Deep Neck spaces and Infection
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Deep Neck spaces and Infection
Dr.Samir M. BawazirConsultant Pediatric ORL.H&NS
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Anatomy of the Cervical Fascia Anatomy of the Deep Neck Spaces Deep Neck Space Infections
Deep Neck Spaces and Infection
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Superficial Layer Deep Layer * Superficial * Middle * Deep
Cervical Fascia
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Superfecial Layer * Platysma * Muscels of facial expression
Cervical Fascia
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Superficial Layer of the Deep Cervical Fascia * Muscels: - SCM - Trapezius
* Glands: - SMG - Parotid
* Spaces: - Posterior Triangle - Suprasternal space
Cervical Fascia
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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
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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
Cervical Fascia
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Carotid Sheath:
* Formed by all 3 layers of deep fascia * Contains carotid A., int. jugular V. and vagus N. (highway to the brain neck and chest)
Cervical Fascia
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Described in relation to the hyoid
* Entire length of the neck. * Suprahyoid. * Infrahyoid
Deep Neck Spaces
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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
Deep Neck Spaces
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• 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
Deep Neck Spaces
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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.
Deep Neck Spaces
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Submandibular Space
- Suprahyoid - Ant./ Lat.- mandible - Sup.- mucosa - Inf. – superficial layer of deep fascia - Post./ Inf.- hyoid
Deep Neck Spaces
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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
Deep Neck Spaces
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Parapharyngeal Space - Suprahyoid - Superior- skull base - Inferior- hyoid - Anterior ptyergomandibular raphe. - Posterior- prevertebral fascia - Medial- buccopharyngeal fascia. - Lateral- superficial layer of deep fascia.
Deep Neck Spaces
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Parapharyngeal Space
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Parapharyngeal Space - Prestyloid + Medial- tonsillar fossa + Lateral- medial pterygoid + Contains fat, connective tissue, nodes - Post styloid + Carotid sheath + Cranial N. IX, X, XII
Deep Neck Spaces
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Peritonsillar space - Suprahyoid - Medial- capsule of the palatine tonsil - Lat.- sup. Phary. Constrictor - Sup.- ant. Tonsil pillar - Inf.- post. Tonsil pillar
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Presentation / Origin of infection Microbiology Imaging Treatment Complications
Deep Neck Space Infections
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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.
Presentation/Origin
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Pediatrics Caused by infectious process in the LN from Nose, Adenoid, NP, Sinuses
Adult Caused by trauma, instrumentation extension from adjoining deep infection
Origin
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Danger Space
Presentation and exam – identical to Ret-Ph. space infection Cause – extension from Retropharyngeal, prevertebral Or parapharyngeal space
Presentation/Origin
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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
Presentation/Origin
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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
Presentation/Origin
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a
Ludwig’s angina
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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
Presentation/Origin
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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
Presentation/Origin
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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
Presentation/Origin
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Preantibiotic era—S.aureus Currently—aerobic Strep species and non-
strep anaerobes Gram-negatives uncommon Almost always polymicrobial Remember resistance
Microbiology
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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)
Imaging
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Ultrasound Advantages
- Avoids radiation - Portable - consistency Disadvantages
- Not widely accepted - Operator dependent - Inferior anatomic detail Uses
- Following infection during therapy - Image guided aspiration
Imaging
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Contrast enhanced CT Advantages
- Quick, easy - Widely available - Superior anatomic detail - Differentiate abscess and cellulitis Disadvantages
- Ionizing radiation - Allergenic contrast agent - Artifact
Imaging
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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
Imaging
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Airway protection
Antibiotic therapy
Surgical drainage
Treatment
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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
Treatment
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LUDWIG’S ANGINA• Admission • Close observation• May need intubation vs trach.
Treatment
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Antibiotic Therapy Cellulitis Improvement in 24-48 hours Abscess?
* 50-90% respond to IV-Abx
Treatment
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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
Treatment
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Surgical Drainage Transoral
- Preoperative CT- where are the great vessels? - Cruciate mucosal incision, blunt spreading through superior pharyngeal constrictor - Nagy, et al: retro-, parapharyngeal or combo in kids, 22/23 successfully treated with intraoralincision and drainage External
Treatment
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Surgical Drainage External
* EXPOSURE, EXPOSURE, EXPOSURE * Levitt: anterior vs. posterior approach * Submandibular incision * Submental incision * T-incision
Treatment
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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
Treatment
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Airway obstruction - Endotracheal intubation - Tracheotomy
Ruptured abscess - Pneumonia - Lung Abscess
Complications
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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
Complications
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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?
Complications
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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
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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
Conclosion
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