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5/2/2012 HOSSAM THABET, M.D. Otolaryngology - Head & Neck Surgery Department Alexandria University 1 5/2/2012 Pediatric Deep Neck Space Suppuration Neck Infections Superficial SNSI Infection involving the superficial neck space between superficial cervical fascia & SLDCF Easy to diagnose & treat Deep DNSI Infections that spread along the deep fascial planes & neck spaces Difficult to diagnose & treat Fascial planes can confine & limit spread of suppuration, but they are imperfect barriers. 2 5/2/2012 DNSI Is a challenging problem 1. Complex anatomy 2. Deep location 3. Difficult surgical access, 4. Proximity to great vs & ns 5. Communication- between spaces & outside the neck life-threatening complications The knowledge of the anatomy of fascial planes, spaces, & lymphatic drainage is the basis for understanding the pathology of DNSI Deep Neck Spaces Anatomy of the Cervical Fascia Anatomy of the Deep Neck Spaces 3 5/2/2012 Middle Cervical Fascia Deep Superficial L. of D.C.F.Middle L. of D.C.F. Muscular D. (Pink) (Investing Layer) Prevertebral Layer of D.C. F. Brown Middle Layer of D.C. F. Alar Layer of D.C. F. Visceral D. Yellow Middle, Alar,& Prevertebral L. of D.C.F. Superficial, Middle, & Deep Cervical fascia 4 5/2/2012 Deep Neck Spaces I. Spaces involving the II. Suprahyoid Spaces entire length of the neck Sumandibular (Sublingual & Submaxillary) Superficial space Retropharyngeal space Masticator space Temporal space Danger space Peritonsillar space Prevertebral space Parapharyngeal space Vascular space Parotid space III. Infrahyoid Spaces Visceral space Cervical Fascia Visceral Space Vascular Space Retropharyngeal Space Alar Space Prevertebral Space Perivertebral Space 5 5/2/2012 C1 Mucosal Space Buccal Space Masticator Space Parotid Space Parapharygeal Spase Carotid Space Perivertebral Space Retropharyngeal Space Etiology Adenotonsillitis & pharyngitis (Most Common) Odontogenic infections (Common in adults) Cervical lymphadenitis Traumatic Infections 1. 2. 3. 4. Oral surgical procedures Oropharyngeal injuries (gun shot, falls onto pencils or sticks) F.B. ingestion; fish bones or other sharp objects Instrumentation, (Esophagoscopy or Bronchoscopy) 6 5/2/2012 Etiology Salivary gland infection Congenital cervical Lesions Branchial cleft anomalies 2. Thyroglossal duct cysts 3. Laryngopyocele Mastoiditis with petrous apicitis & Bezold abscess 1. Immunosuppression (HIV infection, chemotherapy, or immunosuppressant drugs) Pathophysiology DNSI proceeds by one of several paths: Lymphatic spread of infection from oropharynx, oral cavity, or superficial neck Suppurative Lymphadenitis Direct spread 1. 2. 3. Odontogenic abscess Penetrating trauma Sialadenitis Via communication between spaces. Hematogenous infection 7 5/2/2012 Epidemiology Most Common Site Peritonsillar abscess (Ungkanont et al 1995) Submandibular space infections & Ludwig’s angina (Larawin V et al 2006) Retropharyngeal & parapharyngeal abscesses. (Flanary VA, Conley SF 1997, Nagy M et al 1997, & Broughton RA 1992) Pediatric pts Infants to teens / Most common: 3-5 years Male predilection Epidemiology Peritonsillar infections (49%) Retropharyngeal infections (22%) Submandibular infections (14%) Buccal infections (11%) Parapharyngeal space infections (2%) Canine space infections (2%) (Ungkanont et al 1995) 8 5/2/2012 LYMPHATIC SPREAD OF INFECTION FROM PHARYNX, ORAL CAVITY, OR SUPERFICIAL NECK Cervical Suppurative Lymphadenitis 3Y/O Male with suppurated Cervical Lymphadenitis 9 5/2/2012 Cervical Suppurative Lymphadenitis 3Y/O Male with suppurated Cervical Lymphadenitis Cervical Suppurative Lymphadenitis 1.5Y/O Male with suppurated Cervical Lymphadenitis 10 5/2/2012 11 5/2/2012 Cervical Suppurative Lymphadenitis 11 month male with L.N. Suppuration (MRSA) Cervical Suppurative Lymphadenitis 11 month male with L.N. Suppuration (MRSA) 12 5/2/2012 Cervical Suppurative Lymphadenitis Submandibular Space Infection S.M.G S.M.G Suppurative Lymphadenitis with Abscess Formation Cervical Suppurative Lymphadenitis Submental Space Infection Submntal Cellulitis & Lymphadenitis 13 5/2/2012 Cervical Suppurative Lymphadenitis Submental Space Infection Lt Submandibular Lymphadenitis & Submental Abscess Retopharyngeal Abscess 5 Y/O female child with torticollis to left side, fever , dysphagia, neck pain. 14 5/2/2012 Plain. X-ray neck shows widening of the prevertebral space, loss of lordosis, reversed lordosis, CECT shows enlarged adenoid with rim enhancement due to suppurative adenoiditis Lt > Rt RP suppurative lymphadenitis with lucent central area of breakdown. Rt mucosal space abscess & a Rt PPh. lymphadenitis (white arrows) Lt RPA extending into the PPS with rim enhancement & lucent central area of breakdown. 15 5/2/2012 Th.G Lt multiloculated RPA extending into the PPS with rim enhancement & lucent central area of breakdown. Lt ICA is pushed laterally with? spasm Extension of the Lt RPA &PP abscess into the to the visceral space & left thyroid region (Th.G) with lucent area of breakdown Diagnosis 1. Complicated Acute Adenoiditis 2. Retropharyngeal Abscess 3. Lt Parapharyngeal Space Abscess 4. Visceral Space Abscess RPA RPA 5. Vascular Space Involvement MR T2WI showing widening of the retropharyngeal space with hyperintense signal due to Lt retropaharyngeal abscess (RPA) 16 5/2/2012 Retropharyngeal Abscess Management High risk airway! Admit to ICU IV antibiotics Aspiration/Surgical drainage Neck immobilization Parapharyngeal Abscess Pathogenesis Odontogenic & Pharyngotonsillar infections Other DNSI (PPS communicates with Parotid, Masticator, Peritonsillar, Submandibular, & RP, & vascular spaces) Parotitis, Sinusitis Infected neck tumors Infected brachial cleft cysts Chronic otitis, mastoiditis 17 5/2/2012 Parapharyngeal Abscess Clinical Presentation Fever, Trismus, & Neck swelling Torticollis Dysphagia or odynophagia Signs of acute tonsillitis or pharyngitis Neck pain Medial displacement (tonsil /lateral ph. Wall) Cervical lymphadenopathy Parapharyngeal Abscess Management IV abx : 10-15% cure Airway management Surgical drainage 18 5/2/2012 Parapharyngeal Abscess 19 5/2/2012 20 5/2/2012 Nodes Of Rouviere (Lateral Retropharyngeal L.N.) Lateral Ph.L.Ns lies between the ICA & prevertebral muscles at the upper neck. The most cephalad are known as the nodes of Rouviere 21 5/2/2012 Peritonsillar Abscess Most common DNSI in adults Result of acute tonsillitis/ 2-5 days from onset 15 - 25% Recurrence in children Predisposing factors: Chronic tonsillitis Multiple trials of oral Abx Incomplete tonsillectomies Tonsilloliths Dental infection 22 5/2/2012 Tonsillitis Vs Quincy No trismus/drooling Bilateral Tonsils inflammed No peritonsillar swelling Uvula central Aspiration- No pus Imaging Respond to medical tx Trismus & drooling Unilateral Peritonsillar swelling Tonsil pushed medial Uvula deviated Aspiration- pus Imaging No response to tx Peritonsillar Abscess CT (Sensitivity= 100% & Specificity = 75%) Suspicious PE & exclude retroph. abscess Inadequate visualization Young children 23 5/2/2012 Peritonsillar Abscess Medical Management Hydration Analgesia Antibiotics Surgical Management 3 point aspiration – begin in superior-medial pole & advance 0.5 cm more inferior & lateral Needle aspiration I & D - Confirm diagnosis & definitive drainage Tonsillectomy 24 5/2/2012 ODONTOGENIC DNSI 25 5/2/2012 Odontogenic DNSI Peri-apical abscess Most common cause of DNSI in adults Peri-apical abscess is the most common source Prior to the use of antibiotics 70-80% of DNSI were 2ry to pharyngeal infection The following structures play a role in determining the location of an abscess 2ry to a mandibular tooth infection? A. Mylohyoid line B. Buccinator muscle insertion C. Location of the tooth apex Apex Location Space above mylohyoid line Sublingual space below mylohyoid line Submandibular space Incisors Premolars 1st molar 2nd and 3rd molar Yonetsu K, Izumi M, Nakamura. Deep facial infections of odontogenic origin: CT assessment of pathways of space involvement. Am J Neuroradiol January 1998, 19:123-128. 26 5/2/2012 Buccinator Muscle Insertion Buccal Space Abscess Intra-oral abscess Buccinator Muscle The buccinator muscle inserts on the maxilla superiorly and the mandible inferiorly. The location of an abscess secondary to a dental infection depends on where the break in the cortex occurs with reference to the insertion of the buccinator muscle. Intra-oral abscess – cortical break below the insertion on the maxilla and above the insertion on the mandible Buccal space abscess – cortical break above the insertion on the maxilla and below the insertion on the mandible. Submandibular Space Infection a. Sublingual Space (Supramyelohyoid) b. Submaxillary Space (Inframyelohyoid) Superficial - FOM m.m. Superior & Lateral - the mandible Medial- the genial muscles & tongue Inferior - the hyoid bone (The two subdivisions freely Anterior/posterior - digastric ms communicate around the posterior Lateral - deep cervical fascia border of the mylohyoid) Medial - hyoglossus, styloglossus, & mylohyoid ms. 27 5/2/2012 Sublingual Space Infection Etiology: Infection of lower premolars & 1st molar with supramylohyoid perforation of the lingual cortex. Symptoms: FOM swelling with tongue elevation Extension to Submandibular, Submental, & Lateral pharyngeal spaces Drainage via incision of the floor parallel to Wharton's duct Submandibular Space Infection 1. 2. Odontogenic (70%-85%) Sialadenitis, lymphadenitis, FOM lacerations or mandible fractures, & Bezold abscess. The mylohyoid insertion dictates the space affected by odontogenic infection. The apices of 1st molar & ant.teeth (supramylohyoid) Sublingual space involvement The apices of the 2nd & 3rd molars (submylohyoid) Submaxillary space involvement 28 5/2/2012 Submandibular Space Infection Odontogenic Submandibular abscess (amultiloculated low- attenuation mass with peripheral rim enhancement ). Submandibular Space Infection Symptoms: Swelling inferior to the mandible, between the digastric bellies down to the hyoid bone level. Treatment: Antibiotics Surgical Extraoral Drainage an incision below & parallel to the inferior border of the mandible in the region of the angle, blunt dissection to explore the space for loculations of pus 29 5/2/2012 Submental Space Infection Occurs to due to: 1. Lower incisor infection (Thinner buccolabial alveolar plate with leak outside below the myelohyoid) Submental suppurative lymphadenitis Marked external induration No internal swelling of the FOM Moderate Odynophagia & no resp. distress 2. Submental Space Infection Submental Abscess 30 5/2/2012 Ludwig’s Angina Acute, progressive cellulitis of the sublingual & submaxillary spaces (mandibular dental infection 90%) 50% mortality in the preantibiotic era, 10% in wellmanaged patients Common in young adults, M:F= 2:1 or 3:1 ratio Ludwig’s Angina Clinical Picture Dysphagia/Odynophagia/Drooling Neck Pain/Swelling/Fever Throat & FOM Pain Dysphonia/Dysarthria Hot Pottato Voice Airway Obstruction Tongue swelling Restricted neck movement 31 5/2/2012 Ludwig’s Angina Clinical Picture Submandibular & Submental swelling Elevated Woody Tongue & FOM Suprhyoid edema & brawny induration “bull neck” Tenderness over neck Trismus & Fever No fluctuance/lymphadenopathy Percussion tenderness over involved teeth Ludwig’s Angina Infection can easily spread to other deep spaces of the neck and thoracic cavity if diagnosis is delayed 32 5/2/2012 Ludwig’s Angina Management Continuous close monitoring Airway management IV antibiotic therapy (especially for anaerobes) Surgical Drainage if not responsive to abx Masticator Space Infection from Lower 2nd & 3rd molars & extension from contiguous fascial spaces SLDCF Superior Spread of Infection Parotid Space P There is no fascial separation between the medial projection of the buccal fat pad and the MS. Therefore, tumors and infection can spread freely between the buccal & MS. Firm attachment to the mandible the location of the SLDCF with reference to the inferior aspect of the mandible and the muscles in the MS. Note: V3 travels through the MS. 33 5/2/2012 Masticator Space Abscess Infection usually spreads superiorly A B CECT (A and B) show a low attenuation mass with peripheral rim enhancement in the right MS consist with an abscess, with inflammatory changes in and surrounding the parotid. Bone erosion is noted in the ascending ramus of the mandible (B), consistent with osteomyelitis. A B Post contrast axial T1WI (A) & coronal (B) demonstrate a low signal intensity mass with peripheral enhancement (abscess) in the right MS. There is superior extension along the temporalis muscle, which is enlarged & enhancing. Masticator Space Abscess Infection source: Lower 2nd & 3rd molarS & from contiguous fascial spaces (from buccal space 1ry involvement) Extend superiorly , SLDCF is firmly attached to mandible. Communication with the buccal & parotid spaces Symptoms: trismus, posterior-inferior face swelling 34 5/2/2012 Masticator Space Abscess Masticator Space Abscess Submasseteric & parotid infection Masticator space infection Masticator space infection, lateral pterygoid muscle swelling Lt masticator space abscess (arrow), from a molar abscess (arrowhead). 35 5/2/2012 Masticator Space Abscess Treatment: Extraoral or Intraoral Drainage along the pterygomandibular raphe or the angle of mandible for submassetric or pterygomandibular abscess External Drainage for temporal abscess TRAUMATIC DNSI 36 5/2/2012 Retropharyngeal Abscess •18 Y/O male with post traumatic retropharyngeal abscess & Surgical emphysema. Notice the A/F level & loss of cervical lordosis. How would you drain this RPA? (Exteranl Approach) Retropharyngeal Abscess 37 5/2/2012 Retropharyngeal Abscess 38 5/2/2012 Post.Ph.W Prevertebral Ms 39 5/2/2012 3Y/O Female Plain Xray neck lateral view showed widening of the prevertebral space at C6 level CT was ordered Tracheotomy has been performed 40 5/2/2012 Th.G Th.G Th.G Th.G 41 5/2/2012 42 5/2/2012 5 Y/O Male 43 5/2/2012 1.Pharyngoesophegeal perforation 2.Surgical Emphysema 3.Retropharyngeal Abscess 4.Visceral Abscess 5.Mediastinitis & Mediastinal Collection 6.Empyema 44 5/2/2012 “MISTAKES IN MEDICINE ARE MADE BY THOSE WHO DO NOT CARE, MORE THAN THOSE WHO DO NOT KNOW.” 45 5/2/2012 IT IS GOOD TO LEARN FROM YOUR MISTAKES. IT IS EVEN BETTER TO LEARN FROM SOMEBODY ELSE’S! LEARN FROM THE MISTAKES OF OTHERS. YOU CAN’T LIVE LONG ENOUGH TO MAKE THEM ALL YOURSELF 46 5/2/2012 DNSI DUE TO SIALADENITIS Parotid space infection Cause—Bad oral hygiene, sialolithiasis, stomatitis, dehydration, rdiotherapy, Sjogren’s syndrome, severe external otitis, & immune deficincy Tense painful parotid swelling Fever No trismus No fluctuation (dense fascia) Turbid fluid may be expressed from the duct 47 5/2/2012 Parotid space infection Left parotid Abscess Lt Suppurative parotitis with localized abscess formation in parotid L.N. 48 5/2/2012 Parotid space infection Acute bacterial suppurative parotitis in a neonate Rt. Submandibular cellulitis due to Rt Suppurative submandibular Sialadenitis 49 5/2/2012 DNSI of Congenital Origin Infected TGDC Infected BCC 3rd & 4th branchial sinus Infected Thymic Cyst Infected Bronchogenic Cyst Laryngopyocele Infected Dermoid Cyst 50 5/2/2012 Visceral Space Abscess Neck induration, tenderness , & edema Spiking fevers, sepsis Cause: Extension from other spaces 3rd & 4th branchial pouch sinus Infected BCC Infected thymic cysts Infected TGDC 51 5/2/2012 Infected TGDC Branchial Arch Anomalies Cyst External Sinus Internal Sinus Fistula Pharynx Skin BCC with external openings are associated with the 1st & 2nd arches, whereas the 3rd & 4th arches cysts are associated with internal openings 52 5/2/2012 Type I Extremely rare, Ectodermal Duplication anomaly of EAC Parallel to the EAC Pretragal, post auricular cyst or fistula posterior to the pinna or concha. Superior to the main trunk of VII n. Ends in a cul-de- sac on or near a bony plate at the level of the mesotympanum. Surgical Excision Type II A duplication anomaly of membranes & cartilaginous EAC.(ectodermal & mesodermal). Sinus tract extends medial, inferior,& anterior to the EAC and may extend deep to VII n. Fistula in the concha or EAC & in the neck Fistula opens below the angle of mandible at the anterior border of SCM, & superior to hyoid bone. 53 5/2/2012 54 5/2/2012 Coronal T2 FSE F.D 55 5/2/2012 56 5/2/2012 57 5/2/2012 58 5/2/2012 Second Branchial Cleft Cysts 59 5/2/2012 Third Branchial Cleft Cyst 60 5/2/2012 3rd arch Rt. branchial cyst Fourth Branchial Cleft Cysts 61 5/2/2012 Th.G Th.G Th.G AEF Fistula, Methylene Blue Arytenoid Pyriform Fossa Pyriform Fossa Pus Esophagus Esophagus 62 5/2/2012 4th branchial pouch sinus Translaryngeal course of a fourth branchial pouch sinus. Fourth branchial pouch sinus originating in the piriform apex (dashed lines), caudal to the SLN and terminating as a small cyst in the superior pole of the thyroid gland. The sinus tract is near the RLN at the cricothyroid joint. 2Y/O M 63 5/2/2012 2Y/O M 2Y/O M 64 5/2/2012 2Y/O M 2Y/O M 65 5/2/2012 2Y/O M 2Y/O M 66 5/2/2012 2Y/O M 2Y/O M 67 5/2/2012 Bronchogenic Cysts 4th branchial arch cyst & sinus 68 5/2/2012 Imaging OF DNSI Plain x-Ray 1. 2. Lateral neck plain film Chest X-Ray High-resolution Ultrasound CT MRI 69 5/2/2012 Management Of DNSI Four keys to successful management Airway Control 1. 2. 3. Antibiotic Therapy Surgical Drainage 1. 2. 3. Observation Intubation (Flexible fiberoptic guided intubation) Tracheostomy External Drainage Transoral Drainage Image Guided Aspiration Treatment Of The Primary Cause (Dental Infection) Management Of DNSI Antibiotic Therapy Choice of antibiotics: Amoxicillin/clavulanate + Metronidazole Ampicillin/Sulbactam (Unasyn) + Metronidazole Ticarcillin/Clauvulate (Timentin) + Metronidazole Piperacillin/Tazobactam (Zosyn) + Metronidazole Other alternatives Clindamycin + Cipro (PCN allergy) - Adults 2nd gen cephalosporin + Metronidazole (B. Fragilis) Penicillin, gentamicin & flagyl - developing nations 70 5/2/2012 External Surgical Drainage Transoral Surgical Drainage Complications Of DNSI Airway obstruction Ruptured abscess & Aspiration Lung abscess, Pneumonia & Embyema Vascular complications - CA rupture - IJ thrombophlebitis - Cavernous sinus thrombosis Neurologic deficits V.C. paralysis- X involvement Horner’s syndrome –Sympath. chain involvement Transverse Myelitis 71 5/2/2012 Complications Of DNSI Mediastinitis (Descending Necrotizing Mediastinitis) Septicemia Septic emboli Osteomyelitis of cervical vertebrae Atlantoaxial sublaxation (Griesel's syndrome) Necrotizing cervical fasciitis Recurrent Deep Neck Space Infection Conclusion DNSI are potentially lethal infections if they are not diagnosed early and treated properly. DNSI exert fatal effect by causing local airway obstruction or extension to vital areas, such as the mediastinum or carotid sheath. Good knowledge of the anatomy of H & N fascial planes, spaces, & lymphatic drainage are the basis for understanding the pathology of DNSI. Recurrent DNSIs in children are usually due to congenital anomalies, commonly branchial remnants 72 5/2/2012 73