Deep neck space infections

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Deep neck space infections
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fascial compartments of the neck

• Superficial cervical fascia
• Deep cervical fascia
• superficial, middle, and deep layers.
• The superficial (investing) layer of the
  deep cervical fascia invests the
  sternocleidomastoid, trapezius, strap muscles,
  parotid and submandibular
• The middle (visceral) layer surrounds the
  thyroid gland, esophagus and trachea.
• The deep layer of the deep cervical fascia
  splits into prevertebral and alar layers. The
  prevertebral layer lies immediately adjacent to
  the vertebral bodies .
• All contribute to the carotid sheath so that
  infection of any layer may spread directly to
  involve the great vessels of the neck, which have
  direct communication to the chest. 

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catastrophy

• Carotid artery rupture has a 20-40 mortality
  rate.
• Jugular vein thrombosis had a mortality rate of
  60 prior to the use of antibiotics. Identifying
  this complication is essential. Osteomyelitis and
  vertebral erosion can cause subluxation and
  subsequent spinal cord injury. In older children
  and adults, the disease spreads directly into the
  fascial planes and is a more deadly
• Mediastinitis has a 40-50 mortality rate
  secondary to sepsis. Acute necrotizing
  mediastinitis and purulent pericarditis with
  tamponade also can be fatal.

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Anatomic Considerations

• The most common sources of life-threatening soft
  tissue infections of the head and neck are the
  dentition and tonsils.
• Most infections are polymicrobial and the
  responsible bacteria are often normal flora
  (Bacteroides, Peptostreptococcus, Actimomyces,
  Fusobacterium etc). that become virulent and
  invasive when normal barriers are broken (ie.
  tonsillitis, dental abscess, trauma).
• Obligate anaerobes frequently outnumber the
  anaerobes.

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iatrogenic

• Deep space infections can be secondary to
  instrumentation of the upper respiratory tract.
• Laryngoscopy
• Endoscopy
• Feeding tube insertion
• Endotracheal intubation
• Head and neck surgery
• Dental procedures
• Injections

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parapharyngeal space

• This space (also called the lateral pharyngeal
  space or pharyngomaxillary space) occupies a
  critical area in the neck, as it communicates
  with all other fascial spaces. It sits as an
  inverted cone with its base at the base of skull
  and apex at the hyoid bone.
• It can be divided into anterior (prestyloid) and
  posterior (retrostyloid) compartments by the
  styloid process. The anterior compartment
  contains only fat, lymph nodes and muscle. The
  posterior compartment contains the carotid and
  internal jugular vessels, as well as cranial
  nerves IX through XII.

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Parapharyngeal space

• Laterally parotid gland,parotid fascia,
• medial pterygoid,mandible
• Medially pharynx separated by sup.cons
• Posteriorly communicates with
  retropharyngeal space
• Superiorly base of skull,
• Inferiorly sub mandibular gland fascia

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Parapharyngeal spaceinfection/abscess

• It can spread from
• Tonsillitis ,post tonsillectomy
  60
• Dental infections lower last
  molars 35
• Trauma
• Communication with peritonsillar,retropharyngea
  l or submandibular space

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causes

• Tonsillitis
• Peritonsillar abscess
• Dental infections
• Mastoiditis rarely via petrous apex,digastric
  muscle sheath
• Pharyngeal F.B

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Clinical features

• Pain throat,difficult swallowing
• Trismus , spasm of pterygoids
• Pyrexia,malaise,
• Painful external swelling in neck at the
  posterior part of middle third of sternomastoid
• Swelling in retromolar region
• Tonsil pushed medially
• Last cranial nerves palsies
• Parotid pushed laterally

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• CT scanning is the imaging modality of choice and
  is helpful in confirming which compartments are
  involved.

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Treatment

• Systemic antibiotic
• In complicated cases such as septic jugular vein
  thrombosis, several weeks of intravenous
  antibiotics may be required.  
• Incision and drainage
• Vertical incision at the ant.border of scm
• tracheostomy

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Complications

• Acute laryngeal oedema
• Septecimia and ijv thrombophelibitis
• Mediastinitis
• Spread to other spaces of neck

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Retropharyngeal space

• Lies between prevertebral and buccopharyngeal
  fascia
• Extending from skull base to tracheal bifurcation
• Continous below with sup.mediastinum and
  laterally with parapharyngeal space

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Retropharyngeal space infection/abscess

• Acute
• in infants more than 50 due to
  lymphadinitis secondary to URTI
• high grade temp
• sore throat
• head extension and neck stiffness
• respiratory feeding problems

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Retropharyngeal space infection/abscess

• Croupy cough
• Muffled voice
• Cervical lymphadenopathy
• Smooth swelling on one side of post.ph.wall with
  airway impairement
• May obstruct post.nares
• May push the palate down
• Infant spine short and larynx high

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Causes

• predisposing infections pharyngitis, tonsillitis,
  otitis, adenitis, sinusitis, and nasal, salivary,
  and dental infections.
• from contiguous spaces, such as the
  parapharyngeal space (eg, abscesses),
  submandibular space (eg, Ludwig angina), or
  prevertebral space (eg, osteomyelitis, diskitis).
• secondary to penetrating trauma.
• Running and falling down after putting something
  in their mouths (eg, toy, stick, popsicle,
  lollipop, toothbrush) is not unusual in children.
  Because parents may be unaware of these
  predisposing events

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Age

• Almost exclusively a pediatric diagnosis.
• Most incidents occur in children aged 6 months to
  6 years, with a mean age of 3-4 years. Other deep
  neck abscesses (eg, parapharyngeal,
  peritonsillar) are observed more frequently in
  adults and older children.

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Physical

• Most patients are febrile. Some appear toxic and
  irritable.
• Cervical lymphadenopathy, usually unilateral,
  most common
• decreased or painful range of motion of their
  necks or jaws.
• A neck mass or tenderness may be appreciated.
• may present with a muffled "hot potato" voice
  (ie, dysphonia) or with a voice that sounds like
  a duck quack (ie, cri du canard).
• may be able to appreciate a mass in the posterior
  pharyngeal wall.
• As many as 30 of patients have this mass
• This is not midline,.
• "Tracheal rock sign" elicits pain

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Physical

• Patients in respiratory distress or those who
  present with stridor or drooling have potential
  airway compromise.
• These patients prefer to lie supine with their
  necks extended, maximizing their airway patency..
• Address vascular complications in the physical
  examination.
• Jugular vein thrombophlebitis may manifest as
  tender induration at the anterior
  sternocleidomastoid border, vocal cord paralysis,
  or sepsis of an unknown source.
• Carotid artery rupture can be heralded by
  sentinel bleeding from the ear, nose, or mouth.

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In Adults

• Likely to be due to tuberculous infection of the
  cervical spine
• Slow onset
• Pharyngeal discomfort,some dysphagia
• Cervical spine radiography
• Look for associated infections

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Imaging Studies

• A lateral soft tissue neck x-ray is helpful .
• An abscess occupies the soft tissue space, which
  can be observed between the radiolucent airway
  (ie, pharynx, trachea) and the spine.
• Widening of these soft tissues is pathologic
  until proven otherwise.

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Ultrasound

• An imaging modality that is gaining popularity.
  It is safer than CT scan, since it is portable
  and does not use radiation. Ultrasound is also
  less traumatic to children, requiring less
  frequent use of sedation.

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CT scanning

• is currently the imaging modality of choice..
• can be used to determine the presence of an
  abscess and help distinguish it from cellulitis
  (an abscess has a central area of lucency). also
  can assist in determining the location of the
  abscess, extent of abscess spread, and presence
  of any complications.
• CT scan can be more than 90 sensitive.

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MRI

• produces superior images , used when the abscess
  has spread to the CNS.
• this requires a period of time when the patient
  is in an unmonitored setting. Children usually
  require sedation for this test, which is also
  dangerous in any patient with a potentially
  unstable airway.

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Needle aspiration of a suspected abscess

• Aspiration can help determine the presence of an
  abscess and help distinguish it from cellulitis.
  It can be diagnostic and therapeutic.
• An intraoral route usually is indicated, except
  when an abscess is isolated lateral to the
  carotid sheath. In this case, an external
  approach can be used. CT scan or ultrasound can
  help guide the aspiration. With an abscess
  involving multiple spaces, perform needle
  aspiration with an open external approach.

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Complications of retropharyngeal abscesses

• are secondary to mass effect,
• rupture of the abscess, or
• spread of infection.
• Rupture of the abscess can cause aspiration of
  pus, resulting in asphyxiation or pneumonia..
  Spread of the infection to the mediastinum can
  result in mediastinitis, purulent pericarditis
  ,etc. Spread of the infection laterally can
  involve the carotid sheath and cause jugular vein
  thrombosis or carotid artery rupture. Posterior
  spread of infection can result in osteomyelitis
  and erosion of the spinal column, causing
  subluxation and spinal injury. It can evolve into
  necrotizing fasciitis, sepsis, and death

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Treatment

• Incision and drainage
• Limitation of GA
• Infant wrapped and held upright
• Abscess incised with a gaurded knife
• Sinus forceps plunged into it and open
• Copious flow of pus
• Baby face turned down to allow escape
• Immediate relief
• Antibiotics

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Treatment

• Incision and drainage over the post.border of scm
  vertical incision
• Abscess is sought for by dissection between the
  carotid sheath and the prevertebral muscles and
  is drained from the neck
• Tracheostomy
• Anti TB regimes

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Submandibular Space

• The submandibular space extends from the hyoid
  bone to the mucosa of the floor of the mouth. It
  is bound anteriorly and laterally by the mandible
  and inferiorly by the superficial layer of the
  deep cervical fascia.
• The mylohyoid muscle acts as a sling across the
  mandible and divides the submandibular space into
  sublingual and submylohyoid spaces.

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Ludwig angina

• The infection of this space was described by
  Ludwig in 1836.
• He described a gangrenous infection of the neck
  with woody cellulitis without suppuration and
  insidious asphyxiation
• Cellulitis involving fascial spaces between
  muscles and other structures of the posterior
  floor of the mouth that can compromise the
  airway.

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Clinical presentation

• Most patients are young, healthy adults with an
  odontogenic infection. Usually present with mouth
  pain, dysphagia, drooling and stiff neck. In the
  case of Ludwigs angina, massive tongue and floor
  of mouth edema can rapidly lead to posterior and
  superior displacement of the tongue as well as
  anterior displacement out the mouth. The patient
  often maintains the neck in an extended position
  and may have a muffled or "hot potato" voice. The
  neck shows a characteristic erythematous woody
  swelling but fluctuance is usually absent.

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Asphyxia

• The most common cause of death in Ludwigs angina
  is asphyxia. Airway control is the first priority
  of treatment, followed by intravenous antibiotics
  and timely surgical drainage.
• Tracheotomy is still the most widely used method
  of airway control but some authors feel the risk
  of aspiration pneumonia Cricothyroidotomy is
  usually not a good option with in patients with
  massive neck edema. 

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Treatment

• Closely monitor patients with airway compromise
  and do not allow these patients to leave the
  acute care area.
• Sedation and paralytics can relax airway muscles,
  leading to complete obstruction.
• Endotracheal intubation is dangerous unless
  performed under direct visualization. consider
  fiberoptic intubation or a surgical airway (eg,
  cricothyroidotomy, tracheotomy

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Antibiotic therapy

• Broad-spectrum coverage is indicated. Clindamycin
  is first-line treatment,initiated alone or in
  combination with cefoxitin or a
  beta-lactamaseresistant penicillin, such as
  ticarcillin/clavulanate, piperacillin/tazobactam,
  or ampicillin/sulbactam.
• Patients with cellulitis can be treated with
  parenteral antibiotics alone. Closely observe
  these patients for development of an abscess.

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Surgical Care

• Surgical airway control may be necessary in
  patients whose airways are difficult to visualize
  or are obstructed completely. Depending on the
  age of the patient and the experience of the
  physician, perform needle cricothyroidostomy or
  cricothyroidotomy only if the child cannot be
  transported to the operating room safely or
  quickly. Alternatively perform a tracheotomy.

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Pharyngeal Pouches

• Acquired
• protrusion of mucosa through the muscle
  layers of the wall of an organ
• Congenital
• covered by all the muscle layers of the
• e.g Meckels diverticulum

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Pharyngeal pouch
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three inherent areas of weakness

• inferior border of the cricopharyngea with the
  superior oblique fibers of the esophagus. This is
  referred to as Laimer's triangle.
• A second inherent weak point is between the
  oblique and the transverse fibers of the
  cricopharyngeus muscle this is referred to as
  the Killian-Jamieson area, where lateral or
  Killian-Jamieson diverticula can form.
• Then, finally, the most significant area is the
  Killian's triangle, which is formed by the
  inferior-most fibers of the inferior constrictor
  muscle with the superior border of the
  cricopharyngea, and this is thought to be where
  the Zenker's diverticulum develops.

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theories

• One of the primary theories is pharyngoesophageal
  incoordination , an incoordination between the
  opening of the cricopharyngeus and the
  peristaltic contractions propagating the bolus
  through the hypopharynx.
• Another theory of the development of Zenker's is
  that of cricopharyngeal spasm, and that likely
  in response to stimulation by reflux - the
  cricopharyngeus muscle simply spasms down.

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Zenker's diverticulum

• 1877 .the German pathologist, Zenker, described
  that traction diverticulum is formed due to
  external traction on the wall of the digestive
  tract resulting in the pouch formation, whereas
  the pulsion diverticulum is formed because of an
  imbalance of intraluminal force combined with the
  strength of the digestive tract wall. Foregut
  diverticula can also be classified based on their
  anatomic location, one of which is the
  midesophageal diverticulum, another described as
  the epiphrenic diverticulum. There are small
  transitory diverticula which appear throughout
  the swallowing cycle and then disappear and
  then, of course, the hypopharyngeal diverticulum
  or Zenker's diverticulum.

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Zenker's

• It is typically in the seventh and eighth
  decades. It is predominantly in males . Now the
  incidence varies depending on the region that you
  are in. In the United Kingdom, which has the
  highest incidence, it is about 2100,000 people
  per year.

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Clinical features

• Commonest symptoms are dysphagia, regurgitation
  and cough
• Recurrent aspiration can result in pulmonary
  complications
• A carcinoma can develop within the pouch
• Clinical signs are often absent
• A cervical lump may be present that gurgles on
  palpation

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Zenker's present with

• dysphagia, between 80 and 90.
• regurgitation of undigested food.
• The combination of regurgitation of undigested
  food with cervical borborygmi is almost
  pathognomonic of Zenker's diverticulum.
• 30 to 40 will present with aspiration and a
  chronic cough,
• and up to 15 of these total patients will
  actually have episodes of aspiration pneumonia

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diagnostic evaluation

• consists of primarily the barium swallow, which
  shows, as in our patient, a posterior pharyngeal
  diverticulum with pooling of contrast. The
  swallow can also offer other clues.

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Treatment

• Depends on size of pouch and age of patient
• Options include
• Diverticulectomy
• Dohlman's procedure

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Diverticulectomy

• Fascia at anterior border of sternomastoid is
  divided
• Pouch is identified anterior to prevertebral
  fascia
• Pouch is then excised an defect closed
• Cricopharyngeal myotomy is performed to prevent
  recurrence
• Patient should be feed via a nasogastric tube for
  a week postoperatively
• Complications include
• Recurrent laryngeal nerve palsy
• Cervical emphysema
• Mediastinitis
• Cutaneous fistula

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endoscopic diverticulectomy

• reintroduced in 1960 by Dohlman with no more
  mortality and only a 7 recurrence rate.
• In 1993, Collard introduced the next major
  breakthrough in using the endoscopic GIA
  staple-assisted diverticulectomy.
• Other methods that have been used are KTP lasers,
  CO 2 lasers, and flexible endoscopy with
  electrocautery.

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Dohlman's procedure

• Is an endoscopic procedure
• A double-lipped oesophagoscope is used
• Wall between the diverticulum and oesophageal
  wall is exposed
• Hypopharyngeal bar divided with diathermy or
  laser
• Minimally invasive techniques allow
• Shorter duration of anaesthesia
• More rapid resumption of oral intake
• Shorter hospital stay
• Quicker recovery

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• thanks