Deep Neck spaces and Infection

1. Deep Neck spaces and Infection Dr.Samir M. Bawazir Consultant Pediatric ORL.H&NS

2. Deep Neck Spaces and Infection • Anatomy of the Cervical Fascia • Anatomy of the Deep Neck Spaces • Deep Neck Space Infections

3. Cervical Fascia • Superficial Layer • Deep Layer * Superficial * Middle * Deep

5. Cervical Fascia • Superfecial Layer * Platysma * Muscels of facial expression

6. Cervical Fascia • Superficial Layer of the Deep Cervical Fascia * Muscels: - SCM - Trapezius * Glands: - SMG - Parotid * Spaces: - Posterior Triangle - Suprasternal space

7. Meddle Layer of the Deep Cervical Fascia * Muscular Division - Infrahyoid Strap Muscles (St.Hy, St.Th, Th.Hy, Omohy.) * Visceral Division - Pharynx, Larynx, Esophagus,Trachea, Thyroid - Buccopharyngeal fascia

8. Cervical Fascia • Deep Layer of Deep Cervical Fascia * Alar Layer: - Post. visceral layer of middle fascia. - Ant. to prevertibral layer * Prevertibral Layer: - Vertebral bodies - Deep muscles of the neck

9. Cervical Fascia • Carotid Sheath: * Formed by all 3 layers of deep fascia * Contains carotid A., int. jugular V. and vagusN. (highway to the brain neck and chest)

10. Deep Neck Spaces • Described in relation to the hyoid * Entire length of the neck. * Suprahyoid. * Infrahyoid

11. Deep Neck Spaces • Entire length of Neck: * Superficial Space - Surround platysma - Contains areolar tissue, nodes nerves and vessels. - Subplatysmal Flaps. - Involved with cellulitis and superficial abscesses - Treat with I&D along Langer’s lines + Abx

12. Deep Neck Spaces • Retropharyngeal space - Entire Length of Neck - Post. To pharynx and esophagus - Ant. To alar layer of deep fascia - Extend from skull base to T1-T2

13. Deep Neck Spaces • Danger Space -Entire Length of Neck - Ant. Border is alar layer of deep fascia. - Post. Border is prevertebral layer. - Extend from skull base to diaphragm.

14. Deep Neck Spaces • Submandibular Space - Suprahyoid - Ant./ Lat.- mandible - Sup.- mucosa - Inf. – superficial layer of deep fascia - Post./ Inf.- hyoid

15. Deep Neck Spaces Submandibular Space - Sublingual space (under the tongue) content Areolar tissue, Hypoglossal and lingual N., Sublingual gland and Wharton’s duct. - Submylohyoid (submaxillary) Space Ant. Bellies of digastric Submandibular gland

16. Deep Neck Spaces Parapharyngeal Space - Suprahyoid - Superior- skull base - Inferior- hyoid - Anterior ptyergomandibular raphe. - Posterior- prevertebral fascia - Medial- buccopharyngeal fascia. - Lateral- superficial layer of deep fascia.

17. Parapharyngeal Space

18. Deep Neck Spaces Parapharyngeal Space - Prestyloid + Medial- tonsillar fossa + Lateral- medial pterygoid + Contains fat, connective tissue, nodes - Post styloid + Carotid sheath + Cranial N. IX, X, XII

19. Peritonsillar space - Suprahyoid - Medial- capsule of the palatine tonsil - Lat.- sup. Phary. Constrictor - Sup.- ant. Tonsil pillar - Inf.- post. Tonsil pillar

20. Deep Neck Space Infections • Presentation / Origin of infection • Microbiology • Imaging • Treatment • Complications

21. Presentation/Origin Retropharyngeal Abscess • 50% in pt. 6-12 months of age • 96% before 6 years of age • In children – fever, irritability, lymphadenopathy, torticollis, poor oral intake, sore throat, drooling. • In adults-- pain, dysphagia, anorexia, snoring, nasal obstruction, nasal regurgitation. • Dyspnea and respiratory distress • O/E: Lateral posterior oropharyngeal bulge.

22. Origin • Pediatrics Caused by infectious process in the LN from Nose, Adenoid, NP, Sinuses • Adult Caused by trauma, instrumentation extension from adjoining deep infection

23. Presentation/Origin Danger Space • Presentation and exam – identical to Ret-Ph. space infection • Cause – extension from Retropharyngeal, prevertebral Or parapharyngeal space

24. Presentation/Origin Submandibular Space • Pain , drooling, dysphagia, neck stiffness • Anterior neck swelling, floor of mouth edema • Causes- 70-85% have odontogenic origin First molar and anterior Second and third molar • Sialadenitis, lymphadenitis, laceration of the floor of mouth, mandible fractures

25. Presentation/Origin Ludwig’s angina - Cellulitis – not abscess - limited to SM space - Foul serosanguinous fluid, no frank purulence - Fascia, muscle, connective tissue involvement, sparing glands - Direct spread rather than lymphatic spread - Tender, firm anterior neck edema without fluctuance - Hot potato voice - Tachypnea, dyspnea, stridor

26. Ludwig’s angina • a

27. Presentation/Origin Parapharyngeal Space • Fever, chills, malaise • Pain, dysphagia, trismus • Medial bulge of lateral ph. Wall • Cause- infection of pharynx, tonsil, adenoids, dentition, parotid, mastoid, suppurative lymphadenitis, extension from other DNSI

28. Presentation/Origin Peritonsillar Space • Fever, malaise • Dysphagia, odenophagia • Hot potato voice, trismus, bulging of superior tonsil pole and soft palate, deviation of uvula • Cause- extension from tonsillitis

29. Presentation/Origin Anterior Visceral Space • Hoarseness, dyspnea, dysphagia, odynophagia • Erythema, edema of hypopharynx, may extend to include glottis and supraglottis • Anterior neck edema, pain, erythema, crepitus • Cause- FB., instrumentation, extension of infection in thyroid

30. Microbiology • Preantibiotic era—S.aureus • Currently—aerobic Strep species and non-strep anaerobes • Gram-negatives uncommon • Almost always polymicrobial • Remember resistance

31. Imaging • Lateral neck plain film • Screening exam—mainly for retropharyngeal and pretracheal spaces • Normal: for kids7mm at C-2, 14mm at C-6, for adults • 22mm at C-6 • Technique dependent • Sensitivity 83%, compared to CT 100% (Nagy, et al)

32. Imaging Ultrasound • Advantages - Avoids radiation - Portable - consistency • Disadvantages - Not widely accepted - Operator dependent - Inferior anatomic detail • Uses - Following infection during therapy - Image guided aspiration

33. Imaging Contrast enhanced CT • Advantages - Quick, easy - Widely available - Superior anatomic detail - Differentiate abscess and cellulitis • Disadvantages - Ionizing radiation - Allergenic contrast agent - Artifact

34. Imaging MRI • Advantages - No radiation - Safer contrast agent - Better soft tissue detail - Imaging in multiple planes - No artifact by dental fillings • Disadvantages - Increased cost - Increased exam time - Dependent on patient cooperation - Availability

35. Treatment • Airway protection • Antibiotic therapy • Surgical drainage

36. Treatment Airway protection • Observation • Intubation - Direct laryngoscopy: possible risk of rupture and aspiration - Flexible fiberoptic • Tracheostomy - Ideally = planned, awake, local anesthesia - Abscess may overlie trachea - Distorted anatomy and tissue planes

37. Treatment LUDWIG’S ANGINA • Admission • Close observation • May need intubation vstrach.

38. Treatment Antibiotic Therapy • Cellulitis • Improvement in 24-48 hours • Abscess? * 50-90% respond to IV-Abx

39. Treatment Antibiotic Therapy • Polymicrobial infections - Aerobic Strep, anaerobes - Ampicillin/sulbactam with metronidazole • Beta-Lactam resistance in 17-47% of isolates • Alternatives - Third generation cephalosporins - clindamycin • Culture and sensitivity

40. Treatment Surgical Drainage • Transoral - Preoperative CT- where are the great vessels? - Cruciate mucosal incision, blunt spreading throughsuperior pharyngeal constrictor - Nagy, et al: retro-, parapharyngeal or combo in kids, 22/23 successfully treated with intraoralincision and drainage • External

41. Treatment Surgical Drainage • External * EXPOSURE, EXPOSURE, EXPOSURE * Levitt: anterior vs. posterior approach * Submandibular incision * Submental incision * T-incision

42. Treatment Image-guided Aspiration • Patient selection - Smaller abscesses, limited extension, uniloculated - Early specimen collection, reduced expense, avoidance of neck scar • Yeow, et al: Ultrasound guided aspiration 8/10 patients successfully treated with needle aspiration 5/5 patients successful treated with catheter insertion

43. Complications • Airway obstruction - Endotracheal intubation - Tracheotomy • Ruptured abscess - Pneumonia - Lung Abscess

44. Complications Internal Jugular Vein Thrombosis - F/C, prostration, swelling and pain along SCM - Bacteremia, septic embolization, dural sinus thrombosis - IV drug abusers - Treatment + IV antibiotic therapy + Anticoagulation? + Ligation and excision

45. Complications Carotid Artery Rupture - Mortality of 20-40% - Sentinel bleeds from ear, nose, mouth - Majority from internal carotid, less from external carotid, and fewest from common carotid - Treatment + Proximal and distal control + Ligation + Patching or grafting?

46. Mediastinitis • Mortality of 40% • Increasing dyspnea, chest pain • CXR = widened mediastinum • Treatment - EARLY RECOGNITION AND INTERVENTION - Aggressive IV antibiotic therapy - Surgical drainage - Transcervical approach - Chest tube vs. thoracotomy

47. Conclosion • Cervical fascia- superficial & deep • Multiple neck spaces- supra and infra hyoid • Retropharyngeal, paraph, submandibular and peritonsilar spaces are important. • Ludwig’s angina can cause airway obst. • Airway protection first action • Contrasted CT diagnostic • Rx-IV Abx • I&D or aspiration may be neede