Deep cervical Fascial space infections

1. Deep cervical Fascial space infections

2. Fascia of Neck • Cervical Fascia- 2 components • Superficial Cervical Fascia • Envelopes Platysma muscle • Continuous with superficial fascia of face (muscles of facial expression) • Deep Cervical Fascia • Superiorly-attached to inferior border of Mandible • Lower in the neck has 3 divisions • Anterior Layer • Middle Layer • Posterior Layer

3. Deep Cervical Fascia • Each layer envelopes into another • Anterior layer • Investing fascia • Parotideomasseteric • Temporal • Middle layer • Sternohyoid-omohyoid • Sternothyroid-thyrohyoid • Visceral Division • Buccopharyngeal • Pretracheal • Retropharyngeal • Posterior layer • Alar Division • Prevertebral Division

4. Superficial Layer/Investing layer

5. Anterior Layer(superficial or investing layer) • Encircles the neck, splits around SCM and Trapezius-attaches posteriorly to the spinous processes of the cervical vertebrae

6. Anterior Layer(superficial or investing layer) • Forms superficial border of the submandibular space and splits to form the capsule of the gland • Attaches to the inferior border of mandible • Anteriorly-blends with the periosteum of facial bones and is under the muscles of facial expressions • Covers the anterior/posterior belly of digastricus muscle, submandibular salivary gland • Stylomandibular ligament – dense band of the investing fascia • (extends from styloid process to angle of the mandible)

7. Anterior Layer(superficial or investing layer) • Superficially it splits at the inferior border of the mandible to become continous with • Parotidomasseteric fascia – • Covers superficial part of the masseter and splits around the parotid gland • Pterygoid fascia • Encloses the • hyoid bone • Suprahyoid muscles

8. Superficial or Investing layer(contd…) • Inferiorly-Attaches to the shoulder girdle and sternum • At the superior edge of the sternum it splits to form the Suprasternal space (Space of Burns.) *jugular veins anastomose in this area

9. Surrounds infrahyoid (strap) muscles: Sternohyoid, Sternothyroid, Omohyoid, Thyrohyoid Runs between hyoid bone and clavicle Thickens to form a pulley through which the intermediate tendon of the digastric muscle passes, suspending the hyoid bone Middle Layer

10. Middle Layer-Visceral Division • Below hyoid-surrounds trachea, esophagus and thyroid gland • Above the hyoid it wraps around the lateral and posterior sides of the pharynx lying on the superficial side of the pharyngeal constrictor muscles.(Called Buccopharyngeal fascia in this region) • Deep spaces of the neck (lateral pharyngeal, retropharyngeal and pretracheal spaces) all lie on the superficial side of the visceral division.

11. Carotid Sheath- • Base of the skull to the root of the neck • Common and Internal Carotid artery • Internal Jugular vein • Vagusnerve *tubular compartment from base of skull to sternum forms a highway for OI to mediastinum and can cause severe problems

12. Posterior Layer • From skull base(occipital bone) to diaphragm • 2 divisions • Alar • Prevertebral • Danger Space between these fascia

13. Envelops • Thyroid and cricoid cartilages • Pharyngeal tubercle of occipital bone • Attaches to the pterygomandibularraphe, pharyngeal aponeurosis • Inferiorly • Continues into thorax blends with pericardium

14. Posterior Division • 2 divisions • Alar • Prevertebral • Extends from base of skull to diaphragm

15. Alar fascia –Ribbon of fascia and it attaches to the carotid sheath and visceral fascia(middle layer) Extends from skull to seventh cervical vertebra Posterior Layer-Alar Fascia

16. Posterior Division- Prevertebral Fascia • Prevertebral Fascia surrounds the vertebrae and postural muscles of neck and back • Lies just anterior to the periosteum of the vertebrae and is susceptible to infections of it (tuberculosis osteomyelitis) • Usually not invaded by oral and maxillofacial infections.

17. Deep Cervical Fascial Space Infections • Extension of OI beyond the spaces described are Uncommon • Rarely if they do • Serious sequelae • Airway- Compressed, Deviate, obstruct • Invade into vital structures • Extend to the mediastinum

18. Shaped like inverted pyramid with its base at the base of the skull and apex at hyoid. Boundaries Medial-pharyngeal constrictors and overlying Buccopharyngeal fascia Lateral-medial pterygoid Anterior-palatal musculature Superiorly- buccinator and superior pharyngeal constrictor in the middle Inferiorly- stylohyoid and post diagastric muscle Lateral Pharyngeal Space = Everybody’s neighbor…..

19. Lateral Pharyngeal • Aponeurosis of Zuckerkandl and Testut divides the space into anterior (prestyloid) and posterior (poststyloid) compartments • Anterior-areolar ct • Posterior-CN IX, X, XII, hypoglossal, carotid sheath, cervical sympathetic chain

20. Communications • anterior border with submandibular and sublingual space. • Posterior-carotid sheath • retropharyngeal space medially. • Anterosuperiorly extends to the Pterygomandibularraphe

21. Everyone’s neighbor • Sublingual infections enter through buccopharyngeal gap • Submandibular infections can pass around post diagastric or stylohyoid muscle • Retropharyngeal infections can spread easily as there is no membranous separation (direct communication) • Pterygomandibular infections communicate around the anterior border of the medial pterygoid

22. Lateral Pharyngeal space infection • Signs and Symptoms (Prestyloid) • Trismus • Induration of the angle of the jaw • Displacement of the lateral pharyngeal wall and tonsil medially ***Important Notice swelling is not a sign and symptom for prestyloid

23. Lateral Pharyngeal space infection • Signs and Symptoms (Poststyloid)-Posterior part • No trismus • Swelling of the lateral and posterior pharyngeal wall • Neurological deficit of CN IX, X, XII and cervical sympathetic trunk (hornor’s syndrome) Pre-styloid = trismus, Post Styloid – NO trismus

24. Clinical Features • Swelling of Medial Pterygoid muscle • Trismus • Lateral swelling of the neck • Dysphagia • Increased temperature • Thrombosis of IJV • Erosion of carotid artery

25. Retropharyngeal • Extends vertically from the base of the skull to the fusion of the retropharyngeal fascia with the alar fascia (C6-T4) • These 2 fascial layers compose the anterior, posterior and inferior borders of the space. • Anterior boundary-Pharynx • Posteriorly – Vertebral column and Alar fascia • Communicates through Alar fascia to the lateral pharyngeal space superiorly and laterally

26. Retropharyngeal • Contain lymph nodes that drain Waldeyer’s Ring, loose connective tissue • Infections can impinge on airway directly and potentially involve the Danger space (separated by alar fascia)

27. Retropharyngeal • Signs and symptoms • Fever • Pain and Neck rigidity • Dysphagia • Dyspnea • Laryngeal edema • Airway obstruction

28. Aspiration of abscess

29. Peritonsillar space abscess • Rare in young children • Common in Puberty • H/O tonsillitis • Signs and Symptoms • Fever >101 F • Trismus • Inflammation of tonsils • Change in voice • Dysphagia • Dyspnea • Displacement of tonsil

30. **Posterior Extension of Infection SUBLINGUAL SUBMANDIBULAR PTERYGOMANDIBULAR Contents Loose CT Anterior Compartment LATERAL PHARYNGEAL SPACE Contents: Carotid sheath CN 9,10,11(G,V,A) Posterior Compartment Retropharyngeal Ruptures into Alar fascia DANGER SPACE Prevertebralfascia MEDIASTINUM

31. Danger Space • Communicates with the mediastinum • Extends from base of skull to diaphragm • Lies between ALAR fascia and Prevertebral divisions of posterior layer of Deep Cervical Fascia • Continuous with posterior mediastinum in chest

32. Danger Space • Contents: • Cervical region-Areolar connective tissue • Chest-Continuous with mediastinum • Mediastinum contents • Vena cava • Aorta • Thoracic duct • Esophagus

33. Danger space • Infections cause • Compression of major vessels • Lower airway • Upper digestive tract

34. Posterior Extension of Infection SUBLINGUAL SUBMANDIBULAR PTERYGOMANDIBULAR Contents Loose CT Anterior Compartment LATERAL PHARYNGEAL SPACE Contents: Carotid sheath CN 9,10,12(G,V,H) Posterior Compartment Retropharyngeal Ruptures into Alar fascia DANGER SPACE Prevertebral fascia MEDIASTINUM

35. Space b/w lungs Contents Heart Phrenic, Vagus Nerves Trachea Main stem of bronchi Aorta, IVS, SVC Mediastinum

36. Mediastinitis • Life threatening, High Mortatilty • Compresses on the vital stuctures • Interferes with Neurologic control of Heart and lungs • Rupture into lung, trachea, esophagus

37. Management Of Fascial Space Infections • Medically Support the Patient • Surgical removal of the source of Infection • Surgical Drainage • Administration of Antibiotics • Frequent re-evaluation

38. Medically Support the Patient • Airway • Tracheotomy • Endotracheal intubation • Support Host defense mechanisms • Hydration (fluids) • Analgesics • Nutrition • Antibiotics ( Type, Route)

39. Extra Oral Drainage A – temporal and deep temporal space infections B – drains submandibular gland space infections *risdin incision can also be used to drain submandibular space 2 fingers down from B C – drains submental D – drains retropharyngeal or lateral pharyngeal space infections

40. Osteomyelitis • Literal Meaning- Inflammation of Bone • Begins in the Medullary cavity of the bone involving the cancellous bone • Occurs when pus in the medullary region or beneath the periosteum obstructs blood supply • Following ischemia, infected bone becomes necrotic

41. PREDISPOSING FACTORS • Isolated odontogenic infections • Low occurrence (host resistance) • Systemic diseases • Diabetes, agranulocytosis, leukemia, severe anemia, malnutrition, sickle cell anemia • Immunosuppression • Chronic alcoholism and drug abuse • Other conditions that alter vascularity of bone • Radiation, osteoporosis, Paget’s disease, fibrous dysplasia

42. PREDISPOSING FACTORS • Osteomyelitis associated with fractures • Increased incidence with failure to effectively reduce, fixate, and immobilize fractures • Also seen with overzealous fixation due to devascularization

43. Etiology • Initiated by contiguous focus of infection or by hematologic spread • Osteomyelitis in jaws: • 1 – odontogenic infection • 2 – trauma (compound fractures) • Mandible > maxilla • Blood supply to the maxilla is much more extensive and cortical plates are much thinner

44. Vascular supply to the mandible • Primarily single blood supply • Supplied by inferior alveolar a. except coronoid process • Minimally by periosteal blood supply

45. Pathophysiology • Compromise in blood supply • Acute inflammation • Tissue necrosis • Pus formation • increased intramedullary pressure • Ischemia • Accumulation of pus under periosteum • Further reduction of blood supply

46. MICROBIOLOGY • Historically, believed Staph aureus and Staph epidermidis in 80-90% of cases • Currently, believed to be mixed – aerobic/anaerobic infection • Acute – staph is common • Chronic – gram negative and anaerobes

47. 5 classic signs of anaerobic or mixed infection • Foul smelling exudate • Sloughing of necrotic tissue, gas in tissues • Gram staining revealing multiple organisms of different morphologic characteristics • Failure to grow organisms from clinical specimens • Prescence of sequestra

48. CLASSIFICATION of Osteomyelitis • SUPPURATIVE • Acute Suppurative • Chronic Suppurative • Primary • Secondary • Infantile • NONSUPPURATIVE • Chronic sclerosing • Focal sclerosing • Diffuse sclerosing • Garre’ssclerosing • Actinomycotic • Radiation osteomyelitis and necrosis

49. CLINICAL SIGNS AND SYMPTOMS • Acute suppurative • Deep intense pain • High intermittent fever • Paresthesia/anesthesia of mental nerve • Clearly defined etiology

50. CLINICAL SIGNS AND SYMPTOMS • Chronic primary osteomyelitis • Not preceeded by an episode of acute symptoms • Insidious in onset • Slight pain, slow increase in jaw size • Gradual development of sequestra • Usually no fistulae present