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Deep Neck Infections 55 Deep Neck Infections 55 Behrad B. Aynehchi Gady Har-El Deep neck space infections (DNSIs) are a relatively penetrating trauma, surgical instrument trauma, spread infrequent entity in the postpenicillin era. Their occur- from superfi cial infections, necrotic malignant nodes, rence, however, poses considerable challenges in diagnosis mastoiditis with resultant Bezold abscess, and unknown and treatment and they may result in potentially serious causes (3–5). In inner cities, where intravenous drug or even fatal complications in the absence of timely rec- abuse (IVDA) is more common, there is a higher preva- ognition. The advent of antibiotics has led to a continu- lence of infections of the jugular vein and carotid sheath ing evolution in etiology, presentation, clinical course, and from contaminated needles (6–8). The emerging practice antimicrobial resistance patterns. These trends combined of “shotgunning” crack cocaine has been associated with with the complex anatomy of the head and neck under- retropharyngeal abscesses as well (9). These purulent col- score the importance of clinical suspicion and thorough lections from direct inoculation, however, seem to have a diagnostic evaluation. Proper management of a recog- more benign clinical course compared to those spreading nized DNSI begins with securing the airway. Despite recent from infl amed tissue (10). Congenital anomalies includ- advances in imaging and conservative medical manage- ing thyroglossal duct cysts and branchial cleft anomalies ment, surgical drainage remains a mainstay in the treat- must also be considered, particularly in cases where no ment in many cases. apparent source can be readily identifi ed. Regardless of the etiology, infection and infl ammation can spread through- Q1 ETIOLOGY out the various regions via arteries, veins, lymphatics, or direct extension along fascial planes. When confi ned to a Knowledge of the portal of entry enables the surgeon certain area or space, this infl ammatory process will even- to anticipate the pathway of extension within the neck, tually form a phlegmon or abscess. potential complications, and sites for drainage. In the preantibiotic era, the majority of deep neck infections in FASCIAL ORGANIZATION OF THE DEEP adults and children originated from the tonsils and phar- NECK ynx, most commonly leading to parapharyngeal space infections (1). Acute rhinosinusitis in children may also An understanding of the applied anatomy of the neck cause retropharyngeal lymphadenitis. Suppuration of includes a consideration of the layers of the deep cervi- these infl amed nodes can eventually culminate in abscess cal fascia and the compartments or spaces formed by the formation. Early administration of antimicrobials in adult arrangement and attachments of these layers. This knowl- patients has led to a decreased incidence of upper respira- edge is crucial for planning treatment strategies and antici- tory tract infections and consequently signifi cantly fewer pating potential complications. The cervical fascia is divided DNSIs originating from this site. This trend has given way into the superfi cial and deep fascia. The deep fascia is fur- to infections of odontogenic sources becoming the pri- ther subdivided into three layers or components: the super- mary source of deep neck infection in adults, recognizing a fi cial, middle, and deep. A summary of the organization of strong association with poor oral hygiene and lower socio- the cervical fascia is presented in Table 55.1. Figure 55.1 Table 55.1 economic status (2). Additional but less common origins features a midsagittal visualization of the fascia and deep of deep neck infections include salivary gland infections, neck spaces. Figure 55.1 1 JJohnson_Chap55.inddohnson_Chap55.indd 1 88/18/2012/18/2012 55:48:38:48:38 PPMM 2 Section III: General Otolaryngology Superfi cial Cervical Fascia TABLE CLASSIFICATION OF FASCIA The superfi cial cervical fascia lies beneath the skin of the 55.1 IN THE NECK head and neck, extending from the top of the head down to the shoulders, axilla, and thorax. This layer covers adi- • Superfi cial cervical fascia pose tissue, sensory nerves, superfi cial vessels, lymphatics, • Deep cervical fascia the platysma muscle, and the muscles of facial expression. º Superfi cial layer of the deep cervical fascia The platysma is absent in the midline. In contrast to the º Middle layer of the deep cervical fascia deep cervical fascia, which is composed of mainly fi brous ■ Muscular layer connective tissue, the superfi cial cervical fascia is a layer of ■ Visceral layer º Deep layer of the deep cervical fascia fi brofatty tissue connecting the overlying skin to the deeper ■ Alar fascia fascial layers. Infections of this superfi cial space should be ■ Prevertebral fascia managed with appropriate antibiotic therapy in the case of º Carotid sheath formed by contributions of superfi cial, middle, cellulitis or extended to incision and drainage in the pres- and deep layers of deep cervical fascia ence of an abscess (11). Figure 55.1 Midsagittal section of the neck shows the fascia and spaces of the neck. JJohnson_Chap55.inddohnson_Chap55.indd 2 88/18/2012/18/2012 55:48:39:48:39 PPMM Chapter 55: Deep Neck Infections 3 Deep Cervical Fascia lie between the pharyngobasilar fascia anteriorly and the buccopharyngeal fascia posteriorly (12). The two raphes As noted earlier, the deep cervical fascia is a fi brous con- formed by the buccopharyngeal fascia include the poste- nective tissue layer that is, for surgical purposes, subdi- rior midline raphe, which attaches to the alar layer of the vided into the superfi cial, middle, and deep components. deep layer of the deep cervical fascia, and the pterygoman- The appropriate designation for each layer is as follows: dibular raphe within the lateral pharynx (11). Portions of the superfi cial layer of the deep cervical fascia, the middle the middle layer of the deep cervical fascia that surround layer of the deep cervical fascia, and the deep layer of the the trachea and esophagus merge with the fi brous pericar- deep cervical fascia. A practical observation is that layers dium in the superior mediastinum, representing a possible overlying nonexpansile components such as the sternoclei- portal of spread of infection. domastoid muscle (SCM) are well-developed membranes The deep layer of the deep cervical fascia, also known that can be sutured. On the other hand, fascia surrounding as the prevertebral fascia, is composed of two divisions as expansile visceral organs such as the pharynx and cheeks well: the prevertebral and alar divisions. The prevertebral is a loose areolar tissue, not amenable to suture retention. division contains the cervical vertebra, phrenic nerve, and Additionally, muscles and organs within these layers are paraspinous muscles. This fascia runs from the skull base generally free to glide upon contraction and relaxation. to the coccyx, forming the anterior wall of the preverte- The superfi cial layer of the deep cervical fascia, also bral space, with lateral and posterior attachments to the referred to as the investing layer, completely surrounds transverse spinous processes, respectively. The clinical sig- the neck. The superior nuchal line, ligamentum nuchae nifi cance of this boundary is the confi nement of primary of the cervical vertebrae, and the mastoid process are the vertebral infections to the prevertebral space with very lim- posterior attachments. The fascia splits to envelope the ited spread to the danger space. The alar division is situated sternocleidomastoid and trapezius muscles as it courses between the prevertebral division posteriorly and the buc- anteriorly. In the anterosuperior direction, an attachment copharyngeal fascia of the visceral division of the middle is made to the inferior zygomatic arch. Moving inferiorly, layer of the deep cervical fascia anteriorly, separating the the parotid gland is enveloped superfi cially, while the deep retropharyngeal and danger spaces. This layer extends from extent involves the carotid canal of the temporal bone. The the skull base to the second thoracic vertebra. The notable stylomandibular ligament, which separates the parotid structure within this plane is the cervical sympathetic trunk. and submandibular glands, is formed as this investing fas- In reviewing the deep fascial and special relationships cia tracks anteriorly to cover the submandibular gland and within the neck, the following structures are encountered muscles of mastication. The inferior extent includes attach- as one goes from anterior to posterior: the pharyngobasilar ments to the hyoid, acromion, clavicle, and scapular spine. fascia, the esophageal or constrictor musculature, the buc- The suprasternal space of Burns is formed as the fascia sur- copharyngeal fascia of the visceral division of the middle rounds the intermediate tendon of the omohyoid muscle. layer of the deep cervical fascia, the retropharyngeal space, This space may contain a lymph node along with a vessel the alar division of the deep layer of the deep cervical fas- bridging the two anterior jugular veins (12). A useful tool cia, the danger space, the prevertebral division of the deep in understanding the contents of this plane is the “rule of layer of the deep cervical fascia, the prevertebral space, and two’s,” referring to the two muscles above the hyoid bone fi nally the vertebral body (12). (masseter and anterior belly of the digastrics), two mus- The carotid sheath is formed by contributions of all cles that cross the neck (trapezius and SCM), two salivary three layers of the deep cervical fascia, extending from the glands (parotid and submandibular), and two fascial com- skull base to the thorax. Contents of this sheath include partments (parotid and masticator spaces) (11). the common carotid artery, internal jugular vein (IJV), The middle layer of the deep cervical fascia, also called vagus nerve, and ansa cervicalis (11). the visceral fascia, is divided into a muscular and visceral division. The muscular division of the middle layer of the DEEP NECK SPACE ANATOMY deep cervical fascia surrounds the sternohyoid, sternothy- roid, thyrohyoid, and omohyoid strap muscles.
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