Download Pediatric Deep Neck Suppuration

5/2/2012
HOSSAM THABET, M.D.
Otolaryngology - Head & Neck Surgery
Department
Alexandria University
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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.

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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
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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
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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
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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)
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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
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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)
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LYMPHATIC SPREAD OF
INFECTION FROM PHARYNX,
ORAL CAVITY, OR
SUPERFICIAL NECK
Cervical Suppurative Lymphadenitis
3Y/O Male with suppurated Cervical Lymphadenitis
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Cervical Suppurative Lymphadenitis
3Y/O Male with suppurated Cervical Lymphadenitis
Cervical Suppurative Lymphadenitis
1.5Y/O Male with suppurated Cervical Lymphadenitis
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Cervical Suppurative Lymphadenitis
11 month male with L.N. Suppuration (MRSA)
Cervical Suppurative Lymphadenitis
11 month male with L.N. Suppuration (MRSA)
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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
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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.
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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.
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


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)
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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
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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
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Parapharyngeal Abscess
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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
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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
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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
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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
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ODONTOGENIC DNSI
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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.
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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.
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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
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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
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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
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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
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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
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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.
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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
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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).
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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
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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
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Retropharyngeal Abscess
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Post.Ph.W
Prevertebral Ms
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3Y/O Female



Plain Xray neck
lateral view showed
widening of the
prevertebral space
at C6 level
CT was ordered
Tracheotomy has
been performed
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Th.G
Th.G
Th.G
Th.G
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5 Y/O Male
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1.Pharyngoesophegeal perforation
2.Surgical Emphysema
3.Retropharyngeal Abscess
4.Visceral Abscess
5.Mediastinitis & Mediastinal
Collection
6.Empyema
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“MISTAKES IN MEDICINE
ARE MADE BY THOSE WHO
DO NOT CARE, MORE
THAN THOSE WHO DO
NOT KNOW.”
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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
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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

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Parotid space infection
Left parotid Abscess
Lt Suppurative parotitis with localized abscess formation in
parotid L.N.
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Parotid space infection
Acute bacterial suppurative
parotitis in a neonate
Rt. Submandibular cellulitis due to Rt Suppurative submandibular
Sialadenitis
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DNSI of Congenital Origin




Infected TGDC
Infected BCC
3rd & 4th branchial sinus
Infected Thymic Cyst
Infected Bronchogenic
Cyst
 Laryngopyocele
 Infected Dermoid Cyst

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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
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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
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
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.
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Coronal T2 FSE F.D
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Second Branchial Cleft Cysts
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Third Branchial Cleft Cyst
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3rd arch Rt. branchial cyst
Fourth Branchial Cleft Cysts
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Th.G
Th.G
Th.G
AEF
Fistula, Methylene Blue
Arytenoid
Pyriform Fossa
Pyriform Fossa
Pus
Esophagus
Esophagus
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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
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2Y/O M
2Y/O M
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2Y/O M
2Y/O M
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2Y/O M
2Y/O M
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2Y/O M
2Y/O M
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Bronchogenic Cysts
4th branchial arch cyst & sinus
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Imaging OF DNSI

Plain x-Ray
1.
2.



Lateral neck plain film
Chest X-Ray
High-resolution Ultrasound
CT
MRI
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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
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
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
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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
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