Pariyanan Jaruchinda Department Of Otolaryngology Phramongkutklao Hospital

Anatomy of cervical fascia

Cervical fascia

1) Superficial cervical fascia 2) Deep cervical fascia

Superficial Cervical Fascia

• Encircle H&N and attached to clavicle and zygomatic arch • Contain plastysma m.

and external jugular v.

• Marginal mandibular br. of facial n. lies just deep to superficial cervical fascia

Deep Cervical Fascial

1) Superficial layer 2) Middle layer 3) Deep layer

Superficial layer (Enveloping,Investing,Anterior layer)

• From ligamentum nuchae, completely enclose the neck • Encircle trapezius m.

, sternocleidomastiod m.

• Encircle submandibular gl., parotid gl.,masticater muscle • Create superficial sternal space (of Burn)

Middle layer (Cervical layer,Pretracheal layer)

• Encircle strap m.

(muscular division) • Encircle esophagus trachea,thyroid gl., pharynx division) (visceral • Buccopharyngeal fascia ( part of visceral division that cover constrictor m. and buccinator m.)

Deep layer (Carpet fascia)

• • Cover vertebral body and paraspinous m.

Devided into 1. Alar division from base of skull to T2 level 2.Prevertebral division from base of skull to diaphram

Carotid sheath

• Extend from skull base to clavicle • Made up of 3 layer of deep cervical fascia • Contain carotid a., internal jugular v., vagus n. and sympathetic chain • Avenues for spread of infection from neck to mediastinum

Deep Neck Space Anatomy

• Space Involving Entire Length Of Neck • Space Limited To Above The Hyoid Bone • Space limited To Below The Hyoid Bone

Space Involving Entire Length Of Neck

1. Retropharyngeal Space 2. Danger Space (Prevertebral Space) 3. Paravertebral Space 4. Carotid Sheath Space

Retropharyngeal Space

• Between visceral division of middle layer and alar division of deep layer • Extend from skull base to T2 level • Midline raphae • More commom in children due to presence of retropharyngeal node

Danger Space

• Between alar division and prevetebral deep layer division of (locate posterior to retropharyngeal space) • Extend from skull base diaphram to • No midline raphae • Infection spread from neck to posterior mediastinum easily

Paravertebral Space

• Between prevertebral division of deep layer vertebral bodies and • Extend from skull base to coccyx • Infection in this space is rare and spread slowly due to compact connective tissue

Carotid sheath Space

• Made up from all deep cervical fascia • Infection from any deep fascia can spread to this space (lincoln High way)

Space Limit To Above The Hyoid Bone

1. Parapharyngeal Space 2. Submandibular Space 3. Masticator Space 4. Temporal Space 5. Parotid Space

Boundary

Parapharyngeal Space (Lateral phryngeal Space) (Pharyngomaxillaly Space)

• Superiorly • Inferiorly • Laterally • Medially : Skull base : Hyoid bone : Medial pterygoid m.

:Buccopharyngeal fascia • Anteriorly : Submandibular space • Posteromedialy : Prevertebral fascia and retrophryngeal space

Submandibular Space

Divided into 2 spaces by mylohyoid m.

1. Sublingual space (above mylohyoid m.) 2. Submaxillaly space (below mylohyiod m.) • These 2 spaces can communicate each other by mylohyoid cleft

Masticator Space

• Between masticator m . and superficial layer of deep cervical fascia (Masticator m. = massestor m.,medial and lateral pterygoid m. and temporalis muscle) • Locate anterior and lateral to parapharyngeal space

Parotid Space

• Between parotid gl . and superficial layer cervical fascia of deep • Infection can spread easily to parapharyngeal space due to incompleted encircle at upper inner surface of parotid gl.

Space Limit To Below The Hyoid Bone

Anterior Viseral Space (Pretracheal Space) • Between trachea, esophagus and middle layer of deep cervical fascia • Extend from hyoid bone to superior mediastinum

Etiology Of Deep neck Space

1. Dental infection 2. Tonsillar and peritonsillar infection 3. Trauma of upper aerodigestive tract 4. Retropharyngeal lymphadenitis 5. Pott ’ s disease 6. Sialadenitis 7. Bezold ’ s abscess 8. Infection of congenital cyst and fistula 9. Intravenous drug abuse

SPECIFIC DEEP NECK INFECTION

• •

PARAPHARYNGEAL SPACE INFECTION

Most common cause :

Peritonsillar infection Typical finding 1.

Trismus 2. Angle mandible swelling 3. Medial displacement of lateral pharyngeal wall Others : fever, limit neck motion,neurologic deficit (C.N 9,10,12,Horner ’ s syndrom)

PARAPHARYNGEAL SPACE INFECTION

Treatment

1. Evaluate and maintain airway & fluid hydration 2. Parenteral antibiotic high dose 24-48 hrs.

3. If not improve, consider surgical drainage

PARAPHARYNGEAL SPACE INFECTION

Surgical drainage 1. Intraoral approch (for peritonillar abscess only) 2. External approach -transverse submandibular incision -T. shape incision (Mosher)

SUBMANDIBULAR SPACE INFECTION

Most common cause : Dental caries

• Anterior teeth & first molar : infection enter sublingual space • Second & third molar : infection enter submaxillary space

SUBMANDIBULAR SPACE INFECTION

•

Organisms

- Mixed of aerobes (alpha hemolytic strep, staph) and anaerobes make synnergistic effect of endotoxins - Consider gram – in immunocompromize host

SUBMANDIBULAR SPACE INFECTION

Clinical feature (True Lugwig bilaterally • Induration ’ s angina) • Start unilateral and progress of submandibular region and floor of mouth ( severe cellulitis) • Tongue trusted posteriorly and superiorly (cause airway obstruction ) • Drolling , odynophagia, trismus, fever • No purulence (due to no time to developed)

SUBMANDIBULAR SPACE INFECTION

•

Treatment Early stage

(unilat,mild swelling and edema) • -IV antibiotic, extration of infected tooth

Advance stage

(bilateral swelling, dysphagia with drolling) -early airway intervention -surgical drainage (submandibular incision)

RETROPHARYNGEAL SPACE INFECTION PREVERTEBRAL SPACE INFECTION •

Most commmon cause In children

-retropharyngeal lymphadenitis from nose,PNS,ET) •

In adult

-regional truma and endoscopic procedure

RETROPHARYNGEAL SPACE INFECTION PREVERTEBRAL SPACE INFECTION

Clinical feature

• In children irritability,neck rigidity, fever,drolling,muffle cry, airway compromise • In adult fever, sore throat, odynophagia, neck tenderness, dysnea

RETROPHARYNGEAL SPACE INFECTION PREVERTEBRAL SPACE INFECTION

Clinical feature • Retropharyngeal space abscess form abscess lateral to midline • Prevertebral space abscess form abscess in midline • Mediastinitis S&S Dysnea,chest pain, tachycardia, fever,wideded mediastinum

RETROPHARYNGEAL SPACE INFECTION PREVERTEBRAL SPACE INFECTION

Investigation 1.

2.

Lateral neck film C2 > 7 mm. both children and adult C7 > 14 mm. in children > 22 mm. in adult.

Chest film - detection of mediastinitis

RETROPHARYNGEAL SPACE INFECTION PREVERTEBRAL SPACE INFECTION

Treatment

Surgical drainage 1. Intraoral drainage -Lesion confined in larynx esp.child

2. External drainage (Dean) -Lesion beyond pharyngeal level -Airway compromise -Involve other deep neck spaces

PARAVERTEBRAL SPACE INFECTION

• Most common cause Penetrating trauma (F.B, endoscope) TB spine • Infection spread slowly and more localize due to compact CNT.

Clinical feature

Same as others posterior space abscess -Vertebral osteomyelitis and spinal instability

MASTICATOR SPACE INFECTION

• Most common cause carices Dental -

Clinical feature

• Extream trismus facial swelling with minimum

Massesteric space

(lateral compartment) : edema at ramus of mandible

Ptrygomandibular space

(medial compartment): edema at retromolar trigone

MASTICATOR SPACE INFECTION

Treatment 1. Intraoral drainage (medial compartment) - along inner margin of mandibular ramus to the retromolar trigone 2. External approch (lateral compartment) - submandibular incision - preauricular incision or Gilles incision for temporal space abscess

PAROTID SPACE INFECTION

• Most common cause : Bacterial retrograde from oral cavity

Clinical feature

• high fever, weakness, mark swelling and tenderness of parotid gland,fluctuation,pus at stensen ’ s duct

PAROTID SPACE INFECTION

Treatment • IV ATB • Surgical drainage indicated for -fluctuation -medical failure after 24-48 hr. or progression of disease

COMPICATION OF DEEP NECK INFECTION

1. Internal jugular vein thrombosis 2. Cavernous sinus thrombosis 3. Neurologic deficit 4. Osteomyelitis of the mandible 5. Osteomyelitis of the spine 6.

Mediastinitis 7. Pulmonary edema 8. Pericarditis 9. Aspiration 10. Sepsis