5/2/2012
HOSSAM THABET, M.D.
Otolaryngology - Head & Neck Surgery Department Alexandria University
1 5/2/2012
Pediatric Deep Neck Space Suppuration
Neck Infections
Superficial Deep SNSI DNSI
Infection involving the Infections that spread along the superficial neck space deep fascial planes & neck spaces between superficial cervical Difficult to diagnose & treat fascia & SLDCF Fascial planes can confine & limit Easy to diagnose & treat spread of suppuration, but they are imperfect barriers.
2 5/2/2012
DNSI Is a challenging problem
1.Complex anatomy 2.Deep location 3.Difficult surgical access, 4. Proximity to great vs & ns 5.Communication- between spaces & outside the neck life-threatening complications
The knowledge of the anatomy of fascial planes, spaces, & lymphatic drainage is the basis for understanding the pathology of DNSI
Deep Neck Spaces
Anatomy of the Cervical Fascia Anatomy of the Deep Neck Spaces
3 5/2/2012
Middle Cervical Fascia
Deep
Superficial L. of D.C.F.Middle L. of D.C.F. Middle Layer of D.C. F. Alar Layer of D.C. F. Muscular D. (Pink) Visceral D. Yellow (Investing Layer)
Prevertebral Layer of Middle, Alar,& Prevertebral L. of D.C.F. Superficial, Middle, & D.C. F. Brown Deep Cervical fascia
4 5/2/2012
Deep Neck Spaces
I. Spaces involving the II. Suprahyoid Spaces entire length of the neck Sumandibular Superficial space (Sublingual & Submaxillary) Retropharyngeal space Masticator space Danger space Temporal space Prevertebral space Peritonsillar space Vascular space Parapharyngeal space Parotid space III. Infrahyoid Spaces Visceral space
Cervical Fascia Visceral Space
Vascular Space
Retropharyngeal Space
Alar Space
Prevertebral Space
Perivertebral Space
5 5/2/2012
C1 Mucosal Space
Buccal Space
Masticator Space
Parotid Space
Parapharygeal Spase
Carotid Space
Perivertebral Space Retropharyngeal Space
Etiology
Adenotonsillitis & pharyngitis (Most Common)
Odontogenic infections (Common in adults)
Cervical lymphadenitis
Traumatic Infections
1. Oral surgical procedures
2. Oropharyngeal injuries (gun shot, falls onto pencils or sticks)
3. F.B. ingestion; fish bones or other sharp objects
4. Instrumentation, (Esophagoscopy or Bronchoscopy)
6 5/2/2012
Etiology
Salivary gland infection Congenital cervical Lesions 1. Branchial cleft anomalies 2. Thyroglossal duct cysts 3. Laryngopyocele Mastoiditis with petrous apicitis & Bezold abscess Immunosuppression (HIV infection, chemotherapy, or immunosuppressant drugs)
Pathophysiology
DNSI proceeds by one of several paths: Lymphatic spread of infection from oropharynx, oral cavity, or superficial neck Suppurative Lymphadenitis Direct spread 1. Odontogenic abscess 2. Penetrating trauma 3. Sialadenitis Via communication between spaces. Hematogenous infection
7 5/2/2012
Epidemiology
Most Common Site Peritonsillar abscess (Ungkanont et al 1995) Submandibular space infections & Ludwig’s angina (Larawin V et al 2006) Retropharyngeal & parapharyngeal abscesses. (Flanary VA, Conley SF 1997, Nagy M et al 1997, & Broughton RA 1992) Pediatric pts Infants to teens / Most common: 3-5 years Male predilection
Epidemiology
Peritonsillar infections (49%) Retropharyngeal infections (22%) Submandibular infections (14%) Buccal infections (11%) Parapharyngeal space infections (2%) Canine space infections (2%) (Ungkanont et al 1995)
8 5/2/2012
LYMPHATIC SPREAD OF INFECTION FROM PHARYNX, ORAL CAVITY, OR SUPERFICIAL NECK
Cervical Suppurative Lymphadenitis
3Y/O Male with suppurated Cervical Lymphadenitis
9 5/2/2012
Cervical Suppurative Lymphadenitis
3Y/O Male with suppurated Cervical Lymphadenitis
Cervical Suppurative Lymphadenitis
1.5Y/O Male with suppurated Cervical Lymphadenitis
10 5/2/2012
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Cervical Suppurative Lymphadenitis
11 month male with L.N. Suppuration (MRSA)
Cervical Suppurative Lymphadenitis
11 month male with L.N. Suppuration (MRSA)
12 5/2/2012
Cervical Suppurative Lymphadenitis
Submandibular Space Infection
S.M.G S.M.G
Suppurative Lymphadenitis with Abscess Formation
Cervical Suppurative Lymphadenitis Submental Space Infection
Submntal Cellulitis & Lymphadenitis
13 5/2/2012
Cervical Suppurative Lymphadenitis Submental Space Infection
Lt Submandibular Lymphadenitis & Submental Abscess
Retopharyngeal Abscess
5 Y/O female child with torticollis to left side, fever , dysphagia, neck pain.
14 5/2/2012
Plain. X-ray neck shows widening of the prevertebral CECT shows enlarged adenoid space, loss of lordosis, with rim enhancement due to reversed lordosis, suppurative adenoiditis
Lt > Rt RP suppurative lymphadenitis with lucent central Lt RPA extending into the area of breakdown. Rt mucosal PPS with rim enhancement & space abscess & a Rt PPh. lucent central area of lymphadenitis (white arrows) breakdown.
15 5/2/2012
Th.G
Lt multiloculated RPA extending Extension of the Lt RPA &PP into the PPS with rim abscess into the to the visceral enhancement & lucent central space & left thyroid region (Th.G) area of breakdown. Lt ICA is with lucent area of breakdown pushed laterally with? spasm
Diagnosis 1.Complicated Acute Adenoiditis 2.Retropharyngeal Abscess 3.Lt Parapharyngeal Space Abscess 4.Visceral Space Abscess RPA 5.VascularRPA Space Involvement
MR T2WI showing widening of the retropharyngeal space with hyperintense signal due to Lt retropaharyngeal abscess (RPA)
16 5/2/2012
Retropharyngeal Abscess
Management
High risk airway!
Admit to ICU
IV antibiotics
Aspiration/Surgical drainage
Neck immobilization
Parapharyngeal Abscess
Pathogenesis Odontogenic & Pharyngotonsillar infections Other DNSI (PPS communicates with Parotid, Masticator, Peritonsillar, Submandibular, & RP, & vascular spaces) Parotitis, Sinusitis Infected neck tumors Infected brachial cleft cysts Chronic otitis, mastoiditis
17 5/2/2012
Parapharyngeal Abscess
Clinical Presentation Fever, Trismus, & Neck swelling Torticollis Dysphagia or odynophagia Signs of acute tonsillitis or pharyngitis Neck pain Medial displacement (tonsil /lateral ph. Wall) Cervical lymphadenopathy
Parapharyngeal Abscess
Management
IV abx : 10-15% cure
Airway management
Surgical drainage
18 5/2/2012
Parapharyngeal Abscess
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Nodes Of Rouviere (Lateral Retropharyngeal L.N.)
Lateral Ph.L.Ns lies between the ICA & prevertebral muscles at the upper neck. The most cephalad are known as the nodes of Rouviere
21 5/2/2012
Peritonsillar Abscess
Most common DNSI in adults Result of acute tonsillitis/ 2-5 days from onset 15 - 25% Recurrence in children Predisposing factors:
Chronic tonsillitis
Multiple trials of oral Abx
Incomplete tonsillectomies
Tonsilloliths
Dental infection
22 5/2/2012
Tonsillitis Vs Quincy
No trismus/drooling Trismus & drooling Bilateral Unilateral Tonsils inflammed Peritonsillar swelling No peritonsillar swelling Tonsil pushed medial Uvula central Uvula deviated Aspiration- No pus Aspiration- pus Imaging Imaging Respond to medical tx No response to tx
Peritonsillar Abscess
CT (Sensitivity= 100% & Specificity = 75%)
Suspicious PE & exclude retroph. abscess
Inadequate visualization
Young children
23 5/2/2012
Peritonsillar Abscess
Medical Management Hydration Analgesia 3 point aspiration – Antibiotics begin in superior-medial pole & advance 0.5 cm Surgical Management more inferior & lateral
Needle aspiration
I & D - Confirm diagnosis & definitive drainage Tonsillectomy
24 5/2/2012
ODONTOGENIC DNSI
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Odontogenic DNSI Peri-apical abscess
Most common cause of DNSI in adults Peri-apical abscess is the most common source Prior to the use of antibiotics 70-80% of DNSI were 2ry to pharyngeal infection The following structures play a role in determining the location of an abscess 2ry to a mandibular tooth infection? A. Mylohyoid line B. Buccinator muscle insertion C. Location of the tooth apex
Apex Location Space Incisors
Premolars above mylohyoid line Sublingual space 1st molar
2nd and 3rd molar below mylohyoid line Submandibular space Yonetsu K, Izumi M, Nakamura. Deep facial infections of odontogenic origin: CT assessment of pathways of space involvement. Am J Neuroradiol January 1998, 19:123-128.
26 5/2/2012
Buccinator Muscle Insertion
Intra-oral abscess Buccal Space Abscess
Buccinator Muscle
The buccinator muscle inserts on the maxilla superiorly and the mandible inferiorly. The location of an abscess secondary to a dental infection depends on where the break in the cortex occurs with reference to the insertion of the buccinator muscle. Intra-oral abscess – cortical break below the insertion on the maxilla and above the insertion on the mandible Buccal space abscess – cortical break above the insertion on the maxilla and below the insertion on the mandible.
Submandibular Space Infection
a. Sublingual Space b. Submaxillary Space (Supramyelohyoid) (Inframyelohyoid) Superficial - FOM m.m. Superior & Lateral - the mandible Medial- the genial muscles & tongue Inferior - the hyoid bone (The two subdivisions freely Anterior/posterior - digastric ms communicate around the posterior Lateral - deep cervical fascia border of the mylohyoid) Medial - hyoglossus, styloglossus, & mylohyoid ms.
27 5/2/2012
Sublingual Space Infection
Etiology: Infection of lower premolars & 1st molar with supramylohyoid perforation of the lingual cortex. Symptoms: FOM swelling with tongue elevation Extension to Submandibular, Submental, & Lateral pharyngeal spaces
Drainage via incision of the floor parallel to Wharton's duct
Submandibular Space Infection
Odontogenic (70%-85%) Sialadenitis, lymphadenitis, FOM lacerations or mandible fractures, & Bezold abscess. The mylohyoid insertion dictates the space affected by odontogenic infection. 1. The apices of 1st molar & ant.teeth (supramylohyoid) - Sublingual space involvement 2. The apices of the 2nd & 3rd molars (submylohyoid) - Submaxillary space involvement
28 5/2/2012
Submandibular Space Infection
Odontogenic Submandibular abscess
(amultiloculated low- attenuation mass with peripheral rim enhancement ).
Submandibular Space Infection
Symptoms: Swelling inferior to the mandible, between the digastric bellies down to the hyoid bone level. Treatment: Antibiotics Surgical Extraoral Drainage
an incision below & parallel to the inferior border of the mandible in the region of the angle, blunt dissection to explore the space for loculations of pus
29 5/2/2012
Submental Space Infection
Occurs to due to: 1. Lower incisor infection (Thinner buccolabial alveolar plate with leak outside below the myelohyoid) 2. Submental suppurative lymphadenitis Marked external induration No internal swelling of the FOM Moderate Odynophagia & no resp. distress
Submental Space Infection Submental Abscess
30 5/2/2012
Ludwig’s Angina
Acute, progressive cellulitis of the sublingual & submaxillary spaces (mandibular dental infection 90%)
50% mortality in the preantibiotic era, 10% in well- managed patients Common in young adults, M:F= 2:1 or 3:1 ratio
Ludwig’s Angina Clinical Picture Dysphagia/Odynophagia/Drooling
Neck Pain/Swelling/Fever
Throat & FOM Pain
Dysphonia/Dysarthria
Hot Pottato Voice
Airway Obstruction
Tongue swelling
Restricted neck movement
31 5/2/2012
Ludwig’s Angina Clinical Picture
Submandibular & Submental swelling
Elevated Woody Tongue & FOM
Suprhyoid edema & brawny induration “bull neck”
Tenderness over neck
Trismus & Fever
No fluctuance/lymphadenopathy
Percussion tenderness over involved teeth
Ludwig’s Angina
Infection can easily spread to other deep spaces of the neck and thoracic cavity if diagnosis is delayed
32 5/2/2012
Ludwig’s Angina
Management Continuous close monitoring Airway management IV antibiotic therapy (especially for anaerobes) Surgical Drainage if not responsive to abx
Masticator Space
Infection from Lower 2nd & 3rd molars & extension from contiguous fascial spaces
SLDCF
Superior Spread of Infection P Parotid Space Firm attachment to the mandible There is no fascial separation between the the location of the SLDCF with reference to the medial projection of the buccal fat pad and the inferior aspect of the mandible and the muscles MS. Therefore, tumors and infection can spread in the MS. Note: V3 travels through the MS. freely between the buccal & MS.
33 5/2/2012
Masticator Space Abscess Infection usually spreads superiorly
A B A B
CECT (A and B) show a low attenuation Post contrast axial T1WI (A) & coronal mass with peripheral rim enhancement in (B) demonstrate a low signal intensity the right MS consist with an abscess, with mass with peripheral enhancement inflammatory changes in and surrounding (abscess) in the right MS. There is the parotid. Bone erosion is noted in the superior extension along the temporalis ascending ramus of the mandible (B), muscle, which is enlarged & enhancing. consistent with osteomyelitis.
Masticator Space Abscess nd rd Infection source: Lower 2 & 3 molarS & from contiguous fascial spaces (from buccal space 1ry involvement) Extend superiorly , SLDCF is firmly attached to mandible.
Communication with the buccal & parotid spaces Symptoms: trismus, posterior-inferior face swelling
34 5/2/2012
Masticator Space Abscess
Masticator Space Abscess
Submasseteric & parotid infection Masticator space infection
Masticator space infection, lateral Lt masticator space abscess (arrow), pterygoid muscle swelling from a molar abscess (arrowhead).
35 5/2/2012
Masticator Space Abscess
Treatment:
Extraoral or Intraoral Drainage along the pterygomandibular raphe or the angle of mandible for submassetric or pterygomandibular abscess
External Drainage for temporal abscess
TRAUMATIC DNSI
36 5/2/2012
Retropharyngeal Abscess
•18 Y/O male with post traumatic retropharyngeal abscess & Surgical emphysema. Notice the A/F level & loss of cervical lordosis. How would you drain this RPA? (Exteranl Approach)
Retropharyngeal Abscess
37 5/2/2012
Retropharyngeal Abscess
38 5/2/2012
Post.Ph.W
Prevertebral Ms
39 5/2/2012
3Y/O Female
Plain Xray neck lateral view showed widening of the prevertebral space at C6 level CT was ordered Tracheotomy has been performed
40 5/2/2012
Th.G Th.G Th.G Th.G
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5 Y/O Male
43 5/2/2012
1.Pharyngoesophegeal perforation 2.Surgical Emphysema 3.Retropharyngeal Abscess 4.Visceral Abscess 5.Mediastinitis & Mediastinal Collection 6.Empyema
44 5/2/2012
“MISTAKES IN MEDICINE ARE MADE BY THOSE WHO DO NOT CARE, MORE THAN THOSE WHO DO NOT KNOW.”
45 5/2/2012
IT IS GOOD TO LEARN FROM YOUR MISTAKES. IT IS EVEN BETTER TO LEARN FROM SOMEBODY ELSE’S!
LEARN FROM THE MISTAKES OF OTHERS. YOU CAN’T LIVE LONG ENOUGH TO MAKE THEM ALL YOURSELF
46 5/2/2012
DNSI DUE TO SIALADENITIS
Parotid space infection
Cause —Bad oral hygiene, sialolithiasis, stomatitis, dehydration, rdiotherapy, Sjogren’s syndrome, severe external otitis, & immune deficincy Tense painful parotid swelling Fever No trismus No fluctuation (dense fascia) Turbid fluid may be expressed from the duct
47 5/2/2012
Parotid space infection
Left parotid Abscess
Lt Suppurative parotitis with localized abscess formation in parotid L.N.
48 5/2/2012
Parotid space infection
Acute bacterial suppurative parotitis in a neonate
Rt. Submandibular cellulitis due to Rt Suppurative submandibular Sialadenitis
49 5/2/2012
DNSI of Congenital Origin
Infected TGDC Infected Bronchogenic
Infected BCC Cyst rd th 3 & 4 branchial sinus Laryngopyocele
Infected Thymic Cyst Infected Dermoid Cyst
50 5/2/2012
Visceral Space Abscess
Neck induration, tenderness , & edema Spiking fevers, sepsis Cause:
Extension from other spaces rd th 3 & 4 branchial pouch sinus
Infected BCC
Infected thymic cysts
Infected TGDC
51 5/2/2012
Infected TGDC
Branchial Arch Anomalies Cyst External Internal Fistula Sinus Sinus Pharynx Skin
BCC with external openings are associated with the 1st & 2nd arches, whereas the 3rd & 4th arches cysts are associated with internal openings
52 5/2/2012
Type I
Extremely rare,
Ectodermal Duplication anomaly of EAC
Parallel to the EAC
Pretragal, post auricular cyst or fistula posterior to the pinna or concha.
Superior to the main trunk of VII n.
Ends in a cul-de- sac on or near a bony plate at the level of the mesotympanum.
Surgical Excision Type II
A duplication anomaly of membranes & cartilaginous EAC.(ectodermal & mesodermal).
Sinus tract extends medial, inferior,& anterior to the EAC and may extend deep to VII n.
Fistula in the concha or EAC & in the neck
Fistula opens below the angle of mandible at the anterior border of SCM, & superior to hyoid bone.
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Coronal T2 FSE F.D
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Second Branchial Cleft Cysts
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Third Branchial Cleft Cyst
60 5/2/2012
3rd arch Rt. branchial cyst
Fourth Branchial Cleft Cysts
61 5/2/2012
Th.G
Th.G
Th.G
AEF
Fistula, Methylene Blue
Arytenoid Pyriform Fossa Pyriform Fossa
Pus
Esophagus
Esophagus
62 5/2/2012
4th branchial pouch sinus
Fourth branchial pouch sinus originating in Translaryngeal course of a fourth the piriform apex (dashed lines), caudal to branchial pouch sinus. the SLN and terminating as a small cyst in the superior pole of the thyroid gland. The sinus tract is near the RLN at the cricothyroid joint.
2Y/O M
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2Y/O M
2Y/O M
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2Y/O M
2Y/O M
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2Y/O M
2Y/O M
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2Y/O M
2Y/O M
67 5/2/2012
Bronchogenic Cysts
4th branchial arch cyst & sinus
68 5/2/2012
Imaging OF DNSI
Plain x-Ray 1. Lateral neck plain film 2. Chest X-Ray High-resolution Ultrasound
CT
MRI
69 5/2/2012
Management Of DNSI Four keys to successful management Airway Control 1. Observation 2. Intubation (Flexible fiberoptic guided intubation) 3. Tracheostomy Antibiotic Therapy Surgical Drainage 1. External Drainage 2. Transoral Drainage 3. Image Guided Aspiration Treatment Of The Primary Cause (Dental Infection)
Management Of DNSI Antibiotic Therapy
Choice of antibiotics:
Amoxicillin/clavulanate + Metronidazole
Ampicillin/Sulbactam (Unasyn) + Metronidazole
Ticarcillin/Clauvulate (Timentin) + Metronidazole
Piperacillin/Tazobactam (Zosyn) + Metronidazole
Other alternatives
Clindamycin + Cipro (PCN allergy) - Adults nd 2 gen cephalosporin + Metronidazole (B. Fragilis)
Penicillin, gentamicin & flagyl - developing nations
70 5/2/2012
External Surgical Transoral Surgical Drainage Drainage
Complications Of DNSI
Airway obstruction Ruptured abscess & Aspiration Lung abscess, Pneumonia & Embyema Vascular complications - CA rupture - IJ thrombophlebitis - Cavernous sinus thrombosis Neurologic deficits V.C. paralysis- X involvement Horner’s syndrome –Sympath. chain involvement Transverse Myelitis
71 5/2/2012
Complications Of DNSI
Mediastinitis (Descending Necrotizing Mediastinitis) Septicemia Septic emboli Osteomyelitis of cervical vertebrae Atlantoaxial sublaxation (Griesel's syndrome) Necrotizing cervical fasciitis Recurrent Deep Neck Space Infection
Conclusion
DNSI are potentially lethal infections if they are not diagnosed early and treated properly.
DNSI exert fatal effect by causing local airway obstruction or extension to vital areas, such as the mediastinum or carotid sheath.
Good knowledge of the anatomy of H & N fascial planes, spaces, & lymphatic drainage are the basis for understanding the pathology of DNSI.
Recurrent DNSIs in children are usually due to congenital anomalies, commonly branchial remnants
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