Neck Space Infections

Etiology Most common cause in adults Most common cause in pediatric Others : odontogenic, : tonsillar : salivary gland, trauma, FB, instrumentation, local or superficial source, 22% without spesific cause

Anatomy of Cervical Fascia 1. Superficial cervical fascia 2. Deep cervical fascia a) Superficial layer b) Middle layer Muscular division Visceral division c) Deep layer Prevertebral division Alar division

1.

Superficial cervical fascia Continuous sheath of fibrofatty subcutaneous tissue Attachments : zygomatic process to thorax and axilla Contents : platysma, muscles of facial expression

Not considered a part of the deep neck; local I&D and antibiotics Between superficial and deep layers: Fat, sensory nerves, EJ, AJ, superficial lymphatics a) Superficial layer of the deep cervical fascia Enveloping or investing later Insertion at nuchal line of the skull chest and axillary regions; spreads anteriorly to the face and attaches at clavicles Envelopes SCM, trapezius, portion of omohyoid in posterior triangle, parotid and submandibular glands

b)

Middle layer of the deep cervical fascia Muscular division Surrounds straps. Attaches superiorly to hyoid and thyroid cartilage and inferiorly to sternum, clavicle and scapula Visceral division Surrounds thyroid, trachea, esophagus. Superior attached to base of skull, thyroid cartilage and hyoid covers trachea and esophagus and blends with fibrous pericardium

c)

Deep layer of the deep cervical fascia Contents: Paraspinous muscles and cervical vertebrae Prevertebral and alar divisions Prevertebral: Begins anterior to the vertebral bodies, spreads laterally to fuse with transverse processes, extends posteriorly to enclose deep muscles of neck and attaches to vertebral spines. Forms the posterior wall of the danger space and anterior wall of prevertebral space Alar division, Lies between the prevertebral division and the middle layer of the deep cervical fascia Attaches from transverse process to contralateral transverse process, skull base to T2, fuses with visceral division of middle layer of deep cervical fascia. Carotid sheath: made up of all 3 deep layers

Suprahyoid spaces: Pharyngomaxillary / Lateral pharyngeal Submandibular Parotid Masticator Peritonsillar Buccal

Infrahyoid spaces: Anterior visceral Spaces involving entire length of neck: o Retropharyngeal o Danger o Prevertebral o Visceral vascular

Retropharyngeal space Potential space posterior to visceral division of middle layer of deep cervical fascia and anterior to alar division of deep layer of deep cervical fascia Skull base to T1/2/tracheal bifurcation in close approximation to mediastinum Midline raphe-superior constrictor muscles adheres to prevertebral division; separates retropharyngeal nodes into two lateral chains. Contents: fat, CT, LNs which drain nose, NP, soft palate, ET, paranasal sinuses Most commonly seen in peds due to drainage source Peds: preceding URI, fever, dysphagia, odynophagia, nuchal rigidity, asymmetric bulging of post pharyngeal wall due to midline raphe

Adults: pain, dysphagia, cervical motion limitation, noisy breathing Can extend to: mediastinum, danger space, parapharyngeal space

Retropharyngeal space X-ray Lateral soft tissue XR (extension, inspiration) abnormal findings: 1. C2-post pharyngeal soft tissue >7mm 2. C6adults >22mm, peds >14mm 3. STS of post pharyngeal region >50% width of vertebral body

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 Why is it given this name? Extends from skull base to posterior mediastinum to diaphragm 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 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 Why is this called the Lincoln Highway of the neck?

Spaces involving entire length of neck Visceral layer-mid RETROPHARYNGEAL SPACE (until T2)

Alar division-deep DANGER SPACE (until diaphragm)

Prevertebral division PREVERTEBRAL SPACE (until coccyx) Vertebrae

Pharyngomaxillary/Parapharyngeal/ Lateral pharyngeal space Cone in lateral aspect of neck Apex: hyoid bone Base: petrous temporal bone Lateral: superficial layer of deep cervical fascia over the mandible, parotid, internal pterygoid Medial: lateral pharyngeal wall Ant/post: pterygomandibular raphe/ prevertebral fascia Divided into anterior and posterior compartments by styloid bones and muscles Prestyloid/Muscular compartment: Tonsillar fossa medially, internal pterygoid laterally Fat, lymph nodes, parotid masses Displacement of lat pharyngeal wall, early trismus Most common mass pleomorphic adenoma

Post-styloid/Neurovascular compartment: Carotid, IJV, cervical sympathetic chain, CN IX-XII Most common mass - schwannoma

Connects to the majority of other fascial spaces Sources: parotid, masticator, submandibular, peritonsillar, tonsils/pharynx, odontogenic, LN from nose and throat, mastoiditis (Bezold abscess)

Never approach intraorally Traditionally: Mosher incision

Horizontal neck incision follow carotid sheath into space finger dissect below submandibular gland, along posterior belly of digastric deep to mastoid tip toward styloid

Submandibular space Composed of sublingual space superiorly and submaxillary space inferiorly, divided by mylohyoid Boundaries: FOM mucosa above, superficial layer of deep fascia below, mandible ant/lat, hyoid inferiorly, BOT muscles posteriorly Sublingual space: gland, Wharton, CN XII Submaxillary: gland, facial artery, lingual nerve; communicates with sublingual space around posterior border of mylohyoid through submandibular gland Ludwigs angina bilateral cellulitis of submandibular and sublingual spaces Inspect 2nd and 3rd molars apices extend below mylohyoid line providing direct access to submandibular space

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 lateral pharyngeal space (dumbbell shaped masses secondary to stylomandibular ligament) Contents: parotid gland, external carotid, posterior facial vein, facial nerve, lymph nodes Masticator space Superficial layer of deep cervical fascia splits around mandible to form this space and encases muscles of mastication 4 compartments: Masseteric, Pterygoid, Superficial Temporal, Deep Temporal

Contents: masseter, pterygoid muscles, temporalis tendon, inferior alveolar nerves and vessels, body and ramus of mandible, internal maxillary artery

Most common source : 3rd molar Complication: osteomyelitis of mandible

Peritonsillar Boundaries: anterior and posterior pillars, palatine tonsil, superior constrictor muscle Indications for Quincy tonsillectomy? No clear cut indications. Treatment is still controversial. Needle aspiration, I&D, quincy tonsillectomy all equally effective initial management with 10-15% recurrrence rate. Again, 10-15% recurrence after needle aspiration and/or I&D; greatest risk in patients <40 with history of recurrent tonsillitis Buccal space Boundaries: Buccinator muscle, cheek, zygomatic arch, pterygomandibular raphe, inferior mandible Odontogenic source with buccal swelling and preseptal 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 Network of infectious extension

Pathogens

Aerobic: Strep-predom viridans and B-hemolytic streptococci, staph, diphtheroid, Neisseria, Klebsiella, Haemophilus

Anaerobic: Bacteroides, Peptostreptococcus, Eikenella (often clinda resistant), FUsobacterium, B fragilis

Antibiotics Necrotizing fasciitis Fulminent infection, polymicrobial, usually odontogenic source, more frequently in immunocompromised and postoperative PEX: ill, high fever, neck crepitus, exquisitely tender, unimpressive erythema s sharp demarcating border progress to pale then dusky as necrosis progresses can have bullae/blisters/sloughing <48hrs Empiric abx (3rd gen ceph + clinda/flagyl), early surgery, dishwater drainage, leave open, daily debridement, trach, ICU monitoring for: resp failure, mediastinitis (higher mortality 64% vs 15%), DIC, delirium, HBO Diagnosis Pain, trismus, limitation neck motion, swelling, sustained fever, leukocytosis with left shift, lateral neck XR/CT Prevertebral or retropharyngeal hot potato voice, difficult noisy breathing, dys/odynophagia, drooling, neck posturing Parapharyngeal medial displacement of lateral pharyngeal wall, fullness of retromandibular area. Prestyloid trismus, tonsil swelling. Poststyloid-dysphagia Management Hospitalization for airway management, aggressive antibiotics, hydration, I&D If no evidence of airway compromise, abx 24 hrs. 10-15% improve with medical mgmt. Surgery indicated for airway compromise, no significant response to abx in 24-48 hours, evidence of sepsis

Transoral peritonsillar, uncomplicated RP and prevertebral abscesses with mass in oropharynx, uncomplicated sublingual (not for submax extension)

Surgical principles: wide exposure, use readily identifiable landmarks (digastric, hyoid, SCM, cricoid, greater horn of thyroid), blunt dissection, identify carotid sheath early, cultures/biopsy, debridement, irrigation, leave wound open and pack for extensive necrosis, can close less necrotic wound and use drain

Complications 40 yr old pt is admitted for parapharyngeal infection. Started on abx, IVF, observation. Afebrile within 24 hours with improved dysphagia. HD #2 spikes to 104, defervesces, respikes. Whats happening? Thrombophlebitis of IJV Complications signs and symptoms Mediastinitis chest pain, worsened dyspnea, dysphagia, widened mediastinum on CXR Horners, hoarseness, unilateral tongue paresis, plethora of face, choked optic disks, Tobey Ayer, erosion of carotid (critical, pharyngeal bleeding episode, neck hematoma, rare EAC blood Treatment of complications Mediastinitis most commonly via retropharyngeal space > visceral or PP 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, intraop angio if possible (75% CCA or ICA)

References

Baileys Cummings SIPAC Diagnosis and management of deep neck infections Hollinshead Anatomy for Surgeons Head and Neck Head and Neck Imaging Shankar Tom MB, Rice DH. Presentation and management of neck abscesses a retrospective analysis. Laryngoscope 1988;98:877.

Johnson RF, Stewart MG, Wright CC. An evidence-based review of the treatment of peritonsillar abscess. Otolaryngol Head Neck Surg. 2003 Mar;128(3):332-43.

Herzon FS. Peritonsillar abscess: incidence, current management practices, and a proposal for treatment guidelines. Laryngoscope 1995;105 [suppl 74]:17.

Tan PT, et al. Deep neck infections in children. J Microbiol Immunol Infect 2001;34:287-292.