deep neck spaces and infections
TRANSCRIPT
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Deep Neck Spaces and Infections
Elizabeth J. Rosen, MD
Faculty Advisor: Byron J. Bailey, MD
The University of Texas Medical Branch
Department of Otolaryngology
Grand Rounds Presentation
April 17, 2002
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Deep Neck Spaces and Infections
Anatomy of the Cervical Fascia
Anatomy of the Deep Neck Spaces
Deep Neck Space Infections
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Cervical Fascia
Superficial Layer
Deep Layer
Superficial
Middle
Deep
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Cervical Fascia
Superficial Layer
Platysma
Muscles of Facial
Expression
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Cervical Fascia
Superficial Layer of the
Deep Cervical Fascia
Muscles
Sternocleidomastoid
Trapezius
Glands
Submandibular
Parotid
Spaces
Posterior Triangle
Suprasternal space of Burns
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Cervical Fascia
Middle Layer of the
Deep Cervical Fascia
Muscular Division
Infrahyoid Strap
Muscles
Visceral Division
Pharynx, Larynx,
Esophagus, Trachea,
Thyroid
Buccopharyngeal
Fascia
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Cervical Fascia
Deep Layer of Deep
Cervical Fascia
Alar Layer
Posterior to visceral
layer of middle fascia
Anterior to
prevertebral layer
Prevertebral Layer
Vertebral bodies
Deep muscles of the
neck
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Cervical Fascia
Carotid Sheath
Formed by all three
layers of deep fascia
Contains carotid
artery, internal
jugular vein, and
vagus nerve
“Lincoln’s
Highway”
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Deep Neck Spaces
Described in relation to the hyoid
Entire length of the
neck
Suprahyoid
Infrahyoid
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Deep Neck Spaces
Entire Length of Neck:
Superficial Space
Surrounds platysma
Contains areolar tissue,
nodes, nerves and vessels
Subplatysmal Flaps
Involved with cellulitis
and superficial abscesses
Treat with incision along
Langer’s lines, drainage
and antibiotics
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Deep Neck Spaces
Entire Length of
Neck:
Retropharyngeal
Space
Posterior to pharynx
and esophagus
Anterior to alar layer
of deep fascia
Extends from skull
base to T1-T2
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Deep Neck Spaces
Entire Length of Neck:
Danger Space
Anterior border is alar
layer of deep fascia
Posterior border is
prevertebral layer
Extends from skull base
to diaphragm
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Deep Neck Spaces
Entire Length of Neck:
Prevertebral Space
Anterior border is
prevertebral fascia
Posterior border is
vertebral bodies and
deep neck muscles
Extends along entire
length of vertebral
column
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Deep Neck Spaces
Entire Length of
Neck: Visceral
Vascular Space
Carotid Sheath
“Lincoln’s Highway”
Can become
secondarily involved
with any other deep
neck space infection by
direct spread
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Deep Neck Spaces
Suprahyoid:
Submandibular Space
Anterior/Lateral—
mandible
Superior—mucosa
Inferior—superficial layer
of deep fascia
Posterior/Inferior--hyoid
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Deep Neck Spaces
Suprahyoid:
Submandibular Space
Sublingual Space
Areolar tissue
Hypoglossal and lingual
nerves
Sublingual gland
Wharton’s duct
Submylohyoid Space
Anterior bellies of digastrics
Submandibular gland
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Deep Neck Spaces
Suprahyoid: Parapharyngeal Space
Superior—skull base
Inferior—hyoid
Anterior—ptyergomandibular raphe
Posterior—prevertebral fascia
Medial—buccopharyngeal fascia
Lateral—superficial layer of deep fascia
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Deep Neck Spaces
Suprahyoid:
Parapharyngeal Space
Prestyloid
Medial—tonsillar fossa
Lateral—medial pterygoid
Contains fat, connective
tissue, nodes
Poststyloid
Carotid sheath
Cranial nerves IX, X, XII
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Deep Neck Spaces
Suprahyoid:
Peritonsillar Space
Medial—capsule of
palatine tonsil
Lateral—superior
pharyngeal constrictor
Superior—anterior
tonsil pillar
Inferior—posterior
tonsil pillar
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Deep Neck Spaces
Suprahyoid: Masticator
and Temporal Spaces
Formed by the
superficial layer of deep
cervical fascia
Masseter and pterygoids
Temporalis
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Deep Neck Spaces
Suprahyoid: Parotid
Space
Superficial layer of deep
fascia
Dense septa from
capsule into gland
Direct communication to
parapharyngeal space
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Deep Neck Spaces
Infrahyoid: Anterior
Visceral Space
Middle layer of deep
fascia
Contains thyroid,
trachea, esophagus
Extends from thyroid
cartilage into superior
mediastinum
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Deep Neck Space Infections
Presentation/Origin of Infection
Microbiology
Imaging
Treatment
Complications
Special Consideration
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Presentation/Origin
Retropharyngeal Abscess
50% occur in patients 6-12 months of age
96% occur before 6 years of age
Children--fever, irritability, lymphadenopathy,
torticollis, poor oral intake, sore throat, drooling
Adults--pain, dysphagia, anorexia, snoring, nasal
obstruction, nasal regurgitation
Dyspnea and respiratory distress
Lateral posterior oropharyngeal wall bulge
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Presentation/Origin
Pediatrics
Cause—suppurative
process in lymph nodes
Nose, adenoids,
nasopharynx, sinuses
Adults
Cause—trauma,
instrumentation,
extension from
adjoining deep neck
space
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Presentation/Origin
Danger Space
Presentation and exam nearly identical to
retropharyngeal space infection
Cause—extension from retropharyngeal,
prevertebral or parapharyngeal space
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Presentation/Origin
Prevertebral Space
Back, shoulder, neck pain
made worse by deglutition
Dysphagia or dyspnea
Cause—Pott’s abscess, trauma,
osteomyelitis, extension from
retropharyngeal and danger spaces
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Presentation/Origin
Visceral Vascular Space
Induration and tenderness over SCM
Torticollis toward opposite side
Spiking fevers, sepsis
Cause—intravenous drug abuse, extension from
other deep neck spaces
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Presentation/Origin
Submandibular Space
Pain, drooling, dysphagia, neck stiffness
Anterior neck swelling, floor of mouth edema
Cause—70-85% have odontogenic origin
First molar and anterior
Second and third molars
Sialadenitis, lymphadenitis, lacerations of the floor of mouth, mandible fractures
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Presentation/Origin
Ludwig’s angina
1. Cellulitis, not abscess
2. Limited to SM space
3. Foul serosanguinous fluid, no frank purulence
4. Fascia, muscle, connective tissue involvement, sparing glands
5. Direct spread rather than lymphatic spread
Tender, firm anterior neck edema without fluctuance
“Hot potato” voice, drooling
Tachypnea, dyspnea, stridor
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Presentation/Origin
Parapharyngeal Space
Fever, chills, malaise
Pain, dysphagia, trismus
Medial bulge of lateral
pharyngeal wall
Cause—infection of pharynx,
tonsil, adenoids, dentition,
parotid, mastoid, suppurative
lymphadenitis, extension from
other deep neck spaces
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Presentation/Origin
Peritonsillar Space
Fever, malaise
Dysphagia, odynophagia
“Hot-potato” voice,
trismus, bulging of superior
tonsil pole and soft palate,
deviation of uvula
Cause—extension from
tonsillitis
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Presentation/Origin
Masticator
Temporal Space
Pain, trismus
Posterior FOM
edema
Swelling along
ramus of mandible
Cause—
odontogenic, from
third molars
Parotid Space
Pain, trismus
Medial bulge of posterior lateral pharyngeal wall
Cause—parotitis, sialolithiasis, Sjogren’s syndrome
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Presentation/Origin
Anterior Visceral Space
Hoarseness, dyspnea, dysphagia, odynophagia
Erythema, edema of hypopharynx, may extend to
include glottis and supraglottis
Anterior neck edema, pain, erythema, crepitus
Cause—foreign body, instrumentation, extension
of infection in thyroid
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Microbiology
Preantibiotic era—S.aureus
Currently—aerobic Strep species and non-strep
anaerobes
Gram-negatives uncommon
Almost always polymicrobial
Remember resistance
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Imaging
Lateral neck plain film
Screening exam—mainly
for retropharyngeal and
pretracheal spaces
Normal: 7mm at C-2,
14mm at C-6 for kids,
22mm at C-6 for adults
Technique dependent
Extension
Inspiration
Nagy, et al
Sensitivity 83%,
compared to CT 100%
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Imaging
High-resolution Ultrasound
Advantages
Avoids radiation
Portable
Disadvantages
Not widely accepted
Operator dependent
Inferior anatomic detail
Uses
Following infection during therapy
Image guided aspiration
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Imaging
Contrast enhanced CT
Advantages
Quick, easy
Widely available
Familiarity
Superior anatomic detail
Differentiate abscess and cellulitis
Disadvantages
Ionizing radiation
Allergenic contrast agent
Soft tissue detail
Artifact
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Imaging
Contrast enhanced CT
Modality of choice
Miller, et al: CT vs. PE
Accuracy of diagnosis: CT = 77%, PE = 63%
Sensitivity: CT = 95%, PE = 55%
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Imaging
MRI
Advantages
No radiation
Safer contrast agent
Better soft tissue detail
Imaging in multiple planes
No artifact by dental fillings
Disadvantages
Increased cost
Increased exam time
Dependent on patient
cooperation
Availability
Munoz, et al: MRI vs. CT
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Treatment
Airway protection
Antibiotic therapy
Surgical drainage
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Treatment
Airway protection
Observation
Intubation
Direct laryngoscopy: possible risk of rupture and aspiration
Flexible fiberoptic
Tracheostomy
Ideally = planned, awake, local anesthesia
Abscess may overlie trachea
Distorted anatomy and tissue planes
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Treatment
LUDWIG’S ANGINA = PERILOUS AIRWAY
Parhiscar and Har-El
Review of 210 patients with
deep neck abscess
Overall, 20.5% required
tracheostomy
Ludwig’s angina, 75%
required tracheostomy
Attempted intubation in 20 patients
Failed in 11 patients, necessitating
“slash” tracheostomy
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Treatment
Antibiotic Therapy
Cellulitis
Improvement in 24-48 hours
Abscess?
Mayor, et al: review of 31 patients, 19 with CT
evidence of abscess, 90% response
Nagy, 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 Therapy
Polymicrobial infections
Aerobic Strep, anaerobes
Ampicillin/sulbactam with metronidazole
Beta-Lactam resistance in 17-47% of isolates
Alternatives
Third generation cephalosporins
clindamycin
Culture and sensitivity
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Treatment
Surgical Drainage
Transoral
Preoperative CT—where are the great vessels?
Cruciate mucosal incision, blunt spreading through
superior pharyngeal constrictor
Nagy, et al: retro-, parapharyngeal or combo in kids
22/23 successfully treated with intraoral incision and drainage
External
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Treatment
Surgical Drainage
External
EXPOSURE, EXPOSURE, EXPOSURE
Levitt: anterior vs. posterior
approach
Submandibular incision
Submental incision
T-incision
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Treatment
Image-guided Aspiration
Patient selection
Smaller abscesses, limited extension, uniloculated
Poe, et al: CT guided aspiration
Early specimen collection, reduced expense, avoidance of
neck scar
Yeow, et al: Ultrasound guided aspiration
8/10 patients successfully treated with needle aspiration
5/5 patients successful treated with pigtail catheter
insertion
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Complications
Airway obstruction
Endotracheal intubation
Tracheostomy
Ruptured abscess
Pneumonia
Lung Abscess
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Complications
Internal Jugular Vein Thrombosis
Lemierre’s syndrome
F/C, prostration, swelling and pain along SCM
Bacteremia, septic embolization, dural sinus thrombosis
IV drug abusers
Treatment
IV antibiotic therapy
Anticoagulation?
Ligation and excision
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Complications
Carotid Artery Rupture
Mortality of 20-40%
Sentinel bleeds from ear, nose, mouth
Majority from internal carotid, less from external
carotid, and fewest from common carotid
Treatment
Proximal and distal control
Ligation
Patching or grafting?
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Complications
Mediastinitis
Mortality of 40%
Increasing dyspnea, chest pain
CXR = widened mediastinum
Treatment
EARLY RECOGNITION AND INTERVENTION
Aggressive IV antibiotic therapy
Surgical drainage
Transcervical approach
Chest tube vs. thoracotomy
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Special Consideration
Recurrent Deep Neck Space Infection
THINK CONGENITAL ABNORMALITY
Imaging should help make the diagnosis
Nusbaum, et al: 12 cases of recurrent deep neck
infection
Most Common: second branchial cleft cyst
Others: first, third, fourth branchial cleft cysts,
lymphangiomas, thyroglossal duct cysts, cervical
thymic cyst
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Case Presentation
43 y/o man presents to the ER complaining
of mouth and neck pain, he finds it difficult
to swallow and has been spitting out his
saliva.
He also reports progressive swelling in his
neck that it tender to touch.
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Case Presentation
Additional history
Denies recent URI or pharyngitis
Had an infected third molar pulled about 5 days
ago
No difficulty breathing at rest
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Case Presentation
Past Medical History
HTN, renal failure
Past Surgical History
Kidney transplant
Medications
Prednisone, cyclosporin, metoprolol
Allergies
nkda
Social History
Nonsmoker, occasional alcohol
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Case Presentation
Physical Exam
BP 124/70, P 96, RR 18, T 38.0, O2 sat 98% RA
Gen: no distress, uncomfortable, muffled voice
Tender, erythematous edema over right level I & II,
no distinctly palpable nodes, no fluctuance
FOM is slightly edematous and tender but soft, the
tongue is not elevated, evidence of tooth extraction
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Case Presentation
Laboratory Studies
WBCs 21,000, elevated bands
Electrolytes wnl
Cyclosporin level ok
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Case Presentation
CT Neck
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Case Presentation
Treatment
To OR for external incision and drainage, using a transverse, submandibular skin incision
Specimens sent for culture and sensitivities
Penrose drain left in place for continued drainage
IV antibiotic therapy started with Unasyn
POD #2, remains febrile, neck is still erythematous and indurated
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Case Presentation
Follow up on culture and sensitivities
Broaden antibiotic therapy for better
anaerobic and gram-negative coverage