Download - Deep Neck Infection 051005
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
BibliographyBibliography1. Scott, BA, Stiernberg, CM, Driscoll, BP. Deep Neck Space Infections. In: Head and Neck Surgery—Otolaryngology,
2nd ed., Bailey, BJ ed. Philadelphia, Lippincott-Raven Publishers, 1998; 819-352.2. Kirse, DJ, Roberson,DW. Surgical Management of Retropharyngeal Space Infections in Children. Laryngoscope, 111: Kirse, DJ, Roberson,DW. Surgical Management of Retropharyngeal Space Infections in Children. Laryngoscope, 111:
1413-1422, 2000.1413-1422, 2000.3.3. Stalfors, J, Adielsson, A, Ebenfelt, A, Nethander, G, Westin, T. Deep Neck Space Infections Remain a Surgical Stalfors, J, Adielsson, A, Ebenfelt, A, Nethander, G, Westin, T. Deep Neck Space Infections Remain a Surgical
Challenge. A Study of 72 Patients. Acta Otolaryngol 2004; 124: 1191-1196.Challenge. A Study of 72 Patients. Acta Otolaryngol 2004; 124: 1191-1196.4.4. Meher, R, Jain, A, Sabharwal, A, Gupta, B, Singh, I, Agarwal, AK. Deep Neck Abscess: A Prospective Study of 54 Meher, R, Jain, A, Sabharwal, A, Gupta, B, Singh, I, Agarwal, AK. Deep Neck Abscess: A Prospective Study of 54
Cases. The Journal of Laryngology and otology. April 2005. Vol 119, 299-302.Cases. The Journal of Laryngology and otology. April 2005. Vol 119, 299-302.5.5. Nagy, M, Pizzuto, M, Backstrom, J, Brodsky, L. Deep Neck Infections in Children: A New Approach to Diagnosis and Nagy, M, Pizzuto, M, Backstrom, J, Brodsky, L. Deep Neck Infections in Children: A New Approach to Diagnosis and
Treatment. Laryngoscope. 1997; 107 (12): 1627-1634.Treatment. Laryngoscope. 1997; 107 (12): 1627-1634.6.6. Huang, TT, Liu, TC, Chen, PR, Tseng, FY, Yeh, TH, Chen, YS. Deep Neck Infection: Analysis of 185 Cases. Head and Huang, TT, Liu, TC, Chen, PR, Tseng, FY, Yeh, TH, Chen, YS. Deep Neck Infection: Analysis of 185 Cases. Head and
Neck. 26: 854-860. 2004.Neck. 26: 854-860. 2004.7.7. Parhiscar, A, Har-El, G. Deep neck abscess: A retrospective review of 210 cases. Annals of Otology, Rhinology and Parhiscar, A, Har-El, G. Deep neck abscess: A retrospective review of 210 cases. Annals of Otology, Rhinology and
Laryngology, 2001; 110 (11): 1051-54.Laryngology, 2001; 110 (11): 1051-54.8.8. Huang, TT, Tseng, FY, Lie, TC, Hsu, CJ, Chen ,YS. Deep Neck Infection in Diabetic Patients: Comparison of Clinical Huang, TT, Tseng, FY, Lie, TC, Hsu, CJ, Chen ,YS. Deep Neck Infection in Diabetic Patients: Comparison of Clinical
Picture and Outcomes with Nondiabetic Patients. Otolaryngol Head Neck Surg 2005;13:943-7.Picture and Outcomes with Nondiabetic Patients. Otolaryngol Head Neck Surg 2005;13:943-7.9.9. Munoz, A, Castillo, M, Melchor, MA, Gutierrez, R. Acute Neck Infections: Prospective Comparison Between CT and Munoz, A, Castillo, M, Melchor, MA, Gutierrez, R. Acute Neck Infections: Prospective Comparison Between CT and
MRI in 47 Patients. Journal of Comp Ass Tomography. 2001. 25 (5): 733-741.MRI in 47 Patients. Journal of Comp Ass Tomography. 2001. 25 (5): 733-741.10.10. McClay, JE, Murray, AD, Booth, TB. Intravenous Antibiotic Therapy for Deep Neck Abscesses Defined by Computed McClay, JE, Murray, AD, Booth, TB. Intravenous Antibiotic Therapy for Deep Neck Abscesses Defined by Computed
Tomography. Arch Otolaryngol Head Neck Surg. 2003;129:1207 – 1212.Tomography. Arch Otolaryngol Head Neck Surg. 2003;129:1207 – 1212.11.11. Nagy, M, Backstrom, J. Comparison of the sensitivity of lateral neck radiographs and computed tomography Nagy, M, Backstrom, J. Comparison of the sensitivity of lateral neck radiographs and computed tomography
scanning in pediatric deep-neck infections. Laryngoscope, 1999; 109 (5): 775-779.scanning in pediatric deep-neck infections. Laryngoscope, 1999; 109 (5): 775-779.12.12. Chaudhary, N, Agrawal, S, Rai, A. Descending Necrotizing Mediastinitis: Trends in a Developing Country. Ear Nose Chaudhary, N, Agrawal, S, Rai, A. Descending Necrotizing Mediastinitis: Trends in a Developing Country. Ear Nose
Throat. 2005 84(4); 242-50.Throat. 2005 84(4); 242-50.13.13. Harar, R, Cranston, C, Warwick-Brown, N. Descending necrotizing mediastinitis: report of a case following steroid Harar, R, Cranston, C, Warwick-Brown, N. Descending necrotizing mediastinitis: report of a case following steroid
neck injection. Journal Laryngol Otol. Oct 2002, vol 116; 862 – 64.neck injection. Journal Laryngol Otol. Oct 2002, vol 116; 862 – 64.14.14. Kiernan, PD, Hernandez, A, Byrne, W, Bloom, R, Dicicco,B, Hetrick, V, Graling, P, Vaughan, B. Descending Cervical Kiernan, PD, Hernandez, A, Byrne, W, Bloom, R, Dicicco,B, Hetrick, V, Graling, P, Vaughan, B. Descending Cervical
Mediastinitis. Ann Thorac Surg 1998; 65:1483-8.Mediastinitis. Ann Thorac Surg 1998; 65:1483-8.15.15. Akman, C, Kantarci, F, Cetinkaya, S. Imaging in mediastinitis: a systematic review based on aetiology. Clinical Akman, C, Kantarci, F, Cetinkaya, S. Imaging in mediastinitis: a systematic review based on aetiology. Clinical
radiology (2004) 59, 573-85.radiology (2004) 59, 573-85.16. Baqain, Z, Neman, L, Hyde, N. How Serious are Oral Infections? Journ Laryngol Otol. July 2004 (118). 561-65.17.17. Netters, F. Atlas of Human Anatomy 2Netters, F. Atlas of Human Anatomy 2ndnd Ed. Ed.18.18. Lee, KJ. Essentials of Otolaryngology.Lee, KJ. Essentials of Otolaryngology.19.19. Rosen, EJ, Bailey, B, Quinn, FB. Deep Neck Spaces and Infections: Grand Rounds Presentation. Dr. Quinn’s Online Rosen, EJ, Bailey, B, Quinn, FB. Deep Neck Spaces and Infections: Grand Rounds Presentation. Dr. Quinn’s Online
Textbook of Otolaryngology Grand Rounds Archive. 2002. http://www.utmb.edu/otoref/Grnds/Deep-Neck-Spaces-Textbook of Otolaryngology Grand Rounds Archive. 2002. http://www.utmb.edu/otoref/Grnds/Deep-Neck-Spaces-2002-04/Deep-neck-spaces-2002-04.doc2002-04/Deep-neck-spaces-2002-04.doc