Deep neck spaces.pdf

Dr. Supreet Singh Nayyar, AFMC 2011

www.nayyarENT.com

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Anatomy of Cervical Fascia & Deep Neck Spaces www.nayyarENT.com

Divisions

• Superficial cervical fascia

• Deep cervical fascia

• Superficial layer

• Middle layer

• Muscular division

• Visceral division

• Deep layer

• Alar division

• Prevertebral division

Superficial cervical fascia

• Fibro fatty subcutaneous tissue

• Attachments: zygomatic process to thorax and axilla

• Contents: platysma, muscles of facial expression

• Loose at places

• Subcutaneous tissue of eyelids

• Scalp deep to epicranial aponeurosis

• Cheek (buccal fat pad)

• Not considered a part of the deep neck

• Local I&D and antibiotics

Superficial layer of the deep cervical fascia

• Investing or enveloping layer (envelopes neck)

• Insertion at nuchal line of the skull and vertebral spinal processess surrounds neck and

again inserted there

• Superior attach at hyoid & clavicles

further extend upward

attach at mandible (split in two layers, ant & post)

split and enclose submandibular gland

split around masseter & medial pterygoid

follow external surface of masseter (masseteric fascia) to

zygomatic arch

other portion along medial surface of med pterygoid to pterygoid

plate

split & form parotid fascia attach at zygomatic arch

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• Inferior split into two ant & post In b/w, suprasternal space of Burns

• Envelopes

• SCM

• Trapezius

• Portion of omohyoid in posterior triangle

• Parotid

• Submandibular glands

Middle layer of the deep cervical fascia

• Muscular division

• Surrounds straps

• Attaches superiorly to hyoid and thyroid cartilage

• Inferiorly to sternum, clavicle and scapula

• At lateral edges of muscles, blends with superficial layer

• Visceral division ( Pre tracheal layer)

• Surrounds thyroid, trachea,

esophagus

• Superior attached to base of skull,

thyroid cartilage and hyoid

• Inferiorly blends with fibrous

pericardium and is prolonged along

great vessels to superior

mediastinum

• Laterally fuses with superficial layer


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Deep layer of the deep cervical fascia

• Begins anterior to the vertebral bodies spreads laterally to fuse with transverse processes

extends posteriorly to enclose deep muscles of neck(scalene muscles) attaches to

vertebral spines

• Forms the posterior wall of the “danger

space” and anterior wall of prevertebral space

• Contents: Paraspinous muscles and cervical

vertebrae

• In upper part of post. triangle pre vertebral

layer is in contact with superficial layer

• Prevertebral and alar divisions

o B/w transverse processes and across

front of vertebral bodies, pre vertebral

fascia has two parts

Alar part

Attaches from skull base to T2

Fuses with visceral division of middle layer of deep cervical fascia

Pre vertebral part

o Separated by loose connective tissue


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Caotid Sheath

• Made up of all 3 deep layers

• Anterolateral

o Superficial layer of deep cervical fascia (Deep to SCM)

o Partly by pre tracheal layer ( where infra hyoid muscles overlap great vessels)

• Posterior wall

o Lamina from superficial layer

• Medial wall

o Extension of fascia from anterolateral wall to

posterior wall

o This fascia is attached medially to pre

vertebral fascia

• Encloses

o IJV

o Common carotid artery

o Vagus nerve

Deep Neck Spaces

• Spaces involving entire length of neck

o Retropharyngeal o Danger o Prevertebral o Visceral vascular

• Suprahyoid spaces

o Parapharyngeal space ( Pharyngomaxillary/ Lateral pharyngeal ) o Submandibular o Parotid o Masticator o Peritonsillar o Buccal

• Infrahyoid spaces

o Anterior visceral


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Retropharyngeal space

• Potential space

• Posterior to visceral division of middle layer of deep cervical fascia (buccopharyngeal fascia)

• Anterior to alar division of deep layer of deep cervical fascia

• Skull base to tracheal bifurcation (T4)

• Midline raphe

o Superior constrictor muscles adhere to prevertebral division

o Separates retropharyngeal nodes into two lateral compartments (spaces of gilette)

• Contents

o Fat

o LNs (which drain nose, NP, soft palate, ET, paranasal sinuses)

o Connective tissue

• Pathways of infection

o Posterior perforation of oesophagus

o Lymph node infections

o Communication with parapharyngeal space

• Clinical features

o Children preceding URTI, fever, dysphagia, odynophagia, nuchal rigidity,

asymmetric bulging of post pharyngeal wall due to midline raphe

o Adults pain, dysphagia, cervical motion limitation, noisy breathing

• Can extend to: mediastinum, danger space, parapharyngeal space

• Lateral soft tissue XR (extension, inspiration) abnormal findings:

o C2 post pharyngeal soft tissue >7mm

o C6 adults >22mm, paeds>14mm

o Soft tissue shadow of post pharyngeal region >50% width of vertebral body

• Surgical approach

o Intra oral for small abcess

o Cervical ant border of SCM medial to carotid sheath

Danger Space • Potential space between the alar and prevertebral divisions of the deep layer of the deep

cervical fascia

• Posterior to the retropharyngeal space and anterior to the prevertebral space

• Called Danger area because Extends from skull base to posterior mediastinum to

diaphragm spread of infection easily throughout

• Has extensions along nerves for brachial plexus infection can spread and lead to

neuropathy

• Caused by infectious spread from retropharyngeal, prevertebral and parapharyngeal spaces

or less commonly, by lymphatic extension from the nose and throat

• Watch for severe dyspnea, chest pain, widened mediastinum on CXR may need

thoracotomy for drainage


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Prevertebral space

• Potential space posterior to prevertebral division and anterior to vertebral bodies

• Extends from skull base to the coccyx

• Most common cause: iatrogenic/penetrating trauma

• Previous most common cause: TB

Visceral vascular space

• Potential space within the carotid sheath

• Lymphatic vessels within receive drainage from most of the lymphatic vessels in the head

and neck

• Most common source of infection is parapharyngeal space

• Called the “Lincoln Highway” of the neck

PARAPHARYNGEAL ABSCESS

• Definition:

– Suppurative collection in Parapharyngeal space

• Etiology:

– Frequently seen in young adults

– Infection spreads from

• Tonsil and adenoid

• Dental sepsis (last molars)

• Retropharyngeal space

• Ear - mastoiditis/ Bezold’s abscess, petrositis

• Paranasal sinuses

• Parotid gland

• Cervical vertebrae

• External trauma

• Bacteriology

• Hemolytic and non-hemolytic Streptococci

• Fusiform bacilli

• Pneumococci

• Staph aureus

• Clinical features:

• Trismus

• Fever

• Odynophagia

• Neck swelling, behind angle of jaw

• Tonsil and lat pharyngeal wall pushed medially

• D/D: • Quinsy • Retropharyngeal abscess • Tumors of Parapharyngeal space • Aneurysms


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• Complications:

Laryngeal edema

Extension within carotid canal

Mediastinitis

Treatment:

Hospitalization

Fluid and electrolyte balance

Parenteral antibiotics (broad spectrum) penicillin + aminoglycosides +

metronidazole

Airway management

I & D

Never approach intra orally

Traditionally: Mosher incision

Horizontal neck incision

immediately behind

submandibular gland follow

carotid sheath into space finger

dissect below submandibular

gland, along posterior belly of

digastric deep to mastoid tip

toward styloid

Alternative incision along ant

border of SCM

Submandibular space • Composed of sublingual space superiorly and submaxillary space inferiorly, divided by

mylohyoid

• Boundaries

o Floor of mouth mucosa above

o Superficial layer of deep fascia below

o Mandible ant/lat

o Hyoid inferiorly

o Base of tongue muscles posteriorly

• Submandibular gland lies posterior to mylohyoid partly above & partly below it

• At post end of mylohyoid , sublingual & submaxillary spaces communicate

• Sublingual space : submandibular gland, Wharton’s duct , Hypoglossal nerve

• Submaxillary space : submandibular gland, facial artery, lingual nerve

• Ludwig’s angina

o Bilateral cellulitis of submandibular and sublingual spaces

o Etiology

Dental caries (lower 2nd and 3rd molars )


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Floor of mouth trauma

Following dental extraction

o Characteristics

Spreading gangrenous cellulitis

Produces gangrene with serosanguinous, putrid infiltration

o Symptoms

Rapidly spreading gangrenous cellulitis of upper neck

Airway compromise occurs quickly

Drooling of saliva

Mouth pain

Dysphagia

Neck stiffness

o Signs

Fever

Tachycardia

Induration & erythema of floor of the mouth

Postero superior displacement of tongue secondary to floor of mouth

oedema

Neck – woody induration in suprahyoid region without fluctuation

Trismus usually absent

o D/d

Acute submandibular sialoadenitis

Infected ranula

o Investigations

Haemogram

USG Neck – to confirm abcess

Needle aspiration & ABST

Dental X Rays

NCCT Base of skull to root of neck – extent of disease

o Treatment

Airway control with tracheostomy if needed

IV antibiotics

Surgical exploration with division of mylohyoid muscle & drainage

Procedure

o Horizontal incision 2 finger breadth below mandibular

margin from one angle of mandible to another

o Drainage & rubber drain put in place (removed after 48 hrs)

o Wound closure by secondary intention

Complications

Airway obstruction

Spread of infection to parapharyngeal / retropharyngeal space


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Aspiration pneumonia

Lung abcess

Parotid space

• Formed by the splitting and surrounding of superficial layer of deep cervical fascia

• Incomplete at upper inner surface of gland direct communication with parapharyngeal

space (dumb bell shaped masses secondary to stylomandibular ligament)

• Contents

o Parotid gland

o External carotid

o Posterior facial vein

o Facial nerve

o Lymph nodes

• Infections within it are infections of the gland or

nodes

Masticator space • Superficial layer of deep cervical fascia splits around

mandible to form this space and encases muscles of mastication

• Attachments

o Ant massetric fascia attatches to

o Mandible in front of masseter muscle

o Insertion of temporalis muscle along ant border of ramus

o Another part passess in front of ramus, across outer surface

of buccal fat pad to

Maxilla

Buccinator fascia below

o Sup limited by origin of temporalis muscle

o Superficially temporalis muscle’s origin from temporalis fascia

o Deep Extends to pterygoplalatine fossa, ant to lateral pterygoid plate


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• Contents

o Masseter

o Medial Pterygoid muscle

o Temporalis muscle lower portion

o Inferior alveolar nerves and vessels

o Buccal fat pad and it’s extensions

o Body and ramus of mandible

o Internal maxillary artery

• 4 compartments & their drainage (Ballenger)

o Superficial Temporal

Lateral to temporalis muscle

Drainage by hairline incisions extending thru temporalis fascia

o Deep Temporal

Deep to temporalis muscle in infra temporal fossa

Drainage Incision to extend thru temporalis muscle

o Masseteric

Masseter ms & lateral to it

I & D will require preservation of

facial nerve & it’s branches prior to

detachment of fascia from mandible

o Pterygoid

Includes medial pterygoid muscle

Drainage Intraoral incision

• Most common source of infection : 3rd molar

• Sources of infection

o Zygomatic / Temporal bone infections

o Abcess from lower molar teeth

• Abcess points at

o Ant. aspect of masseter muscle into cheek or

mouth

o Post. Below parotid gland

• Complication: osteomyelitis of mandible

Peritonsillar • Boundaries

o Anterior and posterior pillars

o Palatine tonsil

o Superior constrictor muscle

• Content loose areolar tissue

• Aetiology

o Virulent tonsillar infection that breaks through tonsillar capsule

o Recurrent tonsillitis


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o Foreign body

o Dental source of infection

o Leukemia

• Plane of least resistance in this space is adjacent to soft palate so that abcess localizes to sup

pole of tonsil

• Common after puberty

• Symptoms

o History of tonsillitis

o Sore throat

o Dysphagia

o Odynophagia

o Referred otalgia

o Patient’s mouth is partly open or drooling

o Speech is muffled

o Hot potato voice

o Trismus

• Signs

o Fever, malaise

o Trismus

o Erythema of involved area in oropharynx

o Tense swelling of ant. tonsillar pillar & soft palate

o Ant. tonsillar pillar is indistinguishable from tonsils

o Tonsil is pushed forwards & downwards

o Uvula is deviated away from abcess

o Cervical lymphadenopathy tender, enlarged nodes

o 3-7 % cases can be bilateral

• D/d

o Peritonsillar cellulitis – absence of pus during needle aspiration

o Parapharyngeal abcess

o Severe tonsillitis

o Lymphoma

o Sq cell carcinoma

o Parapharyngeal neoplasm

• Inv

o Throat swab

o Haemogram

o CT scan if parapharyngeal infection suspected

o X Ray neck lat view

• Treatment

o Airway protection

o IV antibiotics

o Analgesics


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o IV fluids

o Drainage

Options

Needle aspiration aspirate sup, middle & inf quad of ant pillar

I&D Stab Incision at junction of

o Horizontal line along base of uvula

o Ant pillar

Hot tonsillectomy

o No clear cut indications

o Controversial

o Some surgeons prefer

• 10-15% recurrence

• Greatest risk in patients <40 with history of recurrent tonsillitis

Buccal space • Boundaries

o Buccinator muscle

o Cheek

o Zygomatic arch

o Pterygomandibular raphe

o Inferior mandible

• Odontogenic source with buccal swelling

• Pre septal cellulitis possible

• Complication: cavernous sinus thrombosis

Anterior visceral space

• Pretracheal space from thyroid cartilage to T4 level

• Enclosed by visceral division of middle layer, just deep to straps, surrounds trachea

• Source: esophageal anterior wall perforation, external trauma

• Symptoms: mainly dysphagia, later hoarseness, dyspnea, airway obstruction

• Complication: mediastinitis, airway obstruction


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Network of infectious extension

• PMS=pharyngomaxillary = parapharyngeal space

• VVS = visceral vascular space

Pathogens in Deep neck space infections

• Likely dependent on portal of entry and space involved

• Aerobic: Strep-predom viridans and B-hemolytic streptococci, staph, diphtheroid,

Neisseria, Klebsiella, Haemophilus

• Anaerobic: Bacteroides, Peptostreptococcus, Eikenella (often clinda resistant),

Fusobacterium, B fragilis


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Necrotizing fasciitis

• Fulminant infection

• Polymicrobial

• Usually odontogenic source

• More frequently in immunocompromised and postoperative

• Presentation

o Ill, high fever

o Neck crepitus

o Exquisitely tender

o Unimpressive erythema with sharp demarcating border progress to pale

then dusky as necrosis progresses can have bullae/blisters/sloughing

<48hrs


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• Empiric antibiotic (3rd gen ceph + clinda/flagyl)

• Early surgery

• Dishwater drainage

• Leave open

• Daily debridement

• Tracheostomy

• ICU monitoring for

o Resp failure

o Mediastinitis (higher mortality 64% vs 15%)

o DIC

o Delirium

Complications of deep neck space infections

• Mediastinitis – most commonly via retropharyngeal space (> visceral or

Parapharyngeal space)

• Abdominal abscess – prevertebral space

• IJV septic thrombophlebitis – IVDA, ligate and remove thrombosed vein at I&D

• Neuropathy – Horner’s, hoarseness, unilateral tongue paresis

• Erosion of carotid artery – rare, emergency, clot found in neck at I&D, proximal and

distal control, intra op angio if possible (75% CCA or ICA)

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