Deep Neck Space Infection Mini Lctr

Deep Neck Space Inf Infection ection  Agung D. D. Permana,dr Permana,dr.,M.Kes.,SpT .,M.Kes.,SpTHT-KL HT-KL

Introduction DEEP NECK SPACE INFECTIONS

Life threatening delay in diagnosis/inadequate/inappropriate treatment  complications  mortality rates : 40% head and neck surgeon : cervical fascias & potential spaces  understand the treatment & potential complications antibiotics decreased the incidence and mortality

Anatomy Of The Cervical Fascia • Superficial cervical fascia • Deep cervical fascia 1. Superficial layer 2. Middle layer  - Muscular division - Visceral division

3. Deep layer  - Prevertebral division - Alar division

Investing layer of deep cervical fascia

Sternocleidomastoid

Pretracheal fascia (visceral part) Carotid sheath

T E

Pretracheal fascia (muscular part)

 Alar fascia Buccopharyngeal fascia

Prevertebral fascia

Trapezius

Deep Cervical Fascia

Cervical Fascia

Pathophysiology 

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Deep neck space infections can arise from a multitude of causes.  Whatever the initiating event, development of a deep neck space infection proceeds by one of several paths, as follows: Spread of infection can be from the oral cavity, face, or superficial neck to the deep neck 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 penetrating trauma.

Sign And Symptoms 

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Mass effect of inflamed tissue or abscess cavity on surrounding structures Direct involvement of surrounding structures  with the infectious process

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Presentation

Obtain a detailed history from patients in whom deep neck space infection is suspected. Eliciting a history of the following is important: 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

Retropharyngeal Space Infection Source •  •  •  • 

Nose Sinuses Adenoids Nasopharynx

Manifestations • • • • • •  • • 

Acute URTI in infants & children Dysphagia & odynophagia Drooling & difficult to expell excretions Cervical rigidity Muffled voice Dyspnea Unilateral bulging of posterior pharyngeal wall Sepsis

Retropharyngeal Space Infection 

Pediatrics 

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Cause  — > suppurative process in lymph nodes

"

# Nose,

adenoids, nasopharynx, sinuses!

Adults“ Cause  — > trauma, instrumentation, extension adjoining deep neck space

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Danger Space Infection Source • • •

Retropharyngeal space Prevetebral space Parapharyngeal space

Manifestations • •

Same as primary space infection Severe sepsis

Treatment Same as for primary space infection

Complication s • Potential for rapid spread through the loose areolar tissue • Inferior spread to the posterior mediastinum to the level of diafragma

Prevertebral Space Infection Source • Vertebral bodies • Penetrating injuries • Tuberculosis of the spine

Manifestations • Midline abcess • Cold abcess posterior pharynx • Slow spread of suppuration of this area

Treatment • •

Needle aspiration w/ subsequent antituberculosis th/ Stabilization of spine

Complications Spine instability

 progression

of vetebral process

Visceral Vascular Space Infection  

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potential space within the carotid sheath infections remain relatively localized  compact space contains little areolar connective tissue lymphatics contained within this space receive secondary drainage from most of the lymphatics of the head and neck  “Lincoln Highway of The Neck”  (Mosher )  all three layers of the DCF contribute to the carotid sheath

Visceral Vascular Space Infection Source   

Parapharyngeal space Submandibular space  Visceral space

Treatment   

External drainage I.V. antibiotics Possible ligation of IJV

Complications Manifestations  

Pitting edema over SCM Torticollis

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Septic shock Carotid artery erotions Endocarditis Cavernous sinus thrombosis

Pharingomaxillary Space Infection Prestyloid Compartement [anterior-muscular]    

Fat Lymph nodes Internal maxilarry artery Inferior alveolar, lingual,auriculotemporal nerves

Poststyloid Compartement [posterior-neurovascular]    

Carotid artery Internal jugular vein Symphatetic chain IX, X, XI, XII nerves

Pharingomaxillary Space Infection Source • • • • • •

 Tonsil  Pharynx  Teeth  Temporal bone (petrous)  Parotis gland  Lymph nodes of nose & nasopharynx

Manifestations • • • • •

 Medial displacement of lateral pharyngeal wall and tonsils  Trismus  Parotid edema  Retromandibular neck fullness  Dysphagia

Peritonsillar Space Infection Source Tonsils & pharynx

Manifestations • • • • • • •

 Dysphagia/odynophagia Drooling and “ hot potato voice “  Muffleed voice  Reffered otalgia  Trismus  Displaced tonsil toward midline  Deviated uvula

Submandibular Space Infection Submaxillary space

Sublingual space

• Central compartement • Submental compartement • Submaxillary compartement “subdivided by anterior bellies of digastric m.”  Contents • Submandibular gland • Lymph nodes

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 Sublingual gland  Hypoglossal nerve Wharton’s ducts

Submandibular Space Infection Source • • • •

 Teeth  Salivary glands  Pharynx & tonsils  Sinuses

Manifestations • •

 Dysphagia  Odynophagia

Treatment • •

Underlying pathology External drainage if it progress - sublingual - submandibula

Complications Ludwig’s Angina

Ludwig’s Angina

Ludwig’s angina

Masticator Space Infection Source Molar teeth

Manifestations 1. 2.

Extreme trismus Edema & tenderness over the posterior ramus of mandible

Treatment External drainage

Temporal Space Infection Temporalis m. : - superficial compartments

- deep compartments

Manifestation Pain in this area

Treatment External drainage

Trismus

Anterior Visceral Space Contents • • • • •

 Pharynx  Esophagus  Larynx  Trachea  Thyroid gland

Source • • • • •

 Tonsils  Esophageal injury  Blunt trauma w/ mucosal tear  Acute thyroiditis  Chest infection

Anterior Visceral Space

Microbiology

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Preantibiotic era—S.aureus Currently —aerobic Strep species and non-strep anaerobes Gram-negatives uncommon  Almost always polymicrobial Remember resistance !!!

Imaging 

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Lateral neck plain film "Screening exam — mainly for retropharyngeal and

 pretracheal spaces 

 Normal: 7mm at C-2, 14mm at C-6 for kids, " 

 22mm at C-6 for adults

Imaging

Imaging 

High-resolution Ultrasound 

"Advantages  

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 Avoids radiation Portable

"Disadvantages    

Not widely accepted Operator dependent Inferior anatomic detail "Uses Following infection during therapy Image guided aspiration  

Imaging 

Contrast enhanced CT 

"Advantages     

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Quick, easy  Widely available Familiarity Superior anatomic detail Differentiate abscess and cellulitis

"Disadvantages    

Ionizing radiation  Allergenic contrast agent Soft tissue detail  Artifact

Imaging MRI "Advantages 

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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 patient cooperation  Availability

Treatment 

 Airway protection

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 Antibiotic therapy

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Surgical drainage

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 Airway protection 

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"Intubation 

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"Observation

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 

 Antibiotic Therapy    

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"Alternatives  

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"Polymicrobial infections  Aerobic Strep, anaerobes  Ampicillin/sulbactam with metronidazole "Beta-Lactam resistance in 17-47% of isolates

Third generation cephalosporins clindamycin

"Culture and sensitivity

Treatment 

Surgical Drainage 

Transoral  

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Preoperative CT where are the great vessels? CT— Cruciate mucosal incision, blunt spreading through superior pharyngeal constrictor

External drainage

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Surgical Drainage  

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"External EXPOSURE, EXPOSURE!!!

approach   

Submandibular incision Submental incision T-incision

Complication    

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 Airway obstruction Ruptured abscess Internal Jugular Vein Thrombosis Carotid artery Rupture Mediastinitis

history Physical examination Secure airway Culture, IV antibiotic CT scan No abcess

Large abcess

Small abcess Needle aspiration

Watch and wait

for culture and drainage

24-48 hours

No Impending complication ?

Clinical improvement ?

Yes

Yes No

Continue antibiotic, Needle aspirations

Surgical incision  And drainage

Pharingomaxillary Space Infection Treatment 

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External drainage Tracheotomy

Complications • • • •

Septic thrombosis of IJV Carotid artery erosions Cranial nerve involvement   Mediastinitis

Peritonsillar Space Infection Treatment 

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Peroral drainage   tonsilectomy

Complications Spread into pharyngomaxilary space through posterior pharyngeal wall

Retropharyngeal Space Infection Treatment 1. 2. 3. 4.

Fasting I.V. antibiotics Tracheotomy Emergent surgical drainage - intraoral drainage - external drainage

Complications 1. 2. 3.

Rupture of abcess w/ aspiration & pneumonia Mediastinitis  Airway obstruction

Pharingomaxillary Space Infection Submandibular

Peritonsillar

VVS

Masticator

Temporal

PMS

Parotid

Retropharingeal

Danger Prevertebral

 Anterior Visceral

Mediastinum