Deep Neck Space Infections

Jeffrey Buyten, MD

Faculty Advisor: Francis B. Quinn, Jr., MD

The University of Texas Medical Branch

Department of Otolaryngology

Grand Rounds Presentation

October 5, 2005

Outline

Anatomy

Fascial planes

Spaces

Epidemiology

Etiology

Clinical presentation

Imaging

Bacteriology

Therapy

Medical

Surgical

Complications

Mediastinitis

ανατομία

Cervical Fascia

Superficial Layer

Deep Layer Subdivisions not

histologically separate

Superficial Enveloping layer

Investing layer

Middle Visceral fascia

Prethyroid fascia

Pretracheal fascia

Deep

Superficial Layer

Superior attachment – zygomatic process

Inferior attachment – thorax, axilla.

Similar to subcutaneous tissue

Ensheathes platysma and muscles of facial expression

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

Superficial Layer of the Deep Cervical Fascia

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

Middle Layer of the Deep Cervical Fascia

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.

Deep Layer of Deep Cervical Fascia

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.

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

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

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.

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.

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

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.

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

Submandibular Space

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

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.

Pharyngomaxillary Space

Communicates with several deep neck spaces. Parotid

Masticator

Peritonsillar

Submandibular

Retropharyngeal

Peritonsillar Space

Suprahyoid

Medial—capsule of palatine tonsil

Lateral—superior pharyngeal constrictor

Superior—anterior tonsil pillar

Inferior—posterior tonsil pillar

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

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

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.

Epidemiology

All patients

Avg age b/w 40-50.

More predominant in patients over 50 years.

Pediatric patrents

Infants to teens.

Male predilection in some case series.

Most common age group: 3-5 years.

Etiology Odontogenic

Tonsillitis

IV drug injection

Trauma

Foreign body

Sialoadenitis

Parotitis

Osteomyelitis

Epiglottitis

URI

Iatrogenic

Congenital anomalies

Idiopathic

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

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%

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)

Imaging

Regular cavity wall with ring enhancement (RE)

Sensitivity - 89%

Specificity - 0%

Irregular wall (scalloped)

Sensitivity - 64%

Specificity - 82%

PPV - 94%

Modified and combined data from 738 patients (1, 2, 3, 4, 5, 6, 7).

Bacteriology Aerobic Anaerobic

G (+) n % G (-) n % n %

Total 645 87.40 Total 137 18.56 Total 201 27.24

Strep sp. 229 31.03 Klebsiella sp. 90 12.20 Peptostreptococcus 43 5.83

Staph sp. 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 24.53 Sterile 71 9.62

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.

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

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

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

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 1. Clinical manifestation of severe infection. 2. Demonstration of the characteristic imaging features of mediastinitis. 3. Features of necrotizing mediastinal infection at surgery.

1960-89 – 43 published cases Mortality rate 14-40%

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

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

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

Bibliography 1. 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 2. Kirse, DJ, Roberson,DW. Surgical Management of Retropharyngeal Space Infections in Children. Laryngoscope, 111: 1413-1422,

2000. 3. 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. 4. 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. 5. 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. 6. 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. 7. 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. 8. 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. 9. 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. 10. 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. 11. 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. 12. Chaudhary, N, Agrawal, S, Rai, A. Descending Necrotizing Mediastinitis: Trends in a Developing Country. Ear Nose Throat. 2005

84(4); 242-50. 13. 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. 14. 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. 15. Akman, C, Kantarci, F, Cetinkaya, S. Imaging in mediastinitis: a systematic review based on aetiology. Clinical radiology (2004) 59,

573-85. 16. Baqain, Z, Neman, L, Hyde, N. How Serious are Oral Infections? Journ Laryngol Otol. July 2004 (118). 561-65. 17. Netters, F. Atlas of Human Anatomy 2nd Ed. 18. Lee, KJ. Essentials of Otolaryngology. 19. 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