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October 5, 2005
Spaces
Epidemiology
Etiology
Clinical presentation
Imaging
Bacteriology
Therapy
Medical
Surgical
Complications
Mediastinitis
FASCIA COLLI
Cervical Fascia
Superficial Layer
Deep Layer
Subdivisions not
histologically separate
Superficial
Enveloping layer
Investing layer
Middle
Visceral fascia
Prethyroid fascia
Pretracheal fascia
Deep
Superficial Layer
Superior attachment –
zygomatic process
Inferior attachment –
thorax, axilla.
Similar to
subcutaneous tissue
Ensheathes platysma
and muscles of facial
expression
Superficial Layer of the Deep Cervical Fascia
Surrounds platysma
Contains areolar tissue,
nodes, nerves and vessels
Subplatysmal Flaps
Involved with cellulitis and
superficial abscesses
Treat with incision along
Langer’s lines, drainage
and antibiotics
Retropharyngeal 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.
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”
Lymphatic vessels can
receive drainage from
most of lymphatic
vessels in head and
neck.
Submandibular Space
Suprahyoid 2 compartments
Sublingual space
Areolar tissue
Superior – oral mucosa
Hypoglossal and lingual
Inferior - superficial layer nerves
of deep fascia Sublingual gland
Wharton’s duct
Anterior border –
Superior—skull base
Inferior—hyoid
Anterior—ptyergomandibular
raphe
Posterior—prevertebral fascia
Medial—buccopharyngeal
fascia
Lateral—superficial layer of
deep fascia
Pharyngomaxillary space
Prestyloid
Muscular compartment
Medial—tonsillar fossa
Lateral—medial pterygoid
Contains fat, connective
tissue, nodes
Poststyloid
Neurovascular compartment
Carotid sheath
Cranial nerves IX, X, XI, XII
Sympathetic chain
Stylopharyngeal aponeurosis of
Zuckerkandel and Testut
Alar, buccopharyngeal and
stylomuscular fascia.
Prevents infectious spread
from anterior to posterior.
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
Superior—anterior tonsil
pillar
Inferior—posterior tonsil
pillar
Masticator and Temporal Spaces
Suprahyoid
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
Parotid Space
Suprahyoid
Contains
External carotid artery
Posterior facial vein
Facial nerve
Lymph nodes
Anterior Visceral Space
Infrahyoid Superior border - thyroid
cartilage
aka – pretracheal space Inferior border - anterior
superior mediastinum down to
Enclosed by visceral division of the arch of the aorta.
middle layer of deep fascia
Contains thyroid Posterior border – anterior wall
Surrounds trachea of esophagus
Communicates laterally with
the retropharyngeal space
below the thyroid gland.
Epidemiology
All patients
Avg age b/w 40-50.
More predominant in pts
over 50 years.
Pediatric pts
Infants to teens.
Male predilection in some
case series.
Most common age group:
3-5 years.
Etiology
Odontogenic
Tonsillitis
IV drug injection
Trauma
Foreign body
Sialoadenitis
Parotitis
Osteomyelitis
Epiglottitis
URI
Iatrogenic
Congenital anomalies
Idiopathic
Clinical presentation
Most common symptoms
Sore throat (72%)
Odynophagia (63%)
Pediatric
Fever
Decreased PO
Odynophagia
Malaise
Torticollis
Neck pain
Otalgia
HA
Trismus
Neck swelling
Vocal quality change
Worsening of snoring, sleep apnea
Imaging
Lateral neck plain film
Screening exam
No benefit in pts with
DNI based on strong
clinical suspicion.
Normal:
7mm at C-2
14mm at C-6 for kids
22mm at C-6 for adults
Technique dependent
Extension
Inspiration
Sensitivity 83%,
compared to CT 100%
Imaging
MRI CT with contrast
Pros Pros
MRI superior to CT in Widely available
initial assessment Faster (5-15 minutes)
More precise identification Abscess vs cellulitis
of space involvement Less expensive
(multiplanar) Cons
Better detection of
underlying lesion Contrast
Less dental artifact Radiation
Better for floor of mouth Uniplanar
No radiation Dental artifacts
Non iodine contrast
Cons
Cost
Pt cooperation
Slower (19 to 35 minutes)
Imaging
Regular cavity wall with
ring enhancement (RE)
Sensitivity - 89%
Specificity - 0%
Irregular wall
(scalloped)
Sensitivity - 64%
Specificity - 82%
PPV - 94%
Aerobic
Bacteriology Anaerobic
G (+) n % G (-) n % n %
Staph sp. 112 15.18 Neisseria sp. 20 2.71 Bacteroides sp. 50 6.78
Coagulase neg. Staph sp. 55 7.45 E coli 3 0.41 Provotella sp. 7 0.95
Transoral drainage
Parapharyngeal,
retropharyngeal abscesses
Great vessels lateral to
abscess
Tonsillectomy for exposure
Needle aspiration
Complications
Airway obstruction
Trach 10 – 20%
Ludwig’s angina - 75%
Mediastinitis – 2.7%
UGI bleeding
Sepsis
Pneumonia
IJV thrombosis
Skin defect
Vocal cord palsy
Pleural effusion
Hemorrhage
20 - 80% mortality
Multiple space involvement
Who gets complications?
Older pts
Systemic dz
Immunodeficient pts
HIV
Myelodysplasia
Cirrhosis
DM
Most common systemic
Mbio – Klebsiella pneum. (56%)
33% with complications
Higher mortality rate
Prolonged hospital stay
20 days vs. 10 days
Descending Necrotizing
Mediastinitis
Definition – mediastinal infection in which pathology originates in
fascial spaces of head and neck and extends down.
Retropharyngeal and Danger Space – 71%
Visceral vascular – 20%
Anterior visceral – 7-8%
IV antibiotics
Cervical drainage
Cervical abscesses
Superior mediastinal abscesses
above T4 (tracheal bifurcation)
Transthoracic drainage
Abscesses below T4
Subxyphoid approach
Anterior mediastinal drainage
Thoracostomy tubes
Bibliography
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