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Deep Neck Infections

Dr Imtiaz M Qazi. Deep Neck Infections. Introduction. “Pus in the neck calls for the surgeon’s best judgement , his best skill and often for all of his courage” …… Mosher. Problems. Complex Anatomy: precise localization difficult

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Deep Neck Infections

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  1. Dr Imtiaz M Qazi Deep Neck Infections

  2. Introduction “Pus in the neck calls for the surgeon’s best judgement, his best skill and often for all of his courage” …… Mosher

  3. Problems • Complex Anatomy: precise localization difficult • Deep Location: difficult to palpate, impossible to visualize • Access: intervening neurovascular & soft tissue structures at risk • Proximity: vital structures • Communication: spread to adjacent space, large area of neck

  4. Deep Neck Spaces And Infections • Anatomy of the Cervical Fascia • Anatomy of the Deep Neck Spaces • Deep Neck Space Infections

  5. Cervical Fascia • Superficial Cervical Fascia • Deep Cervical Fascia • Encircle H&N and attached to clavicle and zygomatic arch • Contain plastysma m. and external jugular v. • Marginal mandibular br. of Facial n. lies just deep • to superficial cervical fascia

  6. Deep Cervical fascia • Superficial Layer • Middle Layer • Deep Layer

  7. Superficial Layer DCF Investing/ Enveloping layer Muscles • Sternocleidomastoid • Trapezius Glands • Submandibular • Parotid Space • Suprasternal space of Burns

  8. Middle Layer DCF Muscular Division • Infrahyoid Strap Muscles Visceral Division • Pharynx, Larynx, • Esophagus, Trachea, • Thyroid Buccopharyngeal Fascia

  9. Deep Layer DCF Alar Layer • Posterior to visceral layer of middle fascia • Anterior to prevertebra layer Prevertebral Layer • Vertebral bodies • Deep muscles of the neck

  10. Carotid Sheath • Formed by all three layers of deep fascia • Contains carotid artery, internal jugular vein, and vagus nerve • “Lincoln’s Highway”

  11. Deep Neck Spaces And Infections • Anatomy of the Cervical Fascia • Anatomy of the Deep Neck Spaces • Deep Neck Space Infections

  12. Deep Neck Spaces • Described in relation to the hyoid • Entire length of the neck • 1.Retropharyngeal Space • 2. Danger Space • 3. Prevertebral Space • 4. Visceral Vascular (Carotid) Space • Suprahyoid • 5. Submandibular Space • 6. ParaPharyngeal Space • 7. Masticator/Temporal Space • 8. Parotid Space • 9. Peritonsillar Space • Infrahyoid • 10. Anterior Visceral Space

  13. Deep Neck Spaces • Entire Length of Neck: • 1. Prevertebral Space • Anterior border is prevertebral • fascia, posterior border is vertebral • bodies and deep neck muscles. • Extends along entire length • of vertebral column from skull base to • coccyx • Contains very compact tissue • Spread is therefore slow

  14. Deep Neck Spaces • Entire Length of Neck: • 2. Danger Space • Anterior border is alar layer • of deep fascia, posterior border • is prevertebral layer. • Extends from skull through • posterior mediastinum to • diaphragm. • Contains very loose • areolar tissue offering • little resistance to the spread • of infection to the mediastinum

  15. Deep Neck Spaces • Entire Length of Neck: • 3. Retropharyngeal • Space • Posterior to pharynx • and esophagus, between visceral div • of middle layer and alar div of deep • layer • Extends from skull base to T1-T2 • Midline raphe • Two chains of nodes on either side of the • midline

  16. Deep Neck Spaces • Infrahyoid • 3. Anterior Visceral • Space • Middle layer of deep fascia • Contains thyroid, • trachea, esophagus • Extends from thyroid • cartilage into superior • mediastinum

  17. Deep Neck Spaces • Suprahyoid: • 4. Para Pharyngeal Space • Superior: skull base • Inferior: hyoid • Prestyloid • IMA • Inf Alveolar N • Auriculotemporal N • Connective tissue, fat & nodes • Poststyloid • Carotid sheath • Cranial nerves IX, X, XII • Sympathetic chain

  18. Deep Neck Spaces • Suprahyoid: • 5. Submandibular Space • Anterior/Lateral: mandible • Superior: oral mucosa • Inferior: superficial layer of deep fascia • Posterior/Inferior: hyoid • Supramylohyoid portion • Sublingual gland • Hypoglossal and lingual • nerves • Portion of Submandibular gland • Inframylohyoid portion • Submandibular gland • Wharton’s duct • Anterior bellies of digastrics

  19. Deep Neck Spaces • Suprahyoid: • 6. Masticator and • Temporal Spaces • Bounded by the • superficial layer of deep • cervical fascia • Contains masseter, pterygoids, • temporalis, ramus and • posterior portions of the body • of mandible, inferior alveolar • vessels and nerves

  20. Deep Neck Spaces • Suprahyoid: • 7. Parotid Space • Superficial layer • of deep fascia • Dense septa from • capsule into gland • Relationship • to parapharyngeal space

  21. Deep Neck Spaces

  22. Deep Neck Spaces Submandibular Temporal Masticator Peritonsillar Lateral Pharyngeal Parotid Vascular Retropharyngeal Danger Network of patterns of infectious extension Prevertebral Anterior Visceral Mediastinum

  23. Deep Neck Spaces And Infections • Anatomy of the Cervical Fascia • Anatomy of the Deep Neck Spaces • Deep Neck Space Infections

  24. Deep Neck Space Infections • Before antibiotics - 70% by tonsillar and pharyngeal sources • Most common cause in adults: Odontogenic, IVDA • Most common cause in paeds: Tonsillar, URTI • Others: salivary gland, trauma, FB, instrumentation, local or superficial source • 22% without cause 1. Tom MB, Rice DH: Presentation and management of neck abscesses: a retrospective analysis, Laryngoscope 98:877, 1988

  25. Etiology • Tonsillar and pharyngeal infection • Dental infection • Oral surgical procedures • Trauma of upper aerodigestivetract • Cervical lymphadenitis • Retropharyngeal lymphadenitis • Pott’s disease • Sialadenitis • Bezold’s abscess • Infection of congenital cyst and fistula • Intravenous drug abuse • Necrosis/suppuration of a malignant cervical LN/mass

  26. Bacteriology • Most abscesses contain mixed bacterial flora Aerobes: Streptococci β-hemolytic (Strep pyogehes), Strept. Viridans, Strep pneumoniae Staphylococci, Neisseria, Klebsiella, Haemophilus (Decresed role of b-hemolytic Streptococci) Anaerobes: Bacteroides, Peptostreptococcus, fusobacterium Less common: Pseudomonas, E.coli & H. infuenzae • Anaerobes are understimated (>35%) widespread antibiotic use prior to collection of cultures poor sample collection techniques fragility of anaerobes • Anaerobes produce b-lactamase

  27. Signs and Symptoms • Fever, elevated WBC count, & tenderness • Asymmetry of neck & asstd neck mass/LN • Medial displacement of tonsil or lateral pharyngeal wall • Trismus • Torticollis • Fluctuation usually not palpable • Neural deficit: Horner’s Synd, Hoarseness • Spiking fever: IJV Thrombosis, Septic embolus • Airway obstruction

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

  29. Treatment • Empirical Treatment First-line Clindamycin 600-900mg tid (+/- cefuroxime 0.75-1.5gr tid) or Penicillin G 24 million units/day + Metronidazole 1gr bid Alternatives AMX/CL 1.5-3gr qid or PIP/TZ 2.25gr qid - 4.5 gr tid

  30. Treatment

  31. Imaging • Lateral neck plain film • Screening exam—mainly for retropharyngeal and pretracheal spaces • Normal: 7mm at C-2, 14mm at C-6 for kids, 22mm at C-6 for adults • Technique dependent • Extension • Inspiration • Nagy, et al • Sensitivity 83%, compared to CT 100%

  32. Imaging • Ultrasound (USG) • Advantages • Avoids radiation • Portable • 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 • Familiarity • Superior anatomic detail • Differentiate abscess and cellulitis • Disadvantages • Ionizing radiation • Allergenic contrast agent • Soft tissue detail • 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 Munoz, et al: MRI vs. CT

  35. Management History + Physical examination Culture, IV antibiotics, Airway control, Chest RX CT cellulitis large abscess small abscess needle aspiration for culture & drainage W&W 24-48h complications? improvement? No Yes surgical incision and drainage Continue AB

  36. Complications • Airway obstruction • Internal jugular vein thrombosis • Cavernous sinus thrombosis • Neurologic deficit – Horner’s, hoarseness • Erosion of carotid artery • Osteomyelitis of the mandible • Osteomyelitis of the spine • Mediastinitis • Pulmonary edema • Pericarditis • Aspiration • Sepsis

  37. Para Pharyngeal Abscess • Most common cause : Peritonsillar infection • Typical finding 1.Trismus 2.Angle mandible swelling 3. Medial displacement of lateral pharyngeal wall Others : fever, limit neck motion, neurologic deficit (C.N 9,10,12,Horner’s syndrome)

  38. Para Pharyngeal Abscess Treatment • Evaluate and maintain airway & fluid hydration • Parenteral antibiotic high dose 24-48 hrs. • If not improve, consider surgical drainage Surgical drainage • Intraoral approch (for peritonillar abscess only) 2. External approach -transverse submandibular incision -T. shape incision (Mosher)

  39. Retro Pharyngeal Abscess Clinical feature • In children irritability, neck rigidity, fever, drooling, muffled cry, airway compromise • In adult fever, sore throat, odynophagia, neck tenderness, dyspnoea

  40. Retropharyngeal Abscess Investigation • Lateral neck film - C2 > 7 mm. both children and adult - C7 > 14 mm. in children > 22 mm. in adult. • Chest film - detection of mediastinitis

  41. Retropharyngeal Abscess Treatment Surgical drainage • Intraoral drainage -Lesion confined in RP space esp.child • External drainage (Dean) -Lesion beyond pharyngeal level -Airway compromise -Involve other deep neck spaces

  42. Quinsy • Peritonsillar Space • Fever, malaise • Dysphagia, odynophagia • “Hot-potato” voice, trismus, bulging of superior tonsil pole and soft palate, deviation of uvula • Cause—extension from tonsillitis

  43. Parotid Space Infection • Most common cause : Bacterial retrograde from oral cavity Clinical feature • high fever, weakness, mark swelling and tenderness of parotid gland, fluctuation,pusat stensen’s duct

  44. Ludwig’s Angina Ludwig’s angina is characterized by rapidly spreading cellulitis / infection of the sublingual and submaxillary spaces with associated swelling of the submental region, tongue and floor of the mouth, secondary to dental infection.

  45. Ludwig’s Angina Grodinsky’s criteria (1939): 1.A cellulitis, not an abscess of submandibular space 2. The cellulitis involves all the sublingual and bilateral submaxillary spaces 3. The cellulitis produces a serosanguineous putrid infiltration but very little or no frank pus 4. Fascia, muscle, connective tissue involvement, sparing glands 5. The cellulitis is spread by continuity and not by lymphatics

  46. Ludwig’s Angina

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