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Patient History
CC: Neck mass HPI: 5 yo boy with 3 day history of sore throat, fever,
with 1 day h/o neck swelling, refusing to move neck, c/o
neck pain. No change with amoxicillin x2 days. No drooling, no voice change, refusing food x1day, no
trismus, no noisy breathingBrothers and pt had recent upper resp infection,Neg for: sinus infection, OM, other HN infection, cat
exposure, recent travel, TB contact, CA RFs, trauma,known immunodeficiency (HIV, steroid use)
PMH/PSH/ALL/Fam hx:neg Meds: amoxicillin 2days
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Patient Exam
Gen Alert, appropriate, anxious but in NAD, nostridor, no stertor, no drooling, normal voice,neck held rigid position slightly to right
Ears/Nose: clear bilat, no pus OC/OP: no trismus, teeth WNL, 2+ tonsils, no
asymmetry of soft palate or bulging of posteriorpharyngeal walls visible, soft throughout, tongue
motion normal Neck: 8 x 4cm R upper neck diffusely swollenarea parallel to body of mandible, mildlyerythematous, very TTP, firm, warm to touch
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Differential Diagnosis
V-venous malformation I-Cat scratch disease, TB, atypical mycobacteria,
viral/bacterial LAD, mono, sebaceous cyst, deep spaceabscess, mastoiditis with Bezolds abscess, sialadenitis
T-Hematoma, esophageal perforation, fibromatosis colli A-granulomatous diseases M-parathyroid cyst, thymic cyst, aberrant thyroid
tissue/hyperplasia
I-Kawasaki disease
N-Met, lymphoma, tumors of: thyroid, salivary gland, vascular(carotid body, glomus, hemangioma), neural; lipoma
C-branchial cleft cyst, cystic hygroma, thyroglossal duct cyst,teratoma, dermoid cyst, external laryngocele, plunging ranula
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Imaging
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Deep Neck Space Infections
Alice Lee
April 28, 2005
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Background
Before antibiotics, 70% deep neck infectionswere caused by tonsillar and pharyngealsources. More recently,
Most common cause in adults:odontogenic, IVDA
Most common cause in peds:tonsillar, URI
Others: salivary gland, trauma, FB,instrumentation, local or superficial source
22% without cause (1)1. Tom MB, Rice DH: Presentation and management of neck abscesses: a retrospective analysis, Laryngoscope 98:877, 1988
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Anatomy of Cervical Fascia
Superficial cervical fascia Deep cervical fascia
Superficial layerMiddle layer
Muscular divisionVisceral division
Deep layerPrevertebral division
Alar division
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Anatomy of Cervical Fascia:Superficial cervical fascia
Continuous sheath of fibrofatty subcutaneoustissue
Attachments: zygomatic process to thorax andaxilla
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
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Anatomy of Cervical Fascia:Superficial layer of the deep cervical fascia
Enveloping or investing later Insertion at nuchal line of the skull
chest and axillary regions; spreadsanteriorly to the face and attaches atclavicles
Envelopes SCM, trapezius, portion ofomohyoid in posterior triangle, parotid andsubmandibular glands
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Anatomy of Cervical Fascia:Middle layer of the deep cervical fascia
Muscular divisionSurrounds straps. Attaches superiorly to hyoidand thyroid cartilage and inferiorly to sternum,
clavicle and scapula Visceral divisionSurrounds thyroid, trachea, esophagus. Superiorattached to base of skull, thyroid cartilage andhyoid covers trachea and esophagus andblends with fibrous pericardium
Bonus: What does a portion of the visceraldivision form? (Covers the constrictor andbuccinator muscles)
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Anatomy of Cervical Fascia:Deep layer of the deep cervical fascia
Contents: Paraspinous muscles and cervicalvertebrae
Prevertebral and alar divisions Prevertebral: Begins anterior to the vertebralbodies, spreads laterally to fuse with transverseprocesses, extends posteriorly to enclose deep
muscles of neck and attaches to vertebralspines. Forms the posterior wall of the dangerspace and anterior wall of prevertebral space
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Anatomy of Cervical Fascia:Deep layer of the deep cervical fascia
Alar divisionLies between the prevertebral division and the
middle layer of the deep cervical fascia Attaches from transverse process tocontralateral transverse process, skull base toT2, fuses with visceral division of middle layer of
deep cervical fascia. Carotid sheath: made up of all 3 deep layers
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Cervical fascial planes
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Lymph
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Deep Neck Spaces
Suprahyoid spaces:1. Pharyngomaxillary/
Lateral pharyngeal
2. Submandibular3. Parotid4. Masticator5. Peritonsillar
6. Buccal Infrahyoid spaces:
1. Anterior visceral
Spaces involvingentire length of neck:1. Retropharyngeal
2. Danger3. Prevertebral4. Visceral vascular
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Retropharyngeal space
Potential space posterior to visceral division ofmiddle layer of deep cervical fascia and anteriorto alar division of deep layer of deep cervical
fascia Skull base to T1/2/tracheal bifurcation in closeapproximation to mediastinum
Midline raphe-superior constrictor muscles
adheres to prevertebral division; separatesretropharyngeal nodes into two lateral chains. Contents: fat, CT, LNs which drain nose, NP, soft
palate, ET, paranasal sinuses
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Retropharyngeal space
Most commonly seen inpeds due to drainage source
Peds: preceding URI, fever,dysphagia, odynophagia,nuchal rigidity, asymmetricbulging of post pharyngealwall due to midline raphe
Adults: pain, dysphagia,cervical motion limitation,noisy breathing
Can extend to:mediastinum, danger space,parapharyngeal space
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Retropharyngeal space
Lateral soft tissue XR (extension, inspiration) abnormalfindings:
1. C2-post pharyngeal soft tissue >7mm 2. C6adults >22mm, peds >14mm
3. STS of post pharyngeal region >50% width ofvertebral body
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Danger Space
Potential space between the alar andprevertebral divisions of the deep layer of
the deep cervical fascia Posterior to the retropharyngeal space andanterior to the prevertebral space
Why is it given this name? Extends from skull base to posterior
mediastinum to diaphragm
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Danger Space
Caused by infectious spread fromretropharyngeal, prevertebral and
parapharyngeal spaces or less commonly,by lymphatic extension from the nose andthroat
Watch for severe dyspnea, chest pain,widened mediastinum on CXR mayneed thoracotomy for drainage
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Prevertebral space
Potential space posterior to prevertebraldivision and anterior to vertebral bodies
Extends from skull base to the coccyx Most common cause:
iatrogenic/penetrating trauma
Previous most common cause: TB
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Visceral vascular space
Potential space within the carotid sheath Lymphatic vessels within receive drainage
from most of the lymphatic vessels in thehead and neck
Most common source of infection isparapharyngeal space
Why is this called the Lincoln Highway ofthe neck?
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Spaces involving entire length ofneck
Visceral layer-mid RETROPHARYNGEAL
SPACE (T2)
Alar division-deep DANGER SPACE
(diaphragm)
Prevertebral division
PREVERTEBRALSPACE (coccyx) Vertebrae
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Deep Neck Spaces
Suprahyoid spaces:1. Pharyngomaxillary/
Lateral pharyngeal
2. Submandibular3. Parotid4. Masticator5. Peritonsillar
6. Buccal Infrahyoid spaces:
1. Anterior visceral
Spaces involvingentire length of neck:1. Retropharyngeal
2. Danger3. Prevertebral4. Visceral vascular
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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/ prevertebralfascia
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Pharyngomaxillary/Parapharyngeal/Lateral pharyngeal space
Divided into anterior and posterior compartments bystyloid bones and muscles
Prestyloid/Muscular compartment:
-Tonsillar fossa medially, internal pterygoid laterally-Fat, lymph nodes, parotid masses-Displacement of lat pharyngeal wall, early trismus-Most common mass pleomorphic adenoma
Post-styloid/Neurovascular compartment:-Carotid, IJV, cervical sympathetic chain, CN IX-XII-Most common mass - schwannoma
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Pharyngomaxillary/Parapharyngeal/Lateral pharyngeal space
Connects to the majorityof other fascial spaces
Sources: parotid,
masticator,submandibular,peritonsillar,tonsils/pharynx,odontogenic, LN from
nose and throat,mastoiditis (Bezoldabscess)
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Pharyngomaxillary/Parapharyngeal/Lateral pharyngeal space
Never approachintraorally
Traditionally: Mosherincision
Horizontal neck incision follow carotid sheathinto space fingerdissect belowsubmandibular gland,
along posterior belly ofdigastric deep to mastoidtip toward styloid
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Submandibular space
Composed of sublingual space superiorly andsubmaxillary space inferiorly, divided by mylohyoid
Boundaries: FOM mucosa above, superficial layer ofdeep 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 posteriorborder of mylohyoid through submandibular gland
Ludwigs angina bilateral cellulitis of submandibularand sublingual spaces Inspect 2nd and 3rd molars apices extend below
mylohyoid line providing direct access to submandibularspace
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Parotid space
Formed by the splitting and surrounding ofsuperficial layer of deep cervical fascia;incomplete at upper inner surface of gland =direct communication with lateral pharyngealspace (dumbbell shaped masses secondary tostylomandibular ligament)
Contents: parotid gland, external carotid,posterior facial vein, facial nerve, lymph nodes
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Masticator space
Superficial layer of deep cervical fascia splits aroundmandible to form this space and encases muscles ofmastication
4 compartments: Masseteric, Pterygoid, SuperficialTemporal, Deep Temporal Contents: masseter, pterygoid muscles, temporalis
tendon, inferior alveolar nerves and vessels, body andramus of mandible, internal maxillary artery
Most common source : 3rd molar Complication: osteomyelitis of mandible
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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 equallyeffective initial management with 10-15% recurrrencerate. (1)
Again, 10-15% recurrence after needle aspiration and/orI&D; greatest risk in patients
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Buccal space
Boundaries: Buccinator muscle, cheek,zygomatic arch, pterygomandibular raphe,
inferior mandible Odontogenic source with buccal swelling
and preseptal cellulitis possible
Complication: cavernous sinus thrombosis
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Deep Neck Spaces
Suprahyoid spaces:1. Pharyngomaxillary/
Lateral pharyngeal
2. Submandibular3. Parotid4. Masticator5. Peritonsillar
6. Buccal Infrahyoid spaces:1. Anterior visceral
Spaces involvingentire length of neck:1. Retropharyngeal
2. Danger3. Prevertebral4. Visceral vascular
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Anterior visceral space
Pretracheal space from thyroid cartilage to T4level, enclosed by visceral division of middlelayer, just deep to straps, surrounds trachea
Source: esophageal anterior wall perforation,external trauma
Symptoms: mainly dysphagia, later hoarseness,
dyspnea, airway obstruction Complication: mediastinitis, airway
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Network of infectious extension
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Pathogens
Likely dependent on portal of entry and spaceinvolved Aerobic: Strep-predom viridans and B-hemolytic
streptococci, staph, diphtheroid, Neisseria,
Klebsiella, Haemophilus Anaerobic: Bacteroides, Peptostreptococcus,Eikenella (often clinda resistant),FUsobacterium, B fragilis
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Antibiotics
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Necrotizing fasciitis
Fulminent infection, polymicrobial, usually odontogenicsource, more frequently in immunocompromised andpostoperative
PEX: ill, high fever, neck crepitus, exquisitely tender,unimpressive erythema s sharp demarcating borderprogress to pale then dusky as necrosis progresses can have bullae/blisters/sloughing
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Diagnosis Pain, trismus, limitation
neck motion, swelling,sustained fever,leukocytosis with leftshift, lateral neck XR/CT
Prevertebral orretropharyngeal hot
potato voice, difficultnoisy breathing,dys/odynophagia,drooling, neck posturing
Parapharyngeal medialdisplacement of lateralpharyngeal wall, fullnessof retromandibular area.Prestyloidtrismus, tonsilswelling. Poststyloid-
dysphagia
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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, nosignificant response to abx in 24-48 hours,evidence of sepsis
Transoral peritonsillar, uncomplicated RP andprevertebral abscesses with mass in oropharynx,uncomplicated sublingual (not for submaxextension)
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Management
Surgical principles: wide exposure, usereadily identifiable landmarks (digastric,
hyoid, SCM, cricoid, greater horn ofthyroid), blunt dissection, identify carotidsheath early, cultures/biopsy,debridement, irrigation, leave wound openand pack for extensive necrosis, can closeless necrotic wound and use drain
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Complications
40 yr old pt is admitted forparapharyngeal infection. Started on abx,
IVF, observation. Afebrile within 24 hourswith improved dysphagia. HD #2 spikes to104, defervesces, respikes. Whatshappening?
Thrombophlebitis of IJV
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Complications signs andsymptoms
Mediastinitis chest pain,worsened dyspnea,dysphagia, widenedmediastinum on CXR
Horners, hoarseness,unilateral tongue paresis,plethora of face, chokedoptic disks, Tobey Ayer,erosion of carotid
(critical, pharyngealbleeding episode, neckhematoma, rare EACblood
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Treatment of complications
Mediastinitis most commonly via retropharyngealspace > visceral or PP
Abdominal abscess prevertebral space
IJV septic thrombophlebitis IVDA, ligate and removethrombosed vein at I&D NeuropathyHorners, hoarseness, unilateral tongue
paresis
Erosion of carotid artery rare, emergency, clot found inneck at I&D, proximal and distal control, intraop angio ifpossible (75% CCA or ICA)
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References
Baileys Cummings 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 peritonsillarabscess. Otolaryngol Head Neck Surg. 2003 Mar;128(3):332-43.
Herzon FS. Peritonsillar abscess: incidence, current management practices, and a proposal fortreatment guidelines. Laryngoscope 1995;105 [suppl 74]:1-7.
Tan PT, et al. Deep neck infections in children. J Microbiol Immunol Infect 2001;34:287-292.