Deep Neck Space Infection

Agung D. Permana,dr.,M.Kes.,SpTHT-KL

Introduction
DEEP NECK SPACE INFECTIONS Life threatening delay in diagnosis/inadequate/inappropriate treatment complications mortality rates : 40% head and neck surgeon : cervical fascias & potential spaces understand the treatment & potential complications antibiotics decreased the incidence and mortality

Anatomy Of The Cervical Fascia

Superficial cervical fascia Deep cervical fascia
1. Superficial layer 2. Middle layer - Muscular division
- Visceral division

3. Deep layer - Prevertebral division

- Alar division

Sternocleidomastoid

Investing layer of deep cervical fascia

Pretracheal fascia (visceral part) Carotid sheath

T E
Pretracheal fascia (muscular part)

Alar fascia Buccopharyngeal fascia

Prevertebral fascia

Trapezius

Deep Cervical Fascia

Cervical Fascia

Pathophysiology
Deep neck space infections can arise from a multitude of causes.

Whatever the initiating event, development of a deep neck space infection proceeds by one of several paths, as follows:

Spread of infection can be from the oral cavity, face, or superficial

neck to the deep neck space via the lymphatic system. Lymphadenopathy may lead to suppuration and finally focal abscess formation. Infection can spread among the deep neck spaces by the paths of communication between spaces. Direct infection may occur by penetrating trauma.

Sign And Symptoms

Mass effect of inflamed tissue or abscess cavity

on surrounding structures Direct involvement of surrounding structures with the infectious process

 Presentation Obtain a detailed history from patients in whom deep neck space

infection is suspected. Eliciting a history of the following is important:

Pain Recent dental procedures Upper respiratory tract infections (URTIs) Neck or oral cavity trauma Respiratory difficulties Dysphagia Immunosuppression or immunocompromised status Rate of onset Duration of symptoms

Retropharyngeal Space Infection

Source
Nose Sinuses Adenoids Nasopharynx

Manifestations
Acute URTI in infants & children Dysphagia & odynophagia Drooling & difficult to expell excretions Cervical rigidity Muffled voice Dyspnea Unilateral bulging of posterior pharyngeal wall Sepsis

Retropharyngeal Space Infection

Pediatrics

"

Cause > suppurative process in lymph nodes

adenoids, nasopharynx, sinuses!

#Nose,

Adults
Cause > trauma, instrumentation, extension

adjoining deep neck space

Danger Space Infection

Source
Retropharyngeal space Prevetebral space Parapharyngeal space

Manifestations
Same as primary space infection Severe sepsis

Treatment
Same as for primary space infection

Complications
Potential for rapid spread through the loose areolar tissue Inferior spread to the posterior mediastinum to the level of diafragma

Prevertebral Space Infection

Source
Vertebral bodies Penetrating injuries Tuberculosis of the spine

Manifestations
Midline abcess Cold abcess posterior pharynx Slow spread of suppuration of this area

Treatment
Needle aspiration w/ subsequent antituberculosis th/ Stabilization of spine

Complications
Spine instability progression of vetebral process

Visceral Vascular Space Infection

potential space within the carotid sheath infections remain relatively localized

compact space contains little areolar connective tissue lymphatics contained within this space receive secondary drainage from most of the lymphatics of the head and neck Lincoln Highway of The Neck (Mosher) all three layers of the DCF contribute to the carotid sheath

Visceral Vascular Space Infection

Source
Parapharyngeal space
Submandibular space Visceral space

Treatment

External drainage I.V. antibiotics Possible ligation of IJV

Complications Manifestations
Pitting edema over SCM

Torticollis

Septic shock Carotid artery erotions Endocarditis Cavernous sinus thrombosis

Pharingomaxillary Space Infection

Prestyloid Compartement [anterior-muscular]
Fat Lymph nodes Internal maxilarry artery Inferior alveolar, lingual,auriculotemporal nerves

Poststyloid Compartement [posterior-neurovascular]

Carotid artery Internal jugular vein Symphatetic chain IX, X, XI, XII nerves

Pharingomaxillary Space Infection

Source
Tonsil Pharynx Teeth Temporal bone (petrous) Parotis gland Lymph nodes of nose & nasopharynx
Medial displacement of lateral pharyngeal wall and tonsils Trismus Parotid edema Retromandibular neck fullness Dysphagia

Manifestations

Peritonsillar Space Infection

Source
Tonsils & pharynx

Manifestations
Dysphagia/odynophagia Drooling and hot potato voice Muffleed voice Reffered otalgia Trismus Displaced tonsil toward midline Deviated uvula

Submandibular Space Infection

Submaxillary space
Central compartement Submental compartement Submaxillary compartement subdivided by anterior bellies of digastric m. Contents Submandibular gland Lymph nodes

Sublingual space
Sublingual gland Hypoglossal nerve Whartons ducts

Submandibular Space Infection

Source
Teeth Salivary glands Pharynx & tonsils Sinuses

Treatment
Underlying pathology External drainage if it progress
- sublingual - submandibula

Manifestations
Dysphagia Odynophagia

Complications
Ludwigs Angina

Ludwigs Angina

Ludwigs angina

Masticator Space Infection

Source
Molar teeth

Manifestations
1.

2.

Extreme trismus Edema & tenderness over the posterior ramus of mandible

Treatment
External drainage

Temporal Space Infection

Temporalis m. :
- superficial compartments

- deep compartments

Manifestation
Pain in this area Trismus

Treatment
External drainage

Anterior Visceral Space

Contents
Pharynx Esophagus Larynx Trachea Thyroid gland

Source
Tonsils Esophageal injury Blunt trauma w/ mucosal tear Acute thyroiditis Chest infection

Anterior Visceral Space

Microbiology

Preantibiotic eraS.aureus
Currentlyaerobic Strep species and non-strep

anaerobes Gram-negatives uncommon Almost always polymicrobial Remember resistance !!!

Imaging
Lateral neck plain film "Screening exammainly for retropharyngeal and pretracheal spaces "Normal: 7mm at C-2, 14mm at C-6 for kids,
22mm at C-6 for adults

Imaging

Imaging
High-resolution Ultrasound
"Advantages Avoids radiation Portable

"Disadvantages Not widely accepted Operator dependent Inferior anatomic detail "Uses Following infection during therapy Image guided aspiration

Imaging
Contrast enhanced CT
"Advantages Quick, easy Widely available Familiarity Superior anatomic detail Differentiate abscess and cellulitis "Disadvantages Ionizing radiation Allergenic contrast agent Soft tissue detail Artifact

Imaging
MRI "Advantages

No radiation Safer contrast agent Better soft tissue detail Imaging in multiple planes No artifact by dental fillings

"Disadvantages

Increased cost Increased exam time Dependent on patient cooperation Availability

Treatment
Airway protection
Antibiotic therapy Surgical drainage

 Airway protection
"Observation

"Intubation
Direct laryngoscopy: possible risk of rupture and

aspiration Flexible fiberoptic

"Tracheostomy

Ideally = planned, awake, local anesthesia Abscess may overlie trachea Distorted anatomy and tissue planes

Treatment
Antibiotic Therapy

"Polymicrobial infections Aerobic Strep, anaerobes Ampicillin/sulbactam with metronidazole "Beta-Lactam resistance in 17-47% of isolates

"Alternatives
Third generation cephalosporins clindamycin

"Culture and sensitivity

Treatment
Surgical Drainage
Transoral Preoperative CT where are the great vessels? CT Cruciate mucosal incision, blunt spreading through superior pharyngeal constrictor External drainage

 Surgical Drainage
"External EXPOSURE, EXPOSURE!!!

approach
Submandibular incision Submental incision

T-incision

Complication
Airway obstruction

Ruptured abscess
Internal Jugular Vein Thrombosis Carotid artery Rupture Mediastinitis

history Physical examination Secure airway Culture, IV antibiotic CT scan No abcess Small abcess Needle aspiration Watch and wait 24-48 hours for culture and drainage Large abcess

No
Impending complication ?

Clinical improvement ?

Yes

Yes No
Surgical incision And drainage

Continue antibiotic, Needle aspirations

Pharingomaxillary Space Infection

Treatment

External drainage Tracheotomy

Complications
Septic thrombosis of IJV Carotid artery erosions Cranial nerve involvement Mediastinitis

Peritonsillar Space Infection

Treatment

Peroral drainage tonsilectomy

Complications
Spread into pharyngomaxilary space through posterior pharyngeal wall

Retropharyngeal Space Infection

Treatment
1.
2. 3. 4.

Fasting I.V. antibiotics Tracheotomy Emergent surgical drainage - intraoral drainage - external drainage
Rupture of abcess w/ aspiration & pneumonia Mediastinitis Airway obstruction

Complications
1. 2. 3.

Pharingomaxillary Space Infection

Submandibular
Masticator Temporal

Peritonsillar

PMS

Parotid

Retropharingeal VVS

Danger
Prevertebral

Anterior Visceral

Mediastinum