Deep Neck Space Infections INDIAN ACADEMY
DENTAL
Leader in continuing dental education www.indiandentalacademy.com
www.indiandentalacademy.com
Outline
Anatomy Fascial planes Spaces Epidemiology Etiology Clinical presentation Imaging Bacteriology Therapy Medical Surgical Complications Mediastinitis www.indiandentalacademy.com
ανατομία
www.indiandentalacademy.com
Cervical Fascia
Superficial Layer Deep Layer
Subdivisions not histologically separate Superficial
Middle
Enveloping layer Investing layer Visceral fascia Prethyroid fascia Pretracheal fascia
Deep www.indiandentalacademy.com
Superficial Layer
Superior attachment – zygomatic process Inferior attachment – thorax, axilla. Similar to subcutaneous tissue Ensheathes platysma and muscles of facial expression www.indiandentalacademy.com
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
www.indiandentalacademy.com
Superficial Layer of the Deep Cervical Fascia
www.indiandentalacademy.com
Middle Layer of the Deep Cervical Fascia
Visceral Division
Superior border
Anterior – hyoid and thyroid cartilage Posterior – skull base
Inferior border – continuous with fibrous pericardium in the upper mediastinum.
Buccopharyngeal fascia
Muscular Division
Superior border – hyoid and thyroid cartilage Inferior border – sternum, clavicle and scapula Envelopes infrahyoid strap muscles
Name for portion that covers the pharyngeal constrictors and buccinator.
Envelopes
Thyroid Trachea Esophagus Pharynx Larynx
www.indiandentalacademy.com
Middle Layer of the Deep Cervical Fascia
www.indiandentalacademy.com
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. www.indiandentalacademy.com
Deep Layer of Deep Cervical Fascia
www.indiandentalacademy.com
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.
www.indiandentalacademy.com
Deep Neck Spaces
Described in relation to the hyoid.
Entire length of neck
Suprahyoid
Superficial space Retropharyngeal Danger Prevertebral Vascular visceral
Submandibular Pharyngomaxillary (Parapharyngeal) Parotid Peritonsillar Temporal Masticator
Infrahyoid
Anterior visceral www.indiandentalacademy.com
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
www.indiandentalacademy.com
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. www.indiandentalacademy.com
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.
www.indiandentalacademy.com
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
www.indiandentalacademy.com
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.
www.indiandentalacademy.com
Submandibular Space
Suprahyoid
2 compartments
Superior – oral mucosa Inferior - superficial layer of deep fascia Anterior border – mandible Lateral border - mandible Posterior - hyoid and base of tongue musculature
Sublingual space
Areolar tissue Hypoglossal and lingual nerves Sublingual gland Wharton’s duct
Submaxillary space
Anterior bellies of digastrics
www.indiandentalacademy.com
Submental compartment Submaxillary compartments
Submandibular gland
Submandibular Space
www.indiandentalacademy.com
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
www.indiandentalacademy.com
Pharyngomaxillary space
Prestyloid
Poststyloid
Muscular compartment Medial—tonsillar fossa Lateral—medial pterygoid Contains fat, connective tissue, nodes 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.
www.indiandentalacademy.com
Pharyngomaxillary Space
Communicates with several deep neck spaces.
Parotid Masticator Peritonsillar Submandibular Retropharyngeal www.indiandentalacademy.com
Peritonsillar Space
Suprahyoid
Medial—capsule of palatine tonsil Lateral—superior pharyngeal constrictor Superior—anterior tonsil pillar Inferior—posterior tonsil pillar
www.indiandentalacademy.com
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 www.indiandentalacademy.com by temporalis muscle
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
www.indiandentalacademy.com
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.
www.indiandentalacademy.com
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. www.indiandentalacademy.com
Etiology
Odontogenic Tonsillitis IV drug injection Trauma Foreign body Sialoadenitis Parotitis Osteomyelitis Epiglottitis URI Iatrogenic Congenital anomalies Idiopathic www.indiandentalacademy.com
Clinical presentation
Most common symptoms
Most common symptoms (exluding peritonsillar abscesses)
Sore throat (72%) Odynophagia (63%)
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 www.indiandentalacademy.com
Imaging
Lateral neck plain film
Screening exam No benefit in pts with DNI based on strong clinical suspicion. Normal:
Technique dependent
7mm at C-2 14mm at C-6 for kids 22mm at C-6 for adults Extension Inspiration
Sensitivity 83%, compared to CT 100%
www.indiandentalacademy.com
Imaging
MRI
Pros
CT with contrast
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
Pros
Cons
Cons
Widely available Faster (5-15 minutes) Abscess vs cellulitis Less expensive
Cost Pt cooperation Slower (19 to 35 minutes) www.indiandentalacademy.com
Contrast Radiation Uniplanar Dental artifacts
Imaging
Regular cavity wall with ring enhancement (RE) Sensitivity - 89% Specificity - 0%
Irregular wall (scalloped)
Sensitivity - 64% Specificity - 82% PPV - 94% www.indiandentalacademy.com
Aerobic
G (+)
n
%
Total
645
87.4 0
Strep sp.
229
Staph sp.
Bacteriology
Anaerobic
G (-)
n
%
n
%
Total
137
18.5 6
Total
201
27.24
31.03
Klebsiella sp.
90
12.20
Peptostreptococcus
43
5.83
112
15.18
Neisseria sp.
20
2.71
Bacteroides sp.
50
6.78
B-hemolytic Strep
80
10.84
Acinebacter sp.
7
0.95
Unidentified
46
6.23
Strep viridans
71
9.62
Enterobacter sp.
7
0.95
Bacteroides melaninogenicus
13
1.76
Staph aureus
57
7.72
Proteus sp.
4
0.54
Propionibacterium
9
1.22
Coagulase neg. Staph sp.
55
7.45
E coli
3
0.41
Provotella sp.
7
0.95
Strep pneum
13
1.76
Citrobacter sp
2
0.27
Fusobacterium
7
0.95
Enterococcus
10
1.36
M. Catarrhalis
2
0.27
Bacteroidies fragilis
6
0.81
Mycobacterium tub.*
10
1.36
Pseudomonas sp.
1
0.14
Eubacterium
6
0.81
Micrococcus
8
1.08
H. Parainfluenza
1
0.14
Peptococcus
6
0.81
Diptheroids
7
0.95
H influenzae
1
0.14
Veillonella parvula
5
0.68
Bacillus sp.
6
0.81
Salmonella sp.
1
0.14
Clostridium sp.
4
0.54
Actinomycosis israelii
3
0.41
Lactobacillus
4
0.54
Bifidobacterium sp.
3
0.41
Polymicrobial
181
24.5 3
Sterile
71
9.62
Modified and combined data from 738 patients (1, 2, 3, 4, 5, 6, 7). www.indiandentalacademy.com
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.
www.indiandentalacademy.com
Surgery
External drainage
Landmarks
Transoral drainage
Tip of greater horn of hyoid Cricoid cartilage Styloid process SCM
Parapharyngeal, retropharyngeal abscesses Great vessels lateral to abscess Tonsillectomy for exposure
Needle aspiration
www.indiandentalacademy.com
Complications
Airway obstruction
Mediastinitis – 2.7% UGI bleeding Sepsis Pneumonia IJV thrombosis Skin defect Vocal cord palsy Pleural effusion Hemorrhage
Trach 10 – 20% Ludwig’s angina - 75%
20 - 80% mortality
Multiple space involvement
www.indiandentalacademy.com
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
www.indiandentalacademy.com
Descending Necrotizing Mediastinitis
Definition – mediastinal infection in which pathology originates in fascial spaces of head and neck and extends down.
Criteria for diagnosis 1. 2. 3.
Retropharyngeal and Danger Space – 71% Visceral vascular – 20% Anterior visceral – 7-8%
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%
www.indiandentalacademy.com
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
www.indiandentalacademy.com
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 www.indiandentalacademy.com
Treatment
IV antibiotics Cervical drainage
Transthoracic drainage
Abscesses below T4
Subxyphoid approach
Cervical abscesses Superior mediastinal abscesses above T4 (tracheal bifurcation)
Anterior mediastinal drainage
Thoracostomy tubes www.indiandentalacademy.com
Bibliography 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19.
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-spaces2002-04.doc
www.indiandentalacademy.com
Thank you For more details please visit www.indiandentalacademy.com
www.indiandentalacademy.com