1. Deep Neck Spaces: Surgical Anatomy and Infections

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

3. Cervical Fascia
Superficial Fascia
Deep Fascia
Superficial
Middle
Deep

4. 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

5. 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

6. Superficial Layer of the Deep Cervical Fascia

7. 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

8. Middle Layer of the Deep Cervical Fascia

9. 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.

10. Deep Layer of Deep Cervical Fascia

11. 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

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

13. 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

14. 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.

15. 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

16. 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

17. 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

18. 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

19. Submandibular Space

20. 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

21. 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

22. Pharyngomaxillary Space
Communicates with several deep neck spaces.
Parotid
Masticator
Peritonsillar
Submandibular
Retropharyngeal

23. Peritonsillar Space Suprahyoid Medial—capsule of palatine tonsil
Lateral—superior pharyngeal constrictor

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

25. 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

26. 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

27. 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

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

29. 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

30. 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%

31. 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

32. 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

33. 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

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

35. 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

36. Ludwig’s angina

37. 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

38. 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

39. Parapharyngeal abscess

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

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

42. 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

43. 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%

44. Retropharyngeal Abscess

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

46. 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

47. 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

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

49. 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

50. 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

51. 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

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

53. 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
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

54. 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

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