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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
Cervical Fascia
Enveloping layer Investing layer Visceral fascia Prethyroid fascia Pretracheal fascia
Middle
Deep
Superficial Layer
Superior attachment zygomatic process Inferior attachment thorax, axilla. Similar to subcutaneous tissue Ensheathes platysma and muscles of facial expression
Completely surrounds the neck. Arises from spinous processes. Superior border nuchal line, skull base, zygoma, mandible. Inferior border chest and axilla Splits at mandible and covers the masseter laterally and the medial surface of the medial pterygoid.
Visceral Division
Superior border
Muscular Division
Buccopharyngeal fascia
Superior border hyoid and thyroid cartilage Inferior border sternum, clavicle and scapula Envelopes infrahyoid strap muscles
Envelopes
Name for portion that covers the pharyngeal constrictors and buccinator. Thyroid Trachea Esophagus Pharynx Larynx
Arises from spinous processes and ligamentum nuchae. Splits into two layers at the transverse processes:
Alar layer
Prevertebral layer
Superior border skull base Inferior border upper mediastinum at T1-T2 Superior border skull base Inferior border coccyx Envelopes vertebral bodies and deep muscles of the neck. Extends laterally as the axillary sheath.
Carotid Sheath
Formed by all three layers of deep fascia Anatomically separate from all layers. Contains carotid artery, internal jugular vein, and vagus nerve Lincolns Highway Travels through pharyngomaxillary space. Extends from skull base to thorax.
Suprahyoid
Infrahyoid
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 Langers 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
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
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 Superior oral mucosa Inferior - superficial layer of deep fascia Anterior border mandible Lateral border - mandible Posterior - hyoid and base of tongue musculature
2 compartments
Sublingual space
Submaxillary space
Areolar tissue Hypoglossal and lingual nerves Sublingual gland Whartons duct Anterior bellies of digastrics
Submental compartment Submaxillary compartments
Submandibular gland
Submandibular Space
Pharyngomaxillary space
Suprahyoid aka Parapharyngeal space Superiorskull base Inferiorhyoid Anteriorptyergomandibular raphe Posteriorprevertebral fascia Medialbuccopharyngeal fascia Lateralsuperficial layer of deep fascia
Pharyngomaxillary space
Prestyloid
Poststyloid
Muscular compartment Medialtonsillar fossa Lateralmedial pterygoid Contains fat, connective tissue, nodes Neurovascular compartment Carotid sheath Cranial nerves IX, X, XI, XII Sympathetic chain Alar, buccopharyngeal and stylomuscular fascia. Prevents infectious spread from anterior to posterior.
Pharyngomaxillary Space
Peritonsillar Space
Suprahyoid Medialcapsule of palatine tonsil Lateralsuperior pharyngeal constrictor Superioranterior tonsil pillar Inferiorposterior tonsil pillar
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
Dense septa from capsule into gland Direct communication to parapharyngeal space
Contains
External carotid artery Posterior facial vein Facial nerve Lymph nodes
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
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
Pediatric
Fever Decreased PO Odynophagia Malaise Torticollis Neck pain Otalgia HA Trismus Neck swelling Vocal quality change Worsening of snoring, sleep apnea
Imaging
Screening exam No benefit in pts with DNI based on strong clinical suspicion. Normal:
Technique dependent
7mm at C-2 14mm at C-6 for kids 22mm at C-6 for adults Extension Inspiration
Imaging
MRI
CT with contrast
Pros
Pros
Cons
MRI superior to CT in initial assessment More precise identification of space involvement (multiplanar) Better detection of underlying lesion Less dental artifact Better for floor of mouth No radiation Non iodine contrast Cost Pt cooperation Slower (19 to 35 minutes)
Cons
Widely available Faster (5-15 minutes) Abscess vs cellulitis Less expensive Contrast Radiation Uniplanar Dental artifacts
Imaging
Regular cavity wall with ring enhancement (RE) Sensitivity - 89% Specificity - 0%
Bacteriology
Anaerobic Total
Peptostreptococcus Bacteroides sp. Unidentified Bacteroides melaninogenicus Propionibacterium Provotella sp. Fusobacterium Bacteroidies fragilis Eubacterium Peptococcus Veillonella parvula Clostridium sp. Lactobacillus Bifidobacterium sp.
n 645
229 112 80 71 57 55 13 10 10 8 7 6 3
% 87.40
31.03 15.18 10.84 9.62 7.72 7.45 1.76 1.36 1.36 1.08 0.95 0.81 0.41
G(-) Total
Klebsiella sp. Neisseria sp. Acinebacter sp. Enterobacter sp. Proteus sp. E coli Citrobacter sp M. Catarrhalis Pseudomonas sp. H. Parainfluenza H influenzae Salmonella sp.
n 137
90 20 7 7 4 3 2 2 1 1 1 1
% 18.56
12.20 2.71 0.95 0.95 0.54 0.41 0.27 0.27 0.14 0.14 0.14 0.14
n 201
43 50 46 13 9 7 7 6 6 6 5 4 4 3
27.24
5.83 6.78 6.23 1.76 1.22 0.95 0.95 0.81 0.81 0.81 0.68 0.54 0.54 0.41
Polymicrobial
181
24.53
Sterile
71
9.62
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.
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
Transoral drainage
Parapharyngeal, retropharyngeal abscesses Great vessels lateral to abscess Tonsillectomy for exposure
Needle aspiration
Complications
Airway obstruction
Mediastinitis 2.7% UGI bleeding Sepsis Pneumonia IJV thrombosis Skin defect Vocal cord palsy Pleural effusion Hemorrhage
20 - 80% mortality
HIV Myelodysplasia
Most common systemic Mbio Klebsiella pneum. (56%) 33% with complications Higher mortality rate Prolonged hospital stay
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%
Clinical manifestation of severe infection. Demonstration of the characteristic imaging features of mediastinitis. Features of necrotizing mediastinal infection at surgery.
Clinical Presentation
Symptoms
Respiratory difficulty Tachycardia 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.
Esophageal thickening Obliterated normal fat planes Air fluid levels Pleural effusions CT helps establish dx and surgical plan
Treatment
Cervical abscesses Superior mediastinal abscesses above T4 (tracheal bifurcation) Abscesses below T4 Anterior mediastinal drainage
Transthoracic drainage
Subxyphoid approach
Thoracostomy tubes
Bibliography
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