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Deep Neck Space Infections

October 5, 2005

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Anatomy Fascial planes Spaces Epidemiology Etiology Clinical presentation Imaging Bacteriology Therapy Medical Surgical Complications Mediastinitis


Cervical Fascia

Superficial Layer Deep Layer

Subdivisions not histologically separate Superficial

Enveloping layer Investing layer Visceral fascia Prethyroid fascia Pretracheal fascia



Superficial Layer

Superior attachment zygomatic process Inferior attachment thorax, axilla. Similar to subcutaneous tissue Ensheathes platysma and muscles of facial expression

Superficial Layer of the Deep Cervical Fascia

Completely surrounds the neck. Arises from spinous processes. Superior border nuchal line, skull base, zygoma, mandible. Inferior border chest and axilla Splits at mandible and covers the masseter laterally and the medial surface of the medial pterygoid.

Envelopes SCM Trapezius Submandibular Parotid Forms floor of submandibular space

Superficial Layer of the Deep Cervical Fascia

Middle Layer of the Deep Cervical Fascia

Visceral Division

Muscular Division

Superior border

Anterior hyoid and thyroid cartilage Posterior skull base

Inferior border continuous with

fibrous pericardium in the upper mediastinum.

Buccopharyngeal fascia

Superior border hyoid and thyroid cartilage Inferior border sternum, clavicle and scapula Envelopes infrahyoid strap muscles


Name for portion that covers the pharyngeal constrictors and buccinator. Thyroid Trachea Esophagus Pharynx Larynx

Middle Layer of the Deep Cervical Fascia

Deep Layer of Deep Cervical Fascia

Arises from spinous processes and ligamentum nuchae. Splits into two layers at the transverse processes:

Alar layer

Prevertebral layer

Superior border skull base Inferior border upper mediastinum at T1-T2 Superior border skull base Inferior border coccyx Envelopes vertebral bodies and deep muscles of the neck. Extends laterally as the axillary sheath.

Deep Layer of Deep Cervical Fascia

Carotid Sheath

Formed by all three layers of deep fascia Anatomically separate from all layers. Contains carotid artery, internal jugular vein, and vagus nerve Lincolns Highway Travels through pharyngomaxillary space. Extends from skull base to thorax.

Deep Neck Spaces

Described in relation to the hyoid.

Entire length of neck


Superficial space Retropharyngeal Danger Prevertebral Vascular visceral


Submandibular Pharyngomaxillary (Parapharyngeal) Parotid Peritonsillar Temporal Masticator Anterior visceral

Superficial Space

Entire length of neck

Surrounds platysma Contains areolar tissue, nodes, nerves and vessels Subplatysmal Flaps Involved with cellulitis and superficial abscesses Treat with incision along Langers lines, drainage and antibiotics

Retropharyngeal Space

Entire length of neck. Anterior border - pharynx and esophagus (buccopharyngeal fascia) Posterior border - alar layer of deep fascia Superior border - skull base Inferior border superior mediastinum

Combines with buccopharyngeal fascia at level of T1-T2

Midline raphe connects superior constrictor to the deep layer of deep cervical fascia. Contains retropharyngeal nodes.


Entire length of neck

Anterior border alar layer of deep fascia Posterior border prevertebral layer Extends from skull base to diaphragm Contains loose areolar tissue.

Prevertebral Space

Entire length of neck

Anterior border prevertebral fascia Posterior border vertebral bodies and deep neck muscles Lateral border transverse processes Extends along entire length of vertebral column

Visceral Vascular Space

Entire length of neck

Carotid Sheath Lincoln Highway Lymphatic vessels can receive drainage from most of lymphatic vessels in head and neck.

Submandibular Space

Superior oral mucosa Inferior - superficial layer of deep fascia Anterior border mandible Lateral border - mandible Posterior - hyoid and base of tongue musculature

2 compartments

Sublingual space

Submaxillary space

Areolar tissue Hypoglossal and lingual nerves Sublingual gland Whartons duct Anterior bellies of digastrics
Submental compartment Submaxillary compartments

Submandibular gland

Submandibular Space

Pharyngomaxillary space

aka Parapharyngeal space Superiorskull base Inferiorhyoid Anteriorptyergomandibular raphe Posteriorprevertebral fascia Medialbuccopharyngeal fascia Lateralsuperficial layer of deep fascia

Pharyngomaxillary space



Muscular compartment Medialtonsillar fossa Lateralmedial pterygoid Contains fat, connective tissue, nodes Neurovascular compartment Carotid sheath Cranial nerves IX, X, XI, XII Sympathetic chain Alar, buccopharyngeal and stylomuscular fascia. Prevents infectious spread from anterior to posterior.

Stylopharyngeal aponeurosis of Zuckerkandel and Testut

Pharyngomaxillary Space

Communicates with several deep neck spaces.

Parotid Masticator Peritonsillar Submandibular Retropharyngeal

Peritonsillar Space

Medialcapsule of palatine tonsil Lateralsuperior pharyngeal constrictor Superioranterior tonsil pillar Inferiorposterior tonsil pillar

Masticator and Temporal Spaces


Formed by superficial layer of deep cervical fascia

Masticator space

Antero-lateral to pharyngomaxillary space. Contains

Masseter Pterygoids Body and ramus of the mandible Inferior alveolar nerves and vessels Tendon of the temporalis muscle

Temporal space

Continuous with masticator space. Lateral border temporalis fascia Medial border periosteum of temporal bone Superficial and deep spaces divided by temporalis muscle

Parotid Space

Suprahyoid Superficial layer of deep fascia

Dense septa from capsule into gland Direct communication to parapharyngeal space


External carotid artery Posterior facial vein Facial nerve Lymph nodes

Anterior Visceral Space

Infrahyoid aka pretracheal space Enclosed by visceral division of middle layer of deep fascia Contains thyroid Surrounds trachea

Superior border - thyroid cartilage Inferior border - anterior superior mediastinum down to the arch of the aorta. Posterior border anterior wall of esophagus Communicates laterally with the retropharyngeal space below the thyroid gland.


All patients

Avg age b/w 40-50. More predominant in pts over 50 years.

Pediatric pts

Infants to teens. Male predilection in some case series. Most common age group: 3-5 years.


Odontogenic Tonsillitis IV drug injection Trauma Foreign body Sialoadenitis Parotitis Osteomyelitis Epiglottitis URI Iatrogenic Congenital anomalies Idiopathic

Clinical presentation

Most common symptoms

Sore throat (72%) Odynophagia (63%)

Most common symptoms (exluding peritonsillar abscesses)

Neck swelling (70%) Neck Pain (63%)


Fever Decreased PO Odynophagia Malaise Torticollis Neck pain Otalgia HA Trismus Neck swelling Vocal quality change Worsening of snoring, sleep apnea


Lateral neck plain film

Screening exam No benefit in pts with DNI based on strong clinical suspicion. Normal:

Technique dependent

7mm at C-2 14mm at C-6 for kids 22mm at C-6 for adults
Extension Inspiration

Sensitivity 83%, compared to CT 100%



CT with contrast




MRI superior to CT in initial assessment More precise identification of space involvement (multiplanar) Better detection of underlying lesion Less dental artifact Better for floor of mouth No radiation Non iodine contrast Cost Pt cooperation Slower (19 to 35 minutes)


Widely available Faster (5-15 minutes) Abscess vs cellulitis Less expensive Contrast Radiation Uniplanar Dental artifacts


Regular cavity wall with ring enhancement (RE) Sensitivity - 89% Specificity - 0%

Irregular wall (scalloped)

Sensitivity - 64% Specificity - 82% PPV - 94%

Aerobic G (+) Total

Strep sp.

n 645

Anaerobic n Total
Peptostreptococcus %

% 87.40

G (-) Total
Klebsiella sp.

n 137

% 18.56



Staph sp.
B-hemolytic Strep Strep viridans Staph aureus Coagulase neg. Staph sp. Strep pneum Enterococcus Mycobacterium tub.* Micrococcus Diptheroids Bacillus sp. Actinomycosis israelii

80 71 57 55 13 10 10 8 7 6 3

10.84 9.62 7.72 7.45 1.76 1.36 1.36 1.08 0.95 0.81 0.41

Neisseria sp.
Acinebacter sp. Enterobacter sp. Proteus sp. E coli Citrobacter sp M. Catarrhalis Pseudomonas sp. H. Parainfluenza H influenzae Salmonella sp.

7 7 4 3 2 2 1 1 1 1

0.95 0.95 0.54 0.41 0.27 0.27 0.14 0.14 0.14 0.14

Bacteroides sp.
Unidentified Bacteroides melaninogenicus Propionibacterium Provotella sp. Fusobacterium Bacteroidies fragilis Eubacterium Peptococcus Veillonella parvula Clostridium sp. Lactobacillus Bifidobacterium sp.

46 13 9 7 7 6 6 6 5 4 4 3

6.23 1.76 1.22 0.95 0.95 0.81 0.81 0.81 0.68 0.54 0.54 0.41







Modified and combined data from 738 patients (1, 2, 3, 4, 5, 6, 7).

Antibiotic Therapy

Initial therapy

Cover Gram positive cocci and anaerobes If pt is diabetic, should consider covering gram negatives empirically. Unasyn, Clindamycin, 2nd generation cephalosporin. PCN, gentamicin and flagyl - developing nations.

IV abx alone (based on retro and parapharyngeal infections)

Patient stability and nature of lesion. Cellulitis/phlegmon by CT. Abscesses in clinically stable patient. If no clinical improvement in 24 - 48 hours proceed to surgical intervention.


External drainage


Tip of greater horn of hyoid Cricoid cartilage Styloid process SCM

Transoral drainage

Parapharyngeal, retropharyngeal abscesses Great vessels lateral to abscess Tonsillectomy for exposure

Needle aspiration


Airway obstruction

Mediastinitis 2.7% UGI bleeding Sepsis Pneumonia IJV thrombosis Skin defect Vocal cord palsy Pleural effusion Hemorrhage

Trach 10 20% Ludwigs angina - 75%

Multiple space involvement

20 - 80% mortality

Who gets complications?

Older pts Systemic dz

Immunodeficient pts

Cirrhosis DM

HIV Myelodysplasia

Most common systemic Mbio Klebsiella pneum. (56%) 33% with complications Higher mortality rate Prolonged hospital stay

20 days vs. 10 days

Descending Necrotizing Mediastinitis

Definition mediastinal infection in which pathology originates in fascial spaces of head and neck and extends down.

Retropharyngeal and Danger Space 71% Visceral vascular 20% Anterior visceral 7-8%

Criteria for diagnosis

1. 2. 3.

Clinical manifestation of severe infection. Demonstration of the characteristic imaging features of mediastinitis. Features of necrotizing mediastinal infection at surgery.

1960-89 43 published cases Mortality rate 14-40%

Clinical Presentation


Respiratory difficulty Tachycardia Erythema/edema Skin necrosis Crepitus Chest pain Back pain Shock

Important to have a low threshold for further workup

Mediastinitis Imaging

Plain films

Widened mediastinum (superiorly) Mediastinal emphysema Pleural effusions Changes appear late in the disease.

CT neck and thorax.

Esophageal thickening Obliterated normal fat planes Air fluid levels Pleural effusions CT helps establish dx and surgical plan


IV antibiotics Cervical drainage

Cervical abscesses Superior mediastinal abscesses above T4 (tracheal bifurcation) Abscesses below T4 Anterior mediastinal drainage

Transthoracic drainage

Subxyphoid approach

Thoracostomy tubes

1. 2.

4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19.

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