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1. Deep Neck Space Infections
INDIAN
ACADEMY
DENTAL
Leader in continuing dental education
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2. Outline








Anatomy
 Fascial planes
 Spaces
Epidemiology
Etiology
Clinical presentation
Imaging
Bacteriology
Therapy
 Medical
 Surgical
Complications
 Mediastinitis
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3. ανατομία
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4. Cervical Fascia


Superficial Layer
Deep Layer


Subdivisions not
histologically separate
Superficial



Middle




Enveloping layer
Investing layer
Visceral fascia
Prethyroid fascia
Pretracheal fascia
Deep
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5. Superficial Layer




Superior attachment –
zygomatic process
Inferior attachment –
thorax, axilla.
Similar to
subcutaneous tissue
Ensheathes platysma
and muscles of facial
expression
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6. Superficial Layer of the Deep Cervical
Fascia





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.


Envelopes
 SCM
 Trapezius
 Submandibular
 Parotid
Forms floor of submandibular
space
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7. Superficial Layer of the Deep Cervical
Fascia
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8. 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


Muscular Division


Superior border – hyoid and
thyroid cartilage
Inferior border – sternum, clavicle
and scapula
Envelopes infrahyoid strap
muscles
Name for portion that covers the
pharyngeal constrictors and
buccinator.
Envelopes





Thyroid
Trachea
Esophagus
Pharynx
Larynx
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9. Middle Layer of the Deep Cervical Fascia
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10. 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.
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11. Deep Layer of Deep Cervical Fascia
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12. 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.
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13. Deep Neck Spaces

Described in relation to the hyoid.

Entire length of neck






Suprahyoid







Superficial space
Retropharyngeal
Danger
Prevertebral
Vascular visceral
Submandibular
Pharyngomaxillary (Parapharyngeal)
Parotid
Peritonsillar
Temporal
Masticator
Infrahyoid

Anterior visceral
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14. 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
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15. 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.
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16. 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.
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17. 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
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18. 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.
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19. Submandibular Space

Suprahyoid

2 compartments






Superior – oral mucosa
Inferior - superficial layer
of deep fascia
Anterior border –
mandible
Lateral border - mandible
Posterior - hyoid and
base of tongue
musculature
Sublingual space





Areolar tissue
Hypoglossal and lingual
nerves
Sublingual gland
Wharton’s duct
Submaxillary space

Anterior bellies of digastrics



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Submental compartment
Submaxillary
compartments
Submandibular gland

20. Submandibular Space
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21. 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
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22. Pharyngomaxillary space

Prestyloid





Poststyloid





Muscular compartment
Medial—tonsillar fossa
Lateral—medial pterygoid
Contains fat, connective
tissue, nodes
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.
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23. Pharyngomaxillary Space

Communicates
with several deep
neck spaces.





Parotid
Masticator
Peritonsillar
Submandibular
Retropharyngeal
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24. Peritonsillar Space





Suprahyoid
Medial—capsule of
palatine tonsil
Lateral—superior
pharyngeal constrictor
Superior—anterior tonsil
pillar
Inferior—posterior tonsil
pillar
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25. 


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
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by temporalis muscle

26. 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
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27. 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.
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28. 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.
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29. Etiology













Odontogenic
Tonsillitis
IV drug injection
Trauma
Foreign body
Sialoadenitis
Parotitis
Osteomyelitis
Epiglottitis
URI
Iatrogenic
Congenital anomalies
Idiopathic
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30. Clinical presentation

Most common symptoms



Most common symptoms (exluding peritonsillar abscesses)



Sore throat (72%)
Odynophagia (63%)
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
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31. Imaging

Lateral neck plain film



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
Sensitivity 83%,
compared to CT 100%
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32. Imaging

MRI

Pros









CT with contrast

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
Pros





Cons




Cons



Widely available
Faster (5-15 minutes)
Abscess vs cellulitis
Less expensive
Cost
Pt cooperation
Slower (19 to 35 minutes)
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Contrast
Radiation
Uniplanar
Dental artifacts

33. Imaging


Regular cavity wall with
ring enhancement (RE)
 Sensitivity - 89%
 Specificity - 0%
Irregular wall
(scalloped)



Sensitivity - 64%
Specificity - 82%
PPV - 94%
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34. Aerobic
G (+)
n
%
Total
645
87.4
0
Strep sp.
229
Staph sp.
Bacteriology
Anaerobic
G (-)
n
%
n
%
Total
137
18.5
6
Total
201
27.24
31.03
Klebsiella sp.
90
12.20
Peptostreptococcus
43
5.83
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
Polymicrobial
181
24.5
3
Sterile
71
9.62
Modified and combined data from 738 patients (1, 2, 3, 4, 5, 6, 7).
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35. 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.
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36. Surgery

External drainage

Landmarks





Transoral drainage




Tip of greater horn of hyoid
Cricoid cartilage
Styloid process
SCM
Parapharyngeal,
retropharyngeal abscesses
Great vessels lateral to
abscess
Tonsillectomy for exposure
Needle aspiration
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37. Complications

Airway obstruction











Mediastinitis – 2.7%
UGI bleeding
Sepsis
Pneumonia
IJV thrombosis
Skin defect
Vocal cord palsy
Pleural effusion
Hemorrhage


Trach 10 – 20%
Ludwig’s angina - 75%
20 - 80% mortality
Multiple space involvement
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38. 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
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39. Descending Necrotizing
Mediastinitis

Definition – mediastinal infection in which pathology originates in
fascial spaces of head and neck and extends down.




Criteria for diagnosis
1.
2.
3.


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.
1960-89 – 43 published cases
Mortality rate 14-40%
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40. Clinical Presentation

Symptoms









Respiratory difficulty
Tachycardia
Erythema/edema
Skin necrosis
Crepitus
Chest pain
Back pain
Shock
Important to have a
low threshold for
further workup
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41. 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
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42. Treatment


IV antibiotics
Cervical drainage



Transthoracic drainage


Abscesses below T4
Subxyphoid approach


Cervical abscesses
Superior mediastinal
abscesses above T4 (tracheal
bifurcation)
Anterior mediastinal drainage
Thoracostomy tubes
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43. Bibliography
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
Scott, BA, Stiernberg, CM, Driscoll, BP. Deep Neck Space Infections. In: Head and Neck Surgery—Otolaryngology, 2nd ed., Bailey,
BJ ed. Philadelphia, Lippincott-Raven Publishers, 1998; 819-35
Kirse, DJ, Roberson,DW. Surgical Management of Retropharyngeal Space Infections in Children. Laryngoscope, 111: 1413-1422,
2000.
Stalfors, J, Adielsson, A, Ebenfelt, A, Nethander, G, Westin, T. Deep Neck Space Infections Remain a Surgical Challenge. A Study
of 72 Patients. Acta Otolaryngol 2004; 124: 1191-1196.
Meher, R, Jain, A, Sabharwal, A, Gupta, B, Singh, I, Agarwal, AK. Deep Neck Abscess: A Prospective Study of 54 Cases. The
Journal of Laryngology and otology. April 2005. Vol 119, 299-302.
Nagy, M, Pizzuto, M, Backstrom, J, Brodsky, L. Deep Neck Infections in Children: A New Approach to Diagnosis and Treatment.
Laryngoscope. 1997; 107 (12): 1627-1634.
Huang, TT, Liu, TC, Chen, PR, Tseng, FY, Yeh, TH, Chen, YS. Deep Neck Infection: Analysis of 185 Cases. Head and Neck. 26:
854-860. 2004.
Parhiscar, A, Har-El, G. Deep neck abscess: A retrospective review of 210 cases. Annals of Otology, Rhinology and Laryngology,
2001; 110 (11): 1051-54.
Huang, TT, Tseng, FY, Lie, TC, Hsu, CJ, Chen ,YS. Deep Neck Infection in Diabetic Patients: Comparison of Clinical Picture and
Outcomes with Nondiabetic Patients. Otolaryngol Head Neck Surg 2005;13:943-7.
Munoz, A, Castillo, M, Melchor, MA, Gutierrez, R. Acute Neck Infections: Prospective Comparison Between CT and MRI in 47
Patients. Journal of Comp Ass Tomography. 2001. 25 (5): 733-741.
McClay, JE, Murray, AD, Booth, TB. Intravenous Antibiotic Therapy for Deep Neck Abscesses Defined by Computed Tomography.
Arch Otolaryngol Head Neck Surg. 2003;129:1207 – 1212.
Nagy, M, Backstrom, J. Comparison of the sensitivity of lateral neck radiographs and computed tomography scanning in pediatric
deep-neck infections. Laryngoscope, 1999; 109 (5): 775-779.
Chaudhary, N, Agrawal, S, Rai, A. Descending Necrotizing Mediastinitis: Trends in a Developing Country. Ear Nose Throat. 2005
84(4); 242-50.
Harar, R, Cranston, C, Warwick-Brown, N. Descending necrotizing mediastinitis: report of a case following steroid neck injection.
Journal Laryngol Otol. Oct 2002, vol 116; 862 – 64.
Kiernan, PD, Hernandez, A, Byrne, W, Bloom, R, Dicicco,B, Hetrick, V, Graling, P, Vaughan, B. Descending Cervical Mediastinitis.
Ann Thorac Surg 1998; 65:1483-8.
Akman, C, Kantarci, F, Cetinkaya, S. Imaging in mediastinitis: a systematic review based on aetiology. Clinical radiology (2004) 59,
573-85.
Baqain, Z, Neman, L, Hyde, N. How Serious are Oral Infections? Journ Laryngol Otol. July 2004 (118). 561-65.
Netters, F. Atlas of Human Anatomy 2nd Ed.
Lee, KJ. Essentials of Otolaryngology.
Rosen, EJ, Bailey, B, Quinn, FB. Deep Neck Spaces and Infections: Grand Rounds Presentation. Dr. Quinn’s Online Textbook of
Otolaryngology Grand Rounds Archive. 2002. http://www.utmb.edu/otoref/Grnds/Deep-Neck-Spaces-2002-04/Deep-neck-spaces2002-04.doc
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44. Thank you
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