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 11 5/2/2012 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 19 5/2/2012 20 5/2/2012 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 25 5/2/2012 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