Jan 13, 2016
Anatomy of cervical fascia
Cervical fascia
1) Superficial cervical fascia
2) Deep cervical fascia
Superficial Cervical Fascia
• Encircle H&N and attached to clavicle and zygomatic arch
• Contain plastysma m. and external jugular v.
• Marginal mandibular br. of facial n. lies just deep to superficial cervical fascia
Deep Cervical Fascial
1) Superficial layer
2) Middle layer
3) Deep layer
Superficial layer(Enveloping,Investing,Anterior layer)
• From ligamentum nuchae, completely enclose the neck
• Encircle trapezius m. , sternocleidomastiod m.
• Encircle submandibular gl., parotid gl.,masticater muscle
• Create superficial sternal space (of Burn)
Middle layer(Cervical layer,Pretracheal layer)
• Encircle strap m. (muscular division)
• Encircle esophagus trachea,thyroid gl., pharynx (visceral division)
• Buccopharyngeal fascia ( part of visceral division that cover constrictor m. and buccinator m.)
Deep layer(Carpet fascia)
• Cover vertebral body and paraspinous m.
• Devided into
1. Alar division
from base of skull to T2 level
2.Prevertebral division
from base of skull to diaphram
Carotid sheath
• Extend from skull base to clavicle
• Made up of 3 layer of deep cervical fascia
• Contain carotid a., internal jugular v., vagus n. and sympathetic chain
• Avenues for spread of infection from neck to mediastinum
Deep Neck Space Anatomy
• Space Involving Entire Length Of Neck
• Space Limited To Above The Hyoid Bone
• Space limited To Below The Hyoid Bone
Space Involving Entire Length Of Neck
1. Retropharyngeal Space
2. Danger Space (Prevertebral Space)
3. Paravertebral Space
4. Carotid Sheath Space
Retropharyngeal Space
• Between visceral division of middle layer and alar division of deep layer
• Extend from skull base to T2 level
• Midline raphae• More commom in
children due to presence of retropharyngeal node
Danger Space
• Between alar division and prevetebral division of deep layer (locate posterior to retropharyngeal space)
• Extend from skull base to diaphram
• No midline raphae• Infection spread from
neck to posterior mediastinum easily
Paravertebral Space
• Between prevertebral division of deep layer and vertebral bodies
• Extend from skull base to coccyx
• Infection in this space is rare and spread slowly due to compact connective tissue
Carotid sheath Space
• Made up from all deep cervical fascia
• Infection from any deep fascia can spread to this space (lincoln High way)
Space Limit To Above The Hyoid Bone
1. Parapharyngeal Space
2. Submandibular Space
3. Masticator Space
4. Temporal Space
5. Parotid Space
Parapharyngeal Space(Lateral phryngeal Space)(Pharyngomaxillaly Space)
Boundary
• Superiorly : Skull base• Inferiorly : Hyoid bone• Laterally : Medial pterygoid m.• Medially :Buccopharyngeal fascia• Anteriorly : Submandibular space• Posteromedialy : Prevertebral fascia
and retrophryngeal space
Submandibular Space
Divided into 2 spaces by mylohyoid m.
1. Sublingual space (above mylohyoid m.)
2. Submaxillaly space (below mylohyiod m.)
• These 2 spaces can communicate each other by mylohyoid cleft
Masticator Space• Between masticator m.
and superficial layer of deep cervical fascia
(Masticator m. = massestor m.,medial and lateral pterygoid m. and temporalis muscle)
• Locate anterior and lateral to parapharyngeal space
Parotid Space
• Between parotid gl. and superficial layer of deep cervical fascia
• Infection can spread easily to parapharyngeal space due to incompleted encircle at upper inner surface of parotid gl.
Space Limit To Below The Hyoid Bone
Anterior Viseral Space (Pretracheal Space)
• Between trachea, esophagus and middle layer of deep cervical fascia
• Extend from hyoid bone to superior mediastinum
Etiology Of Deep neck Space1. Dental infection2. Tonsillar and peritonsillar infection3. Trauma of upper aerodigestive
tract4. Retropharyngeal lymphadenitis5. Pott’s disease6. Sialadenitis7. Bezold’s abscess8. Infection of congenital cyst and
fistula9. Intravenous drug abuse
SPECIFIC DEEP NECK INFECTION
PARAPHARYNGEAL SPACE INFECTION
• Most common cause : Peritonsillar infection• Typical finding 1.Trismus 2. Angle mandible
swelling 3. Medial displacement
of lateral pharyngeal wall
Others : fever, limit neck motion,neurologic deficit (C.N 9,10,12,Horner’s syndrom)
PARAPHARYNGEAL SPACE INFECTION
Treatment1. Evaluate and maintain airway & fluid hydration
2. Parenteral antibiotic high dose 24-48 hrs.
3. If not improve, consider surgical drainage
PARAPHARYNGEAL SPACE INFECTION
Surgical drainage
1. Intraoral approch
(for peritonillar abscess only)
2. External approach
-transverse submandibular incision
-T. shape incision (Mosher)
SUBMANDIBULAR SPACE INFECTION
Most common cause : Dental caries
• Anterior teeth & first molar : infection enter sublingual space
• Second & third molar
: infection enter submaxillary space
SUBMANDIBULAR SPACE INFECTION
• Organisms
- Mixed of aerobes(alpha hemolytic strep, staph) and anaerobes make synnergistic effect of endotoxins
- Consider gram – in immunocompromize host
SUBMANDIBULAR SPACE INFECTION
Clinical feature (True Lugwig’s angina)• Start unilateral and progress
bilaterally• Induration of submandibular region
and floor of mouth ( severe cellulitis)• Tongue trusted posteriorly and
superiorly (cause airway obstruction)
• Drolling, odynophagia, trismus, fever
• No purulence(due to no time to developed)
SUBMANDIBULAR SPACE INFECTION
Treatment• Early stage
(unilat,mild swelling and edema)
-IV antibiotic, extration of infected tooth
• Advance stage
(bilateral swelling, dysphagia with drolling)
-early airway intervention
-surgical drainage (submandibular incision)
RETROPHARYNGEAL SPACE INFECTION PREVERTEBRAL SPACE INFECTION
Most commmon cause
• In children
-retropharyngeal lymphadenitis from nose,PNS,ET)
• In adult
-regional truma and endoscopic procedure
RETROPHARYNGEAL SPACE INFECTION PREVERTEBRAL SPACE INFECTION
Clinical feature• In children irritability,neck rigidity,
fever,drolling,muffle cry, airway compromise
• In adult fever, sore throat,
odynophagia, neck tenderness, dysnea
RETROPHARYNGEAL SPACE INFECTION PREVERTEBRAL SPACE INFECTION
Clinical feature
• Retropharyngeal space abscess form abscess lateral to midline
• Prevertebral space abscess
form abscess in midline• Mediastinitis S&S
Dysnea,chest pain, tachycardia, fever,wideded mediastinum
RETROPHARYNGEAL SPACE INFECTION
PREVERTEBRAL SPACE INFECTION
Investigation1. Lateral neck film
- C2 > 7 mm. both children and adult
- C7 > 14 mm. in children
> 22 mm. in adult.
2. Chest film
- detection of mediastinitis
RETROPHARYNGEAL SPACE INFECTION PREVERTEBRAL SPACE INFECTION
Treatment Surgical drainage1. Intraoral drainage -Lesion confined in
larynx esp.child2. External drainage (Dean) -Lesion beyond
pharyngeal level -Airway compromise -Involve other deep neck
spaces
PARAVERTEBRAL SPACE INFECTION
• Most common cause Penetrating trauma (F.B, endoscope)
TB spine• Infection spread slowly
and more localize due to compact CNT.
Clinical feature -Same as others
posterior space abscess -Vertebral osteomyelitis
and spinal instability
MASTICATOR SPACE INFECTION
• Most common cause Dental carices
Clinical feature• Extream trismus with minimum
facial swelling - Massesteric space (lateral compartment) : edema at ramus of mandible - Ptrygomandibular space (medial
compartment): edema at retromolar trigone
MASTICATOR SPACE INFECTION
Treatment
1. Intraoral drainage (medial compartment)
- along inner margin of mandibular ramus to the retromolar trigone
2. External approch (lateral compartment)
- submandibular incision
- preauricular incision or Gilles incision for temporal space abscess
PAROTID SPACE INFECTION
• Most common cause : Bacterial retrograde from oral cavity
Clinical feature• high fever, weakness, mark
swelling and tenderness of parotid gland,fluctuation,pus at stensen’s duct
PAROTID SPACE INFECTION
Treatment
• IV ATB
• Surgical drainage indicated for
-fluctuation
-medical failure after 24-48 hr. or progression
of disease
COMPICATION OF DEEP NECK INFECTION
1. Internal jugular vein thrombosis2. Cavernous sinus thrombosis3. Neurologic deficit4. Osteomyelitis of the mandible5. Osteomyelitis of the spine6. Mediastinitis7. Pulmonary edema8. Pericarditis9. Aspiration10. Sepsis