deep space neck infections s notes alice lee april 28, 2005

7/31/2019 Deep Space Neck Infections s Notes Alice Lee April 28, 2005

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Patient History

CC: Neck mass HPI: 5 yo boy with 3 day history of sore throat, fever,

with 1 day h/o neck swelling, refusing to move neck, c/o

neck pain. No change with amoxicillin x2 days. No drooling, no voice change, refusing food x1day, no

trismus, no noisy breathingBrothers and pt had recent upper resp infection,Neg for: sinus infection, OM, other HN infection, cat

exposure, recent travel, TB contact, CA RFs, trauma,known immunodeficiency (HIV, steroid use)

PMH/PSH/ALL/Fam hx:neg Meds: amoxicillin 2days


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Patient Exam

Gen Alert, appropriate, anxious but in NAD, nostridor, no stertor, no drooling, normal voice,neck held rigid position slightly to right

Ears/Nose: clear bilat, no pus OC/OP: no trismus, teeth WNL, 2+ tonsils, no

asymmetry of soft palate or bulging of posteriorpharyngeal walls visible, soft throughout, tongue

motion normal Neck: 8 x 4cm R upper neck diffusely swollenarea parallel to body of mandible, mildlyerythematous, very TTP, firm, warm to touch


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Differential Diagnosis

V-venous malformation I-Cat scratch disease, TB, atypical mycobacteria,

viral/bacterial LAD, mono, sebaceous cyst, deep spaceabscess, mastoiditis with Bezolds abscess, sialadenitis

T-Hematoma, esophageal perforation, fibromatosis colli A-granulomatous diseases M-parathyroid cyst, thymic cyst, aberrant thyroid

tissue/hyperplasia

I-Kawasaki disease

N-Met, lymphoma, tumors of: thyroid, salivary gland, vascular(carotid body, glomus, hemangioma), neural; lipoma

C-branchial cleft cyst, cystic hygroma, thyroglossal duct cyst,teratoma, dermoid cyst, external laryngocele, plunging ranula


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Imaging


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Deep Neck Space Infections

Alice Lee

April 28, 2005


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Background

Before antibiotics, 70% deep neck infectionswere caused by tonsillar and pharyngealsources. More recently,

Most common cause in adults:odontogenic, IVDA

Most common cause in peds:tonsillar, URI

Others: salivary gland, trauma, FB,instrumentation, local or superficial source

22% without cause (1)1. Tom MB, Rice DH: Presentation and management of neck abscesses: a retrospective analysis, Laryngoscope 98:877, 1988


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Anatomy of Cervical Fascia

Superficial cervical fascia Deep cervical fascia

Superficial layerMiddle layer

Muscular divisionVisceral division

Deep layerPrevertebral division

Alar division


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Anatomy of Cervical Fascia:Superficial cervical fascia

Continuous sheath of fibrofatty subcutaneoustissue

Attachments: zygomatic process to thorax andaxilla

Contents: platysma, muscles of facial expression Not considered a part of the deep neck; local

I&D and antibiotics Between superficial and deep layers: Fat,sensory nerves, EJ, AJ, superficial lymphatics


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Anatomy of Cervical Fascia:Superficial layer of the deep cervical fascia

Enveloping or investing later Insertion at nuchal line of the skull

chest and axillary regions; spreadsanteriorly to the face and attaches atclavicles

Envelopes SCM, trapezius, portion ofomohyoid in posterior triangle, parotid andsubmandibular glands


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Anatomy of Cervical Fascia:Middle layer of the deep cervical fascia

Muscular divisionSurrounds straps. Attaches superiorly to hyoidand thyroid cartilage and inferiorly to sternum,

clavicle and scapula Visceral divisionSurrounds thyroid, trachea, esophagus. Superiorattached to base of skull, thyroid cartilage andhyoid covers trachea and esophagus andblends with fibrous pericardium

Bonus: What does a portion of the visceraldivision form? (Covers the constrictor andbuccinator muscles)


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Anatomy of Cervical Fascia:Deep layer of the deep cervical fascia

Contents: Paraspinous muscles and cervicalvertebrae

Prevertebral and alar divisions Prevertebral: Begins anterior to the vertebralbodies, spreads laterally to fuse with transverseprocesses, extends posteriorly to enclose deep

muscles of neck and attaches to vertebralspines. Forms the posterior wall of the dangerspace and anterior wall of prevertebral space


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Anatomy of Cervical Fascia:Deep layer of the deep cervical fascia

Alar divisionLies between the prevertebral division and the

middle layer of the deep cervical fascia Attaches from transverse process tocontralateral transverse process, skull base toT2, fuses with visceral division of middle layer of

deep cervical fascia. Carotid sheath: made up of all 3 deep layers


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Cervical fascial planes


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Lymph


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Deep Neck Spaces

Suprahyoid spaces:1. Pharyngomaxillary/

Lateral pharyngeal

2. Submandibular3. Parotid4. Masticator5. Peritonsillar

6. Buccal Infrahyoid spaces:

1. Anterior visceral

Spaces involvingentire length of neck:1. Retropharyngeal

2. Danger3. Prevertebral4. Visceral vascular


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Retropharyngeal space

Potential space posterior to visceral division ofmiddle layer of deep cervical fascia and anteriorto alar division of deep layer of deep cervical

fascia Skull base to T1/2/tracheal bifurcation in closeapproximation to mediastinum

Midline raphe-superior constrictor muscles

adheres to prevertebral division; separatesretropharyngeal nodes into two lateral chains. Contents: fat, CT, LNs which drain nose, NP, soft

palate, ET, paranasal sinuses


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Most commonly seen inpeds due to drainage source

Peds: preceding URI, fever,dysphagia, odynophagia,nuchal rigidity, asymmetricbulging of post pharyngealwall due to midline raphe

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

Can extend to:mediastinum, danger space,parapharyngeal space


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Lateral soft tissue XR (extension, inspiration) abnormalfindings:

1. C2-post pharyngeal soft tissue >7mm 2. C6adults >22mm, peds >14mm

3. STS of post pharyngeal region >50% width ofvertebral body


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Danger Space

Potential space between the alar andprevertebral divisions of the deep layer of

the deep cervical fascia Posterior to the retropharyngeal space andanterior to the prevertebral space

Why is it given this name? Extends from skull base to posterior

mediastinum to diaphragm


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Danger Space

Caused by infectious spread fromretropharyngeal, prevertebral and

parapharyngeal spaces or less commonly,by lymphatic extension from the nose andthroat

Watch for severe dyspnea, chest pain,widened mediastinum on CXR mayneed thoracotomy for drainage


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Prevertebral space

Potential space posterior to prevertebraldivision and anterior to vertebral bodies

Extends from skull base to the coccyx Most common cause:

iatrogenic/penetrating trauma

Previous most common cause: TB


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Visceral vascular space

Potential space within the carotid sheath Lymphatic vessels within receive drainage

from most of the lymphatic vessels in thehead and neck

Most common source of infection isparapharyngeal space

Why is this called the Lincoln Highway ofthe neck?


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Spaces involving entire length ofneck

Visceral layer-mid RETROPHARYNGEAL

SPACE (T2)

Alar division-deep DANGER SPACE

(diaphragm)

Prevertebral division

PREVERTEBRALSPACE (coccyx) Vertebrae


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Deep Neck Spaces


Lateral pharyngeal


6. Buccal Infrahyoid spaces:

1. Anterior visceral




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Pharyngomaxillary/Parapharyngeal/Lateral pharyngeal space

Cone in lateral aspect of neck Apex: hyoid bone

Base: petrous temporal bone Lateral: superficial layer of deep cervical fascia

over the mandible, parotid, internal pterygoid

Medial: lateral pharyngeal wall

Ant/post: pterygomandibular raphe/ prevertebralfascia


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Divided into anterior and posterior compartments bystyloid bones and muscles

Prestyloid/Muscular compartment:

-Tonsillar fossa medially, internal pterygoid laterally-Fat, lymph nodes, parotid masses-Displacement of lat pharyngeal wall, early trismus-Most common mass pleomorphic adenoma

Post-styloid/Neurovascular compartment:-Carotid, IJV, cervical sympathetic chain, CN IX-XII-Most common mass - schwannoma


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Connects to the majorityof other fascial spaces

Sources: parotid,

masticator,submandibular,peritonsillar,tonsils/pharynx,odontogenic, LN from

nose and throat,mastoiditis (Bezoldabscess)


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Never approachintraorally

Traditionally: Mosherincision

Horizontal neck incision follow carotid sheathinto space fingerdissect belowsubmandibular gland,

along posterior belly ofdigastric deep to mastoidtip toward styloid


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Submandibular space

Composed of sublingual space superiorly andsubmaxillary space inferiorly, divided by mylohyoid

Boundaries: FOM mucosa above, superficial layer ofdeep fascia below, mandible ant/lat, hyoid inferiorly,BOT muscles posteriorly

Sublingual space: gland, Wharton, CN XII Submaxillary: gland, facial artery, lingual nerve;

communicates with sublingual space around posteriorborder of mylohyoid through submandibular gland

Ludwigs angina bilateral cellulitis of submandibularand sublingual spaces Inspect 2nd and 3rd molars apices extend below

mylohyoid line providing direct access to submandibularspace


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Parotid space

Formed by the splitting and surrounding ofsuperficial layer of deep cervical fascia;incomplete at upper inner surface of gland =direct communication with lateral pharyngealspace (dumbbell shaped masses secondary tostylomandibular ligament)

Contents: parotid gland, external carotid,posterior facial vein, facial nerve, lymph nodes


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Masticator space

Superficial layer of deep cervical fascia splits aroundmandible to form this space and encases muscles ofmastication

4 compartments: Masseteric, Pterygoid, SuperficialTemporal, Deep Temporal Contents: masseter, pterygoid muscles, temporalis

tendon, inferior alveolar nerves and vessels, body andramus of mandible, internal maxillary artery

Most common source : 3rd molar Complication: osteomyelitis of mandible


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Peritonsillar

Boundaries: anterior and posterior pillars, palatine tonsil,superior constrictor muscle

Indications for Quincy tonsillectomy?No clear cut indications. Treatment is still controversial.

Needle aspiration, I&D, quincy tonsillectomy all equallyeffective initial management with 10-15% recurrrencerate. (1)

Again, 10-15% recurrence after needle aspiration and/orI&D; greatest risk in patients


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Buccal space

Boundaries: Buccinator muscle, cheek,zygomatic arch, pterygomandibular raphe,

inferior mandible Odontogenic source with buccal swelling

and preseptal cellulitis possible

Complication: cavernous sinus thrombosis


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Deep Neck Spaces


Lateral pharyngeal


6. Buccal Infrahyoid spaces:1. Anterior visceral




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Anterior visceral space

Pretracheal space from thyroid cartilage to T4level, enclosed by visceral division of middlelayer, just deep to straps, surrounds trachea

Source: esophageal anterior wall perforation,external trauma

Symptoms: mainly dysphagia, later hoarseness,

dyspnea, airway obstruction Complication: mediastinitis, airway


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Network of infectious extension


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Pathogens

Likely dependent on portal of entry and spaceinvolved 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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Antibiotics


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Necrotizing fasciitis

Fulminent infection, polymicrobial, usually odontogenicsource, more frequently in immunocompromised andpostoperative

PEX: ill, high fever, neck crepitus, exquisitely tender,unimpressive erythema s sharp demarcating borderprogress to pale then dusky as necrosis progresses can have bullae/blisters/sloughing


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Diagnosis Pain, trismus, limitation

neck motion, swelling,sustained fever,leukocytosis with leftshift, lateral neck XR/CT

Prevertebral orretropharyngeal hot

potato voice, difficultnoisy breathing,dys/odynophagia,drooling, neck posturing

Parapharyngeal medialdisplacement of lateralpharyngeal wall, fullnessof retromandibular area.Prestyloidtrismus, tonsilswelling. Poststyloid-

dysphagia


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Management

Hospitalization for airway management,aggressive antibiotics, hydration, I&D

If no evidence of airway compromise, abx 24

hrs. 10-15% improve with medical mgmt. Surgery indicated for airway compromise, nosignificant response to abx in 24-48 hours,evidence of sepsis

Transoral peritonsillar, uncomplicated RP andprevertebral abscesses with mass in oropharynx,uncomplicated sublingual (not for submaxextension)


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Management

Surgical principles: wide exposure, usereadily identifiable landmarks (digastric,

hyoid, SCM, cricoid, greater horn ofthyroid), blunt dissection, identify carotidsheath early, cultures/biopsy,debridement, irrigation, leave wound openand pack for extensive necrosis, can closeless necrotic wound and use drain


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Complications

40 yr old pt is admitted forparapharyngeal infection. Started on abx,

IVF, observation. Afebrile within 24 hourswith improved dysphagia. HD #2 spikes to104, defervesces, respikes. Whatshappening?

Thrombophlebitis of IJV


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Complications signs andsymptoms

Mediastinitis chest pain,worsened dyspnea,dysphagia, widenedmediastinum on CXR

Horners, hoarseness,unilateral tongue paresis,plethora of face, chokedoptic disks, Tobey Ayer,erosion of carotid

(critical, pharyngealbleeding episode, neckhematoma, rare EACblood


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Treatment of complications

Mediastinitis most commonly via retropharyngealspace > visceral or PP

Abdominal abscess prevertebral space

IJV septic thrombophlebitis IVDA, ligate and removethrombosed vein at I&D NeuropathyHorners, hoarseness, unilateral tongue

paresis

Erosion of carotid artery rare, emergency, clot found inneck at I&D, proximal and distal control, intraop angio ifpossible (75% CCA or ICA)


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References

Baileys Cummings SIPAC Diagnosis and management of deep neck infections Hollinshead Anatomy for Surgeons Head and Neck Head and Neck Imaging Shankar

Tom MB, Rice DH. Presentation and management of neck abscesses a retrospective analysis.Laryngoscope 1988;98:877.

Johnson RF, Stewart MG, Wright CC. An evidence-based review of the treatment of peritonsillarabscess. Otolaryngol Head Neck Surg. 2003 Mar;128(3):332-43.

Herzon FS. Peritonsillar abscess: incidence, current management practices, and a proposal fortreatment guidelines. Laryngoscope 1995;105 [suppl 74]:1-7.

Tan PT, et al. Deep neck infections in children. J Microbiol Immunol Infect 2001;34:287-292.

deep space neck infections s notes alice lee april 28, 2005

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