Patient History

1
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 hxneg Meds amoxicillin 2days

2
Patient Exam

• Gen Alert, appropriate, anxious but in NAD, no
  stridor, 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 posterior
  pharyngeal walls visible, soft throughout, tongue
  motion normal
• Neck 8 x 4cm R upper neck diffusely swollen area
  parallel to body of mandible, mildly
  erythematous, very TTP, firm, warm to touch

3
Differential Diagnosis

• V-venous malformation
• I-Cat scratch disease, TB, atypical mycobacteria,
  viral/bacterial LAD, mono, sebaceous cyst, deep
  space abscess, 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

4
Imaging
5
Deep Neck Space Infections

• Alice Lee
• April 28, 2005

6
Background

• Before antibiotics, 70 deep neck infections were
  caused by tonsillar and pharyngeal sources. 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 98877, 1988

7
Anatomy of Cervical Fascia

• Superficial cervical fascia
• Deep cervical fascia Superficial layer
  Middle layer Muscular division
  Visceral division Deep layer
  Prevertebral division Alar division

8
Anatomy of Cervical Fascia Superficial cervical
fascia

• Continuous sheath of fibrofatty subcutaneous
  tissue
• Attachments zygomatic process to thorax and
  axilla
• Contents platysma, muscles of facial expression
• Not considered a part of the deep neck local ID
  and antibiotics
• Between superficial and deep layers Fat, sensory
  nerves, EJ, AJ, superficial lymphatics

9
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 spreads anteriorly to the face
  and attaches at clavicles
• Envelopes SCM, trapezius, portion of omohyoid in
  posterior triangle, parotid and submandibular
  glands

10
Anatomy of Cervical Fascia Middle layer of the
deep cervical fascia

• Muscular divisionSurrounds straps. Attaches
  superiorly to hyoid and thyroid cartilage and
  inferiorly to sternum, clavicle and scapula
• Visceral divisionSurrounds thyroid, trachea,
  esophagus. Superior attached to base of skull,
  thyroid cartilage and hyoid? covers trachea and
  esophagus and blends with fibrous pericardium
• Bonus What does a portion of the visceral
  division form? (Covers the constrictor and
  buccinator muscles)

11
Anatomy of Cervical Fascia Deep layer of the
deep cervical fascia

• Contents Paraspinous muscles and cervical
  vertebrae
• Prevertebral and alar divisions
• Prevertebral Begins anterior to the vertebral
  bodies, spreads laterally to fuse with transverse
  processes, extends posteriorly to enclose deep
  muscles of neck and attaches to vertebral spines.
  Forms the posterior wall of the danger space
  and anterior wall of prevertebral space

12
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 to contralateral
  transverse process, skull base to T2, fuses with
  visceral division of middle layer of deep
  cervical fascia.
• Carotid sheath made up of all 3 deep layers

13
Cervical fascial planes
14
Lymph
15
Deep Neck Spaces

• Suprahyoid spaces1. Pharyngomaxillary/
  Lateral pharyngeal 2. Submandibular3.
  Parotid4. Masticator5. Peritonsillar6. Buccal
• Infrahyoid spaces1. Anterior visceral

• Spaces involving entire length of neck1.
  Retropharyngeal2. Danger 3. Prevertebral4.
  Visceral vascular

16
Retropharyngeal space

• Potential space posterior to visceral division of
  middle layer of deep cervical fascia and anterior
  to alar division of deep layer of deep cervical
  fascia
• Skull base to T1/2/tracheal bifurcation in close
  approximation to mediastinum
• Midline raphe-superior constrictor muscles
  adheres to prevertebral division separates
  retropharyngeal nodes into two lateral chains.
• Contents fat, CT, LNs which drain nose, NP, soft
  palate, ET, paranasal sinuses

17
Retropharyngeal space

• Most commonly seen in peds due to drainage source
• Peds preceding URI, fever, dysphagia,
  odynophagia, nuchal rigidity, asymmetric bulging
  of post pharyngeal wall due to midline raphe
• Adults pain, dysphagia, cervical motion
  limitation, noisy breathing
• Can extend to mediastinum, danger space,
  parapharyngeal space

18
Retropharyngeal space

• Lateral soft tissue XR (extension, inspiration)
  abnormal findings
• 1. C2-post pharyngeal soft tissue gt7mm
• 2. C6adults gt22mm, peds gt14mm
• 3. STS of post pharyngeal region gt50 width of
  vertebral body

19
Danger Space

• Potential space between the alar and prevertebral
  divisions of the deep layer of the deep cervical
  fascia
• Posterior to the retropharyngeal space and
  anterior to the prevertebral space
• Why is it given this name?
• Extends from skull base to posterior mediastinum
  to diaphragm

20
Danger Space

• Caused by infectious spread from retropharyngeal,
  prevertebral and parapharyngeal spaces or less
  commonly, by lymphatic extension from the nose
  and throat
• Watch for severe dyspnea, chest pain, widened
  mediastinum on CXR ? may need thoracotomy for
  drainage

21
Prevertebral space

• Potential space posterior to prevertebral
  division and anterior to vertebral bodies
• Extends from skull base to the coccyx
• Most common cause iatrogenic/penetrating trauma
• Previous most common cause TB

22
Visceral vascular space

• Potential space within the carotid sheath
• Lymphatic vessels within receive drainage from
  most of the lymphatic vessels in the head and
  neck
• Most common source of infection is parapharyngeal
  space
• Why is this called the Lincoln Highway of the
  neck?

23
Spaces involving entire length of neck

• Visceral layer-mid
• RETROPHARYNGEAL SPACE (T2)
• Alar division-deep
• DANGER SPACE (diaphragm)
• Prevertebral division
• PREVERTEBRAL SPACE (coccyx)
• Vertebrae

24
Deep Neck Spaces

• Suprahyoid spaces1. Pharyngomaxillary/
  Lateral pharyngeal 2. Submandibular3.
  Parotid4. Masticator5. Peritonsillar6. Buccal
• Infrahyoid spaces1. Anterior visceral

• Spaces involving entire length of neck1.
  Retropharyngeal2. Danger 3. Prevertebral4.
  Visceral vascular

25
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/ prevertebral
  fascia

26
Pharyngomaxillary/Parapharyngeal/ Lateral
pharyngeal space

• Divided into anterior and posterior compartments
  by styloid 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

27
Pharyngomaxillary/Parapharyngeal/ Lateral
pharyngeal space

• Connects to the majority of other fascial spaces
• Sources parotid, masticator, submandibular,
  peritonsillar, tonsils/pharynx, odontogenic, LN
  from nose and throat, mastoiditis (Bezold abscess)

28
Pharyngomaxillary/Parapharyngeal/ Lateral
pharyngeal space

• Never approach intraorally
• Traditionally Mosher incision
• Horizontal neck incision ? follow carotid sheath
  into space ? finger dissect below submandibular
  gland, along posterior belly of digastric deep to
  mastoid tip toward styloid

29
Submandibular space

• Composed of sublingual space superiorly and
  submaxillary space inferiorly, divided by
  mylohyoid
• Boundaries FOM mucosa above, superficial layer
  of deep 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
  posterior border of mylohyoid through
  submandibular gland
• Ludwigs angina bilateral cellulitis of
  submandibular and sublingual spaces
• Inspect 2nd and 3rd molars apices extend below
  mylohyoid line providing direct access to
  submandibular space

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Parotid space

• Formed by the splitting and surrounding of
  superficial layer of deep cervical fascia
  incomplete at upper inner surface of gland
  direct communication with lateral pharyngeal
  space (dumbbell shaped masses secondary to
  stylomandibular ligament)
• Contents parotid gland, external carotid,
  posterior facial vein, facial nerve, lymph nodes

32
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Masticator space

• Superficial layer of deep cervical fascia splits
  around mandible to form this space and encases
  muscles of mastication
• 4 compartments Masseteric, Pterygoid,
  Superficial Temporal, Deep Temporal
• Contents masseter, pterygoid muscles, temporalis
  tendon, inferior alveolar nerves and vessels,
  body and ramus of mandible, internal maxillary
  artery
• Most common source 3rd molar
• Complication osteomyelitis of mandible

34
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, ID, quincy
  tonsillectomy all equally effective initial
  management with 10-15 recurrrence rate. (1)
• Again, 10-15 recurrence after needle aspiration
  and/or ID greatest risk in patients lt40 with
  history of recurrent tonsillitis (2)
• 1. Johnson RF, Stewart MG, Wright CC. An
  evidence-based review of the treatment of
  peritonsillar abscess. Otolaryngol Head Neck
  Surg. 2003 Mar128(3)332-43.
• 2. Herzon FS. Peritonsillar abscess
  incidence, current management practices, and a
  proposal for treatment guidelines. Laryngoscope
  1995105 suppl 741-7.

35
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

36
Deep Neck Spaces

• Suprahyoid spaces1. Pharyngomaxillary/
  Lateral pharyngeal 2. Submandibular3.
  Parotid4. Masticator5. Peritonsillar6. Buccal
• Infrahyoid spaces1. Anterior visceral

• Spaces involving entire length of neck1.
  Retropharyngeal2. Danger 3. Prevertebral4.
  Visceral vascular

37
Anterior visceral space

• Pretracheal space from thyroid cartilage to T4
  level, enclosed by visceral division of middle
  layer, just deep to straps, surrounds trachea
• Source esophageal anterior wall perforation,
  external trauma
• Symptoms mainly dysphagia, later hoarseness,
  dyspnea, airway obstruction
• Complication mediastinitis, airway

38
Network of infectious extension
39
Pathogens

• Likely dependent on portal of entry and space
  involved
• Aerobic Strep-predom viridans and B-hemolytic
  streptococci, staph, diphtheroid, Neisseria,
  Klebsiella, Haemophilus
• Anaerobic Bacteroides, Peptostreptococcus,
  Eikenella (often clinda resistant),
  FUsobacterium, B fragilis

40
Antibiotics
41
Necrotizing fasciitis

• Fulminent infection, polymicrobial, usually
  odontogenic source, more frequently in
  immunocompromised and postoperative
• PEX ill, high fever, neck crepitus, exquisitely
  tender, unimpressive erythema s sharp demarcating
  border ? progress to pale then dusky as necrosis
  progresses ? can have bullae/blisters/sloughing
  lt48hrs
• Empiric abx (3rd gen ceph clinda/flagyl), early
  surgery, dishwater drainage, leave open, daily
  debridement, trach, ICU monitoring for resp
  failure, mediastinitis (higher mortality 64 vs
  15), DIC, delirium, HBO

42
Diagnosis

• Pain, trismus, limitation neck motion, swelling,
  sustained fever, leukocytosis with left shift,
  lateral neck XR/CT
• Prevertebral or retropharyngeal hot potato
  voice, difficult noisy breathing,
  dys/odynophagia, drooling, neck posturing
• Parapharyngeal medial displacement of lateral
  pharyngeal wall, fullness of retromandibular
  area. Prestyloid trismus, tonsil swelling.
  Poststyloid-dysphagia

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Management

• Hospitalization for airway management, aggressive
  antibiotics, hydration, ID
• If no evidence of airway compromise, abx 24 hrs.
  10-15 improve with medical mgmt.
• Surgery indicated for airway compromise, no
  significant response to abx in 24-48 hours,
  evidence of sepsis
• Transoral peritonsillar, uncomplicated RP and
  prevertebral abscesses with mass in oropharynx,
  uncomplicated sublingual (not for submax
  extension)

45
Management

• Surgical principles wide exposure, use readily
  identifiable landmarks (digastric, hyoid, SCM,
  cricoid, greater horn of thyroid), blunt
  dissection, identify carotid sheath early,
  cultures/biopsy, debridement, irrigation, leave
  wound open and pack for extensive necrosis, can
  close less necrotic wound and use drain

46
Complications

• 40 yr old pt is admitted for parapharyngeal
  infection. Started on abx, IVF, observation.
  Afebrile within 24 hours with improved dysphagia.
  HD 2 spikes to 104, defervesces, respikes.
  Whats happening?
• Thrombophlebitis of IJV

47
Complications signs and symptoms

• Mediastinitis chest pain, worsened dyspnea,
  dysphagia, widened mediastinum on CXR
• Horners, hoarseness, unilateral tongue paresis,
  plethora of face, choked optic disks, Tobey Ayer,
  erosion of carotid (critical, pharyngeal bleeding
  episode, neck hematoma, rare EAC blood

48
Treatment of complications

• Mediastinitis most commonly via retropharyngeal
  space gt visceral or PP
• Abdominal abscess prevertebral space
• IJV septic thrombophlebitis IVDA, ligate and
  remove thrombosed vein at ID
• Neuropathy Horners, hoarseness, unilateral
  tongue paresis
• Erosion of carotid artery rare, emergency, clot
  found in neck at ID, proximal and distal
  control, intraop angio if possible (75 CCA or
  ICA)

49
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 198898877.
• Johnson RF, Stewart MG, Wright CC. An
  evidence-based review of the treatment of
  peritonsillar abscess. Otolaryngol Head Neck
  Surg. 2003 Mar128(3)332-43.
• Herzon FS. Peritonsillar abscess incidence,
  current management practices, and a proposal for
  treatment guidelines. Laryngoscope 1995105
  suppl 741-7.
• Tan PT, et al. Deep neck infections in children.
  J Microbiol Immunol Infect 200134287-292.