Deep Neck Space Abscesses and Life-Threatening Infections of the Head and Neck Carl Schreiner, MD F. B. Quinn, MD February 25, 1998

INTRODUCTION s Life-threatening infections - rare s Influence of antibiotics s Lack of systemic signs and Sx s Immunosupression

ANATOMIC CONSIDERATIONS s Teeth, tonsils s Polymicrobial infections –10:1 anaerobes s Pathways of spread –fascial planes –intracranial –periorbital

DEEP NECK SPACE INFECTIONS s Usually odontogenic –young, healthy, delayed Tx s Cervical Fascial Layers –Superficial fascia –Deep fascia u superficial (investing) u middle(visceral) u deep (prevertebral and alar layers)

SUBMANDIBULAR SPACE s Wilhelm Von Ludwig –implies bilateral involvement s boundaries –Hyoid to FOM –Ant/lat - mandible –Mylohyoid “sling” –bucopharyngeal gap

LUDWIG’S ANGINA s dysphagia, drooling, muffled voice s “woody” induration, no fluctuance s Treatment –airway control –IV ABX –Surgical drainage

LATERAL PHARYNGEAL SPACE s Inverted cone - hyoid to base of skull s Pre-styloid compartment –fat, lymph nodes, muscle s Post-styloid –carotid, IJ, CN IX - XII s pain, fever, neck swelling, ?trismus

LATERAL PHARYNGEAL SPACE s Ominous signs –Horners, bleeding, CN palsies, mediastinitis s Treatment –Surgical drainage –IV ABX u jugular vein thrombosis

RETROPHARYNGEAL SPACE s Retropharyngeal space – between alar layer and sup. constrictors – extends to sup mediastinum s Danger space –between alar and prevertebral layers –diaphragm s prevertebral space –down to coccyx

MASTICATOR SPACE s Pterygoids, masseter, temporalis m. s Comm w/ temporal space superiorly s Trismus! s CT can direct surgical approach

PERITONSILLAR ABSCESS s Areolar tissue bound by sup. constrictors s Rarely life-threatening but can spread s Serial aspiration vs I and D

NECROTIZING FASCIITIS s Synergistic, polymicrobial infection s Sup layer of deep fascia s Determining necrosis is Key –gas, crepitance, failure to respond to ABX s Treatment –IV ABX –Radical surgical debridement

ACUTE EPIGLOTTITIS s Now rare in children s “Hot potato” voice, drooling, fever s No FILMS - go to OR! –no fiberoptic exam –bronch, trach equipment ready –change to nasotracheal tube

MUCORMYCOSIS s Progressive, invasive fungal infection s Severe DM or immunocompromised s Black necrotic lesions of nose or palate s Radical surgical debridement to bleeding s Broad, nonseptate hyphae, right angles s Amphoterrible

COMPLICATIONS OF SINUSITIS s Parameningeal, periorbital location s Frontoethmoid sinuses –frontal lobe abscess, meningitis, subdural empyema s Sphenoid sinuses –Sup orbital fissure, cavernous sinus s Sx of increased intracranial pressure

OTOLOGIC COMPLICATIONS s Involve middle or posterior fossa s Epidural abscess>meningitis>brain abscess s Warning signs – early - malodorous discharge, fever, HA – late - facial paralysis., vertigo s Multiple complications are common s Malignant otitis externa