Deep-neck-infection-051005 - Deep Neck Space Infections...

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Unformatted text preview: Deep Neck Space Infections Deep Neck Space Infections 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 Outline Anatomy Fascial planes Spaces Epidemiology Etiology Clinical presentation Imaging Bacteriology Therapy Medical Surgical Complications Mediastinitis ανατομία Cervical Fascia Cervical Fascia Superficial Layer Deep Layer Subdivisions not histologically separate Superficial Middle Enveloping layer Investing layer Visceral fascia Prethyroid fascia Pretracheal fascia Deep Superficial Layer Superficial Layer Superior attachment – zygomatic process Inferior attachment – thorax, axilla. Similar to subcutaneous tissue Ensheathes platysma and muscles of facial expression Superficial Layer of the Deep Cervical 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 Superficial Layer of the Deep Cervical Superficial Layer of the Deep Cervical Fascia Middle Layer of the Deep Cervical Fascia Middle Layer of the Deep Cervical Fascia Visceral Division Superior border Inferior border – continuous with fibrous pericardium in the upper mediastinum. Buccopharyngeal fascia Anterior – hyoid and thyroid cartilage Posterior – skull base Name for portion that covers the pharyngeal constrictors and buccinator. Envelopes Thyroid Trachea Esophagus Pharynx Larynx Muscular Division Superior border – hyoid and thyroid cartilage Inferior border – sternum, clavicle and scapula Envelopes infrahyoid strap muscles Middle Layer of the Deep Cervical Fascia Middle Layer of the Deep Cervical Fascia Deep Layer of Deep Cervical Fascia 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 T1­T2 Prevertebral layer Superior border – skull base Inferior border – coccyx Envelopes vertebral bodies and deep muscles of the neck. Extends laterally as the axillary sheath. Deep Layer of Deep Cervical Fascia Deep Layer of Deep Cervical Fascia Carotid 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 “Lincoln’s Highway” Travels through pharyngomaxillary space. Extends from skull base to thorax. Deep Neck Spaces 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 Superficial Space 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 Retropharyngeal Space 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 T1­T2 Midline raphe connects superior constrictor to the deep layer of deep cervical fascia. Contains retropharyngeal nodes. Space 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 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 Visceral Vascular Space 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. Submandibular Space 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 Submental compartment Submaxillary compartments Submandibular gland Submandibular Space Submandibular Space Pharyngomaxillary space 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 Pharyngomaxillary space 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. Pharyngomaxillary Space Pharyngomaxillary Space Communicates with several deep neck spaces. Parotid Masticator Peritonsillar Submandibular Retropharyngeal Peritonsillar Space Peritonsillar Space Suprahyoid Medial—capsule of palatine tonsil Lateral—superior pharyngeal constrictor Superior—anterior tonsil pillar Inferior—posterior tonsil pillar Masticator and Temporal Masticator and Temporal Spaces Suprahyoid Formed by superficial layer of deep cervical fascia Masticator space Antero­lateral 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 by temporalis muscle Parotid Space 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 Anterior Visceral Space 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. Epidemiology Epidemiology All patients Avg age b/w 40­50. More predominant in pts over 50 years. Pediatric pts Infants to teens. Male predilection in some case series. Most common age group: 3­5 years. Etiology Etiology Odontogenic Tonsillitis IV drug injection Trauma Foreign body Sialoadenitis Parotitis Osteomyelitis Epiglottitis URI Iatrogenic Congenital anomalies Idiopathic Clinical presentation 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 Imaging Imaging Lateral neck plain film Screening exam No benefit in pts with DNI based on strong clinical suspicion. Normal: Technique dependent 7mm at C­2 14mm at C­6 for kids 22mm at C­6 for adults Extension Inspiration Sensitivity 83%, compared to CT 100% Imaging Imaging MRI Pros 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 Cons Cost Pt cooperation Slower (19 to 35 minutes) CT with contrast Pros Widely available Faster (5­15 minutes) Abscess vs cellulitis Less expensive Cons Contrast Radiation Uniplanar Dental artifacts Imaging Imaging Regular cavity wall with ring enhancement (RE) Sensitivity ­ 89% Specificity ­ 0% Irregular wall (scalloped) Sensitivity ­ 64% Specificity ­ 82% PPV ­ 94% Aerobic G (+) n % Total 645 87.40 Strep sp. 229 Staph sp. Bacteriology Anaerobic G (-) n % n % Total 137 18.56 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). Antibiotic Therapy 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. Surgery 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 Complications 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 Who gets complications? 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 Descending Necrotizing 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 – 7­8% Clinical manifestation of severe infection. Demonstration of the characteristic imaging features of mediastinitis. Features of necrotizing mediastinal infection at surgery. 1960­89 – 43 published cases Mortality rate 14­40% Clinical Presentation 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 Mediastinitis Imaging 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 Treatment 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 Bibliography 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, Lippincott­Raven Publishers, 1998; 819­35 Kirse, DJ, Roberson,DW. Surgical Management of Retropharyngeal Space Infections in Children. Laryngoscope, 111: 1413­1422, 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: 1191­1196. 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, 299­302. Nagy, M, Pizzuto, M, Backstrom, J, Brodsky, L. Deep Neck Infections in Children: A New Approach to Diagnosis and Treatment. Laryngoscope. 1997; 107 (12): 1627­1634. Huang, TT, Liu, TC, Chen, PR, Tseng, FY, Yeh, TH, Chen, YS. Deep Neck Infection: Analysis of 185 Cases. Head and Neck. 26: 854­860. 2004. Parhiscar, A, Har­El, G. Deep neck abscess: A retrospective review of 210 cases. Annals of Otology, Rhinology and Laryngology, 2001; 110 (11): 1051­54. 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;13:943­7. 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): 733­741. 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 deep­neck infections. Laryngoscope, 1999; 109 (5): 775­779. Chaudhary, N, Agrawal, S, Rai, A. Descending Necrotizing Mediastinitis: Trends in a Developing Country. Ear Nose Throat. 2005 84(4); 242­50. Harar, R, Cranston, C, Warwick­Brown, 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; 65:1483­8. Akman, C, Kantarci, F, Cetinkaya, S. Imaging in mediastinitis: a systematic review based on aetiology. Clinical radiology (2004) 59, 573­85. Baqain, Z, Neman, L, Hyde, N. How Serious are Oral Infections? Journ Laryngol Otol. July 2004 (118). 561­65. 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.­Neck­Spaces­2002­04/Deep­neck­spaces­ 2002­04.doc ...
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