Upload
connor-wood
View
227
Download
2
Tags:
Embed Size (px)
Citation preview
INFECTIONS OF THE DEEP INFECTIONS OF THE DEEP
SPACES OF THE NECKSPACES OF THE NECK
• Anatomy of the Cervical FasciaAnatomy of the Cervical Fascia
• Anatomy of the Deep Neck SpacesAnatomy of the Deep Neck Spaces
• Deep Neck Space InfectionsDeep Neck Space Infections
DEEP NECK SPACES AND DEEP NECK SPACES AND
INFECTIONSINFECTIONS
• Superficial fasciaSuperficial fascia
• DeepDeep fasciafascia
Superficial layerSuperficial layer
Middle layer Middle layer
Deep layerDeep layer
CERVICAL FASCIACERVICAL FASCIA
…This division… must be considered arbitrary and created by man rather than nature in order to convert an anatomical thought into a verbal picture…
Levitt, 1968
Superficial layer of the deep cervical fasciaSuperficial layer of the deep cervical fascia
““the enveloping layer”the enveloping layer”
MusclesMuscles
SternocleidomastoidSternocleidomastoid
TrapeziusTrapezius
GlandsGlands
SubmandibularSubmandibular
ParotidParotid
SpacesSpaces
Subvaginal space Subvaginal space
Suprasternal space of BurnsSuprasternal space of Burns
DEEP CERVICAL FASCIADEEP CERVICAL FASCIA
Middle layer of the deep cervical fasciaMiddle layer of the deep cervical fascia
Muscular DivisionMuscular Division
Infrahyoid Strap MusclesInfrahyoid Strap Muscles
Visceral DivisionVisceral Division
Pharynx, Larynx,Pharynx, Larynx,
Esophagus, Trachea,Esophagus, Trachea,
ThyroidThyroid
Buccopharyngeal FasciaBuccopharyngeal Fascia
DEEP CERVICAL FASCIADEEP CERVICAL FASCIA
Deep Layer of Deep Cervical FasciaDeep Layer of Deep Cervical Fascia
Alar LayerAlar Layer
Posterior to visceral layer Posterior to visceral layer
of middle fasciaof middle fascia
Anterior to prevertebral layerAnterior to prevertebral layer
Prevertebral LayerPrevertebral Layer
Vertebral bodiesVertebral bodies
Deep muscles of the neckDeep muscles of the neck
DEEP CERVICAL FASCIADEEP CERVICAL FASCIA
Carotid SheathCarotid Sheath
Formed by all three layers of deep fasciaFormed by all three layers of deep fascia
Contains carotid artery, internal jugular vein, and Contains carotid artery, internal jugular vein, and vagus nervevagus nerve
Runs from the skull through the lateral pharyngeal Runs from the skull through the lateral pharyngeal space into the chestspace into the chest
SPECIAL FASCIAL SHEATHSPECIAL FASCIAL SHEATH
A. Entire length of the neck
1. Retropharyngeal Space
2. Danger Space
3. Prevertebral Space
4. Visceral Vascular Space
Described in relation to the hyoid
B. Suprahyoid
5. Submandibular Space
6. Lateral Pharyngeal Space
7. Masticator/Temporal Space
8. Parotid Space
9. Peritonsillar Space
C. Infrahyoid
10. Anterior Visceral Space
Levitt, 1968
DEEP NECK SPACESDEEP NECK SPACES
Entire Length of Neck:Entire Length of Neck:
1. Prevertebral Space1. Prevertebral Space
Anterior border is prevertebral Anterior border is prevertebral
fascia, posterior border is vertebral fascia, posterior border is vertebral
bodies and deep neck muscles.bodies and deep neck muscles.
Extends along entire length Extends along entire length
of vertebral column.of vertebral column.
Conteins very compact tissueConteins very compact tissue
DEEP NECK SPACESDEEP NECK SPACES
Entire Length of Neck:Entire Length of Neck:
2. Danger Space2. Danger Space
Anterior border is alar layer Anterior border is alar layer
of deep fascia, posterior border of deep fascia, posterior border
is prevertebral layer.is prevertebral layer.
Extends from skull throughExtends from skull through
posterior mediastinum to posterior mediastinum to
diaphragm.diaphragm.
Conteins very loose Conteins very loose
areolar tissue offeringareolar tissue offering
little resistance to the spreadlittle resistance to the spread
of infection to the mediastinumof infection to the mediastinum
DEEP NECK SPACESDEEP NECK SPACES
Entire Length of Neck:
3. Retropharyngeal 3. Retropharyngeal
SpaceSpace
Posterior to pharynxPosterior to pharynx
and esophagus, anterior and esophagus, anterior
to alar layer of deep fasciato alar layer of deep fascia
Extends from skull base Extends from skull base
to T1-T2to T1-T2
Two chains of nodes on Two chains of nodes on
either side of the midlineeither side of the midline
DEEP NECK SPACESDEEP NECK SPACES
InfrahyoidInfrahyoid
3. Anterior Visceral 3. Anterior Visceral
SpaceSpaceMiddle layer of deep fasciaMiddle layer of deep fascia
Contains thyroid,Contains thyroid,
trachea, esophagustrachea, esophagus
Extends from thyroidExtends from thyroid
cartilage into superiorcartilage into superior
mediastinummediastinum
DEEP NECK SPACESDEEP NECK SPACES
Suprahyoid:Suprahyoid:
4. Lateral Pharyngeal 4. Lateral Pharyngeal
SpaceSpaceSuperior: Superior: skull baseskull base
Inferior: Inferior: hyoidhyoid
DEEP NECK SPACESDEEP NECK SPACES
PrestyloidPrestyloid
Contains fat, connectiveContains fat, connective
tissue, nodestissue, nodes
PoststyloidPoststyloid
Carotid sheathCarotid sheath
Cranial nerves IX, X, XIICranial nerves IX, X, XII
Suprahyoid: Suprahyoid:
5. Submandibular Space5. Submandibular SpaceAnterior/Lateral: Anterior/Lateral: mandiblemandible
Superior: Superior: oral mucosaoral mucosa
Inferior: Inferior: superficial layer of deep fasciasuperficial layer of deep fascia
Posterior/Inferior: Posterior/Inferior: hyoidhyoid
DEEP NECK SPACESDEEP NECK SPACES
Supramylohyoid portionSupramylohyoid portion
Sublingual glandSublingual gland
Hypoglossal and lingualHypoglossal and lingual
nervesnerves
Portion of Submandibular glandPortion of Submandibular gland
Inframylohyoid portionInframylohyoid portion
Submandibular gland Submandibular gland
Wharton’s ductWharton’s duct
Anterior bellies of digastricsAnterior bellies of digastrics
Suprahyoid:Suprahyoid:
6. Masticator and 6. Masticator and
Temporal SpacesTemporal SpacesBounded by theBounded by the
superficial layer of deepsuperficial layer of deep
cervical fasciacervical fascia
Contains masseter, pterygoids,Contains masseter, pterygoids,
temporalis, ramus and temporalis, ramus and
posterior portions of the bodyposterior portions of the body
of mandible, inferior alveolar of mandible, inferior alveolar
vessels and nervesvessels and nerves
DEEP NECK SPACESDEEP NECK SPACES
Suprahyoid:Suprahyoid:
7. Parotid Space7. Parotid Space
Superficial layer Superficial layer
of deep fasciaof deep fascia
Dense septa from Dense septa from
capsule into glandcapsule into gland
Relationship Relationship
to parapharyngeal spaceto parapharyngeal space
DEEP NECK SPACESDEEP NECK SPACES
DEEP NECK SPACESDEEP NECK SPACES
DEEP NECK SPACESDEEP NECK SPACES
DEEP NECK SPACESDEEP NECK SPACES
DEEP NECK SPACESDEEP NECK SPACES
DEEP NECK SPACESDEEP NECK SPACES
DEEP NECK SPACESDEEP NECK SPACES
Network of patterns of infectious extensionNetwork of patterns of infectious extension
MasticatorMasticator
LateralLateral
PharyngealPharyngeal
DangerDanger
MediastinumMediastinum
TemporalTemporal
ParotidParotid
RetropharyngealRetropharyngeal
SubmandibularSubmandibular
PeritonsillarPeritonsillar
VascularVascular
Anterior Anterior VisceralVisceral
PrevertebralPrevertebral
DEEP NECK SPACESDEEP NECK SPACES
CAUSES OF DEEP NECK INFECTIONSCAUSES OF DEEP NECK INFECTIONS(ENT Department, Treviso Regional Hospital)(ENT Department, Treviso Regional Hospital)
0 10 20 30 40 50 60
Miscellaneous
Lymphadenitis
Dental
Sialadenitis
Pharyngitis
Unknown
151 cases (1991-2003)
AGE DISTRIBUTIONAGE DISTRIBUTION(ENT Department, Treviso Regional Hospital)(ENT Department, Treviso Regional Hospital)
151 cases (1991-2003)
0
5
10
15
20
25
30
35
0-5 10-20 20-30 30-40 40-50 50-60 60-70 70-80 80-90 >90
CLINICAL PRESENTATIONCLINICAL PRESENTATION(ENT Department, Treviso Regional Hospital)(ENT Department, Treviso Regional Hospital)
151 cases (1991-2003)
0 10 20 30 40 50 60 70 80 90 100
OTALGIA
DYSPHONIA
TRISMA
DYSPNEA
ODYNOPHAGIA
PHARYNGODYNIA
DYSPHAGIA
FEVER
DISTRIBUTION OF CASESDISTRIBUTION OF CASES(ENT Department, Treviso Regional Hospital)(ENT Department, Treviso Regional Hospital)
151 cases (1991-2003)
0 10 20 30 40 50 60
Retropharyngeal
Parotid/Masticatory
Ludwig's angina
Lateral pharyngeal
Submandibular
DEEP NECK SPACE INFECTIONSDEEP NECK SPACE INFECTIONS
PediatricsPediatrics
Suppurative process in Suppurative process in retropharyngeal nodes from retropharyngeal nodes from
nose, adenoids, nasopharynx nose, adenoids, nasopharynx or sinuses infectionsor sinuses infections
Fever, irritability, Fever, irritability, lymphadenopathy, torticollis, lymphadenopathy, torticollis, poor oral intake, sore throat, poor oral intake, sore throat,
droolingdrooling
AdultsAdults
Trauma Instrumentation; extension from Trauma Instrumentation; extension from adjoining deep neck spaceadjoining deep neck space
Pain, dysphagia, anorexia, snoring, nasal Pain, dysphagia, anorexia, snoring, nasal obstruction, nasal regurgitation. obstruction, nasal regurgitation.
Origin and clinical presentation of infectionOrigin and clinical presentation of infection
Retropharyngeal InfectionsRetropharyngeal Infections
Dyspnea and respiratory distressDyspnea and respiratory distress
UnilateralUnilateral posterior pharyngeal swelling posterior pharyngeal swelling (the buccopharyngeal fascia (the buccopharyngeal fascia is adherent to the alar fascia in the medline)is adherent to the alar fascia in the medline)
DEEP NECK SPACE INFECTIONSDEEP NECK SPACE INFECTIONS
Retropharyngeal InfectionsRetropharyngeal Infections
AdultAdult ChildChild
DEEP NECK SPACE INFECTIONSDEEP NECK SPACE INFECTIONS
Clinical Presentation and Origin of infectionClinical Presentation and Origin of infection
Danger Space InfectionsDanger Space Infections
• Presentation and exam nearly identical to retropharyngeal Presentation and exam nearly identical to retropharyngeal
space infection but the infection spreads rapidly through space infection but the infection spreads rapidly through
the loose areolar tissue within this space to the posteriorthe loose areolar tissue within this space to the posterior
mediastinummediastinum
• Extension from retropharyngeal, prevertebral or lateral Extension from retropharyngeal, prevertebral or lateral
pharyngeal spacepharyngeal space
DEEP NECK SPACE INFECTIONSDEEP NECK SPACE INFECTIONS
• Back, shoulder, neck pain made worse by deglutitionBack, shoulder, neck pain made worse by deglutition
Dysphagia or dyspneaDysphagia or dyspnea
Bulding mass in the Bulding mass in the midlinemidline of the pharynx of the pharynx
• Extension from retropharyngeal and danger spaces,Extension from retropharyngeal and danger spaces,
Pott’s abscess, iatrogenic trauma, osteomyelitisPott’s abscess, iatrogenic trauma, osteomyelitis
Clinical Presentation and Origin of infectionClinical Presentation and Origin of infection
Prevertebral Space InfectionsPrevertebral Space Infections
DEEP NECK SPACE INFECTIONSDEEP NECK SPACE INFECTIONS
Prevertebral Space InfectionsPrevertebral Space Infections
DEEP NECK SPACE INFECTIONSDEEP NECK SPACE INFECTIONS
Clinical Presentation and Origin of infectionClinical Presentation and Origin of infection
Anterior Visceral SpaceAnterior Visceral Space
• Dysphagia, odynophagia, hoarseness, dyspneaDysphagia, odynophagia, hoarseness, dyspnea
Edema of hypopharynxEdema of hypopharynx
Anterior neck edema with subcutaneous emphysemaAnterior neck edema with subcutaneous emphysema
• Extension from retropharyngeal, perforation of anterior Extension from retropharyngeal, perforation of anterior
esophageal wall, foreign body, external trauma, esophageal wall, foreign body, external trauma,
extension of infection in thyroidextension of infection in thyroid
DEEP NECK SPACE INFECTIONSDEEP NECK SPACE INFECTIONS
Anterior Visceral SpaceAnterior Visceral Space
DEEP NECK SPACE INFECTIONSDEEP NECK SPACE INFECTIONS
• Induration and tenderness deep to the SCMInduration and tenderness deep to the SCM
Torticollis toward opposite sideTorticollis toward opposite side
Septicemia, spiking feversSepticemia, spiking fevers
• Intravenous drug abuse, Intravenous drug abuse,
extension from other deep neck spacesextension from other deep neck spaces
Clinical Presentation and Origin of infectionClinical Presentation and Origin of infection
Visceral Vascular Space Infections Visceral Vascular Space Infections
DEEP NECK SPACE INFECTIONSDEEP NECK SPACE INFECTIONS
Visceral Vascular Space Infections:Visceral Vascular Space Infections:Lemierre Syndrome Lemierre Syndrome
DEEP NECK SPACE INFECTIONSDEEP NECK SPACE INFECTIONS
• Pain, drooling, dysphagia, neck stiffnessPain, drooling, dysphagia, neck stiffness
Anterior neck swelling, floor of mouth edemaAnterior neck swelling, floor of mouth edema
• 70% have odontogenic origin70% have odontogenic origin
First molar: First molar: supramylohyoid spacespace
Second and third molars: Second and third molars: inframylohyoid space space
Sialadenitis, lymphadenitisSialadenitis, lymphadenitis
Lacerations of the floor of mouth, mandible fracturesLacerations of the floor of mouth, mandible fractures
Tonsillar diseaseTonsillar disease
Ludwig’s anginaLudwig’s angina
Clinical Presentation and Origin of infectionClinical Presentation and Origin of infection
Submandibular Space InfectionsSubmandibular Space Infections
DEEP NECK SPACE INFECTIONSDEEP NECK SPACE INFECTIONS
Particular Clinical PresentationParticular Clinical Presentation
Ludwig’s anginaLudwig’s angina (Morbus Strangolatorius)(Morbus Strangolatorius)
Grodinsky’s criteria (1939):
1.1. 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
DEEP NECK SPACE INFECTIONSDEEP NECK SPACE INFECTIONS
Clinical PresentationClinical Presentation
Ludwig’s anginaLudwig’s angina
““Woody” hardness with well defined border. Woody” hardness with well defined border.
Comparative slight inflammation of throat and absence of Comparative slight inflammation of throat and absence of infection in regional lymph nodesinfection in regional lymph nodes
““Hot potato” voice, drooling, tachypnea, dyspnea, stridorHot potato” voice, drooling, tachypnea, dyspnea, stridor
Complications:Complications:
1. Spread along the styloglossus muscle back into the 1. Spread along the styloglossus muscle back into the parapharyngeal spaceparapharyngeal space retropharyngeal space retropharyngeal space superior mediastinum superior mediastinum
2. Tongue displacement posteriorly and superiorly against the 2. Tongue displacement posteriorly and superiorly against the palate with respiratory embarrassment palate with respiratory embarrassment (Morbus strangolatorius)(Morbus strangolatorius)
DEEP NECK SPACE INFECTIONSDEEP NECK SPACE INFECTIONS
Ludwig’s anginaLudwig’s angina
DENTALSCANDENTALSCAN
DENTALSCAN DENTALSCAN
DEEP NECK SPACE INFECTIONSDEEP NECK SPACE INFECTIONS
• Sore throat, dysphagia, odynophagia, otalgia, trismus Sore throat, dysphagia, odynophagia, otalgia, trismus
Medial bulge of lateral pharyngeal wallMedial bulge of lateral pharyngeal wall
• Infection of pharynx, tonsil, adenoids, teeth,Infection of pharynx, tonsil, adenoids, teeth,
parotid, mastoid (parotid, mastoid (Bezold’s abscessBezold’s abscess), suppurative lymphadenitis,), suppurative lymphadenitis,
extension from other deep neck spacesextension from other deep neck spaces
Clinical Presentation and Origin of infectionClinical Presentation and Origin of infection
Lateral Pharyngeal Space Infections Lateral Pharyngeal Space Infections
DEEP NECK SPACE INFECTIONSDEEP NECK SPACE INFECTIONS
Lateral Pharyngeal Space Infections Lateral Pharyngeal Space Infections
DEEP NECK SPACE INFECTIONSDEEP NECK SPACE INFECTIONS
Clinical Presentation and Origin of infectionClinical Presentation and Origin of infection
Parotid Space infectionsParotid Space infections
• Pain, swelling of the angle of jaw, medial bulge Pain, swelling of the angle of jaw, medial bulge
of posterior lateral pharyngeal wall, of posterior lateral pharyngeal wall,
• Parotitis, sialolithiasis, Sjogren’s syndromeParotitis, sialolithiasis, Sjogren’s syndrome
DEEP NECK SPACE INFECTIONSDEEP NECK SPACE INFECTIONS
Parotid Space infectionsParotid Space infections
1.1. Most abscesses contained mixed bacterial flora Most abscesses contained mixed bacterial flora
Aerobes: Aerobes: Streptococci Streptococci -hemolytic (Strept. viridans)-hemolytic (Strept. viridans)
Staphylococci, Neisseria, Klebsiella, HaemophilusStaphylococci, Neisseria, Klebsiella, Haemophilus
(Decresed role of (Decresed role of -hemolytic -hemolytic Streptococci)Streptococci)
Anaerobes:Anaerobes: Bacteroides, Peptostreptococcus Bacteroides, Peptostreptococcus
2.2. Anaerobes are understimated (>35%)Anaerobes are understimated (>35%)
widespread antibiotic use prior to collection of cultureswidespread antibiotic use prior to collection of cultures
poor sample collection techniquespoor sample collection techniques
fragility of anaerobesfragility of anaerobes
3.3. Anaerobes product Anaerobes product -lactamase-lactamase
BACTERIOLOGYBACTERIOLOGY
Gold Standard:Gold Standard:
To initiate antibiotic treatment To initiate antibiotic treatment
after appropiate cultures are obtainedafter appropiate cultures are obtained
BATTERIOLOGYBATTERIOLOGY
Empirical TreatmentEmpirical Treatment
BATTERIOLOGYBATTERIOLOGY
Empirical TreatmentEmpirical Treatment
First-lineFirst-line
Clindamycin 600-900mg tidClindamycin 600-900mg tid
(+/- cefuroxime 0.75-1.5gr tid)(+/- cefuroxime 0.75-1.5gr tid)
oror
Penicillin G Penicillin G
24 million units/day 24 million units/day
++
Metronidazole 1gr bidMetronidazole 1gr bid
AlternativesAlternatives
AMX/CL 1.5-3gr qidAMX/CL 1.5-3gr qid
oror
PIP/TZ 2.25gr qid - 4.5 gr tid PIP/TZ 2.25gr qid - 4.5 gr tid
BATTERIOLOGYBATTERIOLOGY CultureCulture
Needle Aspiration Needle Aspiration
through intact skin or mucosal surface cleaned with antiseptic through intact skin or mucosal surface cleaned with antiseptic
Blood culture bottle for aerobes
Blood culture bottle for anaerobes
Sterile container for Gram and
Ziehl-Nielsen Stain
BATTERIOLOGYBATTERIOLOGY
Two to Three Blood CultureTwo to Three Blood Culture
Blood culture bottle for aerobes
Blood culture bottle for anaerobes
DEEP NECK SPACE INFECTIONSDEEP NECK SPACE INFECTIONS
Diagnostic StudiesDiagnostic Studies
Radiographs of the chestRadiographs of the chest
Lateral soft tissue radiographsLateral soft tissue radiographs
UltrasonographyUltrasonography
Contrast Enhanced CTContrast Enhanced CT
MRI MRI
DEEP NECK SPACE INFECTIONSDEEP NECK SPACE INFECTIONS
Diagnostic StudiesDiagnostic Studies
Contrast Enhanced Computer TomographyContrast Enhanced Computer Tomography
Intravenous contrast may help identify an abscess as a “rim-Intravenous contrast may help identify an abscess as a “rim-enhancing lesion” with a low-density center.enhancing lesion” with a low-density center.
A gas-fluid level or gas bubbles are also diagnostic of an A gas-fluid level or gas bubbles are also diagnostic of an abscessabscess
Intravenous contrast also helps delineate vascular structures Intravenous contrast also helps delineate vascular structures (e.g. trombosis of the jugular vein)(e.g. trombosis of the jugular vein)
DEEP NECK SPACE INFECTIONSDEEP NECK SPACE INFECTIONS
MANAGEMENTMANAGEMENT
History + Physical examination
Culture, IV antibiotics, Airway control, Chest RX
CTcellulitis
small abscess
large abscess
needle aspirationfor culture e drainage
surgical incisionand drainage
W&W24-48h
improvement?
Continue AB
YesNo
complications?