Deep Neck Space Infection Mini Lctr

8/10/2019 Deep Neck Space Infection Mini Lctr

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Agung D. Permana,dr.,M.Kes.,SpTHT-KL

Deep Neck Space Infection


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Introduction

DEEP NECK SPACE INFECTIONS

Life threateningdelay in diagnosis/inadequate/inappropriate treatment

complicationsmortality rates : 40%head and neck surgeon :cervical fascias & potential spacesunderstand thetreatment & potential complicationsantibiotics decreased the incidence and mortality


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Anatomy Of The Cervical Fascia

Superficial cervical fascia

Deep cervical fascia

1. Superficial layer2. Middle layer

- Muscular division

- Visceral division

3. Deep layer

- Prevertebral division- Alar division


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Sternocleidomastoid

TrapeziusDeep Cervical Fascia

Investing layer of deep cervical fascia

Prevertebral fascia

Pretrachealfascia

(visceral part)

Carotid sheath

Buccopharyngeal fascia

Alar fascia

Pretracheal fascia

(muscular part)

T

E


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Cervical Fascia


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Pathophysiology

Deep neck space infections can arise from a multitude of causes.Whatever the initiating event, development of a deep neck spaceinfection proceeds by one of several paths, as follows:

Spread of infection can be from the oral cavity, face, or superficial

neck to the deep neck space via the lymphatic system. Lymphadenopathy may lead to suppuration and finally focal

abscess formation. Infection can spread among the deep neck spaces by the paths of

communication between spaces. Direct infection may occur by penetrating trauma.


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Sign And Symptoms

Mass effect of inflamed tissue or abscess cavityon surrounding structures

Direct involvement of surrounding structureswith the infectious process


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Presentation Obtain a detailed history from patients in whom deep neck space

infection is suspected. Eliciting a history of the following isimportant:

Pain Recent dental procedures Upper respiratory tract infections (URTIs) Neck or oral cavity trauma Respiratory difficulties

Dysphagia Immunosuppression or immunocompromised status Rate of onset Duration of symptoms


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Retropharyngeal Space Infection

Source Nose

Sinuses

Adenoids

Nasopharynx

Manifestations Acute URTI in infants & children

Dysphagia & odynophagia

Drooling & difficult to expell excretions

Cervical rigidity

Muffled voice Dyspnea

Unilateral bulging of posterior pharyngeal wall

Sepsis


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Pediatrics "Cause> suppurative process in lymph nodes

#Nose, adenoids, nasopharynx, sinuses!

Adults Cause> trauma, instrumentation, extension

adjoining deep neck space


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Danger Space Infection

Source Retropharyngeal space

Prevetebral space

Parapharyngeal space

Manifestations Same as primary space infection

Severe sepsis

TreatmentSame as for primary space infection

Complications Potential for rapid spread through the loose areolar tissue

Inferior spread to the posterior mediastinum to the level of diafragma


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Prevertebral Space Infection

Manifestations

Midline abcess Cold abcess posterior pharynx

Slow spread of suppuration of this area

Treatment Needle aspiration w/ subsequent antituberculosis th/

Stabilization of spine

Source Vertebral bodies

Penetrating injuries

Tuberculosis of the spine

ComplicationsSpine instabilityprogression of vetebral process


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Visceral Vascular Space Infection

potential space within the carotid sheath infections remain relatively localized

compact space contains little areolarconnective tissue

lymphatics contained within this space receivesecondary drainage from most of thelymphatics of the head and neck

Lincoln Highway of The Neck(Mosher) all

three layers of the DCF contribute to thecarotid sheath


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Visceral Vascular Space Infection

Source Parapharyngeal space

Submandibular space

Visceral space

Manifestations

Pitting edema over SCM Torticollis

Treatment External drainage

I.V. antibiotics

Possible ligation of IJV

Complications Septic shock

Carotid artery erotions Endocarditis

Cavernous sinusthrombosis


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Pharingomaxillary Space Infection

Prestyloid Compartement [anterior-muscular] Fat

Lymph nodes

Internal maxilarry artery

Inferior alveolar, lingual,auriculotemporal nerves

Poststyloid Compartement [posterior-neurovascular] Carotid artery

Internal jugular vein

Symphatetic chain

IX, X, XI, XII nerves


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Source Tonsil

Pharynx

Teeth

Temporal bone (petrous)

Parotis gland Lymph nodes of nose &

nasopharynx

Manifestations Medial displacement of lateral

pharyngeal wall and tonsils Trismus

Parotid edema

Retromandibular neck fullness

Dysphagia


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Peritonsillar Space Infection

SourceTonsils & pharynx

Manifestations Dysphagia/odynophagia

Drooling and hot potato voice

Muffleed voice

Reffered otalgia

Trismus

Displaced tonsil toward midline Deviated uvula


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Submandibular Space Infection

Sublingual space Sublingual gland

Hypoglossal nerve

Whartons ducts

Submaxillary spaceCentral compartement

Submental compartement

Submaxillary compartement

subdivided by anterior bellies ofdigastric m.

Contents

Submandibular gland

Lymph nodes


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Submandibular Space Infection

Source Teeth

Salivary glands

Pharynx & tonsils

Sinuses

Manifestations Dysphagia

Odynophagia

Treatment Underlying pathology

External drainage if it progress- sublingual

- submandibula

ComplicationsLudwigs Angina


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Ludwigs Angina


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Ludwigs angina


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Temporal Space Infection

Temporalis m. :- superficial compartments

- deep compartments

Manifestation

Pain in this area Trismus

Treatment

External drainage


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Anterior Visceral Space

Contents Pharynx

Esophagus

Larynx

Trachea Thyroid gland

Source Tonsils

Esophageal injury Blunt trauma w/ mucosal tear

Acute thyroiditis

Chest infection


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Anterior Visceral Space


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Microbiology

Preantibiotic eraS.aureus

Currentlyaerobic Strep species and non-strepanaerobes

Gram-negatives uncommon

Almost always polymicrobial

Remember resistance !!!


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Imaging

Lateral neck plain film

"Screening exammainly for retropharyngeal and

pretracheal spaces

"Normal: 7mm at C-2, 14mm at C-6 for kids,

22mm at C-6 for adults


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Imaging


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Imaging

High-resolution Ultrasound "Advantages

Avoids radiation

Portable

"Disadvantages Not widely accepted

Operator dependent

Inferior anatomic detail

"Uses

Following infection during therapy

Image guided aspiration


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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


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Treatment

Airway protection

Antibiotic therapy

Surgical drainage


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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


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Treatment

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


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Treatment

Surgical Drainage

Transoral Preoperative CT where are the great vessels? CT

Cruciate mucosal incision, blunt spreading through superiorpharyngeal constrictor

External drainage


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Surgical Drainage

"External

EXPOSURE, EXPOSURE!!!

approach

Submandibular incision

Submental incision T-incision


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Complication

Airway obstruction Ruptured abscess

Internal Jugular Vein Thrombosis

Carotid artery Rupture Mediastinitis


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history

Physical examination

Secure airway

Culture, IV antibiotic

CT scan

Small abcess

Needle aspiration

for culture and drainage

Impending complication ?

No abcess Large abcess

Watch and wait

24-48 hours

Clinical improvement ?

Continue antibiotic,

Needle aspirations

Surgical incision

And drainage

No

YesYes No


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Treatment External drainage

Tracheotomy

Complications Septic thrombosis of IJV

Carotid artery erosions

Cranial nerve involvement Mediastinitis


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Peritonsillar Space Infection

Treatment

Peroral drainage

tonsilectomy

Complications

Spread into pharyngomaxilaryspace through posteriorpharyngeal wall


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Treatment1. Fasting

2. I.V. antibiotics

3. Tracheotomy

4. Emergent surgical drainage- intraoral drainage

- external drainage

Complications1. Rupture of abcess w/

aspiration & pneumonia2. Mediastinitis

3. Airway obstruction


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PMS

MasticatorSubmandibular

Peritonsillar

VVSDanger

MediastinumAnterior Visceral

Temporal

Parotid

Prevertebral

Retropharingeal



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Documents

Deep Neck Space Infection Mini Lctr