Deep Neck Space Deep Neck Space InfectionsInfections

UTMB Department of OtolaryngologyUTMB Department of Otolaryngology

Jeffrey Buyten, MDJeffrey Buyten, MD

Francis B. Quinn, MDFrancis B. Quinn, MD

October 5, 2005October 5, 2005

Best viewed as a PowerPoint slideshow to insureThat overlays are seen.

OutlineOutline

AnatomyAnatomy Fascial planesFascial planes SpacesSpaces

EpidemiologyEpidemiology EtiologyEtiology Clinical presentationClinical presentation ImagingImaging BacteriologyBacteriology TherapyTherapy

MedicalMedical SurgicalSurgical

ComplicationsComplications MediastinitisMediastinitis

ανατομίαανατομία

Cervical FasciaCervical Fascia

Superficial LayerSuperficial Layer Deep LayerDeep Layer

Subdivisions not Subdivisions not histologically separatehistologically separate

SuperficialSuperficial Enveloping layerEnveloping layer Investing layerInvesting layer

MiddleMiddle Visceral fasciaVisceral fascia Prethyroid fasciaPrethyroid fascia Pretracheal fasciaPretracheal fascia

DeepDeep

Superficial LayerSuperficial Layer

Superior attachment Superior attachment – zygomatic process– zygomatic process

Inferior attachment – Inferior attachment – thorax, axilla.thorax, axilla.

Similar to Similar to subcutaneous tissuesubcutaneous tissue

Ensheathes platysma Ensheathes platysma and muscles of facial and muscles of facial expressionexpression

Superficial Layer of the Deep Cervical Superficial Layer of the Deep Cervical FasciaFascia

Completely surrounds the Completely surrounds the neck.neck.

Arises from spinous Arises from spinous processes.processes.

Superior border – nuchal Superior border – nuchal line, skull base, zygoma, line, skull base, zygoma, mandible.mandible.

Inferior border – chest and Inferior border – chest and axillaaxilla

Splits at mandible and Splits at mandible and covers the masseter covers the masseter laterally and the medial laterally and the medial surface of the medial surface of the medial pterygoid.pterygoid.

EnvelopesEnvelopes SCMSCM TrapeziusTrapezius SubmandibularSubmandibular ParotidParotid

Forms floor of Forms floor of submandibular spacesubmandibular space

Superficial Layer of the Deep Cervical Superficial Layer of the Deep Cervical FasciaFascia

Middle Layer of the Deep Cervical Middle Layer of the Deep Cervical FasciaFascia

Muscular DivisionMuscular Division Superior border – hyoid and Superior border – hyoid and

thyroid cartilagethyroid cartilage Inferior border – sternum, Inferior border – sternum,

clavicle and scapulaclavicle and scapula Envelopes infrahyoid strap Envelopes infrahyoid strap

musclesmuscles

Visceral DivisionVisceral Division Superior borderSuperior border

Anterior – hyoid and thyroid Anterior – hyoid and thyroid cartilagecartilage

Posterior – skull basePosterior – skull base Inferior borderInferior border – continuous with – continuous with

fibrous pericardium in the upper fibrous pericardium in the upper mediastinum.mediastinum.

Buccopharyngeal fasciaBuccopharyngeal fascia Name for portion that covers Name for portion that covers

the pharyngeal constrictors the pharyngeal constrictors and buccinator.and buccinator.

EnvelopesEnvelopes ThyroidThyroid TracheaTrachea EsophagusEsophagus PharynxPharynx LarynxLarynx

Middle Layer of the Deep Cervical Middle Layer of the Deep Cervical FasciaFascia

Deep Layer of Deep Cervical FasciaDeep Layer of Deep Cervical Fascia

Arises from spinous processes and Arises from spinous processes and ligamentum nuchae.ligamentum nuchae.

Splits into two layers at the transverse Splits into two layers at the transverse processes:processes: Alar layerAlar layer

Superior border – skull baseSuperior border – skull base Inferior border – upper mediastinum at T1-T2Inferior border – upper mediastinum at T1-T2

Prevertebral layerPrevertebral layer Superior border – skull baseSuperior border – skull base Inferior border – coccyxInferior border – coccyx Envelopes vertebral bodies and deep muscles of the Envelopes vertebral bodies and deep muscles of the

neck.neck. Extends laterally as the axillary sheath.Extends laterally as the axillary sheath.

Deep Layer of Deep Cervical FasciaDeep Layer of Deep Cervical Fascia

Carotid SheathCarotid Sheath Formed by all three layers of deep fasciaFormed by all three layers of deep fascia Anatomically separate from all layers.Anatomically separate from all layers. Contains carotid artery, internal jugular vein, and vagus nerveContains carotid artery, internal jugular vein, and vagus nerve ““Lincoln’s Highway”Lincoln’s Highway” Travels through pharyngomaxillary space.Travels through pharyngomaxillary space. Extends from skull base to thorax.Extends from skull base to thorax.

Deep Neck SpacesDeep Neck Spaces Described in relation to the Described in relation to the

hyoid.hyoid. Entire length of neckEntire length of neck

Superficial spaceSuperficial space RetropharyngealRetropharyngeal DangerDanger PrevertebralPrevertebral Vascular visceralVascular visceral

SuprahyoidSuprahyoid SubmandibularSubmandibular Pharyngomaxillary Pharyngomaxillary

(Parapharyngeal)(Parapharyngeal) ParotidParotid PeritonsillarPeritonsillar TemporalTemporal MasticatorMasticator

InfrahyoidInfrahyoid Anterior visceralAnterior visceral

Superficial SpaceSuperficial Space Entire length of neckEntire length of neck

Surrounds platysmaSurrounds platysma Contains areolar tissue, Contains areolar tissue,

nodes, nerves and nodes, nerves and vesselsvessels

Subplatysmal FlapsSubplatysmal Flaps Involved with cellulitis Involved with cellulitis

and superficial abscessesand superficial abscesses Treat with incision along Treat with incision along

Langer’s lines, drainage Langer’s lines, drainage and antibioticsand antibiotics

Retropharyngeal SpaceRetropharyngeal Space Entire length of neck.Entire length of neck.

Anterior border - pharynx and Anterior border - pharynx and esophagus (buccopharyngeal esophagus (buccopharyngeal fascia)fascia)

Posterior border - alar layer of Posterior border - alar layer of deep fasciadeep fascia

Superior border - skull baseSuperior border - skull base Inferior border – superior Inferior border – superior

mediastinummediastinum Combines with Combines with

buccopharyngeal fascia at buccopharyngeal fascia at level of T1-T2level of T1-T2

Midline raphe connects Midline raphe connects superior constrictor to the superior constrictor to the deep layer of deep cervical deep layer of deep cervical fascia.fascia.

Contains retropharyngeal Contains retropharyngeal nodes.nodes.

SpaceSpace

Entire length of Entire length of neck neck

Anterior border - Anterior border - alar layer of deep alar layer of deep fasciafascia

Posterior border - Posterior border - prevertebral layerprevertebral layer

Extends from Extends from skull base to skull base to diaphragmdiaphragm

Contains loose Contains loose areolar tissue.areolar tissue.

Prevertebral SpacePrevertebral Space

Entire length of neck Entire length of neck

Anterior border - Anterior border - prevertebral fasciaprevertebral fascia

Posterior border - Posterior border - vertebral bodies and vertebral bodies and deep neck musclesdeep neck muscles

Lateral border – Lateral border – transverse processestransverse processes

Extends along entire Extends along entire length of vertebral length of vertebral columncolumn

Visceral Vascular SpaceVisceral Vascular Space

Entire length of Entire length of neck neck

Carotid SheathCarotid Sheath ““Lincoln Highway”Lincoln Highway” Lymphatic vessels Lymphatic vessels

can receive can receive drainage from most drainage from most of lymphatic vessels of lymphatic vessels in head and neck.in head and neck.

Submandibular SpaceSubmandibular Space

SuprahyoidSuprahyoid

Superior – oral mucosaSuperior – oral mucosa Inferior - superficial Inferior - superficial

layer of deep fascialayer of deep fascia Anterior border – Anterior border –

mandiblemandible Lateral border - Lateral border -

mandiblemandible Posterior - hyoid and Posterior - hyoid and

base of tongue base of tongue musculaturemusculature

2 compartments2 compartments Sublingual spaceSublingual space

Areolar tissueAreolar tissue Hypoglossal and lingual Hypoglossal and lingual

nervesnerves Sublingual glandSublingual gland Wharton’s ductWharton’s duct

Submaxillary spaceSubmaxillary space Anterior bellies of Anterior bellies of

digastricsdigastrics Submental Submental

compartmentcompartment Submaxillary Submaxillary

compartmentscompartments Submandibular glandSubmandibular gland

Submandibular SpaceSubmandibular Space

Pharyngomaxillary spacePharyngomaxillary space

SuprahyoidSuprahyoid

aka – Parapharyngeal aka – Parapharyngeal spacespace

Superior—skull baseSuperior—skull base Inferior—hyoidInferior—hyoid Anterior—Anterior—

ptyergomandibular rapheptyergomandibular raphe Posterior—prevertebral Posterior—prevertebral

fasciafascia Medial—buccopharyngeal Medial—buccopharyngeal

fasciafascia Lateral—superficial layer of Lateral—superficial layer of

deep fasciadeep fascia

Pharyngomaxillary spacePharyngomaxillary space

Prestyloid Prestyloid Muscular compartmentMuscular compartment Medial—tonsillar fossaMedial—tonsillar fossa Lateral—medial pterygoidLateral—medial pterygoid Contains fat, connective Contains fat, connective

tissue, nodestissue, nodes Poststyloid Poststyloid

Neurovascular compartmentNeurovascular compartment Carotid sheathCarotid sheath Cranial nerves IX, X, XI, XIICranial nerves IX, X, XI, XII Sympathetic chainSympathetic chain

Stylopharyngeal Stylopharyngeal aponeurosis of aponeurosis of Zuckerkandel and TestutZuckerkandel and Testut Alar, buccopharyngeal and Alar, buccopharyngeal and

stylomuscular fascia.stylomuscular fascia. Prevents infectious spread Prevents infectious spread

from anterior to posterior.from anterior to posterior.

Pharyngomaxillary SpacePharyngomaxillary Space

Communicates with several deep neck spaces. Parotid Masticator Peritonsillar Submandibular Retropharyngeal

Peritonsillar SpacePeritonsillar Space

SuprahyoidSuprahyoid

Medial—capsule of Medial—capsule of palatine tonsilpalatine tonsil

Lateral—superior Lateral—superior pharyngeal constrictorpharyngeal constrictor

Superior—anterior Superior—anterior tonsil pillartonsil pillar

Inferior—posterior Inferior—posterior tonsil pillartonsil pillar

Masticator and Temporal Masticator and Temporal SpacesSpaces SuprahyoidSuprahyoid

Formed by superficial layer of Formed by superficial layer of deep cervical fasciadeep cervical fascia

Masticator spaceMasticator space Antero-lateral to Antero-lateral to

pharyngomaxillary space.pharyngomaxillary space. ContainsContains

MasseterMasseter Pterygoids Pterygoids Body and ramus of the mandibleBody and ramus of the mandible Inferior alveolar nerves and Inferior alveolar nerves and

vesselsvessels Tendon of the temporalis muscleTendon of the temporalis muscle

Temporal spaceTemporal space Continuous with masticator Continuous with masticator

space.space. Lateral border – temporalis fasciaLateral border – temporalis fascia Medial border – periosteum of Medial border – periosteum of

temporal bonetemporal bone Superficial and deep spaces Superficial and deep spaces

divided by temporalis muscledivided by temporalis muscle

Parotid SpaceParotid Space SuprahyoidSuprahyoid

Superficial layer of deep Superficial layer of deep fasciafascia Dense septa from capsule Dense septa from capsule

into glandinto gland Direct communication to Direct communication to

parapharyngeal spaceparapharyngeal space

ContainsContains External carotid arteryExternal carotid artery Posterior facial veinPosterior facial vein Facial nerveFacial nerve Lymph nodesLymph nodes

Anterior Visceral SpaceAnterior Visceral Space Infrahyoid Infrahyoid

aka – pretracheal spaceaka – pretracheal space

Enclosed by visceral division Enclosed by visceral division of middle layer of deep fasciaof middle layer of deep fascia

Contains thyroidContains thyroid Surrounds tracheaSurrounds trachea

Superior border - thyroid Superior border - thyroid cartilagecartilage

Inferior border - anterior Inferior border - anterior superior mediastinum superior mediastinum down to the arch of the down to the arch of the aorta.aorta.

Posterior border – anterior Posterior border – anterior wall of esophaguswall of esophagus

Communicates laterally Communicates laterally with the retropharyngeal with the retropharyngeal space below the thyroid space below the thyroid gland.gland.

EpidemiologyEpidemiology

All patientsAll patients Avg age b/w 40-50.Avg age b/w 40-50. More predominant in More predominant in

pts over 50 years.pts over 50 years.

Pediatric ptsPediatric pts Infants to teens.Infants to teens. Male predilection in Male predilection in

some case series.some case series. Most common age Most common age

group: 3-5 years.group: 3-5 years.

EtiologyEtiology OdontogenicOdontogenic TonsillitisTonsillitis IV drug injectionIV drug injection TraumaTrauma Foreign body Foreign body Sialoadenitis Sialoadenitis ParotitisParotitis OsteomyelitisOsteomyelitis EpiglottitisEpiglottitis URIURI IatrogenicIatrogenic Congenital anomaliesCongenital anomalies IdiopathicIdiopathic

Clinical presentationClinical presentation Most common symptomsMost common symptoms

Sore throat (72%)Sore throat (72%) Odynophagia (63%)Odynophagia (63%)

Most common symptoms (exluding peritonsillar abscesses)Most common symptoms (exluding peritonsillar abscesses) Neck swelling (70%)Neck swelling (70%) Neck Pain (63%)Neck Pain (63%)

PediatricPediatric FeverFever Decreased PODecreased PO OdynophagiaOdynophagia MalaiseMalaise TorticollisTorticollis Neck painNeck pain OtalgiaOtalgia HAHA TrismusTrismus Neck swellingNeck swelling Vocal quality changeVocal quality change Worsening of snoring, sleep apneaWorsening of snoring, sleep apnea

ImagingImaging Lateral neck plain Lateral neck plain

filmfilm Screening examScreening exam No benefit in pts with No benefit in pts with

DNI based on strong DNI based on strong clinical suspicion.clinical suspicion.

Normal:Normal: 7mm at C-27mm at C-2 14mm at C-6 for kids14mm at C-6 for kids 22mm at C-6 for 22mm at C-6 for

adultsadults Technique dependentTechnique dependent

ExtensionExtension InspirationInspiration

Sensitivity 83%, Sensitivity 83%, compared to CT 100%compared to CT 100%

ImagingImaging CT with contrastCT with contrast

ProsPros Widely availableWidely available Faster (5-15 minutes)Faster (5-15 minutes) Abscess vs cellulitisAbscess vs cellulitis Less expensiveLess expensive

ConsCons ContrastContrast RadiationRadiation UniplanarUniplanar Dental artifactsDental artifacts

MRIMRI Pros Pros

MRI superior to CT in MRI superior to CT in initial assessment initial assessment

More precise More precise identification of space identification of space involvement involvement (multiplanar)(multiplanar)

Better detection of Better detection of underlying lesionunderlying lesion

Less dental artifactLess dental artifact Better for floor of mouthBetter for floor of mouth No radiationNo radiation Non iodine contrastNon iodine contrast

ConsCons CostCost Pt cooperationPt cooperation Slower (19 to 35 Slower (19 to 35

minutes)minutes)

ImagingImaging

Regular cavity wall Regular cavity wall with ring with ring enhancement (RE)enhancement (RE) Sensitivity - 89%Sensitivity - 89% Specificity - 0%Specificity - 0%

Irregular wall Irregular wall (scalloped)(scalloped) Sensitivity - 64%Sensitivity - 64% Specificity - 82%Specificity - 82% PPV - 94%PPV - 94%

Modified and combined data from 738 patients (1, 2, 3, 4, 5, 6, 7).

BacteriologyAerobic               Anaerobic    

G (+) n %   G (-) n %     n %

Total 64587.40   Total 137

18.56   Total 201 27.24

Strep sp. 229 31.03   Klebsiella sp. 90 12.20   Peptostreptococcus 43 5.83

Staph sp. 112 15.18   Neisseria sp. 20 2.71   Bacteroides sp. 50 6.78

B-hemolytic Strep 80 10.84   Acinebacter sp. 7 0.95   Unidentified 46 6.23

Strep viridans 71 9.62   Enterobacter sp. 7 0.95   Bacteroides melaninogenicus 13 1.76

Staph aureus 57 7.72   Proteus sp. 4 0.54   Propionibacterium 9 1.22

Coagulase neg. Staph sp. 55 7.45   E coli 3 0.41   Provotella sp. 7 0.95

Strep pneum 13 1.76   Citrobacter sp 2 0.27   Fusobacterium 7 0.95

Enterococcus 10 1.36   M. Catarrhalis 2 0.27   Bacteroidies fragilis 6 0.81

Mycobacterium tub.* 10 1.36   Pseudomonas sp. 1 0.14   Eubacterium 6 0.81

Micrococcus 8 1.08   H. Parainfluenza 1 0.14   Peptococcus 6 0.81

Diptheroids 7 0.95   H influenzae 1 0.14   Veillonella parvula 5 0.68

Bacillus sp. 6 0.81   Salmonella sp. 1 0.14   Clostridium sp. 4 0.54

Actinomycosis israelii 3 0.41           Lactobacillus 4 0.54

        Bifidobacterium sp. 3 0.41

Polymicrobial 18124.53   Sterile 71 9.62        

Antibiotic TherapyAntibiotic Therapy

Initial therapyInitial therapy Cover Gram positive cocci and Cover Gram positive cocci and

anaerobesanaerobes If pt is diabetic, should consider If pt is diabetic, should consider

covering gram negatives empirically.covering gram negatives empirically. Unasyn, Clindamycin, 2Unasyn, Clindamycin, 2ndnd generation generation

cephalosporin.cephalosporin. PCN, gentamicin and flagyl - PCN, gentamicin and flagyl -

developing nations. developing nations.

IV abx alone (based on retro and IV abx alone (based on retro and parapharyngeal infections)parapharyngeal infections)

Patient stability and nature of lesion.Patient stability and nature of lesion. Cellulitis/phlegmon by CT.Cellulitis/phlegmon by CT. Abscesses in clinically stable patient.Abscesses in clinically stable patient. If no clinical improvement in 24 - 48 If no clinical improvement in 24 - 48

hours proceed to surgical hours proceed to surgical intervention.intervention.

SurgerySurgery

External drainageExternal drainage LandmarksLandmarks

Tip of greater horn of Tip of greater horn of hyoidhyoid

Cricoid cartilageCricoid cartilage Styloid processStyloid process SCMSCM

Transoral drainageTransoral drainage Parapharyngeal, Parapharyngeal,

retropharyngeal abscessesretropharyngeal abscesses Great vessels lateral to Great vessels lateral to

abscessabscess Tonsillectomy for exposureTonsillectomy for exposure

Needle aspirationNeedle aspiration

ComplicationsComplications

Airway obstructionAirway obstruction Trach 10 – 20%Trach 10 – 20% Ludwig’s angina - 75%Ludwig’s angina - 75%

Mediastinitis – 2.7%Mediastinitis – 2.7% UGI bleedingUGI bleeding SepsisSepsis PneumoniaPneumonia IJV thrombosisIJV thrombosis Skin defectSkin defect Vocal cord palsyVocal cord palsy Pleural effusionPleural effusion HemorrhageHemorrhage

20 - 80% mortality20 - 80% mortality Multiple space Multiple space

involvementinvolvement

Who gets complications?Who gets complications? Older ptsOlder pts Systemic dzSystemic dz

Immunodeficient ptsImmunodeficient pts HIVHIV MyelodysplasiaMyelodysplasia

CirrhosisCirrhosis DMDM

Most common systemicMost common systemic Mbio – Klebsiella pneum. Mbio – Klebsiella pneum.

(56%) (56%) 33% with complications33% with complications Higher mortality rateHigher mortality rate Prolonged hospital stayProlonged hospital stay

20 days vs. 10 days20 days vs. 10 days

Descending Necrotizing Descending Necrotizing MediastinitisMediastinitis

Definition – mediastinal infection in which pathology Definition – mediastinal infection in which pathology originates in fascial spaces of head and neck and extends originates in fascial spaces of head and neck and extends down.down.

Retropharyngeal and Danger Space – 71%Retropharyngeal and Danger Space – 71% Visceral vascular – 20%Visceral vascular – 20% Anterior visceral – 7-8%Anterior visceral – 7-8%

Criteria for diagnosisCriteria for diagnosis1.1. Clinical manifestation of severe infection.Clinical manifestation of severe infection.2.2. Demonstration of the characteristic imaging features of mediastinitis.Demonstration of the characteristic imaging features of mediastinitis.3.3. Features of necrotizing mediastinal infection at surgery.Features of necrotizing mediastinal infection at surgery.

1960-89 – 43 published cases1960-89 – 43 published cases Mortality rate 14-40%Mortality rate 14-40%

Clinical PresentationClinical Presentation

SymptomsSymptoms Respiratory difficultyRespiratory difficulty TachycardiaTachycardia Erythema/edemaErythema/edema Skin necrosisSkin necrosis CrepitusCrepitus Chest painChest pain Back painBack pain ShockShock

Important to have Important to have a low threshold for a low threshold for further workupfurther workup

Mediastinitis ImagingMediastinitis Imaging

Plain filmsPlain films Widened mediastinum Widened mediastinum

(superiorly)(superiorly) Mediastinal emphysemaMediastinal emphysema Pleural effusionsPleural effusions Changes appear late in the Changes appear late in the

disease.disease.

CT neck and thorax.CT neck and thorax. Esophageal thickeningEsophageal thickening Obliterated normal fat Obliterated normal fat

planesplanes Air fluid levelsAir fluid levels Pleural effusionsPleural effusions CT helps establish dx and CT helps establish dx and

surgical plansurgical plan

TreatmentTreatment

IV antibioticsIV antibiotics Cervical drainageCervical drainage

Cervical abscessesCervical abscesses Superior mediastinal Superior mediastinal

abscesses above T4 (tracheal abscesses above T4 (tracheal bifurcation)bifurcation)

Transthoracic drainageTransthoracic drainage Abscesses below T4Abscesses below T4

Subxyphoid approachSubxyphoid approach Anterior mediastinal drainageAnterior mediastinal drainage

Thoracostomy tubesThoracostomy tubes

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