deep-neck spaces infections
TRANSCRIPT
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Deep Neck Spaces and Infections
Elizabeth J. Rosen, MDByron J. Bailey, MD4/17/02
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Deep Neck Spaces and
InfectionsAnatomy of the Cervical Fascia
Anatomy of the Deep Neck Spaces
Deep Neck Space Infections
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Cervical Fascia
Superficial Layer
Deep LayerSuperficialMiddle
Deep
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Cervical Fascia
Superficial Layer
PlatysmaMuscles of FacialExpression
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Cervical Fascia
Superficial Layer of theDeep Cervical Fascia
MusclesSternocleidomastoidTrapezius
GlandsSubmandibularParotid
SpacesPosterior Triangle
Suprasternal space of Burns
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Cervical Fascia
Middle Layer of theDeep Cervical Fascia
Muscular DivisionInfrahyoid StrapMuscles
Visceral DivisionPharynx, Larynx,
Esophagus, Trachea,ThyroidBuccopharyngealFascia
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Cervical Fascia
Deep Layer of DeepCervical Fascia
Alar LayerPosterior to viscerallayer of middle fasciaAnterior to
prevertebral layerPrevertebral Layer
Vertebral bodiesDeep muscles of theneck
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Cervical Fascia
Carotid SheathFormed by all threelayers of deep fasciaContains carotidartery, internal
jugular vein, and
vagus nerveLincolnsHighway
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Deep Neck Spaces
Described in relation to the hyoid
Entire length of theneck SuprahyoidInfrahyoid
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Deep Neck Spaces
Entire Length of Neck:Superficial Space
Surrounds platysmaContains areolar tissue,nodes, nerves and vesselsSubplatysmal FlapsInvolved with cellulitisand superficial abscessesTreat with incision alongLangers lines, drainageand antibiotics
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Deep Neck Spaces
Entire Length of Neck:RetropharyngealSpace
Posterior to pharynxand esophagusAnterior to alar layerof deep fasciaExtends from skullbase to T1-T2
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Deep Neck Spaces
Entire Length of Neck:Danger Space
Anterior border is alarlayer of deep fasciaPosterior border isprevertebral layerExtends from skull baseto diaphragm
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Deep Neck Spaces
Entire Length of Neck:Prevertebral Space
Anterior border isprevertebral fasciaPosterior border isvertebral bodies anddeep neck musclesExtends along entirelength of vertebralcolumn
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Deep Neck Spaces
Entire Length of Neck: VisceralVascular Space
Carotid SheathLincolns Highway
Can becomesecondarily involvedwith any other deepneck space infection bydirect spread
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Deep Neck Spaces
Suprahyoid:Submandibular Space
Anterior/Lateral mandibleSuperior mucosaInferior superficial layerof deep fasciaPosterior/Inferior--hyoid
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Deep Neck Spaces
Suprahyoid:Submandibular Space
Sublingual SpaceAreolar tissueHypoglossal and lingualnerves
Sublingual glandWhartons duct
Submylohyoid SpaceAnterior bellies of digastrics
Submandibular gland
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Deep Neck Spaces
Suprahyoid:Parapharyngeal Space
Superior skull baseInferior hyoidAnterior ptyergomandibular raphe
Posterior prevertebralfasciaMedial
buccopharyngeal fasciaLateral superficial layerof deep fascia
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Deep Neck Spaces
Suprahyoid:Parapharyngeal Space
PrestyloidMedial tonsillar fossaLateral medial pterygoidContains fat, connective
tissue, nodesPoststyloid
Carotid sheathCranial nerves IX, X, XII
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Deep Neck Spaces
Suprahyoid:Peritonsillar Space
Medial capsule of palatine tonsilLateral superiorpharyngeal constrictorSuperior anteriortonsil pillarInferior posteriortonsil pillar
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Deep Neck Spaces
Suprahyoid: Masticatorand Temporal Spaces
Formed by thesuperficial layer of deepcervical fascia
Masseter and pterygoids
Temporalis
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Deep Neck Spaces
Suprahyoid: ParotidSpace
Superficial layer of deepfasciaDense septa fromcapsule into glandDirect communication toparapharyngeal space
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Deep Neck Spaces
Infrahyoid: AnteriorVisceral Space
Middle layer of deepfasciaContains thyroid,trachea, esophagusExtends from thyroidcartilage into superiormediastinum
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Deep Neck Space Infections
Presentation/Origin of Infection
MicrobiologyImagingTreatment
ComplicationsSpecial Consideration
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Presentation/Origin
Retropharyngeal Abscess50% occur in patients 6-12 months of age96% occur before 6 years of ageChildren--fever, irritability, lymphadenopathy,torticollis, poor oral intake, sore throat, droolingAdults--pain, dysphagia, anorexia, snoring, nasalobstruction, nasal regurgitationDyspnea and respiratory distress
Lateral posterior oropharyngeal wall bulge
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Presentation/Origin
PediatricsCause suppurativeprocess in lymph nodes
Nose, adenoids,nasopharynx, sinuses
AdultsCause trauma,instrumentation,extension fromadjoining deep neck space
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Presentation/Origin
Danger SpacePresentation and exam nearly identical toretropharyngeal space infectionCause extension from retropharyngeal,prevertebral or parapharyngeal space
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Presentation/Origin
Prevertebral SpaceBack, shoulder, neck painmade worse by deglutitionDysphagia or dyspneaCause Potts abscess, trauma,osteomyelitis, extension fromretropharyngeal and danger spaces
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Presentation/Origin
Visceral Vascular SpaceInduration and tenderness over SCMTorticollis toward opposite sideSpiking fevers, sepsisCause intravenous drug abuse, extension fromother deep neck spaces
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Presentation/Origin
Submandibular SpacePain, drooling, dysphagia, neck
stiffnessAnterior neck swelling, floor of mouth edemaCause 70-85% have odontogenicorigin
First molar and anteriorSecond and third molars
Sialadenitis, lymphadenitis,lacerations of the floor of mouth,
mandible fractures
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Presentation/Origin
Ludwigs angina 1. Cellulitis, not abscess2. Limited to SM space3. Foul serosanguinous fluid, nofrank purulence4. Fascia, muscle, connectivetissue involvement, sparingglands
5. Direct spread rather thanlymphatic spread
Tender, firm anterior neck edema without fluctuanceHot potato voice, drooling Tachypnea, dyspnea, stridor
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Presentation/Origin
Parapharyngeal SpaceFever, chills, malaisePain, dysphagia, trismusMedial bulge of lateralpharyngeal wallCause infection of pharynx,tonsil, adenoids, dentition,parotid, mastoid, suppurativelymphadenitis, extension fromother deep neck spaces
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Presentation/Origin
Peritonsillar SpaceFever, malaiseDysphagia, odynophagiaHot - potato voice,trismus, bulging of superiortonsil pole and soft palate,deviation of uvulaCause extension fromtonsillitis
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Presentation/Origin
MasticatorTemporal Space
Pain, trismusPosterior FOMedemaSwelling alongramus of mandibleCause odontogenic, fromthird molars
Parotid SpacePain, trismus
Medial bulgeof posteriorlateralpharyngealwallCause parotitis,sialolithiasis,Sjogrenssyndrome
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Presentation/Origin
Anterior Visceral SpaceHoarseness, dyspnea, dysphagia, odynophagiaErythema, edema of hypopharynx, may extend toinclude glottis and supraglottisAnterior neck edema, pain, erythema, crepitusCause foreign body, instrumentation, extensionof infection in thyroid
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Microbiology
Preantibiotic era S.aureus
Currently aerobic Strep species and non-strepanaerobesGram-negatives uncommon
Almost always polymicrobialRemember resistance
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Imaging
Lateral neck plain filmScreening exam mainlyfor retropharyngeal and
pretracheal spacesNormal: 7mm at C-2,14mm at C-6 for kids,22mm at C-6 for adultsTechnique dependent
ExtensionInspiration
Nagy, et alSensitivity 83%,compared to CT 100%
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Imaging
High-resolution UltrasoundAdvantages
Avoids radiationPortable
DisadvantagesNot widely accepted
Operator dependentInferior anatomic detail
UsesFollowing infection during therapy
Image guided aspiration
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Imaging
Contrast enhanced CTAdvantages
Quick, easyWidely availableFamiliaritySuperior anatomic detailDifferentiate abscess andcellulitis
DisadvantagesIonizing radiationAllergenic contrast agentSoft tissue detail
Artifact
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Imaging
Contrast enhanced CTModality of choiceMiller, et al: CT vs. PE
Accuracy of diagnosis: CT = 77%, PE = 63%Sensitivity: CT = 95%, PE = 55%
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Imaging
MRIAdvantages
No radiationSafer contrast agentBetter soft tissue detailImaging in multiple planesNo artifact by dental fillings
DisadvantagesIncreased costIncreased exam timeDependent on patientcooperationAvailability
Munoz, et al: MRI vs. CT
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Treatment
Airway protection
Antibiotic therapy
Surgical drainage
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Treatment
Airway protectionObservationIntubation
Direct laryngoscopy: possible risk of rupture andaspirationFlexible fiberoptic
TracheostomyIdeally = planned, awake, local anesthesiaAbscess may overlie tracheaDistorted anatomy and tissue planes
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Treatment
LUDWIGS ANGINA = PERILOUS AIRWAY Parhiscar and Har-El
Review of 210 patients withdeep neck abscessOverall, 20.5% requiredtracheostomyLudwigs angina, 75%
required tracheostomyAttempted intubation in 20 patientsFailed in 11 patients, necessitating
slash tracheostomy
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Treatment
Antibiotic TherapyCellulitisImprovement in 24-48 hoursAbscess?
Mayor, et al: review of 31 patients, 19 with CT
evidence of abscess, 90% responseNagy, 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 TherapyPolymicrobial infections
Aerobic Strep, anaerobesAmpicillin/sulbactam with metronidazole
Beta-Lactam resistance in 17-47% of isolates
AlternativesThird generation cephalosporinsclindamycin
Culture and sensitivity
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Treatment
Surgical DrainageTransoral
Preoperative CT where are the great vessels?Cruciate mucosal incision, blunt spreading throughsuperior pharyngeal constrictor
Nagy, et al: retro-, parapharyngeal or combo in kids22/23 successfully treated with intraoral incision and drainage
External
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Treatment
Surgical DrainageExternal
EXPOSURE, EXPOSURE, EXPOSURELevitt: anterior vs. posteriorapproach
Submandibular incisionSubmental incisionT-incision
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Treatment
Image-guided AspirationPatient selection
Smaller abscesses, limited extension, uniloculated
Poe, et al: CT guided aspirationEarly specimen collection, reduced expense, avoidance of
neck scarYeow, et al: Ultrasound guided aspiration
8/10 patients successfully treated with needle aspiration5/5 patients successful treated with pigtail catheterinsertion
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Complications
Airway obstructionEndotracheal intubationTracheostomy
Ruptured abscessPneumoniaLung Abscess
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Complications
Internal Jugular Vein ThrombosisLemierres syndrome F/C, prostration, swelling and pain along SCMBacteremia, septic embolization, dural sinusthrombosis
IV drug abusersTreatmentIV antibiotic therapyAnticoagulation?
Ligation and excision
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Complications
Carotid Artery RuptureMortality of 20-40%Sentinel bleeds from ear, nose, mouthMajority from internal carotid, less from externalcarotid, and fewest from common carotid
TreatmentProximal and distal controlLigation
Patching or grafting?
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Complications
MediastinitisMortality of 40%
Increasing dyspnea, chest painCXR = widened mediastinumTreatment
EARLY RECOGNITION AND INTERVENTIONAggressive IV antibiotic therapySurgical drainage
Transcervical approach
Chest tube vs. thoracotomy
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Special Consideration
Recurrent Deep Neck Space InfectionTHINK CONGENITAL ABNORMALITYImaging should help make the diagnosisNusbaum, et al: 12 cases of recurrent deep neck infection
Most Common: second branchial cleft cystOthers: first, third, fourth branchial cleft cysts,lymphangiomas, thyroglossal duct cysts, cervicalthymic cyst
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Case Presentation
43 y/o man presents to the ER complainingof mouth and neck pain, he finds it difficultto swallow and has been spitting out hissaliva.He also reports progressive swelling in hisneck that it tender to touch.
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Case Presentation
Additional historyDenies recent URI or pharyngitisHad an infected third molar pulled about 5 daysagoNo difficulty breathing at rest
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Case Presentation
Past Medical HistoryHTN, renal failure
Past Surgical HistoryKidney transplant
MedicationsPrednisone, cyclosporin, metoprolol
Allergiesnkda
Social HistoryNonsmoker, occasional alcohol
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Case Presentation
Physical ExamBP 124/70, P 96, RR 18, T 38.0, O2 sat 98% RAGen: no distress, uncomfortable, muffled voiceTender, erythematous edema over right level I & II,no distinctly palpable nodes, no fluctuance
FOM is slightly edematous and tender but soft, thetongue is not elevated, evidence of tooth extraction
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Case Presentation
Laboratory StudiesWBCs 21,000, elevated bandsElectrolytes wnlCyclosporin level ok
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Case Presentation
CT Neck
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Case Presentation
TreatmentTo OR for external incision and drainage, usinga transverse, submandibular skin incisionSpecimens sent for culture and sensitivitiesPenrose drain left in place for continued drainage
IV antibiotic therapy started with Unasyn
POD #2, remains febrile, neck is stillerythematous and indurated
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Case Presentation
Follow up on culture and sensitivitiesBroaden antibiotic therapy for betteranaerobic and gram-negative coverage