Deep Neck Space Infections

Jeffrey Buyten, MD
Faculty Advisor: Francis B. Quinn, Jr., MD
The University of Texas Medical Branch
Department of Otolaryngology
Grand Rounds Presentation
October 5, 2005
 Outline
 Anatomy
 Fascial planes

 Spaces

 Epidemiology
 Etiology
 Clinical presentation
 Imaging
 Bacteriology
 Therapy
 Medical

 Surgical

 Complications
 Mediastinitis
ανατομία
 Cervical Fascia
 Superficial Layer
 Deep Layer
 Subdivisions not
histologically separate
 Superficial
 Enveloping layer
 Investing layer
 Middle
 Visceral fascia
 Prethyroid fascia
 Pretracheal fascia
 Deep
 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 Fascia

 Completely surrounds the  Envelopes

neck.  SCM
 Arises from spinous processes.  Trapezius
 Superior border – nuchal line,  Submandibular
skull base, zygoma, mandible.  Parotid
 Inferior border – chest and  Forms floor of submandibular
axilla space
 Splits at mandible and covers
the masseter laterally and the
medial surface of the medial
pterygoid.
Superficial Layer of the Deep Cervical Fascia
Middle Layer of the Deep Cervical Fascia

 Visceral Division  Muscular Division

 Superior border  Superior border – hyoid and
 Anterior – hyoid and thyroid cartilage thyroid cartilage
 Posterior – skull base  Inferior border – sternum, clavicle
 Inferior border – continuous with and scapula
fibrous pericardium in the upper
mediastinum.  Envelopes infrahyoid strap
muscles
 Buccopharyngeal fascia
 Name for portion that covers the
pharyngeal constrictors and
buccinator.
 Envelopes
 Thyroid
 Trachea
 Esophagus
 Pharynx
 Larynx
Middle Layer of the 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 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.
Deep Layer of Deep Cervical Fascia
 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
 Described in relation to the hyoid.
 Entire length of neck
 Superficial space
 Retropharyngeal
 Danger
 Prevertebral
 Vascular visceral
 Suprahyoid
 Submandibular
 Pharyngomaxillary (Parapharyngeal)
 Parotid
 Peritonsillar
 Temporal
 Masticator
 Infrahyoid
 Anterior visceral
 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
 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.

 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
 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
 Entire length of neck

 Carotid Sheath
 “Lincoln Highway”
 Lymphatic vessels can
receive drainage from
most of lymphatic
vessels in head and
neck.
 Submandibular Space
 Suprahyoid  2 compartments
 Sublingual space
Areolar tissue
 Superior – oral mucosa 
 Hypoglossal and lingual
 Inferior - superficial layer nerves
of deep fascia  Sublingual gland
Wharton’s duct
 Anterior border – 

mandible  Submaxillary space

 Anterior bellies of digastrics
 Lateral border - mandible  Submental compartment
 Posterior - hyoid and  Submaxillary
compartments
base of tongue  Submandibular gland
musculature
Submandibular 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
 Prestyloid
 Muscular compartment
 Medial—tonsillar fossa
 Lateral—medial pterygoid
 Contains fat, connective
tissue, nodes
 Poststyloid
 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
 Communicates
with several deep
neck spaces.
 Parotid
 Masticator
 Peritonsillar
 Submandibular
 Retropharyngeal
 Peritonsillar Space
 Suprahyoid

 Medial—capsule of
palatine tonsil
 Lateral—superior
pharyngeal constrictor
 Superior—anterior tonsil
pillar
 Inferior—posterior tonsil
pillar
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
by temporalis muscle
 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
 Infrahyoid  Superior border - thyroid
cartilage
 aka – pretracheal space  Inferior border - anterior
superior mediastinum down to
 Enclosed by visceral division of the arch of the aorta.
middle layer of deep fascia
 Contains thyroid  Posterior border – anterior wall
 Surrounds trachea of esophagus
 Communicates laterally with
the retropharyngeal space
below the thyroid gland.
 Epidemiology
 All patients
 Avg age b/w 40-50.
 More predominant in
patients over 50 years.

 Pediatric patrents
 Infants to teens.
 Male predilection in some
case series.
 Most common age group:
3-5 years.
 Etiology
 Odontogenic
 Tonsillitis
 IV drug injection
 Trauma
 Foreign body
 Sialoadenitis
 Parotitis
 Osteomyelitis
 Epiglottitis
 URI
 Iatrogenic
 Congenital anomalies
 Idiopathic
 Clinical presentation
 Most common symptoms
 Sore throat (72%)
 Odynophagia (63%)

 Most common symptoms (exluding peritonsillar abscesses)

 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
 Lateral neck plain film
 Screening exam
 No benefit in pts with
DNI based on strong
clinical suspicion.
 Normal:
 7mm at C-2
 14mm at C-6 for kids
 22mm at C-6 for adults
 Technique dependent
 Extension
 Inspiration
 Sensitivity 83%,
compared to CT 100%
 Imaging
 MRI  CT with contrast
 Pros  Pros
 MRI superior to CT in  Widely available
initial assessment  Faster (5-15 minutes)
 More precise identification  Abscess vs cellulitis
of space involvement  Less expensive
(multiplanar)  Cons
 Better detection of
underlying lesion  Contrast
 Less dental artifact  Radiation
 Better for floor of mouth  Uniplanar
 No radiation  Dental artifacts
 Non iodine contrast
 Cons
 Cost
 Pt cooperation
 Slower (19 to 35 minutes)
 Imaging
 Regular cavity wall with
ring enhancement (RE)
 Sensitivity - 89%

 Specificity - 0%

 Irregular wall
(scalloped)
 Sensitivity - 64%
 Specificity - 82%
 PPV - 94%
Aerobic
Bacteriology Anaerobic

G (+) n % G (-) n % n %

Total 645 87.40 Total 137 18.56 Total 201 27.24

Strep sp. 229 31.03 Klebsiella sp. 90 12.20 Peptostreptococcus 43 5.83

Staph sp. 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 24.53 Sterile 71 9.62

Modified and combined data from 738 patients (1, 2, 3, 4, 5, 6, 7).

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
 External drainage
 Landmarks
 Tip of greater horn of hyoid
 Cricoid cartilage
 Styloid process
 SCM

 Transoral drainage
 Parapharyngeal,
retropharyngeal abscesses
 Great vessels lateral to
abscess
 Tonsillectomy for exposure

 Needle aspiration
 Complications
 Airway obstruction
 Trach 10 – 20%
 Ludwig’s angina - 75%
 Mediastinitis – 2.7%
 UGI bleeding
 Sepsis
 Pneumonia
 IJV thrombosis
 Skin defect
 Vocal cord palsy
 Pleural effusion
 Hemorrhage
 20 - 80% mortality
 Multiple space involvement
 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
Mediastinitis
 Definition – mediastinal infection in which pathology originates in
fascial spaces of head and neck and extends down.
 Retropharyngeal and Danger Space – 71%
 Visceral vascular – 20%
 Anterior visceral – 7-8%

 Criteria for diagnosis

1. Clinical manifestation of severe infection.
2. Demonstration of the characteristic imaging features of mediastinitis.
3. Features of necrotizing mediastinal infection at surgery.

 1960-89 – 43 published cases

 Mortality rate 14-40%
 Clinical Presentation
 Symptoms  Important to have a
 Respiratory difficulty low threshold for
 Tachycardia further workup
 Erythema/edema
 Skin necrosis
 Crepitus
 Chest pain
 Back pain
 Shock
 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
 IV antibiotics
 Cervical drainage
 Cervical abscesses
 Superior mediastinal abscesses
above T4 (tracheal bifurcation)
 Transthoracic drainage
 Abscesses below T4
 Subxyphoid approach
 Anterior mediastinal drainage
 Thoracostomy tubes
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