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Neck Space Infections

Etiology

• Most common cause in adults : odontogenic,

• Most common cause in pediatric : tonsillar

• Others : salivary gland, trauma, FB, instrumentation,

local or superficial source, 22% without

spesific cause

Anatomy of Cervical Fascia

1. Superficial cervical fascia

2. Deep cervical fascia

a) Superficial layer

b) Middle layer

•Muscular division

•Visceral division

c) Deep layer

•Prevertebral division

•Alar division

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1. Superficial cervical fascia

•Continuous sheath of fibrofatty subcutaneous tissue

•Attachments : zygomatic process to thorax and axilla

•Contents : platysma, muscles of facial expression

•Not considered a part of the deep neck; local I&D and antibiotics

•Between superficial and deep layers: Fat, sensory nerves, EJ, AJ, superficial

lymphatics

a) Superficial layer of the deep cervical fascia

• Enveloping or investing later

• Insertion at nuchal line of the skull chest and axillary regions; spreads anteriorly

to the face and attaches at clavicles

• Envelopes SCM, trapezius, portion of omohyoid in posterior triangle, parotid and

submandibular glands

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b) Middle layer of the deep cervical fascia

• Muscular division

Surrounds straps. Attaches superiorly to hyoid and thyroid cartilage and inferiorly

to sternum, clavicle and scapula

• Visceral division

Surrounds thyroid, trachea, esophagus. Superior attached to base of skull, thyroid

cartilage and hyoid covers trachea and esophagus and blends with fibrous

pericardium

c) Deep layer of the deep cervical fascia

• Contents: Paraspinous muscles and cervical vertebrae

• Prevertebral and alar divisions

Prevertebral: Begins anterior to the vertebral bodies, spreads laterally to

fuse with transverse processes, extends posteriorly to enclose deep muscles

of neck and attaches to vertebral spines. Forms the posterior wall of the

“danger space” and anterior wall of prevertebral space

Alar division, Lies between the prevertebral division and the middle layer

of the deep cervical fascia

• Attaches from transverse process to contralateral transverse process, skull base to

T2, fuses with visceral division of middle layer of deep cervical fascia.

• Carotid sheath: made up of all 3 deep layers

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Suprahyoid spaces:

• Pharyngomaxillary / Lateral pharyngeal

• Submandibular

• Parotid

• Masticator

• Peritonsillar

• Buccal

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Infrahyoid spaces:

• Anterior visceral

• Spaces involving entire length of neck:

o Retropharyngeal

o Danger

o Prevertebral

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o Visceral vascular

Retropharyngeal space

• Potential space posterior to visceral division of middle layer of deep cervical fascia

and anterior to alar division of deep layer of deep cervical fascia

• Skull base to T1/2/tracheal bifurcation in close approximation to mediastinum

• Midline raphe-superior constrictor muscles adheres to prevertebral division; separates

retropharyngeal nodes into two lateral chains.

• Contents: fat, CT, LNs which drain nose, NP, soft palate, ET, paranasal sinuses

• Most commonly seen in peds due to drainage source

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• Peds: preceding URI, fever, dysphagia, odynophagia, nuchal rigidity, asymmetric

bulging of post pharyngeal wall due to midline raphe

• Adults: pain, dysphagia, cervical motion limitation, noisy breathing

• Can extend to: mediastinum, danger space, parapharyngeal space

Retropharyngeal space X-ray

• Lateral soft tissue XR (extension, inspiration) abnormal findings:

• 1. C2-post pharyngeal soft tissue >7mm

• 2. C6–adults >22mm, peds >14mm

• 3. STS of post pharyngeal region >50% width of vertebral body

Danger Space

• Potential space between the alar and prevertebral divisions of the deep layer of the

deep cervical fascia

• Posterior to the retropharyngeal space and anterior to the prevertebral space

• Why is it given this name? Extends from skull base to posterior mediastinum to

diaphragm

• Caused by infectious spread from retropharyngeal, prevertebral and parapharyngeal

spaces or less commonly, by lymphatic extension from the nose and throat

• Watch for severe dyspnea, chest pain, widened mediastinum on CXR may need

thoracotomy for drainage

Prevertebral space

• Potential space posterior to prevertebral division and anterior to vertebral bodies

• Extends from skull base to the coccyx

• Most common cause: iatrogenic/penetrating trauma

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• Previous most common cause: TB

Visceral vascular space

• Potential space within the carotid sheath

• Lymphatic vessels within receive drainage from most of the lymphatic vessels in the

head and neck

• Most common source of infection is parapharyngeal space

• Why is this called the “Lincoln Highway” of the neck?

Spaces involving entire length of neck

• Visceral layer-mid

• RETROPHARYNGEAL SPACE (until T2)

• Alar division-deep

• DANGER SPACE (until diaphragm)

• Prevertebral division

• PREVERTEBRAL SPACE (until coccyx)

• Vertebrae

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Pharyngomaxillary/Parapharyngeal/ Lateral pharyngeal space

• Cone in lateral aspect of neck

• Apex: hyoid bone

• Base: petrous temporal bone

• Lateral: superficial layer of deep cervical fascia over the mandible, parotid, internal

pterygoid

• Medial: lateral pharyngeal wall

• Ant/post: pterygomandibular raphe/ prevertebral fascia

• Divided into anterior and posterior compartments by styloid bones and muscles

• Prestyloid/Muscular compartment:

• Tonsillar fossa medially, internal pterygoid laterally

• Fat, lymph nodes, parotid masses

• Displacement of lat pharyngeal wall, early trismus

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• Most common mass – pleomorphic adenoma

• Post-styloid/Neurovascular compartment:

• Carotid, IJV, cervical sympathetic chain, CN IX-XII

• Most common mass - schwannoma

• Connects to the majority of other fascial spaces

• Sources: parotid, masticator, submandibular, peritonsillar, tonsils/pharynx,

odontogenic, LN from nose and throat, mastoiditis (Bezold abscess)

• Never approach intraorally

• Traditionally: Mosher incision

• Horizontal neck incision follow carotid sheath into space finger dissect below

submandibular gland, along posterior belly of digastric deep to mastoid tip toward

styloid

Submandibular space

• Composed of sublingual space superiorly and submaxillary space inferiorly, divided

by mylohyoid

• Boundaries: FOM mucosa above, superficial layer of deep fascia below, mandible

ant/lat, hyoid inferiorly, BOT muscles posteriorly

• Sublingual space: gland, Wharton, CN XII

• Submaxillary: gland, facial artery, lingual nerve; communicates with sublingual space

around posterior border of mylohyoid through submandibular gland

• Ludwig’s angina – bilateral cellulitis of submandibular and sublingual spaces

• Inspect 2nd and 3rd molars – apices extend below mylohyoid line providing direct

access to submandibular space

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Parotid space

• Formed by the splitting and surrounding of superficial layer of deep cervical fascia;

incomplete at upper inner surface of gland = direct communication with lateral

pharyngeal space (dumbbell shaped masses secondary to stylomandibular ligament)

• Contents: parotid gland, external carotid, posterior facial vein, facial nerve, lymph

nodes

Masticator space

• Superficial layer of deep cervical fascia splits around mandible to form this space and

encases muscles of mastication

• 4 compartments: Masseteric, Pterygoid, Superficial Temporal, Deep Temporal

• Contents: masseter, pterygoid muscles, temporalis tendon, inferior alveolar nerves and

vessels, body and ramus of mandible, internal maxillary artery

• Most common source : 3rd molar

• Complication: osteomyelitis of mandible

Peritonsillar

• Boundaries: anterior and posterior pillars, palatine tonsil, superior constrictor muscle

• Indications for Quincy tonsillectomy?

No clear cut indications. Treatment is still controversial. Needle aspiration, I&D,

quincy tonsillectomy all equally effective initial management with 10-15%

recurrrence rate.

• Again, 10-15% recurrence after needle aspiration and/or I&D; greatest risk in patients

<40 with history of recurrent tonsillitis

Buccal space

• Boundaries: Buccinator muscle, cheek, zygomatic arch, pterygomandibular raphe,

inferior mandible

• Odontogenic source with buccal swelling and preseptal cellulitis possible11

• Complication: cavernous sinus thrombosis

Anterior visceral space

• Pretracheal space from thyroid cartilage to T4 level, enclosed by visceral division of

middle layer, just deep to straps, surrounds trachea

• Source: esophageal anterior wall perforation, external trauma

• Symptoms: mainly dysphagia, later hoarseness, dyspnea, airway obstruction

• Complication: mediastinitis, airway

• Network of infectious extension

Pathogens

• Aerobic: Strep-predom viridans and B-hemolytic streptococci, staph, diphtheroid,

Neisseria, Klebsiella, Haemophilus

• Anaerobic: Bacteroides, Peptostreptococcus, Eikenella (often clinda resistant),

FUsobacterium, B fragilis

Antibiotics

• Necrotizing fasciitis

• Fulminent infection, polymicrobial, usually odontogenic source, more frequently in

immunocompromised and postoperative

• PEX: ill, high fever, neck crepitus, exquisitely tender, unimpressive erythema s sharp

demarcating border progress to pale then dusky as necrosis progresses can have

bullae/blisters/sloughing <48hrs

• Empiric abx (3rd gen ceph + clinda/flagyl), early surgery, dishwater drainage, leave

open, daily debridement, trach, ICU monitoring for: resp failure, mediastinitis (higher

mortality 64% vs 15%), DIC, delirium, HBO

Diagnosis

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• Pain, trismus, limitation neck motion, swelling, sustained fever, leukocytosis with left

shift, lateral neck XR/CT

• Prevertebral or retropharyngeal – hot potato voice, difficult noisy breathing,

dys/odynophagia, drooling, neck posturing

• Parapharyngeal – medial displacement of lateral pharyngeal wall, fullness of

retromandibular area. Prestyloid –trismus, tonsil swelling. Poststyloid-dysphagia

Management

• Hospitalization for airway management, aggressive antibiotics, hydration, I&D

• If no evidence of airway compromise, abx 24 hrs. 10-15% improve with medical

mgmt.

• Surgery indicated for airway compromise, no significant response to abx in 24-48

hours, evidence of sepsis

• Transoral – peritonsillar, uncomplicated RP and prevertebral abscesses with mass in

oropharynx, uncomplicated sublingual (not for submax extension)

• Surgical principles: wide exposure, use readily identifiable landmarks (digastric,

hyoid, SCM, cricoid, greater horn of thyroid), blunt dissection, identify carotid sheath

early, cultures/biopsy, debridement, irrigation, leave wound open and pack for

extensive necrosis, can close less necrotic wound and use drain

Complications

• 40 yr old pt is admitted for parapharyngeal infection. Started on abx, IVF,

observation. Afebrile within 24 hours with improved dysphagia. HD #2 spikes to 104,

defervesces, respikes. What’s happening?

• Thrombophlebitis of IJV

• Complications – signs and symptoms

• Mediastinitis – chest pain, worsened dyspnea, dysphagia, widened mediastinum on

CXR

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• Horners, hoarseness, unilateral tongue paresis, plethora of face, choked optic disks,

Tobey Ayer, erosion of carotid (critical, pharyngeal bleeding episode, neck

hematoma, rare EAC blood

Treatment of complications

• Mediastinitis – most commonly via retropharyngeal space > visceral or PP

• Abdominal abscess – prevertebral space

• IJV septic thrombophlebitis – IVDA, ligate and remove thrombosed vein at I&D

• Neuropathy – Horner’s, hoarseness, unilateral tongue paresis

• Erosion of carotid artery – rare, emergency, clot found in neck at I&D, proximal and

distal control, intraop angio if possible (75% CCA or ICA)

References

• Bailey’s

• Cumming’s

• SIPAC – Diagnosis and management of deep neck infections

• Hollinshead Anatomy for Surgeons – Head and Neck

• Head and Neck Imaging – Shankar

• Tom MB, Rice DH. Presentation and management of neck abscesses a

retrospective analysis. Laryngoscope 1988;98:877.

• Johnson RF, Stewart MG, Wright CC. An evidence-based review of the

treatment of peritonsillar abscess. Otolaryngol Head Neck Surg. 2003

Mar;128(3):332-43.

• Herzon FS. Peritonsillar abscess: incidence, current management practices,

and a proposal for treatment guidelines. Laryngoscope 1995;105 [suppl 74]:1-

7.

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• Tan PT, et al. Deep neck infections in children. J Microbiol Immunol Infect

2001;34:287-292.

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