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 breathing Brothers 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

Patient Exam
Gen Alert, appropriate, anxious but in NAD, no

stridor, 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 posterior pharyngeal walls visible, soft throughout, tongue motion normal Neck: 8 x 4cm R upper neck diffusely swollen area parallel to body of mandible, mildly erythematous, very TTP, firm, warm to touch

Differential Diagnosis
V-venous malformation I-Cat scratch disease, TB, atypical mycobacteria,
viral/bacterial LAD, mono, sebaceous cyst, deep space abscess, 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

Imaging

Deep Neck Space Infections

Alice Lee April 28, 2005

Background
Before antibiotics, 70% deep neck infections

were caused by tonsillar and pharyngeal sources. 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

Anatomy of Cervical Fascia

Superficial cervical fascia Deep cervical fascia

Superficial layer Middle layer Muscular division Visceral division Deep layer Prevertebral division Alar division

Anatomy of Cervical Fascia: Superficial cervical fascia

Continuous sheath of fibrofatty subcutaneous

tissue Attachments: zygomatic process to thorax and axilla 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

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; spreads anteriorly to the face and attaches at clavicles Envelopes SCM, trapezius, portion of omohyoid in posterior triangle, parotid and submandibular glands

Anatomy of Cervical Fascia:

Muscular division

Middle layer of the deep cervical fascia

Surrounds straps. Attaches superiorly to hyoid and thyroid cartilage and inferiorly to sternum, clavicle and scapula Visceral division Surrounds thyroid, trachea, esophagus. Superior attached to base of skull, thyroid cartilage and hyoid covers trachea and esophagus and blends with fibrous pericardium Bonus: What does a portion of the visceral division form? (Covers the constrictor and buccinator muscles)

Anatomy of Cervical Fascia:

Deep layer of the deep cervical fascia

Contents: Paraspinous muscles and cervical

vertebrae Prevertebral and alar divisions Prevertebral: Begins anterior to the vertebral bodies, spreads laterally to fuse with transverse processes, extends posteriorly to enclose deep muscles of neck and attaches to vertebral spines. Forms the posterior wall of the danger space and anterior wall of prevertebral space

Anatomy of Cervical Fascia:

Alar division

Deep layer of the deep cervical fascia

Lies between the prevertebral division and the middle layer of the deep cervical fascia Attaches from transverse process to contralateral transverse process, skull base to T2, fuses with visceral division of middle layer of deep cervical fascia. Carotid sheath: made up of all 3 deep layers

Cervical fascial planes

Lymph

Deep Neck Spaces

Spaces involving
entire length of neck: 1. Retropharyngeal 2. Danger 3. Prevertebral 4. Visceral vascular

Suprahyoid spaces:

1. Pharyngomaxillary/ Lateral pharyngeal 2. Submandibular 3. Parotid 4. Masticator 5. Peritonsillar 6. Buccal Infrahyoid spaces: 1. Anterior visceral

Retropharyngeal space
Potential space posterior to visceral division of

middle layer of deep cervical fascia and anterior to alar division of deep layer of deep cervical fascia Skull base to T1/2/tracheal bifurcation in close approximation to mediastinum Midline raphe-superior constrictor muscles adheres to prevertebral division; separates retropharyngeal nodes into two lateral chains. Contents: fat, CT, LNs which drain nose, NP, soft palate, ET, paranasal sinuses

Retropharyngeal space
Most commonly seen in

peds due to drainage source Peds: preceding URI, fever, dysphagia, odynophagia, nuchal rigidity, asymmetric bulging of post pharyngeal wall due to midline raphe Adults: pain, dysphagia, cervical motion limitation, noisy breathing Can extend to: mediastinum, danger space, parapharyngeal space

Retropharyngeal space
Lateral soft tissue XR (extension, inspiration) abnormal
findings: 1. C2-post pharyngeal soft tissue >7mm 2. C6adults >22mm, peds >14mm 3. STS of post pharyngeal region >50% width of vertebral body

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

Danger Space
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

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 Why is this called the Lincoln Highway of the neck?

Spaces involving entire length of neck

Visceral layer-mid RETROPHARYNGEAL

SPACE (T2) Alar division-deep DANGER SPACE (diaphragm) Prevertebral division PREVERTEBRAL SPACE (coccyx) Vertebrae

Deep Neck Spaces

Spaces involving
entire length of neck: 1. Retropharyngeal 2. Danger 3. Prevertebral 4. Visceral vascular

Suprahyoid spaces:

1. Pharyngomaxillary/ Lateral pharyngeal 2. Submandibular 3. Parotid 4. Masticator 5. Peritonsillar 6. Buccal Infrahyoid spaces: 1. Anterior visceral

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/ prevertebral fascia

Pharyngomaxillary/Parapharyngeal/ Lateral pharyngeal space

Divided into anterior and posterior compartments by

styloid 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

Pharyngomaxillary/Parapharyngeal/ Lateral pharyngeal space

Connects to the majority

of other fascial spaces Sources: parotid, masticator, submandibular, peritonsillar, tonsils/pharynx, odontogenic, LN from nose and throat, mastoiditis (Bezold abscess)

Pharyngomaxillary/Parapharyngeal/ Lateral pharyngeal space

Never approach

intraorally Traditionally: Mosher incision Horizontal neck incision follow carotid sheath into space finger dissect below submandibular gland, along posterior belly of digastric deep to mastoid tip toward styloid

Submandibular space
Composed of sublingual space superiorly and
submaxillary space inferiorly, divided by mylohyoid Boundaries: FOM mucosa above, superficial layer of deep 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 posterior border of mylohyoid through submandibular gland Ludwigs angina bilateral cellulitis of submandibular and sublingual spaces Inspect 2nd and 3rd molars apices extend below mylohyoid line providing direct access to submandibular space

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 lateral pharyngeal space (dumbbell shaped masses secondary to stylomandibular ligament) Contents: parotid gland, external carotid, posterior facial vein, facial nerve, lymph nodes

Masticator space
Superficial layer of deep cervical fascia splits around

mandible to form this space and encases muscles of mastication 4 compartments: Masseteric, Pterygoid, Superficial Temporal, Deep Temporal Contents: masseter, pterygoid muscles, temporalis tendon, inferior alveolar nerves and vessels, body and ramus of mandible, internal maxillary artery Most common source : 3rd molar Complication: osteomyelitis of mandible

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 equally effective initial management with 10-15% recurrrence rate. (1) Again, 10-15% recurrence after needle aspiration and/or I&D; greatest risk in patients <40 with history of recurrent tonsillitis (2)
1. Johnson RF, Stewart MG, Wright CC. An evidence-based review of the treatment of peritonsillar abscess. Otolaryngol Head Neck Surg. 2003 Mar;128(3):332-43. 2. Herzon FS. Peritonsillar abscess: incidence, current management practices, and a proposal for treatment guidelines. Laryngoscope 1995;105 [suppl 74]:1-7.

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

Deep Neck Spaces

Spaces involving
entire length of neck: 1. Retropharyngeal 2. Danger 3. Prevertebral 4. Visceral vascular

Suprahyoid spaces:

1. Pharyngomaxillary/ Lateral pharyngeal 2. Submandibular 3. Parotid 4. Masticator 5. Peritonsillar 6. Buccal Infrahyoid spaces: 1. Anterior visceral

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

Network of infectious extension

Pathogens

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

Antibiotics

Necrotizing fasciitis
Fulminent infection, polymicrobial, usually odontogenic

source, more frequently in immunocompromised and postoperative PEX: ill, high fever, neck crepitus, exquisitely tender, unimpressive erythema s sharp demarcating border progress to pale then dusky as necrosis progresses can have bullae/blisters/sloughing <48hrs Empiric abx (3rd gen ceph + clinda/flagyl), early surgery, dishwater drainage, leave open, daily debridement, trach, ICU monitoring for: resp failure, mediastinitis (higher mortality 64% vs 15%), DIC, delirium, HBO

Diagnosis

Pain, trismus, limitation

neck motion, swelling, sustained fever, leukocytosis with left shift, lateral neck XR/CT Prevertebral or retropharyngeal hot potato voice, difficult noisy breathing, dys/odynophagia, drooling, neck posturing Parapharyngeal medial displacement of lateral pharyngeal wall, fullness of retromandibular area. Prestyloid trismus, tonsil swelling. Poststyloiddysphagia

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, no significant response to abx in 24-48 hours, evidence of sepsis Transoral peritonsillar, uncomplicated RP and prevertebral abscesses with mass in oropharynx, uncomplicated sublingual (not for submax extension)

Management
Surgical principles: wide exposure, use
readily identifiable landmarks (digastric, hyoid, SCM, cricoid, greater horn of thyroid), blunt dissection, identify carotid sheath early, cultures/biopsy, debridement, irrigation, leave wound open and pack for extensive necrosis, can close less necrotic wound and use drain

Complications
40 yr old pt is admitted for
parapharyngeal infection. Started on abx, IVF, observation. Afebrile within 24 hours with improved dysphagia. HD #2 spikes to 104, defervesces, respikes. Whats happening? Thrombophlebitis of IJV

Complications signs and symptoms

Mediastinitis chest pain,

worsened dyspnea, dysphagia, widened mediastinum on CXR Horners, hoarseness, unilateral tongue paresis, plethora of face, choked optic disks, Tobey Ayer, erosion of carotid (critical, pharyngeal bleeding episode, neck hematoma, rare EAC blood

Treatment of complications
Mediastinitis most commonly via retropharyngeal

space > visceral or PP Abdominal abscess prevertebral space IJV septic thrombophlebitis IVDA, ligate and remove thrombosed vein at I&D Neuropathy Horners, hoarseness, unilateral tongue paresis Erosion of carotid artery rare, emergency, clot found in neck at I&D, proximal and distal control, intraop angio if possible (75% CCA or ICA)

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 peritonsillar abscess. Otolaryngol Head Neck Surg. 2003 Mar;128(3):332-43. Herzon FS. Peritonsillar abscess: incidence, current management practices, and a proposal for treatment 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.