Deep Neck Space Infections

CLAUDIA MARISCA 030.09.055

Anatomy of Cervical Fascia

Superficial Layer of Deep Cervical Fascia (Investing Layer)
Middle Layer of Deep Cervical Fascia Muscular layer Visceral layer Deep Layer of Deep Cervical Fascia Alar fascia Prevertebral fascia Carotid Sheath

Spaces involving the entire length of the neck

Retropharyngeal space (syn. retrovisceral, retroesophageal, posterior visceral) Danger space Prevertebral space Visceral vascular space

Spaces Limited to Above the Hyoid Bone Parapharyngeal space (syn. pharyngomaxillary, lateral pharyngeal, peripharyngeal) Submandibular and submental space Parotid space Masticator space Peritonsillar space Temporal space

Spaces Limited to Below the Hyoid Bone Pretracheal space Suprasternal space

Spaces Involving the Entire Neck

Retropharyngeal Space

Retropharyngeal Space
Between visceral division of middle layer and alar division of deep layer Extend from skull base to T2 level Midline raphae More commom in children due to presence of retropharyngeal node

Danger Space
Between alar division and prevetebral division of deep layer (locate posterior to retropharyngeal space)

Extend from skull base to diaphram

No midline raphae Infection spread from neck to posterior mediastinum easily

Paravertebral Space
Between prevertebral division of deep layer and vertebral bodies Extend from skull base to coccyx Infection in this space is rare and spread slowly due to compact connective tissue

Visceral Vascular Space

Made up from all deep cervical fascia Infection from any deep fascia can spread to this space (lincoln High way)

Spaces Above the Hyoid Bone

Parapharyngeal Space Submandibular Space Masticator Space

Temporal Space
Parotid Space

Parapharyngeal Space

Boundary

Superiorly : Skull base

Inferiorly Laterally Medially Anteriorly : Hyoid bone : Medial pterygoid m. :Buccopharyngeal fascia : Submandibular space and retrophryngeal space

Posteromedialy : Prevertebral fascia

Submandibular Space
Divided into 2 spaces by mylohyoid m. Sublingual space (above mylohyoid m.) Submaxillaly space (below mylohyiod m.) These 2 spaces can communicate each other by mylohyoid cleft

Masticator Space
Between masticator m. and superficial layer of deep cervical fascia (Masticator m. = massestor m.,medial and lateral pterygoid m. and temporalis muscle) Locate anterior and lateral to parapharyngeal space

Parotid Space
Between parotid gl. and superficial layer of deep cervical fascia Infection can spread easily to parapharyngeal space due to incompleted encircle at upper inner surface of parotid gl.

Peritonsillar Space
This space is found just lateral to the tonsillar capsule and medial to the superior constrictor muscle The pus can spread beyond the confines of this space into the parapharyngeal space

Temporal Space
This space between the temporal fascia laterally and the periosteum of the squamous portion of the temporal bone medially

Spaces Limited Below the Hyoid Bone

Anterior Viseral Space (Pretracheal Space)
Between trachea, esophagus and middle layer of deep cervical fascia Extend from hyoid bone to superior mediastinum

Suprasternal Space
This space just superior to the sternal notch between the clavicular heads where the superficial layer of deep cervical fascia splits into limit it.

Etiology of Deep Neck Space

Dental infection Tonsillar and peritonsillar infection Trauma of upper aerodigestive tract Retropharyngeal lymphadenitis Potts disease Sialadenitis Bezolds abscess Infection of congenital cyst and fistula Intravenous drug abuse

Diagnosis
Fever, pain, and swelling are the most common presenting symptoms. Swelling and elevated temperature is seen among most patients. Most patients will show evidence of dehydration from dysphagia and odinophagia and trismus.

 Plain lateral and anteroposterior radiographs are useful in the diagnosis of neck space infections. The presence of radiopaque foreign bodies, tracheal deviation, subcutaneus air, fluid within the soft tissues, lymphadenopathy, widening of the mediastinum as in mediastinitis, pulmonary edema, and pneumomediastinum may be indicators of abscess formation

CT characteristics of an abscess include low attenuation, contrast enhancement of the abscess wall, tissue edema surrounding the abscess, and a cystic or multiloculated appearance.

Management

Complication
Infectious complications Carotid artery erosion and hemorrhage Internal jugular thrombosis Cavernous sinus thrombosis Neurologic deficits

Horner syndrome
Cranial nerves IX-XII Osteomyelitis of the mandible Osteomyelitis of the spine Mediastinitis Pulmonary edema Pericarditis Aspiration (spontaneous rupture) Sepsis

Complication (2)
Surgical complications Damage to neurovascular strictures Wound infections

Septicemia
Scarring Aspiration (rupture from instrumentation)

Specific Deep Neck Space Infections

Retropharyngeal Space Abscess

Most abscess of the retropharyngeal space occur in children. Most infections begin in the nose or nasopharynx and adenoids, and paranasal sinuses and drain to these nodes which go on to suppurate. Fever, dysphagia, odynophagia, nuchal rigidity, and airway compromise may occur. Snoring and stertor may occur. In adults retropharyngeal abscesses are more likely caused by instrumentation, foreign body and trauma.

Emergencies Deep Neck Infections

Loss of airway Septic Shock Carotid Blowout

Internal Jugular Thrombosis

Treatment Deep Neck Space Infections

Watch for impending airway obstruction Stabilize airway, breathing, and circulation Intravenous hydration Empirical antibiotic therapy covering broad spectrum including anaerobes Obtain blood cultures Imaging studies including roentgenograms and contrast-enhanced CT scans Inflammation without abscess formation: continue supportive management with hydration and antibiotics Inflammation with abscess formation: aspiration and/or incise and drain abscess in operating room plus supportive care and antibiotics

Address source of infection and prevent recurrence

Wound care and healing by secondary intention Change antibiotics based upon microbiologic culture and sensitivity results Maintain nutrition and supportive care

Treatment Emergencies
Abscess formation Airway obstruction Vascular compromise: arterial Aspirate and follow or preferably incise drain and pack abscess cavity Stabilize airway. If large abscess presents in airway perform cricothyrotomy or an emergency tracheostomy Aneurysm formation: interventional radiological consult and embolization of aneurysm Threatened rupture/rupture: interventional radiological consult and embolization with coils/ surgical exploration and ligation of offending vessel Anticoagulation vs. ligation and evacuation of thrombus. Prevent embolic lung abscesses Support airway and circulation in ICU. IV antibiotics. Eliminate source of infection. Obtain help from intensivist.

Vascular compromise venous Septic shock

Mediastinitis and mediastinal abscess

Support airway and circulation in ICU. Antibiotics. Mediastinal drainage by thoracic surgeon. Eliminate source of reinfection.

Prevertebral and Danger Space Infections

Prevertebral space infections were the result of pyogenic organisms or tuberculosis of the vertebral bodies Iatrogenic or penetrating trauma is by far the common etiology of condition. When the danger space involved, the loose areolar tissue forms an ineffective barrier to the spread of infection Patients become progressively more toxic as the infection spreads, and findings of mediastinitis and mediastinal empyema occur. Treatment is by drainage by an external approach and appropriate antibiotic treatment.

Parapharyngeal Space Infection

Most common cause : Peritonsillar infection Typical finding 1.Trismus 2. Angle mandible swelling 3. Medial displacement of lateral pharyngeal wall

Others : fever, limit neck motion,neurologic deficit (C.N 9,10,12,Horners syndrom)

Treatment
Evaluate and maintain airway & fluid hydration Parenteral antibiotic high dose 24-48 hrs. If not improve, consider surgical drainage

 Surgical drainage 1. Intraoral approch

(for peritonillar abscess only)

2. External approach -transverse submandibular incision -T. shape incision (Mosher)

Submandibular Space Infection

Most common cause : Dental caries Anterior teeth & first molar : infection enter sublingual space Second & third molar : infection enter submaxillary space

Clinical Features ( True Ludwigs Angina)

Start unilateral and progress bilaterally Induration of submandibular region and floor of mouth ( severe cellulitis)

Tongue trusted posteriorly and superiorly (cause airway obstruction)

Drolling, odynophagia, trismus, fever

No purulence(due to no time to developed)

Treatment
Early stage (unilat,mild swelling and edema) -IV antibiotic, extration of infected tooth Advance stage (bilateral swelling, dysphagia with drolling) -early airway intervention -surgical drainage (submandibular incision)

Masticator Space Infection

Most common cause Dental carices Clinical feature Extreme trismus with minimum facial swelling Massesteric space (lateral compartment) : edema at ramus of mandible

- Ptrygomandibular space (medial compartment):

edema at retromolar trigone

Treatment
1. Intraoral drainage (medial compartment) - along inner margin of mandibular ramus to the retromolar trigone - submandibular incision - preauricular incision or Gilles incision for temporal space abscess

2. External approch (lateral compartment)

Parotid Space Infection and Treatment

Most common cause : Bacterial retrograde from oral cavity Clinical feature : high fever, weakness, mark swelling and tenderness of parotid gland,fluctuation,pus at stensens duct IV Antibiotic Surgical drainage indicated for -fluctuation -medical failure after 24-48 hr. or progression of disease