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Dr.

Supreet Singh Nayyar, AFMC

2011

Anatomy of Cervical Fascia & Deep Neck Spaces Divisions


Superficial cervical fascia Deep cervical fascia Superficial layer Middle layer Muscular division Visceral division Deep layer Alar division Prevertebral division

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Superficial cervical fascia


Fibro fatty subcutaneous tissue Attachments: zygomatic process to thorax and axilla Contents: platysma, muscles of facial expression Loose at places Subcutaneous tissue of eyelids Scalp deep to epicranial aponeurosis Cheek (buccal fat pad) Not considered a part of the deep neck Local I&D and antibiotics

Superficial layer of the deep cervical fascia


Investing or enveloping layer (envelopes neck) Insertion at nuchal line of the skull and vertebral spinal processess surrounds neck and again inserted there Superior attach at hyoid & clavicles further extend upward attach at mandible (split in two layers, ant & post) split and enclose submandibular gland split around masseter & medial pterygoid follow external surface of masseter (masseteric fascia) to zygomatic arch other portion along medial surface of med pterygoid to pterygoid plate split & form parotid fascia attach at zygomatic arch

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Dr. Supreet Singh Nayyar, AFMC

2011

Inferior split into two ant & post In b/w, suprasternal space of Burns Envelopes SCM Trapezius Portion of omohyoid in posterior triangle Parotid Submandibular glands

Middle layer of the deep cervical fascia


Muscular division Surrounds straps Attaches superiorly to hyoid and thyroid cartilage Inferiorly to sternum, clavicle and scapula At lateral edges of muscles, blends with superficial layer Visceral division ( Pre tracheal layer) Surrounds thyroid, trachea, esophagus Superior attached to base of skull, thyroid cartilage and hyoid Inferiorly blends with fibrous pericardium and is prolonged along great vessels to superior mediastinum Laterally fuses with superficial layer

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Dr. Supreet Singh Nayyar, AFMC

2011

Deep layer of the deep cervical fascia


Begins anterior to the vertebral bodies spreads laterally to fuse with transverse processes extends posteriorly to enclose deep muscles of neck(scalene muscles) attaches to vertebral spines Forms the posterior wall of the danger space and anterior wall of prevertebral space Contents: Paraspinous muscles and cervical vertebrae In upper part of post. triangle pre vertebral layer is in contact with superficial layer Prevertebral and alar divisions o B/w transverse processes and across front of vertebral bodies, pre vertebral fascia has two parts Alar part Attaches from skull base to T2 Fuses with visceral division of middle layer of deep cervical fascia Pre vertebral part o Separated by loose connective tissue

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Dr. Supreet Singh Nayyar, AFMC

2011

Caotid Sheath
Made up of all 3 deep layers Anterolateral o Superficial layer of deep cervical fascia (Deep to SCM) o Partly by pre tracheal layer ( where infra hyoid muscles overlap great vessels) Posterior wall o Lamina from superficial layer Medial wall o Extension of fascia from anterolateral wall to posterior wall o This fascia is attached medially to pre vertebral fascia Encloses o IJV o Common carotid artery o Vagus nerve

Deep Neck Spaces


Spaces involving entire length of neck
o o o o Retropharyngeal Danger Prevertebral Visceral vascular

Suprahyoid spaces
o o o o o o Parapharyngeal space ( Pharyngomaxillary/ Lateral pharyngeal ) Submandibular Parotid Masticator Peritonsillar Buccal

Infrahyoid spaces
o Anterior visceral

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Dr. Supreet Singh Nayyar, AFMC

2011

Retropharyngeal space
Potential space Posterior to visceral division of middle layer of deep cervical fascia (buccopharyngeal fascia) Anterior to alar division of deep layer of deep cervical fascia Skull base to tracheal bifurcation (T4) Midline raphe o Superior constrictor muscles adhere to prevertebral division o Separates retropharyngeal nodes into two lateral compartments (spaces of gilette) Contents o Fat o LNs (which drain nose, NP, soft palate, ET, paranasal sinuses) o Connective tissue Pathways of infection o Posterior perforation of oesophagus o Lymph node infections o Communication with parapharyngeal space Clinical features o Children preceding URTI, fever, dysphagia, odynophagia, nuchal rigidity, asymmetric bulging of post pharyngeal wall due to midline raphe o Adults pain, dysphagia, cervical motion limitation, noisy breathing Can extend to: mediastinum, danger space, parapharyngeal space Lateral soft tissue XR (extension, inspiration) abnormal findings: o C2 post pharyngeal soft tissue >7mm o C6 adults >22mm, paeds>14mm o Soft tissue shadow of post pharyngeal region >50% width of vertebral body Surgical approach o Intra oral for small abcess o Cervical ant border of SCM medial to carotid sheath

Danger Space
Potential space between the alar and prevertebral divisions of the deep layer of the deep cervical fascia Posterior to the retropharyngeal space and anterior to the prevertebral space Called Danger area because Extends from skull base to posterior mediastinum to diaphragm spread of infection easily throughout Has extensions along nerves for brachial plexus infection can spread and lead to neuropathy Caused by infectious spread from retropharyngeal, prevertebral and parapharyngeal spaces or less commonly, by lymphatic extension from the nose and throat Watch for severe dyspnea, chest pain, widened mediastinum on CXR may need thoracotomy for drainage
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Dr. Supreet Singh Nayyar, AFMC

2011

Prevertebral space
Potential space posterior to prevertebral division and anterior to vertebral bodies Extends from skull base to the coccyx Most common cause: iatrogenic/penetrating trauma Previous most common cause: TB Visceral vascular space Potential space within the carotid sheath Lymphatic vessels within receive drainage from most of the lymphatic vessels in the head and neck Most common source of infection is parapharyngeal space Called the Lincoln Highway of the neck PARAPHARYNGEAL ABSCESS Definition: Suppurative collection in Parapharyngeal space Etiology: Frequently seen in young adults Infection spreads from Tonsil and adenoid Dental sepsis (last molars) Retropharyngeal space Ear - mastoiditis/ Bezolds abscess, petrositis Paranasal sinuses Parotid gland Cervical vertebrae External trauma Bacteriology Hemolytic and non-hemolytic Streptococci Fusiform bacilli Pneumococci Staph aureus Clinical features: Trismus Fever Odynophagia Neck swelling, behind angle of jaw Tonsil and lat pharyngeal wall pushed medially D/D: Quinsy Retropharyngeal abscess Tumors of Parapharyngeal space Aneurysms

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Dr. Supreet Singh Nayyar, AFMC

2011

Complications: Treatment:

Laryngeal edema Extension within carotid canal Mediastinitis Hospitalization Fluid and electrolyte balance Parenteral antibiotics (broad spectrum) penicillin + aminoglycosides + metronidazole Airway management I&D Never approach intra orally Traditionally: Mosher incision Horizontal neck incision immediately behind submandibular gland follow carotid sheath into space finger dissect below submandibular gland, along posterior belly of digastric deep to mastoid tip toward styloid Alternative incision along ant border of SCM

Submandibular space
Composed of sublingual space superiorly and submaxillary space inferiorly, divided by mylohyoid Boundaries o Floor of mouth mucosa above o Superficial layer of deep fascia below o Mandible ant/lat o Hyoid inferiorly o Base of tongue muscles posteriorly Submandibular gland lies posterior to mylohyoid partly above & partly below it At post end of mylohyoid , sublingual & submaxillary spaces communicate Sublingual space : submandibular gland, Whartons duct , Hypoglossal nerve Submaxillary space : submandibular gland, facial artery, lingual nerve Ludwigs angina o Bilateral cellulitis of submandibular and sublingual spaces o Etiology Dental caries (lower 2nd and 3rd molars )
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Dr. Supreet Singh Nayyar, AFMC

2011

Floor of mouth trauma Following dental extraction Characteristics Spreading gangrenous cellulitis Produces gangrene with serosanguinous, putrid infiltration Symptoms Rapidly spreading gangrenous cellulitis of upper neck Airway compromise occurs quickly Drooling of saliva Mouth pain Dysphagia Neck stiffness Signs Fever Tachycardia Induration & erythema of floor of the mouth Postero superior displacement of tongue secondary to floor of mouth oedema Neck woody induration in suprahyoid region without fluctuation Trismus usually absent D/d Acute submandibular sialoadenitis Infected ranula Investigations Haemogram USG Neck to confirm abcess Needle aspiration & ABST Dental X Rays NCCT Base of skull to root of neck extent of disease Treatment Airway control with tracheostomy if needed IV antibiotics Surgical exploration with division of mylohyoid muscle & drainage Procedure o Horizontal incision 2 finger breadth below mandibular margin from one angle of mandible to another o Drainage & rubber drain put in place (removed after 48 hrs) o Wound closure by secondary intention Complications Airway obstruction Spread of infection to parapharyngeal / retropharyngeal space

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Dr. Supreet Singh Nayyar, AFMC

2011

Aspiration pneumonia Lung abcess

Parotid space
Formed by the splitting and surrounding of superficial layer of deep cervical fascia Incomplete at upper inner surface of gland direct communication with parapharyngeal space (dumb bell shaped masses secondary to stylomandibular ligament) Contents o Parotid gland o External carotid o Posterior facial vein o Facial nerve o Lymph nodes Infections within it are infections of the gland or nodes

Masticator space
Superficial layer of deep cervical fascia splits around mandible to form this space and encases muscles of mastication Attachments o Ant massetric fascia attatches to o Mandible in front of masseter muscle o Insertion of temporalis muscle along ant border of ramus o Another part passess in front of ramus, across outer surface of buccal fat pad to Maxilla Buccinator fascia below o Sup limited by origin of temporalis muscle o Superficially temporalis muscles origin from temporalis fascia o Deep Extends to pterygoplalatine fossa, ant to lateral pterygoid plate

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Dr. Supreet Singh Nayyar, AFMC

2011

Contents o Masseter o Medial Pterygoid muscle o Temporalis muscle lower portion o Inferior alveolar nerves and vessels o Buccal fat pad and its extensions o Body and ramus of mandible o Internal maxillary artery 4 compartments & their drainage (Ballenger) o Superficial Temporal Lateral to temporalis muscle Drainage by hairline incisions extending thru temporalis fascia o Deep Temporal Deep to temporalis muscle in infra temporal fossa Drainage Incision to extend thru temporalis muscle o Masseteric Masseter ms & lateral to it I & D will require preservation of facial nerve & its branches prior to detachment of fascia from mandible o Pterygoid Includes medial pterygoid muscle Drainage Intraoral incision Most common source of infection : 3rd molar Sources of infection o Zygomatic / Temporal bone infections o Abcess from lower molar teeth Abcess points at o Ant. aspect of masseter muscle into cheek or mouth o Post. Below parotid gland Complication: osteomyelitis of mandible

Peritonsillar
Boundaries o Anterior and posterior pillars o Palatine tonsil o Superior constrictor muscle Content loose areolar tissue Aetiology o Virulent tonsillar infection that breaks through tonsillar capsule o Recurrent tonsillitis
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Dr. Supreet Singh Nayyar, AFMC

2011

o Foreign body o Dental source of infection o Leukemia Plane of least resistance in this space is adjacent to soft palate so that abcess localizes to sup pole of tonsil Common after puberty Symptoms o History of tonsillitis o Sore throat o Dysphagia o Odynophagia o Referred otalgia o Patients mouth is partly open or drooling o Speech is muffled o Hot potato voice o Trismus Signs o Fever, malaise o Trismus o Erythema of involved area in oropharynx o Tense swelling of ant. tonsillar pillar & soft palate o Ant. tonsillar pillar is indistinguishable from tonsils o Tonsil is pushed forwards & downwards o Uvula is deviated away from abcess o Cervical lymphadenopathy tender, enlarged nodes o 3-7 % cases can be bilateral D/d o Peritonsillar cellulitis absence of pus during needle aspiration o Parapharyngeal abcess o Severe tonsillitis o Lymphoma o Sq cell carcinoma o Parapharyngeal neoplasm Inv o Throat swab o Haemogram o CT scan if parapharyngeal infection suspected o X Ray neck lat view Treatment o Airway protection o IV antibiotics o Analgesics
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Dr. Supreet Singh Nayyar, AFMC

2011

IV fluids Drainage Options Needle aspiration aspirate sup, middle & inf quad of ant pillar I&D Stab Incision at junction of o Horizontal line along base of uvula o Ant pillar Hot tonsillectomy o No clear cut indications o Controversial o Some surgeons prefer 10-15% recurrence Greatest risk in patients <40 with history of recurrent tonsillitis

o o

Buccal space
Boundaries o Buccinator muscle o Cheek o Zygomatic arch o Pterygomandibular raphe o Inferior mandible Odontogenic source with buccal swelling Pre septal cellulitis possible Complication: cavernous sinus thrombosis

Anterior visceral space


Pretracheal space from thyroid cartilage to T4 level Enclosed by visceral division of middle layer, just deep to straps, surrounds trachea Source: esophageal anterior wall perforation, external trauma Symptoms: mainly dysphagia, later hoarseness, dyspnea, airway obstruction Complication: mediastinitis, airway obstruction

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Dr. Supreet Singh Nayyar, AFMC

2011

Network of infectious extension PMS=pharyngomaxillary = parapharyngeal space VVS = visceral vascular space Pathogens in Deep neck space infections
Likely dependent on portal of entry and space involved Aerobic: Strep-predom viridans and B-hemolytic streptococci, staph, diphtheroid, Neisseria, Klebsiella, Haemophilus Anaerobic: Bacteroides, Peptostreptococcus, Eikenella (often clinda resistant), Fusobacterium, B fragilis

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Dr. Supreet Singh Nayyar, AFMC

2011

Necrotizing fasciitis
Fulminant infection Polymicrobial Usually odontogenic source More frequently in immunocompromised and postoperative Presentation o Ill, high fever o Neck crepitus o Exquisitely tender o Unimpressive erythema with sharp demarcating border progress to pale then dusky as necrosis progresses can have bullae/blisters/sloughing <48hrs
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Dr. Supreet Singh Nayyar, AFMC

2011

Empiric antibiotic (3rd gen ceph + clinda/flagyl) Early surgery Dishwater drainage Leave open Daily debridement Tracheostomy ICU monitoring for o Resp failure o Mediastinitis (higher mortality 64% vs 15%) o DIC o Delirium

Complications of deep neck space infections


Mediastinitis most commonly via retropharyngeal space (> visceral or Parapharyngeal space) Abdominal abscess prevertebral space IJV septic thrombophlebitis IVDA, ligate and remove thrombosed vein at I&D Neuropathy Horners, hoarseness, unilateral tongue paresis Erosion of carotid artery rare, emergency, clot found in neck at I&D, proximal and distal control, intra op angio if possible (75% CCA or ICA)

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