Deep Fascial Spaces 1

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DEEP FASCIAL SPACES IN OMFS AND THEIR

MANAGEMENT


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CONTENTS

Introduction The problem Etiology Pathophysiology Cervical fascia Deep neck spaces and their presentation Microbiology

Lab studies Imaging Treatment

-Medical-Surgical

Follow up care Complications Special considerations Future and controversies References


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INTRODUCTION

For centuries, the diagnosis and

treatment of deep neck spaceinfections have challenged physiciansand surgeons.

The complexity and the deep locationof this region make diagnosis andtreatment of infections in this areadifficult.

These infections remain an importanthealth problem with significant risks ofmorbidity and mortality.


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infections of the deep neck spaces were

associated with high rates of morbidity andmortality

Complication rate of the past has been

reduced with the advent of modernmicrobiology and hematology, the

development of sophisticated diagnostic

tools (eg, CT, MRI),

The effectiveness of modern antibiotics, andthe continued development of medical

intensive care protocols and surgical

techniques.


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The Problem:

Complex anatomy

Deep location

Access

Proximity

Communication


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ETIOLOGY:

Tonsillar and pharyngeal infections

Dental infections or abscesses Oral surgical procedures or removal of

suspension wires

Salivary gland infection or obstruction

Trauma to the oral cavity and pharynx

Foreign body aspiration

Cervical lymphadenitis

Branchial cleft anomalies Thyroglossal duct cysts

Thyroiditis


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Mastoiditis with petrous apicitis and Bezold

abscess Laryngopyocele

IV drug use

Necrosis and suppuration of a malignant

cervical lymph node or mass patients who are immunosuppressed

because of human immunodeficiency virus(HIV) infection, chemotherapy, or

immunosuppressant drugs fortransplantation.

As many as 20-50% of deep neck infectionshave no identifiable cause


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PATHOPHYSIOLOGY

Spread of infection can be from the oral

cavity, face, or superficial neck to the deepneck space via the lymphatic system.

Lymphadenopathy may lead to suppuration

and finally focal abscess formation. Infection can spread among the deep neck

spaces by the paths of communication

between spaces.

Direct infection may occur by penetratingtrauma.


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The signs and symptoms of a deep neck

abscess develop because of thefollowing:

Mass effect of inflamed tissue or

abscess cavity on surroundingstructures

Direct involvement of surrounding

structures with the infectious process


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Peritonsillar infections (49%)

Retropharyngeal infections (22%)

Submandibular infections (14%)

Buccal infections (11%) Parapharyngeal space infections (2%)

Canine space infections (2%)


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study by Asmar of retropharyngeal

abscess microbiology demonstratedpolymicrobial culture results in almost90% of patients. Aerobes were found in

all cultures, and anaerobes werefound in more than 50% of patients.Other studies have shown an average

of at least 5 isolates from cultures.


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CLINICAL ASPECTS:

Eliciting a history

Pain Recent dental procedures

Upper respiratory tract infections (URTIs)

Neck or oral cavity trauma Respiratory difficulties

Dysphagia

Immunosuppression or

immunocompromised status Rate of onset

Duration of symptoms


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Physical examination should focus on:

determining the location of theinfection,

the deep neck spaces involved,

and any potential functionalcompromise or complications thatmay be developing.

A comprehensive head and neckexamination should be performed,including examination of the dentitionand tonsils.


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The most consistent signs of a deep

neck space infection are

fever,

elevated WBC count,

and tenderness.


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Other signs and symptoms :

Asymmetry of the neckand associated neck massesor lymphadenopathy - 70% of pediatricretropharyngeal abscesses (Thompson )

Medial displacement of the lateral pharyngeal wall

and tonsil caused by parapharyngeal spaceinvolvement

Trismus - inflammation of the pterygoid muscles

Torticollis and decreased range of motion of the neck- inflammation of the paraspinal muscles

Fluctuance that may not be palpable because of thedeep location and the extensive overlying soft tissueand muscles (eg, sternocleidomastoid muscle)


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Possible neural deficits, particularly of the

cranial nerves (eg, hoarseness from truevocal cord paralysis with carotid sheath andvagal involvement), and Horner syndrome

from involvement of the cervical

sympathetic chain

Regularly spiking fevers (may suggest

internal jugular vein thrombophlebitis and

septic embolization) Tachypnea and shortness of breath (may

suggest pulmonary complications and warn

of impending airway obstruction)


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Cervical Fascia

Superficial Layer

Deep Layer

Superficial

Middle Deep


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C


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Cervical Fascia

Superficial Layer

Platysma

Muscles of Facial

Expression


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C i l F i


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Cervical Fascia

Superficial Layer of

the Deep CervicalFascia

Muscles

Sternocleidomastoid

Trapezius

Glands

Submandibular

Parotid

Spaces

Posterior Triangle

Suprasternal space ofBurns


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C i l F i


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Cervical Fascia

Middle Layer of the

Deep CervicalFascia

Muscular Division

Infrahyoid StrapMuscles

Visceral Division Pharynx, Larynx,

Esophagus,Trachea, Thyroid

Buccopharyngeal

Fascia


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Deep Layer of Deep Cervical

Fascia Alar Layer

Posterior to visceral layer of middlefascia

Anterior to prevertebral layer

Prevertebral Layer

Vertebral bodies

Deep muscles of the neck


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Ce ical Fascia


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Cervical Fascia

Carotid Sheath

Formed by all three layers of deep fascia

Contains carotid artery, internal jugularvein, and vagus nerve

Lincolns Highway


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Deep Neck Spaces


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Deep Neck Spaces

Described in relation to the hyoid

Entire length of the

neck

Suprahyoid

Infrahyoid


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Deep Neck Spaces


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Deep Neck Spaces

Entire Length of Neck: Superficial

Space

Surrounds platysma

Contains areolar tissue, nodes, nerves

and vessels Subplatysmal Flaps

Involved with cellulitis and superficialabscesses

Treat with incision along Langers lines,drainage and antibiotics


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Deep Neck Spaces


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Deep Neck Spaces

Entire Length of Neck:

Retropharyngeal Space Posterior to pharynx and esophagus

Anterior to alar layer of deep fascia

Extends from skull base to T1-T2


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Deep Neck Spaces


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Deep Neck Spaces

Entire Length of Neck: Danger

Space Anterior border is alar layer of deep

fascia

Posterior border is prevertebral layer

Extends from skull base to diaphragm


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Deep Neck Spaces


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Deep Neck Spaces

Entire Length of Neck:Prevertebral Space

Anterior border is prevertebral fascia

Posterior border is vertebral bodies

and deep neck muscles

Extends along entire length ofvertebral column


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Deep Neck Spaces


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Deep Neck Spaces

Entire Length of Neck: VisceralVascular Space

Carotid Sheath

Lincolns Highway

Can become secondarily involved with anyother deep neck space infection by directspread


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Deep Neck Spaces


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Deep Neck Spaces

Suprahyoid: Submandibular

Space Anterior/Lateralmandible

Superiormucosa

Inferiorsuperficial layer of deep

fascia

Posterior/Inferior--hyoid


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Deep Neck Spaces


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Deep Neck Spaces

Suprahyoid:

SubmandibularSpace

Sublingual Space

Areolar tissue

Hypoglossal and lingualnerves

Sublingual gland

Whartons duct

Submylohyoid Space Anterior bellies of

digastrics

Submandibular gland


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Deep Neck Spaces


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Deep Neck Spaces

Suprahyoid: Parapharyngeal

Space Superiorskull base

Inferiorhyoid

Anteriorptyergomandibular

raphe Posteriorprevertebral fascia

Medialbuccopharyngeal fascia

Lateralsuperficial layer of deep

fascia


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Deep Neck Spaces


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Deep Neck Spaces

Suprahyoid: Parapharyngeal

Space Prestyloid

Medialtonsillar fossa

Lateralmedial pterygoid

Contains fat, connective tissue, nodes

Poststyloid

Carotid sheath

Cranial nerves IX, X, XII


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Deep Neck Spaces


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Deep Neck Spaces

Suprahyoid: Peritonsillar Space

Medialcapsule of palatine tonsil Lateralsuperior pharyngeal

constrictor

Superioranterior tonsillar pillar

Inferiorposterior tonsillar pillar


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Deep Neck Spaces


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Deep Neck Spaces

Infrahyoid: Anterior Visceral Space

Middle layer of deep fascia Contains thyroid, trachea, esophagus

Extends from thyroid cartilage intosuperior mediastinum


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Deep Neck Space Infections


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Deep Neck Space Infections

Presentation/Origin of Infection

Microbiology

Imaging

Treatment

Complications

Special Consideration

Presentation/Origin


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Presentation/Origin

Retropharyngeal Abscess 50% occur in patients 6-12 months of age

96% occur before 6 years of age

Children--fever, irritability, lymphadenopathy,torticollis, poor oral intake, sore throat,drooling

Adults--pain, dysphagia, anorexia, snoring,

nasal obstruction, nasal regurgitation Dyspnea and respiratory distress

Lateral posterior oropharyngeal wall bulge

Presentation/Origin


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Presentation/Origin

Pediatrics

Causesuppurativeprocess in lymphnodes

Nose, adenoids,nasopharynx, sinuses

Adults

Causetrauma,instrumentation,extension fromadjoining deep neck

space

Presentation/Origin


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Presentation/Origin

Danger Space

Presentation and exam nearly identical toretropharyngeal space infection

Causeextension from retropharyngeal,

prevertebral or parapharyngeal space

Presentation/Origin


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Presentation/Origin

Prevertebral Space

Back, shoulder, neck pain made worseby deglutition

Dysphagia or dyspnea

CausePotts abscess, trauma,

osteomyelitis, extension from

retropharyngeal and danger spaces

Presentation/Origin


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Presentation/Origin

Visceral Vascular Space

Induration and tenderness over SCM

Torticollis toward opposite side

Spiking fevers, sepsis

Causeintravenous drug abuse,extension from other deep neck spaces

Presentation/Origin


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Presentation/Origin

Submandibular Space Pain, drooling, dysphagia,

neck stiffness

Anterior neck swelling, floorof mouth edema

Cause70-85% haveodontogenic origin

First molar and anterior

Second and third molars

Sialadenitis, lymphadenitis,lacerations of the floor ofmouth, mandible fractures

Presentation/Origin


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Presentation/Origin

Ludwigs angina

Cellulitis, not abscess

Foul serosanguinous fluid,no frank purulence

Fascia, muscle, connectivetissue involvement, sparing

glands Direct spread rather than

lymphatic spread

Tender, firm anterior neckedema without fluctuance

Hot potato voice,drooling

Tachypnea, dyspnea,stridor

Presentation/Origin


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Presentation/Origin

Parapharyngeal Space

Fever, chills, malaise

Pain, dysphagia, trismus

Medial bulge of lateralpharyngeal wall

Causeinfection ofpharynx, tonsil, adenoids,dentition, parotid,mastoid, suppurative

lymphadenitis, extensionfrom other deep neckspaces

Presentation/Origin


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Presentation/Origin

Peritonsillar Space

Fever, malaise Dysphagia,

odynophagia

Hot-potato voice,

trismus, bulging ofsuperior tonsil pole andsoft palate, deviationof uvula

Causeextensionfrom tonsillitis

Presentation/Origin


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Presentation/Origin

Masticator

TemporalSpace

Pain, trismus

Posterior FOMedema

Swelling alongramus ofmandible

Causeodontogenic,from thirdmolars

Parotid

Space Pain,trismus

Medialbulge ofposteriorlateralpharyngealwall

Causeparotitis,sialolithiasis,Sjogrenssyndrome

Presentation/Origin


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Presentation/Origin

Anterior Visceral Space

Hoarseness, dyspnea, dysphagia,odynophagia

Erythema, edema of hypopharynx, may

extend to include glottis and supraglottis Anterior neck edema, pain, erythema,

crepitus

Causeforeign body, instrumentation,

extension of infection in thyroid

Microbiology


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c ob o ogy

Preantibiotic eraS.aureus

Currentlyaerobic Strep species andnon-strep anaerobes

Gram-negatives uncommon

Almost always polymicrobial Resistance

The microbiology of deep neck infections


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gy p

Mixed aerobic and anaerobic organisms, often with apredominance of oral flora.

Both gram-positive and gram-negative organisms may becultured.

Group A beta-hemolytic streptococcal species(Streptococcus pyogenes),

alpha-hemolytic streptococcal species (Streptococcusviridans, Streptococcus pneumoniae),

Staphylococcus aureus, Fusobacterium nucleatum, Bacteroides melaninogenicus,

Bacteroides oralis, andSpirochaeta, Peptostreptococcus, and Neisseria species Pseudomonasspecies,

Escherichia coli, and Haemophilus influenzae

Lab Studies :


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Blood chemistries

Complete blood cell count Clotting profile (particularly important in

patients who require surgical drainage)

Blood cultures (may be indicated in septicpatients)

Abscess cultures with Gram stains (critical

to direct antimicrobial therapy

Imaging


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g g

Lateral neck plain film

Screening exammainly forretropharyngeal andpretracheal spaces

Normal: 6mm at C-2,14mm at C-6 forchildren

22mm at C-6 for adults

Technique dependent

Extension

Inspiration

Nagy, et al Sensitivity 83%,

compared to CT 100%

Imaging


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g g

High-resolution Ultrasound

Advantages Avoids radiation

Portable

Disadvantages Not widely accepted

Operator dependent

Inferior anatomic detail

Uses Following infection during therapy Image guided aspiration


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Chest radiography:

To evaluate the mediastinum,

Check for subcutaneous air orpneumomediastinum,

Displacement of the air stripe, orconcurrent pneumonia suggesting

aspiration.

Imaging


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g g

Contrast enhanced

CT Advantages

Quick, easy

Widely available

Familiarity Superior anatomicdetail

Differentiate abscessand cellulitis

Disadvantages Ionizing radiation Allergenic contrast

agent

Soft tissue detail

Artifact
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Imaging
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Contrast enhanced CT

Modality of choice

Miller, et al: CT vs. PE

Accuracy of diagnosis: CT = 77%, PE = 63%

Sensitivity: CT = 95%, PE = 55%

Imaging


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MRI

Advantages No radiation

Safer contrast agent

Better soft tissue detail

Imaging in multiple

planes No artifact by dental

fillings

Disadvantages

Increased cost

Increased exam time

Dependent on patientcooperation

Availability

Munoz, et al: MRI vs. CT


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Arteriography:

This may be helpful when carotid,jugular, or innominate involvement issuggested.

Treatment


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Medical therapy:

Airway

Cultures

Volume andmetabolicresuscitation

I.V Antibiotics

Treatment


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Airway protection Observation

Intubation Direct laryngoscopy: possible risk of rupture

and aspiration Flexible fiberoptic

Tracheostomy Ideally = planned, awake, local anesthesia

Abscess may overlie trachea

Distorted anatomy and tissue planes

Treatment


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LUDWIGS ANGINA = PERILOUS AIRWAY Parhiscar and Har-El Review of 210 patients with

deep neck abscess

Overall, 20.5% requiredtracheostomy

Ludwigs angina, 75%

required tracheostom

Attempted intubation in20 patients

Failed in 11 patients,

Treatment


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Antibiotic Therapy

Cellulitis

Improvement in 24-48 hours

Abscess?

Mayor, et al: review of 31 patients, 19 withCT evidence of abscess, 90% response

Nagy, et al: review of 47 pediatric patients,51% response rate, only 7 of these had CT

evidence of abscess

Treatment


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Antibiotic Therapy

Polymicrobial infections Aerobic Strep, anaerobes

Ampicillin/sulbactam with metronidazole

Beta-Lactam resistance in 17-47% of

isolates

Alternatives Third generation cephalosporins

clindamycin

Culture and sensitivity

Treatment


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Surgical Drainage

Incision and drainage is the cornerstone oftherapy for the treatment of deep neckspace abscesses

Transoral

Preoperative CTwhere are the great vessels?

Cruciate mucosal incision, blunt spreading throughsuperior pharyngeal constrictor

Nagy, et al: retro-, parapharyngeal or combo in kids

22/23 successfully treated with intraoral incision anddrainage

External

INTRAOPERATIVE DETAILS


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Surgical approaches to the deep neck

spacesApproach used depends on

the precise location of the abscess,

the size of the collection,

and its relation to the great vessels andother important anatomic structures of

the neck.

Treatment


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Surgical Drainage

ExternalEXPOSURE, EXPOSURE, EXPOSURE

Levitt: anterior vs. posterior

approach

Submandibular incision

Submental incision

T-incision


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Treatment


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Image-guided Aspiration Patient selection Smaller abscesses, limited extension,

uniloculated

Poe, et al: CT guided aspiration Early specimen collection, reduced expense,

avoidance of neck scar

Yeow, et al: Ultrasound guided aspiration

8/10 patients successfully treated with needleaspiration

5/5 patients successful treated with pigtailcatheter insertion

NEEDLE ASPIRATION


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FNA may be used in patients with small

easily reachable abscesses or inpatients who are too unstable toundergo general anesthesia.

This procedure may require theassistance of CT scanning orultrasound guidance.

It may provide preliminary culturespecimens before formal incision anddrainage

PRE OPERATIVE DETAILS


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The most important preoperative

considerations are :

stabilization of the airway

volume and metabolic resuscitation

initiation of antibiotics.

POSTOPERATIVE DETAILS :


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Observe the patient for signs of a responseto therapy

Reaccumulation of fluid must be recognizedand treated with appropriate drainageprocedures

Cultures and sensitivities must be monitored,and antibiotics must be tailoredappropriately

The patient's airway must also be monitored

closely for signs of obstruction Finally, the patient must be monitored for

signs of impending complications

FOLLOW UP CARE :


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Monitoring the complete resolution of

the infection Surgical sites must be monitored for

complete healing and to ensure that

reaccumulation of an abscess doesnot occur

Any question of redevelopment of an

infection warrants reimaging andpossible reexploration.

Complications


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Airway obstruction from compression of thetrachea

Aspiration -Due to perforation of aretropharyngeal abscess with drainage ofpus into the airway.

Aspiration may occur spontaneously or

during endotracheal intubation. Vascular complications (ie, thrombosis of

the internal jugular vein, carotid arteryerosion and rupture)

Mediastinitis from inferior spread alongfascial lines

Neurologic deficits:

Complications:


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Septic emboli: These emboli can lead topulmonary, brain, or joint seeding andresultant abscesses.

Septic shock

Necrotizing cervical fasciitis: This is a

fulminant infection involving necrosis of theconnective tissue that spreads via fascialplanes. It has particularly high morbidity andmortality rates.

Osteomyelitis due to local spread to bonesof the spine, mandible, or skull base

Grisel syndrome (ie, inflammatory torticolliscausing cervical vertebral subluxation)

Complications


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Internal Jugular Vein Thrombosis Lemierres syndrome

prostration, swelling and pain alongSCM

Bacteremia, septic embolization, duralsinus thrombosis

IV drug abusers

Treatment

IV antibiotic therapy Anticoagulation?

Ligation and excision


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NECROTISING FASCITIS

Fulminant bacterial infection causingnecrosis of the superficial fascialplanes with widespread involvement

of the surrounding soft tissues andconcurrent systemic toxicity.

Joseph Jones 1871

TermedWilson 1952


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Clinical presentation:

Begins 2-4 days after insult Skin-red, tense, shiny

Within hoursdusky discoloration of

skin with small ill defined purplishpatches.

Blisters and vesicles

Skin beneath blistersnecrotic andblue


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Klabacha (depth of involvement)

Type IEpidermis Type IIDermis

Type IIIFascia

Type IVMuscle

Space 1to galea superiorly,chestwall inferiorly


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Treatment:

Early recognition Definitive surgical drainage and

debridement

- Apron incison

- Fasciotomy (Bear claw) incisions


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Grey foul serosanguinous dishwater

exudate Irrigation

Wound caredigital exploration

Iv antibotics

Autogenous split thickness grafts


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HBOUniv of Maryland protocol

Min of 30 dives at 2-2.4 atm for 90 to 120 min3 times the first day

Twice daily thereafter

Mortality rate30%

COMPLICATIONS:

IJV thrombosis

Carotid erosionMediastinitis

DIC

Intracranial involvement

Complications


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Mediastinitis

Descending necrotizing mediastinitis(DNM)

Mortality of 40%

Increasing dyspnea, chest pain CXR = widened mediastinum

Treatment

EARLY RECOGNITION AND INTERVENTION

Aggressive IV antibiotic therapy

Surgical drainage

Transcervical approach

Chest tube vs. thoracotomy


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Mediastinitis

Descending necrotizing mediastinitis (DNM) Estera- criteria for DNM

Clinical evidence of severe 1.oropharyngeal

infection

2.Characteristic radiographic features ofmediastinitis

3.Documentation of necrotizing mediastinal

infection at operation4.Establishment of relationship between DNM

and oropharyngeal source


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Clinical presentation:

Males 5:1

High fever

Tachycardia

Tachypnea

Hypotension Pleuritic chest pain Dyspnea

Retrosternal discomfort

Brawny edema Induration of neck, chest

Crepitus


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Chest x raywidening of the

mediastinum Pneumomediastinum

Pleural effusion

Obliteration of retrosternal orretrocardiac clarity


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Routes of spread from neck (Flynn)

Pearse8% of cervical infections-pretracheal space to anteriormediastinum

21% - middle mediastinumviscerovascular space 3Alincolnshighway

71% - posterior mediastinum via

Retropharyngeal space to the dangerspace which is continous with theposterior mediastinum.


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TREATMENT :

Early recognition Airway control

Aggressive surgical intervention

Transcervical approach

Chest tube vs. thoracotomy

Appropriate antibiotic therapy

Supportive systemic care

Hbo


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Special Consideration


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Recurrent Deep Neck SpaceInfection

CONGENITAL ABNORMALITY ??

Imaging - diagnosis

Nusbaum, et al: 12 cases of recurrentdeep neck infection

Most Common: second branchial cleft cyst

Others: first, third, fourth branchial cleftcysts, lymphangiomas, thyroglossal ductcysts, cervical thymic cyst

OUTCOME AND PROGNOSIS


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Patients treated for deep neck infectionscan be expected to fully recover as long asthe infection is treated properly and in atimely manner.

Patients whose treatment is delayed canexpect a greater number of complicationsand a prolonged course of recovery.

Once a deep neck infection has fullyresolved, no particular predisposition existsfor recurrence.

FUTURE AND CONTROVERSIES


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The greatest controversy regarding deep

neck infections concerns whether all deepneck abscesses require surgical treatment orwhether some abscesses can be treated

medically.

Surgical therapy can be reserved forpatients whose symptoms do not respond

within 48 hours

However, this issue is still being debated in

the literature, and clinical judgment must be

used with each individual patient.

REFERENCES:

O l d M ill f i l i f ti 4th diti


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Oral and Maxillofacial infections-4th editionTopazian and Goldberg

Anatomy for surgeons-head and neck -Hollinshead Contemporary Oral and maxillofacial surgery-

Larry J Peterson vol-2 Surgical pathology Vol 5-Fonseca series

Surgical anatomy of the head and neck-Mcvay Surgical Management of orofacial infections

Thomas R Flynn - Atlas of oral and maxillofacialclinics of North America Vol 8, number 1, March2000.

Diagnostic imaging of maxillofacial infectionsOMSCNA 2003 39-49

CummingsHead and neck surgery Vol 2

Nonsurgical management of deep neck infections - Tipsfrom Other Journals American Family Physician, May,1992

Necrotizing soft tissue infections: a primary care review
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Necrotizing soft tissue infections: a primary care reviewAmerican Family Physician, July 15, 2003 by AdrienneJ. Headley

Extensive deep neck space abscess due to B-Haemolytic group G Streptococci-A case reportMalini A, Mohiyuddin S MA, Indian Journal of MedicalMicrobiology: 2004 : 22 : 263-265

Int J Oral Maxillofac Surg. 2002 Jun;31(3):327-9.

Ultrasound-guided surgical drainage of face and neckabscesses.

Deep Fascial Space Infection of the Neck: A ContinuingChallenge Nashaat S. Hamza, MD, John Farrel, MD,Melvin Strauss, MD, Robert A. Bonomo, MD South Med J

96(9):928-932, 2003. Acute neck infections in children: Turkish Journal ofpediatrics 2004:46
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