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DEEP NECK INFECTION

DEEP NECK INFECTION. Anatomy of cervical fascia. Cervical fascia 1) Superficial cervical fascia 2) Deep cervical fascia. Superficial Cervical Fascia. Encircle H&N and attached to clavicle and zygomatic arch Contain plastysma m. and external jugular v.

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DEEP NECK INFECTION

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  1. DEEP NECK INFECTION

  2. Anatomy of cervical fascia Cervical fascia 1) Superficial cervical fascia 2) Deep cervical fascia

  3. Superficial 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

  4. Deep Cervical Fascial • Superficial layer • Middle layer • Deep layer

  5. Superficial layer(Enveloping,Investing,Anterior layer) • From ligamentum nuchae, completely enclose the neck • Encircle trapezius m. , sternocleidomastiod m. • Encircle submandibular gl.,parotid gl.,masticater muscle • Create superficial sternal space (of Burn)

  6. Middle layer(Cervical layer,Pretracheal layer) • Encircle strap m. (muscular division) • Encircle esophagus trachea,thyroid gl.,pharynx (visceral division) • Buccopharyngeal fascia ( part of visceral division that cover constrictor m. and buccinator m.)

  7. Deep layer(Carpet fascia) • Cover vertebral body and paraspinous m. • Devided into 1. Alar division from base of skull to T2 level 2.Prevertebral division from base of skull to diaphram

  8. Carotid sheath • Extend from skull base to clavicle • Made up of 3 layer of deep cervical fascia • Contain carotid a.,internal jugular v., vagus n. andsympathetic chain • Avenues for spread of infection from neck to mediastinum

  9. Deep Neck Space Anatomy • Space Involving Entire Length Of Neck • Space Limited To Above The Hyoid Bone • Space limited To Below The Hyoid Bone

  10. Space Involving Entire Length Of Neck • Retropharyngeal Space • Danger Space (Prevertebral Space) • Paravertebral Space • Carotid Sheath Space

  11. Retropharyngeal Space • Between visceral division of middle layer and alar division of deep layer • Extend from skull base to T2 level • Midline raphae • More commom in children due to presence of retropharyngeal node

  12. Danger Space • Betweenalar division and prevetebral division of deep layer (locate posterior to retropharyngeal space) • Extend from skull base to diaphram • No midline raphae • Infection spread from neck to posterior mediastinum easily

  13. Paravertebral Space • Between prevertebral division of deep layer and vertebral bodies • Extend from skull base to coccyx • Infection in this space is rare and spread slowly due to compact connective tissue

  14. Carotid sheath Space • Made up from all deep cervical fascia • Infection from any deep fascia can spread to this space (lincoln High way)

  15. Space Limit To Above The Hyoid Bone • Parapharyngeal Space • Submandibular Space • Masticator Space • Temporal Space • Parotid Space

  16. Parapharyngeal Space(Lateral phryngeal Space)(Pharyngomaxillaly Space) Boundary • Superiorly : Skull base • Inferiorly : Hyoid bone • Laterally : Medial pterygoid m. • Medially :Buccopharyngeal fascia • Anteriorly : Submandibular space • Posteromedialy : Prevertebral fascia and retrophryngeal space

  17. Submandibular Space Divided into 2 spaces by mylohyoid m. • Sublingual space (above mylohyoid m.) • Submaxillaly space (below mylohyiod m.) • These 2 spaces can communicate each other by mylohyoid cleft

  18. Masticator Space • Betweenmasticator m. and superficial layer of deep cervical fascia (Masticator m. = massestor m.,medial and lateral pterygoid m. and temporalis muscle) • Locate anterior and lateral to parapharyngeal space

  19. Parotid Space • Between parotid gl. and superficial layer of deep cervical fascia • Infection can spread easily to parapharyngeal space due to incompleted encircle at upper inner surface of parotid gl.

  20. Space Limit To Below The Hyoid Bone Anterior Viseral Space (Pretracheal Space) • Between trachea, esophagus and middle layer of deep cervical fascia • Extend from hyoid bone to superior mediastinum

  21. Etiology Of Deep neck Space • Dental infection • Tonsillar and peritonsillar infection • Trauma of upper aerodigestive tract • Retropharyngeal lymphadenitis • Pott’s disease • Sialadenitis • Bezold’s abscess • Infection of congenital cyst and fistula • Intravenous drug abuse

  22. SPECIFIC DEEP NECK INFECTION

  23. PARAPHARYNGEAL SPACE INFECTION • 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 syndrom)

  24. PARAPHARYNGEAL SPACE INFECTION Treatment • Evaluate and maintain airway & fluid hydration • Parenteral antibiotic high dose 24-48 hrs. • If not improve, consider surgical drainage

  25. PARAPHARYNGEAL SPACE INFECTION Surgical drainage • Intraoral approch (for peritonillar abscess only) 2.External approach -transverse submandibular incision -T. shape incision (Mosher)

  26. SUBMANDIBULAR SPACE INFECTION Most common cause : Dental caries • Anterior teeth & first molar : infection enter sublingual space • Second & third molar : infection enter submaxillary space

  27. SUBMANDIBULAR SPACE INFECTION • Organisms - Mixed of aerobes(alpha hemolytic strep, staph) and anaerobes make synnergistic effect of endotoxins - Consider gram – in immunocompromize host

  28. SUBMANDIBULAR SPACE INFECTION Clinical feature (True Lugwig’s angina) • Start unilateral and progress bilaterally • Induration of submandibular region and floor of mouth ( severe cellulitis) • Tongue trusted posteriorly and superiorly (cause airway obstruction) • Drolling, odynophagia, trismus, fever • No purulence(due to no time to developed)

  29. SUBMANDIBULAR SPACE INFECTION Treatment • Early stage (unilat,mild swelling and edema) -IV antibiotic, extration of infected tooth • Advance stage (bilateral swelling, dysphagia with drolling) -early airway intervention -surgical drainage (submandibular incision)

  30. RETROPHARYNGEAL SPACE INFECTION PREVERTEBRAL SPACE INFECTION Most commmon cause • In children -retropharyngeal lymphadenitis from nose,PNS,ET) • In adult -regional truma and endoscopic procedure

  31. RETROPHARYNGEAL SPACE INFECTION PREVERTEBRAL SPACE INFECTION Clinical feature • In children irritability,neck rigidity, fever,drolling,muffle cry, airway compromise • In adult fever, sore throat, odynophagia, neck tenderness, dysnea

  32. RETROPHARYNGEAL SPACE INFECTION PREVERTEBRAL SPACE INFECTION Clinical feature • Retropharyngeal space abscess form abscess lateral to midline • Prevertebral space abscess form abscess in midline • Mediastinitis S&S Dysnea,chest pain, tachycardia, fever,wideded mediastinum

  33. RETROPHARYNGEAL SPACE INFECTION PREVERTEBRAL SPACE INFECTION 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

  34. RETROPHARYNGEAL SPACE INFECTION PREVERTEBRAL SPACE INFECTION Treatment Surgical drainage • Intraoral drainage -Lesion confined in larynx esp.child • External drainage (Dean) -Lesion beyond pharyngeal level -Airway compromise -Involve other deep neck spaces

  35. PARAVERTEBRAL SPACE INFECTION • Most common cause Penetrating trauma(F.B, endoscope) TB spine • Infection spread slowly and more localize due to compact CNT. Clinical feature -Same as others posterior space abscess -Vertebral osteomyelitis and spinal instability

  36. MASTICATOR SPACE INFECTION • Most common causeDental carices Clinical feature • Extream trismus with minimum facial swelling • Massesteric space (lateral compartment) : edema at ramus of mandible - Ptrygomandibular space (medial compartment): edema at retromolar trigone

  37. MASTICATOR SPACE INFECTION Treatment 1.Intraoral drainage (medial compartment) - along inner margin of mandibular ramus to the retromolar trigone • External approch (lateral compartment) - submandibular incision - preauricular incision or Gilles incision for temporal space abscess

  38. PAROTID SPACE INFECTION • Most common cause : Bacterial retrograde from oral cavity Clinical feature • high fever, weakness, mark swelling and tenderness of parotid gland,fluctuation,pus at stensen’s duct

  39. PAROTID SPACE INFECTION Treatment • IV ATB • Surgical drainage indicated for -fluctuation -medical failure after 24-48 hr. or progression of disease

  40. COMPICATION OF DEEP NECK INFECTION • Internal jugular vein thrombosis • Cavernous sinus thrombosis • Neurologic deficit • Osteomyelitis of the mandible • Osteomyelitis of the spine • Mediastinitis • Pulmonary edema • Pericarditis • Aspiration • Sepsis

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