Download Deep Neck Spaces

Deep Neck Spaces: Surgical
Anatomy and Infections
Deep Neck Spaces and
Infections
• Anatomy of the Cervical Fascia
• Anatomy of the Deep Neck Spaces
• Deep Neck Space Infections
Cervical Fascia
• Superficial Fascia
• Deep Fascia
– Superficial
– Middle
– Deep
Superficial Layer
• Superior attachment –
zygomatic process
• Inferior attachment –
thorax, axilla.
• Similar to
subcutaneous tissue
• Ensheathes platysma
and muscles of facial
expression
• Marginal mandibular
lies deep to it
Superficial Layer of the Deep Cervical
Fascia
• Completely surrounds the neck
from skull to chest
• Arises from spinous
processes, ligamentum
nuchae
• Superior border – nuchal line,
skull base, zygoma, mandible.
• Inferior border –scapula,
clavicle and manubrium
• 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
– Superior border
•
•
Anterior – hyoid and thyroid cartilage
Posterior – skull base
– Inferior border – continuous with
fibrous pericardium in the upper
mediastinum.
– Buccopharyngeal fascia
• Name for portion that covers the
pharyngeal constrictors and
buccinator.
– Envelopes
•
•
•
•
•
Thyroid
Trachea
Esophagus
Pharynx
Larynx
•
Muscular Division
– Superior border – hyoid and
thyroid cartilage
– Inferior border – sternum, clavicle
and scapula
– Envelopes infrahyoid strap
muscles
Middle Layer of the Deep Cervical Fascia
Deep Layer of Deep Cervical Fascia
• Arises from spinous processes and ligamentum
nuchae.
• Lies deep to the trapezius
• Forms fascial carpet of the posterior triangle,
which is also the fascia on the lateral surface of
scalene muscles
• Reflected outwards as a sleeve along the
brachial plexus and axillary vessels
• Splits into two layers at the transverse
processes:
– Alar layer
– Prevertebral layer
• Envelopes vertebral bodies and deep muscles of the neck.
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
“Lincoln’s Highway”
Travels through pharyngomaxillary space.
Extends from skull base to thorax.
At the level of clavicle it fuses with the covering of great vessels at
the root of neck and the pericardium
Deep Neck Spaces
• Described in relation to the hyoid
– Entire length of the
neck
– Suprahyoid
– Infrahyoid
Deep Neck Spaces
• Entire Length of Neck:
Superficial Space
– Surrounds platysma
– Contains areolar tissue,
nodes, nerves and vessels
– Subplatysmal Flaps
– Involved in cellulitis and
superficial abscesses
– Treat with incision along
Langer’s 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 T4
• Midline raphe- spaces of
Gilette
• Contains retropharyngeal
nodes.
Space
• 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.
• Space 4 of Grodinsky
and Holyoke
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”
• Can become
secondarily involved
with any other deep
neck space infection by
direct spread
Submandibular Space
• Suprahyoid
• 2 compartments
– Sublingual space
• Superior – oral mucosa
• Inferior - superficial layer
of deep fascia
• Anterior border –
mandible
• Lateral border - mandible
• Posterior - hyoid and
base of tongue
musculature
• Areolar tissue
• Hypoglossal and lingual
nerves
• Sublingual gland
• Wharton’s duct
– Submaxillary space
• Anterior bellies of digastrics
– Submental compartment
– Submaxillary
compartments
• Submandibular gland
Submandibular Space
Pharyngomaxillary space
• Suprahyoid: Parapharyngeal
Space (lateral pharyngeal,
peripharyngeal,
pharyngomaxillary,
pterygopharyngeal,
pterygomandibular,
pharyngomasticatory)
–
–
–
–
–
Superior—skull base
Inferior—hyoid
Posterior—prevertebral fascia
Medial—buccopharyngeal fascia
Lateral—med pterygoid, mandible,
parotid
Pharyngomaxillary space
• Prestyloid
–
–
–
–
Muscular compartment
Medial—tonsillar fossa
Lateral—medial pterygoid
Contains fat, connective
tissue, nodes, int maxillary
a., inf alveolar n., lingual n.,
auriculotemporal n.
• Poststyloid
– Neurovascular
compartment
– Carotid sheath
– Cranial nerves IX, X, XI, XII
– Sympathetic chain
Pharyngomaxillary Space
• Communicates
with several deep
neck spaces.
– Parotid
– Masticator
– Peritonsillar
– Submandibular
– Retropharyngeal
Peritonsillar Space
• Suprahyoid
• Medial—capsule
of palatine tonsil
• Lateral—superior
pharyngeal
constrictor
Parotid Space
• Suprahyoid
• Superficial layer of
deep fascia
– Dense septa from
capsule into gland
– Direct communication
to parapharyngeal
space
Masticator and Temporal
Spaces
•
Suprahyoid
•
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
Deep Neck Spaces
• Infrahyoid: Visceral
Compartment (Space
3 of Grodinsky and
Holyoke)
– Middle layer of deep
fascia
– Contains thyroid,
trachea, esophagus
– Extends from thyroid
cartilage into superior
mediastinum
Deep Neck Spaces
• Infrahyoid: Visceral
Compartment
– 2 spaces• Retrovisceral space
{Retropharyngeal space}
– Extends along whole length of neck
• Pretracheal space
– Superiorly - attachment of strap
muscles to thyroid and hyoid
– Inferiorly - up to upper border of
arch of aorta
Deep Neck Space Infections
•
•
•
•
•
Etiology/ pathogenesis of Infection
Microbiology
Clinical manifestations
Some specific infections
Complications
Etiology/pathogenesis
• DNSI have been recognised from the time of Galen in
2nd century AD
• Preantibiotic era – 70% from infections of pharynx and
tonsils
• Present situation
–
–
–
–
–
–
–
–
–
Dental infection (major source)
Peritonsillar cellulitis or abscess
Upper aerodigestive tract trauma
Retropharyngeal lymphadenitis
Pott’s disease
Sialadenitis – submandibular, parotid
From temporal bone- Bezold’s abscess, petrous apex infections
Congenital cysts and fistulas
Intravenous drug abuse
Microbiology
• Preantibiotic era – S. aureus
• Currently
– Aerobes – alpha hemolytic Streptococci, S. aureus
– Anaerobes – Fusobacterium, Bacteroides,
Peptostreptococcus, Veilonella
• Gram-negatives uncommon
• Almost always polymicrobial
• Asmar (1990) – 90% polymicrobial, aerobes
found in all, anaerobes in >50%
Clinical manifestations
• Pain
– Constant feature
– Indication of extension or resolution
– Exception – retropharyngeal abscess in children
• Fever
– Constant feature
– Initial spike, followed by elevated temperature
– Spiking temperatures- doubt septicemia/septic thrombophlebitis of
IJV/mediastinal extension
•
•
•
•
•
•
Swelling
Trismus and limitation of neck movements – depending on site
Progressive dysphagia and odynophagia
Voice change
Dyspnoea
Chest pain
Ludwig’s angina
• Described by William Friedrich von
Ludwig, 1836 (“gangrenous induration of the
connective tissues of the neck which
advances to involve the tissues which cover
the small muscles between the larynx and
the floor of mouth”)
• Infection of submandibular space
– Anterior teeth and first molars – infection
of sublingual space
– Second and third molars – infection of
submaxillary space
Ludwig’s angina
• Criteria for diagnosis
– Rapidly progressive cellulitis, not an abscess
– Develops along fascial planes by direct spread, not
lymphatic spread
– Does not involve submandibular gland or lymph
nodes
– Involves both sublingual and submaxillary spaces,
usually bilateral
• Pseudo – ludwig’s angina
– Other inflammatory conditions involving floor of
mouth
– Limited infections involving only sublingual space,
submandibular lymph nodes, submandibular gland,
submental space, or abscesses involving one or
more of these spaces
Etiology
• 75-80% dental cause
• Extraction of a diseased molar initiates
infection
• Penetrating injury of the floor of mouth
• Mandibular fractures
Clinical features
• Young man with poor dentition, increasing
oral or neck pain and swelling
• Increasing edema and induration of
perimandibular region and floor of mouth
• Thrusting of tongue posteriorly and
superiorly
• Neck rigidity, trismus, odynophagia, fever
• Dyspnoea and strider
Ludwig’s angina
Ludwig’s angina
TREATMENT
• Early stage- IV antibiotics {penicillin +
metronidazole}, extraction of the diseased tooth
• Late stage– Airway {tracheostomy }
– Surgery
• Horizontal incision with wide exposure
• Tissues have peculiar “salt pork” appearance,
with woody induration, watery edema, and
little bleeding
• Gross purulence is rare
• Multiple drains/wound kept open
Parapharyngeal abscess
• Causes
–
–
–
–
Peritonsillar abscess
Dental infection
From other spaces
Trauma
• Clinical features
– Anterior compartment
•
•
•
•
Prolapse of tonsil
Trismus
External swelling behind angle of jaw
Odynophagia, fever
– Posterior compartment
•
•
•
•
•
Bulge of LPW behind posterior pillar
Lower cranial n. paralysis
Horner’s syndrome
Swelling of parotid region
Odynophagia, fever
Parapharyngeal abscess
Parapharyngeal abscess
• Treatment
– IV antibiotics
– Surgery
• External approach
– Transverse submandibular incision
– Mosher’s T-shaped incision
Retropharyngeal Abscess
• Pediatrics
– Cause—suppurative
process in lymph
nodes
• Nose, adenoids,
nasopharynx, sinuses
• Adults
– Cause—trauma,
instrumentation,
extension from
adjoining deep neck
space
Retropharyngeal Abscess
– 50% occur in patients 6-12 months of age
– 96% occur before 6 years of age
– Children - fever, irritability,
lymphadenopathy, torticollis, poor oral
intake, sore throat, drooling
– Adults - pain, dysphagia, odynophagia,
anorexia
– Dyspnea and respiratory distress
– Lateral posterior oropharyngeal wall bulge
Retropharyngeal Abscess
• Lateral neck plain film
– Screening
investigation
– Normal: 7mm at C-2,
14mm at C-6 for kids,
22mm at C-6 for adults
(Wholey et al)
– Loss of cervical
lordosis
– Technique dependent
• Extension
• Inspiration
– Nagy et al
• Sensitivity 83%,
compared to CT
100%
Retropharyngeal Abscess
Retropharyngeal Abscess
• Treatment
– IV antibiotics and fluid replacement
– Surgical drainage
• Intraoral
• External – tracheostomy + anterior cervical
approach
Peritonsillar abscess (quinsy)
• Cause
– Extension from tonsillitis
– De novo
• Clinical features
–
–
–
–
–
–
Fever with chills and rigor
Odynophagia
“Hot Potato” voice
Halitosis
Trismus
Congested tonsil with edematous pillar
• Treatment
– IV antibiotics and fluids
– Surgical drainage
• Intraoral
•
Masticator Temporal Space
infection
Cause
– Odontogenic
– Trauma
• Superficial compartment
– Extensive facial swelling
– Severe trismus
– Pain
• Deep compartment
–
–
–
–
Trismus
Pain
Dysphagia and odynophagia
Intraoral swelling in RMT area
• Treatment
– IV antibiotics
– Surgery
• Intraoral
– Along inner margin of mandibular ramus in RMT area
• External
– Horizontal incision, 2-3cm beneath angle of mandible
Complications
• Airway obstruction
– Tracheostomy
– Endotracheal intubation
• Ruptured abscess
– Pneumonia
– Lung Abscess
Complications
• Internal Jugular Vein Thrombophlebitis
(Lemierre’s syndrome)
–
–
–
–
Fusobacterium necrophorum
High fever with chills and rigor
Swelling and pain along SCM
Bacteremia, septic embolization, dural sinus
thrombosis
– IV drug abusers
– Treatment
• IV antibiotics
• Anticoagulation - controversial
• Ligation and excision
Complications
• Carotid Artery Rupture
– Mortality of 20-40%
– Sentinel bleeds from ear, nose, mouth
– Majority from internal carotid, less from
external carotid, and fewest from common
carotid
– Treatment
• Proximal and distal control
• Ligation
• Patching or grafting
Complications
• Mediastinitis
– Mortality of 40%
– Increasing dyspnea, chest pain
– CXR - widened mediastinum
– Treatment
• EARLY RECOGNITION AND INTERVENTION
• Aggressive IV antibiotic therapy
• Surgical drainage
– Transcervical approach
– Chest tube vs. thoracotomy
Complications
•
•
•
•
Cranial nerve deficits
Necrotising cervical fasciitis
Osteomyelitis
Grisel syndrome ( inflammatory torticollis
causing cervical vertebral subluxation )
Deep neck space infections- A relook at the
present day clinical profile and management
Ramesh A, Sameer N, Kumar S, Thakar A, Deka RC
Hospital plus vol III, No. 8, August 1998
•
•
•
•
30 cases 1990-1997
Parapharyngeal space most commonly involved
Dental and unknown etiology most prevalent
Mixed flora- need to include metronidazole and
aminoglycoside
• Airway compromise, mediastinal involvement,
IJV thrombosis
• Need for early surgical exploration in ……
• CT scan reliable in detecting extent and airway
compromise to help plan surgery
Special considerations
• Airway protection
– Observation
– Intubation
• Direct laryngoscopy: risk of rupture
and aspiration
• Flexible fiberoptic
– Tracheostomy
• Safest
• Abscess may overlie trachea
• Distorted anatomy and tissue planes
Special considerations
• Image-guided Aspiration
– Patient selection
• Smaller abscesses, limited extension,
uniloculated
– Advantages
• Early specimen collection
• Reduced expense
• Avoidance of neck scar