Deep Neck Spaces: Surgical Anatomy and Infections

Deep Neck Spaces and Infections Anatomy of the Cervical Fascia Anatomy of the Deep Neck Spaces Deep Neck Space Infections

Cervical Fascia Superficial Fascia Deep Fascia Superficial Middle Deep

Superficial Layer Superior attachment – zygomatic process Inferior attachment – thorax, axilla. Similar to subcutaneous tissue Ensheathes platysma and muscles of facial expression Marginal mandibular lies deep to it

Superficial Layer of the Deep Cervical Fascia Completely surrounds the neck from skull to chest Arises from spinous processes, ligamentum nuchae Superior border – nuchal line, skull base, zygoma, mandible. Inferior border –scapula, clavicle and manubrium 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 Fascia

Middle Layer of the Deep Cervical Fascia Visceral Division Superior border Anterior – hyoid and thyroid cartilage Posterior – skull base Inferior border – continuous with fibrous pericardium in the upper mediastinum. Buccopharyngeal fascia 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

Deep Layer of Deep Cervical Fascia Arises from spinous processes and ligamentum nuchae. Lies deep to the trapezius Forms fascial carpet of the posterior triangle, which is also the fascia on the lateral surface of scalene muscles Reflected outwards as a sleeve along the brachial plexus and axillary vessels Splits into two layers at the transverse processes: Alar layer Prevertebral layer Envelopes vertebral bodies and deep muscles of the neck.

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. At the level of clavicle it fuses with the covering of great vessels at the root of neck and the pericardium

Deep Neck Spaces Described in relation to the hyoid Entire length of the neck Suprahyoid Infrahyoid

Deep Neck Spaces Entire Length of Neck: Superficial Space Surrounds platysma Contains areolar tissue, nodes, nerves and vessels Subplatysmal Flaps Involved in 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 T4 Midline raphe- spaces of Gilette 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. Space 4 of Grodinsky and Holyoke

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” Can become secondarily involved with any other deep neck space infection by direct spread

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 2 compartments 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

Pharyngomaxillary space Suprahyoid: Parapharyngeal Space (lateral pharyngeal, peripharyngeal, pharyngomaxillary, pterygopharyngeal, pterygomandibular, pharyngomasticatory) Superior—skull base Inferior—hyoid Posterior—prevertebral fascia Medial—buccopharyngeal fascia Lateral—med pterygoid, mandible, parotid

Pharyngomaxillary space Prestyloid Muscular compartment Medial—tonsillar fossa Lateral—medial pterygoid Contains fat, connective tissue, nodes, int maxillary a., inf alveolar n., lingual n., auriculotemporal n. Poststyloid Neurovascular compartment Carotid sheath Cranial nerves IX, X, XI, XII Sympathetic chain

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

Parotid Space Suprahyoid Superficial layer of deep fascia Dense septa from capsule into gland Direct communication to parapharyngeal space

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

Deep Neck Spaces Infrahyoid: Visceral Compartment (Space 3 of Grodinsky and Holyoke) Middle layer of deep fascia Contains thyroid, trachea, esophagus Extends from thyroid cartilage into superior mediastinum

Deep Neck Spaces Infrahyoid: Visceral Compartment 2 spaces- Retrovisceral space {Retropharyngeal space} Extends along whole length of neck Pretracheal space Superiorly - attachment of strap muscles to thyroid and hyoid Inferiorly - up to upper border of arch of aorta

Deep Neck Space Infections Etiology/ pathogenesis of Infection Microbiology Clinical manifestations Some specific infections Complications

Etiology/pathogenesis DNSI have been recognised from the time of Galen in 2nd century AD Preantibiotic era – 70% from infections of pharynx and tonsils Present situation Dental infection (major source) Peritonsillar cellulitis or abscess Upper aerodigestive tract trauma Retropharyngeal lymphadenitis Pott’s disease Sialadenitis – submandibular, parotid From temporal bone- Bezold’s abscess, petrous apex infections Congenital cysts and fistulas Intravenous drug abuse

Microbiology Preantibiotic era – S. aureus Currently Aerobes – alpha hemolytic Streptococci, S. aureus Anaerobes – Fusobacterium, Bacteroides, Peptostreptococcus, Veilonella Gram-negatives uncommon Almost always polymicrobial Asmar (1990) – 90% polymicrobial, aerobes found in all, anaerobes in >50%

Clinical manifestations Pain Constant feature Indication of extension or resolution Exception – retropharyngeal abscess in children Fever Initial spike, followed by elevated temperature Spiking temperatures- doubt septicemia/septic thrombophlebitis of IJV/mediastinal extension Swelling Trismus and limitation of neck movements – depending on site Progressive dysphagia and odynophagia Voice change Dyspnoea Chest pain

Ludwig’s angina Described by William Friedrich von Ludwig, 1836 (“gangrenous induration of the connective tissues of the neck which advances to involve the tissues which cover the small muscles between the larynx and the floor of mouth”) Infection of submandibular space Anterior teeth and first molars – infection of sublingual space Second and third molars – infection of submaxillary space

Ludwig’s angina Criteria for diagnosis Pseudo – ludwig’s angina Rapidly progressive cellulitis, not an abscess Develops along fascial planes by direct spread, not lymphatic spread Does not involve submandibular gland or lymph nodes Involves both sublingual and submaxillary spaces, usually bilateral Pseudo – ludwig’s angina Other inflammatory conditions involving floor of mouth Limited infections involving only sublingual space, submandibular lymph nodes, submandibular gland, submental space, or abscesses involving one or more of these spaces

Etiology 75-80% dental cause Extraction of a diseased molar initiates infection Penetrating injury of the floor of mouth Mandibular fractures

Clinical features Young man with poor dentition, increasing oral or neck pain and swelling Increasing edema and induration of perimandibular region and floor of mouth Thrusting of tongue posteriorly and superiorly Neck rigidity, trismus, odynophagia, fever Dyspnoea and strider

Ludwig’s angina

Ludwig’s angina TREATMENT Early stage- IV antibiotics {penicillin + metronidazole}, extraction of the diseased tooth Late stage- Airway {tracheostomy } Surgery Horizontal incision with wide exposure Tissues have peculiar “salt pork” appearance, with woody induration, watery edema, and little bleeding Gross purulence is rare Multiple drains/wound kept open

Parapharyngeal abscess Causes Peritonsillar abscess Dental infection From other spaces Trauma Clinical features Anterior compartment Prolapse of tonsil Trismus External swelling behind angle of jaw Odynophagia, fever Posterior compartment Bulge of LPW behind posterior pillar Lower cranial n. paralysis Horner’s syndrome Swelling of parotid region Odynophagia, fever

Parapharyngeal abscess

Parapharyngeal abscess Treatment IV antibiotics Surgery External approach Transverse submandibular incision Mosher’s T-shaped incision

Retropharyngeal Abscess Pediatrics Cause—suppurative process in lymph nodes Nose, adenoids, nasopharynx, sinuses Adults Cause—trauma, instrumentation, extension from adjoining deep neck space

Retropharyngeal Abscess 50% occur in patients 6-12 months of age 96% occur before 6 years of age Children - fever, irritability, lymphadenopathy, torticollis, poor oral intake, sore throat, drooling Adults - pain, dysphagia, odynophagia, anorexia Dyspnea and respiratory distress Lateral posterior oropharyngeal wall bulge

Retropharyngeal Abscess Lateral neck plain film Screening investigation Normal: 7mm at C-2, 14mm at C-6 for kids, 22mm at C-6 for adults (Wholey et al) Loss of cervical lordosis Technique dependent Extension Inspiration Nagy et al Sensitivity 83%, compared to CT 100%

Retropharyngeal Abscess

Retropharyngeal Abscess Treatment IV antibiotics and fluid replacement Surgical drainage Intraoral External – tracheostomy + anterior cervical approach

Peritonsillar abscess (quinsy) Cause Extension from tonsillitis De novo Clinical features Fever with chills and rigor Odynophagia “Hot Potato” voice Halitosis Trismus Congested tonsil with edematous pillar Treatment IV antibiotics and fluids Surgical drainage Intraoral

Masticator Temporal Space infection Cause Odontogenic Trauma Superficial compartment Extensive facial swelling Severe trismus Pain Deep compartment Trismus Dysphagia and odynophagia Intraoral swelling in RMT area Treatment IV antibiotics Surgery Intraoral Along inner margin of mandibular ramus in RMT area External Horizontal incision, 2-3cm beneath angle of mandible

Complications Airway obstruction Ruptured abscess Tracheostomy Endotracheal intubation Ruptured abscess Pneumonia Lung Abscess

Complications Internal Jugular Vein Thrombophlebitis (Lemierre’s syndrome) Fusobacterium necrophorum High fever with chills and rigor Swelling and pain along SCM Bacteremia, septic embolization, dural sinus thrombosis IV drug abusers Treatment IV antibiotics Anticoagulation - controversial Ligation and excision

Complications Carotid Artery Rupture Mortality of 20-40% Sentinel bleeds from ear, nose, mouth Majority from internal carotid, less from external carotid, and fewest from common carotid Treatment Proximal and distal control Ligation Patching or grafting

Complications Mediastinitis Mortality of 40% Increasing dyspnea, chest pain CXR - widened mediastinum Treatment EARLY RECOGNITION AND INTERVENTION Aggressive IV antibiotic therapy Surgical drainage Transcervical approach Chest tube vs. thoracotomy

Complications Cranial nerve deficits Necrotising cervical fasciitis Osteomyelitis Grisel syndrome ( inflammatory torticollis causing cervical vertebral subluxation )

Deep neck space infections- A relook at the present day clinical profile and management Ramesh A, Sameer N, Kumar S, Thakar A, Deka RC Hospital plus vol III, No. 8, August 1998 30 cases 1990-1997 Parapharyngeal space most commonly involved Dental and unknown etiology most prevalent Mixed flora- need to include metronidazole and aminoglycoside Airway compromise, mediastinal involvement, IJV thrombosis Need for early surgical exploration in …… CT scan reliable in detecting extent and airway compromise to help plan surgery

Special considerations Airway protection Observation Intubation Direct laryngoscopy: risk of rupture and aspiration Flexible fiberoptic Tracheostomy Safest Abscess may overlie trachea Distorted anatomy and tissue planes

Special considerations Image-guided Aspiration Patient selection Smaller abscesses, limited extension, uniloculated Advantages Early specimen collection Reduced expense Avoidance of neck scar