Deep Neck Space Infections

UTMB Department of Otolaryngology

Jeffrey Buyten, MD
Francis B. Quinn, MD
October 5, 2005

Best viewed as a PowerPoint slideshow to insure

That overlays are seen.
 Outline
 Anatomy
 Fascial planes

 Spaces

 Epidemiology
 Etiology
 Clinical presentation
 Imaging
 Bacteriology
 Therapy
 Medical

 Surgical

 Complications
 Mediastinitis
ανατομία
 Cervical Fascia
 Superficial Layer
 Deep Layer
 Subdivisions not
histologically separate
 Superficial
 Enveloping layer
 Investing layer
 Middle
 Visceral fascia
 Prethyroid fascia
 Pretracheal fascia
 Deep
 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  Envelopes

neck.  SCM
 Arises from spinous processes.  Trapezius
 Superior border – nuchal line,  Submandibular
skull base, zygoma, mandible.  Parotid
 Inferior border – chest and  Forms floor of submandibular
axilla space
 Splits at mandible and covers
the masseter laterally and the
medial surface of the medial
pterygoid.
Superficial Layer of the Deep Cervical Fascia
Middle Layer of the Deep Cervical Fascia

 Visceral Division  Muscular Division

 Superior border  Superior border – hyoid and
 Anterior – hyoid and thyroid cartilage thyroid cartilage
 Posterior – skull base  Inferior border – sternum, clavicle
 Inferior border – continuous with and scapula
fibrous pericardium in the upper
mediastinum.
 Envelopes infrahyoid strap
muscles
 Buccopharyngeal fascia
 Name for portion that covers the
pharyngeal constrictors and
buccinator.
 Envelopes
 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
 Superior border – skull base
 Inferior border – upper mediastinum at T1-T2
 Prevertebral layer
 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
 “Lincoln’s 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
 Suprahyoid
 Submandibular
 Pharyngomaxillary (Parapharyngeal)
 Parotid
 Peritonsillar
 Temporal
 Masticator
 Infrahyoid
 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
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
 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.

 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.
 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
 Suprahyoid  2 compartments
 Sublingual space
 Areolar tissue
 Superior – oral mucosa  Hypoglossal and lingual
 Inferior - superficial layer nerves
of deep fascia  Sublingual gland
Wharton’s duct
Anterior border –


mandible
 Submaxillary space
 Anterior bellies of digastrics
 Lateral border - mandible  Submental compartment
 Posterior - hyoid and  Submaxillary compartments
base of tongue  Submandibular gland
musculature
Submandibular Space
 Pharyngomaxillary space
 Suprahyoid

 aka – Parapharyngeal space

 Superior—skull base
 Inferior—hyoid
 Anterior—ptyergomandibular
raphe
 Posterior—prevertebral fascia
 Medial—buccopharyngeal
fascia
 Lateral—superficial layer of
deep fascia
 Pharyngomaxillary space
 Prestyloid
 Muscular compartment
 Medial—tonsillar fossa
 Lateral—medial pterygoid
 Contains fat, connective
tissue, nodes
 Poststyloid
 Neurovascular compartment
 Carotid sheath
 Cranial nerves IX, X, XI, XII
 Sympathetic chain
 Stylopharyngeal aponeurosis
of Zuckerkandel and Testut
 Alar, buccopharyngeal and
stylomuscular fascia.
 Prevents infectious spread
from anterior to posterior.
 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
 Superior—anterior tonsil
pillar
 Inferior—posterior tonsil
pillar
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
 Parotid Space
 Suprahyoid

 Superficial layer of deep fascia

 Dense septa from capsule into
gland
 Direct communication to
parapharyngeal space

 Contains
 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.
 Epidemiology
 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.
 Etiology
 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%)

 Pediatric
 Fever
 Decreased PO
 Odynophagia
 Malaise
 Torticollis
 Neck pain
 Otalgia
 HA
 Trismus
 Neck swelling
 Vocal quality change
 Worsening of snoring, sleep apnea
 Imaging
 Lateral neck plain film
 Screening exam
 No benefit in pts with
DNI based on strong
clinical suspicion.
 Normal:
 7mm at C-2
 14mm at C-6 for kids
 22mm at C-6 for adults
 Technique dependent
 Extension
 Inspiration
 Sensitivity 83%,
compared to CT 100%
 Imaging
 MRI  CT with contrast
 Pros  Pros
 MRI superior to CT in
 Widely available
initial assessment  Faster (5-15 minutes)
 More precise identification  Abscess vs cellulitis
of space involvement  Less expensive
(multiplanar)  Cons
 Better detection of
underlying lesion
 Contrast
 Less dental artifact
 Radiation
 Better for floor of mouth
 Uniplanar
 No radiation
 Dental artifacts
 Non iodine contrast
 Cons
 Cost
 Pt cooperation
 Slower (19 to 35 minutes)
 Imaging
 Regular cavity wall with
ring enhancement (RE)
 Sensitivity - 89%

 Specificity - 0%

 Irregular wall
(scalloped)
 Sensitivity - 64%
 Specificity - 82%
 PPV - 94%
Aerobic        
Bacteriology       Anaerobic    

G (+) n %   G (-) n %     n %

87.4 18.5
Total 645 0   Total 137 6   Total 201 27.24

Strep sp. 229 31.03   Klebsiella sp. 90 12.20   Peptostreptococcus 43 5.83

Staph sp. 112 15.18   Neisseria sp. 20 2.71   Bacteroides sp. 50 6.78

B-hemolytic Strep 80 10.84   Acinebacter sp. 7 0.95   Unidentified 46 6.23

Strep viridans 71 9.62   Enterobacter sp. 7 0.95   Bacteroides melaninogenicus 13 1.76

Staph aureus 57 7.72   Proteus sp. 4 0.54   Propionibacterium 9 1.22

Coagulase neg. Staph sp. 55 7.45   E coli 3 0.41   Provotella sp. 7 0.95

Strep pneum 13 1.76   Citrobacter sp 2 0.27   Fusobacterium 7 0.95

Enterococcus 10 1.36   M. Catarrhalis 2 0.27   Bacteroidies fragilis 6 0.81

Mycobacterium tub.* 10 1.36   Pseudomonas sp. 1 0.14   Eubacterium 6 0.81

Micrococcus 8 1.08   H. Parainfluenza 1 0.14   Peptococcus 6 0.81

Diptheroids 7 0.95   H influenzae 1 0.14   Veillonella parvula 5 0.68

Bacillus sp. 6 0.81   Salmonella sp. 1 0.14   Clostridium sp. 4 0.54

Actinomycosis israelii 3 0.41           Lactobacillus 4 0.54

        Bifidobacterium sp. 3 0.41

24.5
Polymicrobial 181 3   Sterile 71 9.62        

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.
Surgery
 External drainage
 Landmarks
 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
 Complications
 Airway obstruction
 Trach 10 – 20%
 Ludwig’s angina - 75%
 Mediastinitis – 2.7%
 UGI bleeding
 Sepsis
 Pneumonia
 IJV thrombosis
 Skin defect
 Vocal cord palsy
 Pleural effusion
 Hemorrhage
 20 - 80% mortality
 Multiple space involvement
 Who gets complications?
 Older pts
 Systemic dz
 Immunodeficient pts
 HIV
 Myelodysplasia
 Cirrhosis
 DM
 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. Clinical manifestation of severe infection.
2. Demonstration of the characteristic imaging features of mediastinitis.
3. Features of necrotizing mediastinal infection at surgery.

 1960-89 – 43 published cases

 Mortality rate 14-40%
 Clinical Presentation
 Symptoms  Important to have a
 Respiratory difficulty low threshold for
 Tachycardia further workup
 Erythema/edema
 Skin necrosis
 Crepitus
 Chest pain
 Back pain
 Shock
 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
 Treatment
 IV antibiotics
 Cervical drainage
 Cervical abscesses
 Superior mediastinal abscesses
above T4 (tracheal bifurcation)
 Transthoracic drainage
 Abscesses below T4
 Subxyphoid approach
 Anterior mediastinal drainage
 Thoracostomy tubes
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