Deep Neck Space InfectionSchool of Medicine Padjajaran UniversityDepartmen of Otolaryngology HNSHasan Sadikin General HospitalBandung 2007Dr Sinta Sari R, M.Kes,Sp THT-KL

IntroductionDEEP NECK SPACE INFECTIONS

antibiotics decreased the incidence and mortalitydeep neck space infections remain life threateningdelay in diagnosis/inadequate/inappropriate treatment complications (mediastinitis) mortality rates : 40%head and neck surgeon :cervical fascias & potential spaces understand the treatment & potential complications

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

Cervical Fascia

Retropharyngeal Space InfectionSource 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

Retropharyngeal Space InfectionTreatmentFastingI.V. antibioticsTracheotomyEmergent surgical drainage- intraoral drainage- external drainageComplicationsRupture of abcess w/ aspiration & pneumoniaMediastinitisAirway obstruction

Danger Space InfectionSourceRetropharyngeal spacePrevetebral spaceParapharyngeal spaceManifestationsSame as primary space infectionSevere sepsisTreatmentSame as for primary space infectionComplications Potential for rapid spread through the loose areolar tissue Inferior spread to the posterior mediastinum to the level of diafragma

Prevertebral Space InfectionManifestations Midline abcess Cold abcess posterior pharynx Slow spread of suppuration of this areaTreatmentNeedle aspiration w/ subsequent antituberculosis th/Stabilization of spineSource Vertebral bodies Penetrating injuries Tuberculosis of the spineComplicationsSpine instability progression of vetebral process

Visceral Vascular Space Infectionpotential space within the carotid sheathinfections 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 InfectionSourceParapharyngeal spaceSubmandibular spaceVisceral space

ManifestationsPitting edema over SCMTorticollis

TreatmentExternal drainageI.V. antibioticsPossible ligation of IJV

ComplicationsSeptic shockCarotid artery erotionsEndocarditisCavernous sinus thrombosis

Pharingomaxillary Space Infection

Pharingomaxillary Space InfectionPrestyloid Compartement [anterior-muscular]FatLymph nodesInternal maxilarry arteryInferior alveolar, lingual,auriculotemporal nerves

Poststyloid Compartement [posterior-neurovascular]Carotid arteryInternal jugular veinSymphatetic chainIX, X, XI, XII nerves

Pharingomaxillary Space InfectionSource Tonsil Pharynx Teeth Temporal bone (petrous) Parotis gland Lymph nodes of nose & nasopharynxManifestations Medial displacement of lateral pharyngeal wall and tonsils Trismus Parotid edema Retromandibular neck fullness Dysphagia

Pharingomaxillary Space InfectionTreatment External drainageTracheotomyComplications Septic thrombosis of IJV Carotid artery erosions Cranial nerve involvement Mediastinitis

Pharingomaxillary Space InfectionPMSMasticatorSubmandibularPeritonsillarVVSDangerMediastinumAnterior VisceralTemporalParotidPrevertebralRetropharingeal

Submandibular Space InfectionSublingual space Sublingual gland Hypoglossal nerve Whartons ductsSubmaxillary space Central compartement Submental compartement Submaxillary compartementsubdivided by anterior bellies of digastric m.Contents Submandibular gland Lymph nodes

Submandibular Space InfectionSource Teeth Salivary glands Pharynx & tonsils SinusesManifestations Dysphagia Odynophagia

TreatmentUnderlying pathologyExternal drainage if it progress- sublingual- submandibula

Complications Ludwigs Angina

Masticator Space InfectionSourceMolar teeth

ManifestationsExtreme trismus Edema & tenderness over the posterior ramus of mandible

TreatmentExternal drainage

Temporal Space InfectionTemporalis m. :- superficial compartments- deep compartments ManifestationPain in this area Trismus TreatmentExternal drainage

Peritonsillar Space InfectionSourceTonsils & pharynx

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

PERITONSILLAR ABSCESS

Peritonsillar Space InfectionTreatment Peroral drainage tonsilectomy

Complications Spread into pharyngomaxilary space through posterior pharyngeal wall

Anterior Visceral SpaceContents Pharynx Esophagus Larynx Trachea Thyroid gland

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

Anterior Visceral SpaceManifestationsDysphagia/odynophagiaHoarsenessDyspneaEmphysema

ComplicationsSerious infectionLaryngeal edemaMediastinal emphysemaBronchopneumoniaSepsis TreatmentFastingI.V. hydrationAntibioticsTracheotomySurgical drainage

historyPhysical examinationSecure airwayCulture, IV antibioticCT scanSmall abcessNeedle aspiration for culture and drainageImpending complication ?No abcessLarge abcessWatch and wait 24-48 hoursClinical improvement ?Continue antibiotic,Needle aspirationsSurgical incisionAnd drainageNoYesYesNo