deep neck space infections

1. Deep Neck Space Infections UTMB Department of Otolaryngology Jeffrey Buyten, MD Francis B. Quinn, MD October 5, 2005

2. Outline Anatomy Fascial planes Spaces Epidemiology Etiology Clinical presentation Imaging Bacteriology Therapy Medical Surgical Complications Mediastinitis

3. a?at?�?a

4. Cervical Fascia Superficial Layer Deep Layer Subdivisions not histologically separate Superficial Enveloping layer Investing layer Middle Visceral fascia Prethyroid fascia Pretracheal fascia Deep

5. Superficial Layer Superior attachment � zygomatic process Inferior attachment � thorax, axilla. Similar to subcutaneous tissue Ensheathes platysma and muscles of facial expression

6. Superficial Layer of the Deep Cervical Fascia Completely surrounds the neck. Arises from spinous processes. Superior border � nuchal line, skull base, zygoma, mandible. Inferior border � chest and axilla Splits at mandible and covers the masseter laterally and the medial surface of the medial pterygoid. Envelopes SCM Trapezius Submandibular Parotid Forms floor of submandibular space

7. Superficial Layer of the Deep Cervical Fascia

8. Middle Layer of the Deep Cervical Fascia Muscular Division Superior border � hyoid and thyroid cartilage Inferior border � sternum, clavicle and scapula Envelopes infrahyoid strap muscles Visceral Division Superior border Anterior � hyoid and thyroid cartilage Posterior � skull base Inferior border � continuous with fibrous pericardium in the upper mediastinum. Buccopharyngeal fascia Name for portion that covers the pharyngeal constrictors and buccinator. Envelopes Thyroid Trachea Esophagus Pharynx Larynx

9. Middle Layer of the Deep Cervical Fascia

10. Deep Layer of Deep Cervical Fascia Arises from spinous processes and ligamentum nuchae. Splits into two layers at the transverse processes: Alar layer Superior border � skull base Inferior border � upper mediastinum at T1-T2 Prevertebral layer Superior border � skull base Inferior border � coccyx Envelopes vertebral bodies and deep muscles of the neck. Extends laterally as the axillary sheath.

11. Deep Layer of Deep Cervical Fascia

12. Carotid Sheath Formed by all three layers of deep fascia Anatomically separate from all layers. Contains carotid artery, internal jugular vein, and vagus nerve �Lincoln�s Highway� Travels through pharyngomaxillary space. Extends from skull base to thorax.

13. Deep Neck Spaces Described in relation to the hyoid. Entire length of neck Superficial space Retropharyngeal Danger Prevertebral Vascular visceral Suprahyoid Submandibular Pharyngomaxillary (Parapharyngeal) Parotid Peritonsillar Temporal Masticator Infrahyoid Anterior visceral

14. Superficial Space Entire length of neck Surrounds platysma Contains areolar tissue, nodes, nerves and vessels Subplatysmal Flaps Involved with cellulitis and superficial abscesses Treat with incision along Langer�s lines, drainage and antibiotics

15. Retropharyngeal Space Entire length of neck. Anterior border - pharynx and esophagus (buccopharyngeal fascia) Posterior border - alar layer of deep fascia Superior border - skull base Inferior border � superior mediastinum Combines with buccopharyngeal fascia at level of T1-T2 Midline raphe connects superior constrictor to the deep layer of deep cervical fascia. Contains retropharyngeal nodes.

16. Space Entire length of neck Anterior border - alar layer of deep fascia Posterior border - prevertebral layer Extends from skull base to diaphragm Contains loose areolar tissue.

17. Prevertebral Space Entire length of neck Anterior border - prevertebral fascia Posterior border - vertebral bodies and deep neck muscles Lateral border � transverse processes Extends along entire length of vertebral column

18. Visceral Vascular Space Entire length of neck Carotid Sheath �Lincoln Highway� Lymphatic vessels can receive drainage from most of lymphatic vessels in head and neck.

19. Submandibular Space Suprahyoid Superior � oral mucosa Inferior - superficial layer of deep fascia Anterior border � mandible Lateral border - mandible Posterior - hyoid and base of tongue musculature 2 compartments Sublingual space Areolar tissue Hypoglossal and lingual nerves Sublingual gland Wharton�s duct Submaxillary space Anterior bellies of digastrics Submental compartment Submaxillary compartments Submandibular gland

21. Pharyngomaxillary space Suprahyoid aka � Parapharyngeal space Superior�skull base Inferior�hyoid Anterior�ptyergomandibular raphe Posterior�prevertebral fascia Medial�buccopharyngeal fascia Lateral�superficial layer of deep fascia

22. Pharyngomaxillary space Prestyloid Muscular compartment Medial�tonsillar fossa Lateral�medial pterygoid Contains fat, connective tissue, nodes Poststyloid Neurovascular compartment Carotid sheath Cranial nerves IX, X, XI, XII Sympathetic chain Stylopharyngeal aponeurosis of Zuckerkandel and Testut Alar, buccopharyngeal and stylomuscular fascia. Prevents infectious spread from anterior to posterior.

23. Pharyngomaxillary Space Communicates with several deep neck spaces. Parotid Masticator Peritonsillar Submandibular Retropharyngeal

24. Peritonsillar Space Suprahyoid Medial�capsule of palatine tonsil Lateral�superior pharyngeal constrictor Superior�anterior tonsil pillar Inferior�posterior tonsil pillar

25. Masticator and Temporal Spaces Suprahyoid Formed by superficial layer of deep cervical fascia Masticator space Antero-lateral to pharyngomaxillary space. Contains Masseter Pterygoids Body and ramus of the mandible Inferior alveolar nerves and vessels Tendon of the temporalis muscle Temporal space Continuous with masticator space. Lateral border � temporalis fascia Medial border � periosteum of temporal bone Superficial and deep spaces divided by temporalis muscle

26. Parotid Space Suprahyoid Superficial layer of deep fascia Dense septa from capsule into gland Direct communication to parapharyngeal space Contains External carotid artery Posterior facial vein Facial nerve Lymph nodes

27. Anterior Visceral Space Infrahyoid aka � pretracheal space Enclosed by visceral division of middle layer of deep fascia Contains thyroid Surrounds trachea Superior border - thyroid cartilage Inferior border - anterior superior mediastinum down to the arch of the aorta. Posterior border � anterior wall of esophagus Communicates laterally with the retropharyngeal space below the thyroid gland.

28. Epidemiology All patients Avg age b/w 40-50. More predominant in pts over 50 years. Pediatric pts Infants to teens. Male predilection in some case series. Most common age group: 3-5 years.

29. Etiology Odontogenic Tonsillitis IV drug injection Trauma Foreign body Sialoadenitis Parotitis Osteomyelitis Epiglottitis URI Iatrogenic Congenital anomalies Idiopathic

30. Clinical presentation Most common symptoms Sore throat (72%) Odynophagia (63%) Most common symptoms (exluding peritonsillar abscesses) Neck swelling (70%) Neck Pain (63%) Pediatric Fever Decreased PO Odynophagia Malaise Torticollis Neck pain Otalgia HA Trismus Neck swelling Vocal quality change Worsening of snoring, sleep apnea

31. Imaging Lateral neck plain film Screening exam No benefit in pts with DNI based on strong clinical suspicion. Normal: 7mm at C-2 14mm at C-6 for kids 22mm at C-6 for adults Technique dependent Extension Inspiration Sensitivity 83%, compared to CT 100%

32. Imaging CT with contrast Pros Widely available Faster (5-15 minutes) Abscess vs cellulitis Less expensive Cons Contrast Radiation Uniplanar Dental artifacts MRI Pros MRI superior to CT in initial assessment More precise identification of space involvement (multiplanar) Better detection of underlying lesion Less dental artifact Better for floor of mouth No radiation Non iodine contrast Cons Cost Pt cooperation Slower (19 to 35 minutes)

33. Imaging Regular cavity wall with ring enhancement (RE) Sensitivity - 89% Specificity - 0% Irregular wall (scalloped) Sensitivity - 64% Specificity - 82% PPV - 94%

35. Antibiotic Therapy Initial therapy Cover Gram positive cocci and anaerobes If pt is diabetic, should consider covering gram negatives empirically. Unasyn, Clindamycin, 2nd generation cephalosporin. PCN, gentamicin and flagyl - developing nations. IV abx alone (based on retro and parapharyngeal infections) Patient stability and nature of lesion. Cellulitis/phlegmon by CT. Abscesses in clinically stable patient. If no clinical improvement in 24 - 48 hours proceed to surgical intervention.

36. Surgery External drainage Landmarks Tip of greater horn of hyoid Cricoid cartilage Styloid process SCM Transoral drainage Parapharyngeal, retropharyngeal abscesses Great vessels lateral to abscess Tonsillectomy for exposure Needle aspiration

37. Complications Airway obstruction Trach 10 � 20% Ludwig�s angina - 75% Mediastinitis � 2.7% UGI bleeding Sepsis Pneumonia IJV thrombosis Skin defect Vocal cord palsy Pleural effusion Hemorrhage 20 - 80% mortality Multiple space involvement

38. Who gets complications? Older pts Systemic dz Immunodeficient pts HIV Myelodysplasia Cirrhosis DM Most common systemic Mbio � Klebsiella pneum. (56%) 33% with complications Higher mortality rate Prolonged hospital stay 20 days vs. 10 days

39. Descending Necrotizing Mediastinitis Definition � mediastinal infection in which pathology originates in fascial spaces of head and neck and extends down. Retropharyngeal and Danger Space � 71% Visceral vascular � 20% Anterior visceral � 7-8% Criteria for diagnosis Clinical manifestation of severe infection. Demonstration of the characteristic imaging features of mediastinitis. Features of necrotizing mediastinal infection at surgery. 1960-89 � 43 published cases Mortality rate 14-40%

40. Clinical Presentation Symptoms Respiratory difficulty Tachycardia Erythema/edema Skin necrosis Crepitus Chest pain Back pain Shock Important to have a low threshold for further workup

41. Mediastinitis Imaging Plain films Widened mediastinum (superiorly) Mediastinal emphysema Pleural effusions Changes appear late in the disease. CT neck and thorax. Esophageal thickening Obliterated normal fat planes Air fluid levels Pleural effusions CT helps establish dx and surgical plan

42. Treatment IV antibiotics Cervical drainage Cervical abscesses Superior mediastinal abscesses above T4 (tracheal bifurcation) Transthoracic drainage Abscesses below T4 Subxyphoid approach Anterior mediastinal drainage Thoracostomy tubes

43. Bibliography 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; 819-35 Kirse, DJ, Roberson,DW. Surgical Management of Retropharyngeal Space Infections in Children. Laryngoscope, 111: 1413-1422, 2000. 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. 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. 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. 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. 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. 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. 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. 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. 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. Chaudhary, N, Agrawal, S, Rai, A. Descending Necrotizing Mediastinitis: Trends in a Developing Country. Ear Nose Throat. 2005 84(4); 242-50. 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. 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. Akman, C, Kantarci, F, Cetinkaya, S. Imaging in mediastinitis: a systematic review based on aetiology. Clinical radiology (2004) 59, 573-85. Baqain, Z, Neman, L, Hyde, N. How Serious are Oral Infections? Journ Laryngol Otol. July 2004 (118). 561-65. Netters, F. Atlas of Human Anatomy 2nd Ed. Lee, KJ. Essentials of Otolaryngology. 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-2002-04/Deep-neck-spaces-2002-04.doc