/Origin

Retropharyngeal Abscess50% occur in patients 6-12 months of age96% occur before 6 years of ageChildren--fever, irritability, lymphadenopathy,torticollis, poor oral intake, sore throat, droolingAdults--pain, dysphagia, anorexia, snoring, nasalobstruction, nasal regurgitationDyspnea and respiratory distress

Lateral posterior oropharyngeal wall bulge


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Presentation/Origin

PediatricsCause suppurativeprocess in lymph nodes

Nose, adenoids,nasopharynx, sinuses

AdultsCause trauma,instrumentation,extension fromadjoining deep neck space


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Presentation/Origin

Danger SpacePresentation and exam nearly identical toretropharyngeal space infectionCause extension from retropharyngeal,prevertebral or parapharyngeal space


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Presentation/Origin

Prevertebral SpaceBack, shoulder, neck painmade worse by deglutitionDysphagia or dyspneaCause Potts abscess, trauma,osteomyelitis, extension fromretropharyngeal and danger spaces


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Presentation/Origin

Visceral Vascular SpaceInduration and tenderness over SCMTorticollis toward opposite sideSpiking fevers, sepsisCause intravenous drug abuse, extension fromother deep neck spaces


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Presentation/Origin

Submandibular SpacePain, drooling, dysphagia, neck

stiffnessAnterior neck swelling, floor of mouth edemaCause 70-85% have odontogenicorigin

First molar and anteriorSecond and third molars

Sialadenitis, lymphadenitis,lacerations of the floor of mouth,

mandible fractures


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Presentation/Origin

Ludwigs angina 1. Cellulitis, not abscess2. Limited to SM space3. Foul serosanguinous fluid, nofrank purulence4. Fascia, muscle, connectivetissue involvement, sparingglands

5. Direct spread rather thanlymphatic spread

Tender, firm anterior neck edema without fluctuanceHot potato voice, drooling Tachypnea, dyspnea, stridor


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Presentation/Origin

Parapharyngeal SpaceFever, chills, malaisePain, dysphagia, trismusMedial bulge of lateralpharyngeal wallCause infection of pharynx,tonsil, adenoids, dentition,parotid, mastoid, suppurativelymphadenitis, extension fromother deep neck spaces


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Presentation/Origin

Peritonsillar SpaceFever, malaiseDysphagia, odynophagiaHot - potato voice,trismus, bulging of superiortonsil pole and soft palate,deviation of uvulaCause extension fromtonsillitis


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Presentation/Origin

MasticatorTemporal Space

Pain, trismusPosterior FOMedemaSwelling alongramus of mandibleCause odontogenic, fromthird molars

Parotid SpacePain, trismus

Medial bulgeof posteriorlateralpharyngealwallCause parotitis,sialolithiasis,Sjogrenssyndrome


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Presentation/Origin

Anterior Visceral SpaceHoarseness, dyspnea, dysphagia, odynophagiaErythema, edema of hypopharynx, may extend toinclude glottis and supraglottisAnterior neck edema, pain, erythema, crepitusCause foreign body, instrumentation, extensionof infection in thyroid


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Microbiology

Preantibiotic era S.aureus

Currently aerobic Strep species and non-strepanaerobesGram-negatives uncommon

Almost always polymicrobialRemember resistance


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Imaging

Lateral neck plain filmScreening exam mainlyfor retropharyngeal and

pretracheal spacesNormal: 7mm at C-2,14mm at C-6 for kids,22mm at C-6 for adultsTechnique dependent

ExtensionInspiration

Nagy, et alSensitivity 83%,compared to CT 100%


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Imaging

High-resolution UltrasoundAdvantages

Avoids radiationPortable

DisadvantagesNot widely accepted

Operator dependentInferior anatomic detail

UsesFollowing infection during therapy

Image guided aspiration


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Imaging

Contrast enhanced CTAdvantages

Quick, easyWidely availableFamiliaritySuperior anatomic detailDifferentiate abscess andcellulitis

DisadvantagesIonizing radiationAllergenic contrast agentSoft tissue detail

Artifact


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Imaging

Contrast enhanced CTModality of choiceMiller, et al: CT vs. PE

Accuracy of diagnosis: CT = 77%, PE = 63%Sensitivity: CT = 95%, PE = 55%


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Imaging

MRIAdvantages

No radiationSafer contrast agentBetter soft tissue detailImaging in multiple planesNo artifact by dental fillings

DisadvantagesIncreased costIncreased exam timeDependent on patientcooperationAvailability

Munoz, et al: MRI vs. CT


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Treatment

Airway protection

Antibiotic therapy

Surgical drainage


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Treatment

Airway protectionObservationIntubation

Direct laryngoscopy: possible risk of rupture andaspirationFlexible fiberoptic

TracheostomyIdeally = planned, awake, local anesthesiaAbscess may overlie tracheaDistorted anatomy and tissue planes


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Treatment

LUDWIGS ANGINA = PERILOUS AIRWAY Parhiscar and Har-El

Review of 210 patients withdeep neck abscessOverall, 20.5% requiredtracheostomyLudwigs angina, 75%

required tracheostomyAttempted intubation in 20 patientsFailed in 11 patients, necessitating

slash tracheostomy


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Treatment

Antibiotic TherapyCellulitisImprovement in 24-48 hoursAbscess?

Mayor, et al: review of 31 patients, 19 with CT

evidence of abscess, 90% responseNagy, et al: review of 47 pediatric patients, 51%response rate, only 7 of these had CT evidence of abscess


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Treatment

Antibiotic TherapyPolymicrobial infections

Aerobic Strep, anaerobesAmpicillin/sulbactam with metronidazole

Beta-Lactam resistance in 17-47% of isolates

AlternativesThird generation cephalosporinsclindamycin

Culture and sensitivity


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Treatment

Surgical DrainageTransoral

Preoperative CT where are the great vessels?Cruciate mucosal incision, blunt spreading throughsuperior pharyngeal constrictor

Nagy, et al: retro-, parapharyngeal or combo in kids22/23 successfully treated with intraoral incision and drainage

External


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Treatment

Surgical DrainageExternal

EXPOSURE, EXPOSURE, EXPOSURELevitt: anterior vs. posteriorapproach

Submandibular incisionSubmental incisionT-incision


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Treatment

Image-guided AspirationPatient selection

Smaller abscesses, limited extension, uniloculated

Poe, et al: CT guided aspirationEarly specimen collection, reduced expense, avoidance of

neck scarYeow, et al: Ultrasound guided aspiration

8/10 patients successfully treated with needle aspiration5/5 patients successful treated with pigtail catheterinsertion


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Complications

Airway obstructionEndotracheal intubationTracheostomy

Ruptured abscessPneumoniaLung Abscess


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Complications

Internal Jugular Vein ThrombosisLemierres syndrome F/C, prostration, swelling and pain along SCMBacteremia, septic embolization, dural sinusthrombosis

IV drug abusersTreatmentIV antibiotic therapyAnticoagulation?

Ligation and excision


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Complications

Carotid Artery RuptureMortality of 20-40%Sentinel bleeds from ear, nose, mouthMajority from internal carotid, less from externalcarotid, and fewest from common carotid

TreatmentProximal and distal controlLigation

Patching or grafting?


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Complications

MediastinitisMortality of 40%

Increasing dyspnea, chest painCXR = widened mediastinumTreatment

EARLY RECOGNITION AND INTERVENTIONAggressive IV antibiotic therapySurgical drainage

Transcervical approach

Chest tube vs. thoracotomy


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Special Consideration

Recurrent Deep Neck Space InfectionTHINK CONGENITAL ABNORMALITYImaging should help make the diagnosisNusbaum, et al: 12 cases of recurrent deep neck infection

Most Common: second branchial cleft cystOthers: first, third, fourth branchial cleft cysts,lymphangiomas, thyroglossal duct cysts, cervicalthymic cyst


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Case Presentation

43 y/o man presents to the ER complainingof mouth and neck pain, he finds it difficultto swallow and has been spitting out hissaliva.He also reports progressive swelling in hisneck that it tender to touch.


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Case Presentation

Additional historyDenies recent URI or pharyngitisHad an infected third molar pulled about 5 daysagoNo difficulty breathing at rest


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Case Presentation

Past Medical HistoryHTN, renal failure

Past Surgical HistoryKidney transplant

MedicationsPrednisone, cyclosporin, metoprolol

Allergiesnkda

Social HistoryNonsmoker, occasional alcohol


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Case Presentation

Physical ExamBP 124/70, P 96, RR 18, T 38.0, O2 sat 98% RAGen: no distress, uncomfortable, muffled voiceTender, erythematous edema over right level I & II,no distinctly palpable nodes, no fluctuance

FOM is slightly edematous and tender but soft, thetongue is not elevated, evidence of tooth extraction


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Case Presentation

Laboratory StudiesWBCs 21,000, elevated bandsElectrolytes wnlCyclosporin level ok


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Case Presentation

CT Neck


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Case Presentation

TreatmentTo OR for external incision and drainage, usinga transverse, submandibular skin incisionSpecimens sent for culture and sensitivitiesPenrose drain left in place for continued drainage

IV antibiotic therapy started with Unasyn

POD #2, remains febrile, neck is stillerythematous and indurated


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Case Presentation

Follow up on culture and sensitivitiesBroaden antibiotic therapy for betteranaerobic and gram-negative coverage

Deep-Neck Spaces Infections

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