深颈部间隙感染.ppt

DeepNeckSpacesandInfections ElizabethJ Rosen MDByronJ Bailey MD4 17 02 DeepNeckSpacesandInfections AnatomyoftheCervicalFasciaAnatomyoftheDeepNeckSpacesDeepNeckSpaceInfections CervicalFascia SuperficialLayerDeepLayerSuperficialMiddleDeep CervicalFascia SuperficialLayerPlatysmaMusclesofFacialExpression CervicalFascia SuperficialLayeroftheDeepCervicalFasciaMusclesSternocleidomastoidTrapeziusGlandsSubmandibularParotidSpacesPosteriorTriangleSuprasternalspaceofBurns CervicalFascia MiddleLayeroftheDeepCervicalFasciaMuscularDivisionInfrahyoidStrapMusclesVisceralDivisionPharynx Larynx Esophagus Trachea ThyroidBuccopharyngealFascia CervicalFascia DeepLayerofDeepCervicalFasciaAlarLayerPosteriortoviscerallayerofmiddlefasciaAnteriortoprevertebrallayerPrevertebralLayerVertebralbodiesDeepmusclesoftheneck CervicalFascia CarotidSheathFormedbyallthreelayersofdeepfasciaContainscarotidartery internaljugularvein andvagusnerve Lincoln sHighway DeepNeckSpaces DescribedinrelationtothehyoidEntirelengthoftheneckSuprahyoidInfrahyoid DeepNeckSpaces EntireLengthofNeck SuperficialSpaceSurroundsplatysmaContainsareolartissue nodes nervesandvesselsSubplatysmalFlapsInvolvedwithcellulitisandsuperficialabscessesTreatwithincisionalongLanger slines drainageandantibiotics DeepNeckSpaces EntireLengthofNeck RetropharyngealSpacePosteriortopharynxandesophagusAnteriortoalarlayerofdeepfasciaExtendsfromskullbasetoT1 T2 DeepNeckSpaces EntireLengthofNeck DangerSpaceAnteriorborderisalarlayerofdeepfasciaPosteriorborderisprevertebrallayerExtendsfromskullbasetodiaphragm DeepNeckSpaces EntireLengthofNeck PrevertebralSpaceAnteriorborderisprevertebralfasciaPosteriorborderisvertebralbodiesanddeepneckmusclesExtendsalongentirelengthofvertebralcolumn DeepNeckSpaces EntireLengthofNeck VisceralVascularSpaceCarotidSheath Lincoln sHighway Canbecomesecondarilyinvolvedwithanyotherdeepneckspaceinfectionbydirectspread DeepNeckSpaces Suprahyoid SubmandibularSpaceAnterior Lateral mandibleSuperior mucosaInferior superficiallayerofdeepfasciaPosterior Inferior hyoid DeepNeckSpaces Suprahyoid SubmandibularSpaceSublingualSpaceAreolartissueHypoglossalandlingualnervesSublingualglandWharton sductSubmylohyoidSpaceAnteriorbelliesofdigastricsSubmandibulargland DeepNeckSpaces Suprahyoid ParapharyngealSpaceSuperior skullbaseInferior hyoidAnterior ptyergomandibularraphePosterior prevertebralfasciaMedial buccopharyngealfasciaLateral superficiallayerofdeepfascia DeepNeckSpaces Suprahyoid ParapharyngealSpacePrestyloidMedial tonsillarfossaLateral medialpterygoidContainsfat connectivetissue nodesPoststyloidCarotidsheathCranialnervesIX X XII DeepNeckSpaces Suprahyoid PeritonsillarSpaceMedial capsuleofpalatinetonsilLateral superiorpharyngealconstrictorSuperior anteriortonsilpillarInferior posteriortonsilpillar DeepNeckSpaces Suprahyoid MasticatorandTemporalSpacesFormedbythesuperficiallayerofdeepcervicalfasciaMasseterandpterygoidsTemporalis DeepNeckSpaces Suprahyoid ParotidSpaceSuperficiallayerofdeepfasciaDenseseptafromcapsuleintoglandDirectcommunicationtoparapharyngealspace DeepNeckSpaces Infrahyoid AnteriorVisceralSpaceMiddlelayerofdeepfasciaContainsthyroid trachea esophagusExtendsfromthyroidcartilageintosuperiormediastinum DeepNeckSpaceInfections Presentation OriginofInfectionMicrobiologyImagingTreatmentComplicationsSpecialConsideration Presentation Origin RetropharyngealAbscess50 occurinpatients6 12monthsofage96 occurbefore6yearsofageChildren fever irritability lymphadenopathy torticollis poororalintake sorethroat droolingAdults pain dysphagia anorexia snoring nasalobstruction nasalregurgitationDyspneaandrespiratorydistressLateralposteriororopharyngealwallbulge Presentation Origin PediatricsCause suppurativeprocessinlymphnodesNose adenoids nasopharynx sinuses AdultsCause trauma instrumentation extensionfromadjoiningdeepneckspace Presentation Origin DangerSpacePresentationandexamnearlyidenticaltoretropharyngealspaceinfectionCause extensionfromretropharyngeal prevertebralorparapharyngealspace Presentation Origin PrevertebralSpaceBack shoulder neckpainmadeworsebydeglutitionDysphagiaordyspneaCause Pott sabscess trauma osteomyelitis extensionfromretropharyngealanddangerspaces Presentation Origin VisceralVascularSpaceIndurationandtendernessoverSCMTorticollistowardoppositesideSpikingfevers sepsisCause intravenousdrugabuse extensionfromotherdeepneckspaces Presentation Origin SubmandibularSpacePain drooling dysphagia neckstiffnessAnteriorneckswelling floorofmouthedemaCause 70 85 haveodontogenicoriginFirstmolarandanteriorSecondandthirdmolarsSialadenitis lymphadenitis lacerationsofthefloorofmouth mandiblefractures Presentation Origin Ludwig sangina1 Cellulitis notabscess2 LimitedtoSMspace3 Foulserosanguinousfluid nofrankpurulence4 Fascia muscle connectivetissueinvolvement sparingglands5 DirectspreadratherthanlymphaticspreadTender firmanteriorneckedemawithoutfluctuance Hotpotato voice droolingTachypnea dyspnea stridor Presentation Origin ParapharyngealSpaceFever chills malaisePain dysphagia trismusMedialbulgeoflateralpharyngealwallCause infectionofpharynx tonsil adenoids dentition parotid mastoid suppurativelymphadenitis extensionfromotherdeepneckspaces Presentation Origin PeritonsillarSpaceFever malaiseDysphagia odynophagia Hot potato voice trismus bulgingofsuperiortonsilpoleandsoftpalate deviationofuvulaCause extensionfromtonsillitis Presentation Origin MasticatorTemporalSpacePain trismusPosteriorFOMedemaSwellingalongramusofmandibleCause odontogenic fromthirdmolars ParotidSpacePain trismusMedialbulgeofposteriorlateralpharyngealwallCause parotitis sialolithiasis Sjogren ssyndrome Presentation Origin AnteriorVisceralSpaceHoarseness dyspnea dysphagia odynophagiaErythema edemaofhypopharynx mayextendtoincludeglottisandsupraglottisAnteriorneckedema pain erythema crepitusCause foreignbody instrumentation extensionofinfectioninthyroid Microbiology Preantibioticera S aureusCurrently aerobicStrepspeciesandnon strepanaerobesGram negativesuncommonAlmostalwayspolymicrobialRememberresistance Imaging LateralneckplainfilmScreeningexam mainlyforretropharyngealandpretrachealspacesNormal 7mmatC 2 14mmatC 6forkids 22mmatC 6foradultsTechniquedependentExtensionInspirationNagy etalSensitivity83 comparedtoCT100 Imaging High resolutionUltrasoundAdvantagesAvoidsradiationPortableDisadvantagesNotwidelyacceptedOperatordependentInferioranatomicdetailUsesFollowinginfectionduringtherapyImageguidedaspiration Imaging ContrastenhancedCTAdvantagesQuick easyWidelyavailableFamiliaritySuperioranatomicdetailDifferentiateabscessandcellulitisDisadvantagesIonizingradiationAllergeniccontrastagentSofttissuedetailArtifact Imaging ContrastenhancedCTModalityofchoiceMiller etal CTvs PEAccuracyofdiagnosis CT 77 PE 63 Sensitivity CT 95 PE 55 Imaging MRIAdvantagesNoradiationSafercontrastagentBettersofttissuedetailImaginginmultipleplanesNoartifactbydentalfillingsDisadvantagesIncreasedcostIncreasedexamtimeDependentonpatientcooperationAvailabilityMunoz etal MRIvs CT Treatment AirwayprotectionAntibiotictherapySurgicaldrainage Treatment AirwayprotectionObservationIntubationDirectlaryngoscopy possibleriskofruptureandaspirationFlexiblefiberopticTracheostomyIdeally planned awake localanesthesiaAbscessmayoverlietracheaDistortedanatomyandtissueplanes Treatment LUDWIG SANGINA PERILOUSAIRWAYParhiscarandHar ElReviewof210patientswithdeepneckabscessOverall 20 5 requiredtracheostomyLudwig sangina 75 requiredtracheostomyAttemptedintubationin20patientsFailedin11patients necessitating slash tracheostomy Treatment AntibioticTherapyCellulitisImprovementin24 48hoursAbscess Mayor etal reviewof31patients 19withCTevidenceofabscess 90 responseNagy etal reviewof47pediatricpatients 51 responserate only7ofthesehadCTevidenceofabscess Treatment AntibioticTherapyPolymicrobialinfectionsAerobicStrep anaerobesAmpicillin sulbactamwithmetronidazoleBeta Lactamresistancein17 47 ofisolatesAlternativesThirdgenerationcephalosporinsclindamycinCultureandsensitivity Treatment SurgicalDrainageTransoralPreoperativeCT wherearethegreatvessels Cruciatemucosalincision bluntspreadingthroughsuperiorpharyngealconstrictorNagy etal retro parapharyngealorcomboinkids22 23successfullytreatedwithintraoralincisionanddrainageExternal Treatment SurgicalDrainageExternalEXPOSURE EXPOSURE EXPOSURELevitt anteriorvs posteriorapproachSubmandibularincisionSubmentalincisionT incision Treatment Image guidedAspirationPatientselectionSmallerabscesses limitedextension uniloculatedPoe etal CTguidedaspirationEarlyspecimencollection reducedexpense avoidanceofneckscarYeow etal Ultrasoundguidedaspiration8 10patientssuccessfullytreatedwithneedleaspiration5 5patientssuccessfultreatedwithpigtailcatheterinsertion Complications AirwayobstructionEndotrachealintubationTracheostomyRupturedabscessPneumoniaLungAbscess Complications InternalJugularVeinThrombosisLemierre ssyndromeF C prostration swellingandpainalongSCMBacteremia septicembolization duralsinusthrombosisIVdrugabusersTreatmentIVantibiotictherapyAnticoagulation Ligationandexcision Complications CarotidArteryRuptureMortalityof20 40 Sentinelbleedsfromear nose mouthMajorityfrominternalcarotid lessfromexternalcarotid andfewestfromcommoncarotidTreatmentProximalanddistalcontrolLigationPatchingorgrafting Complications MediastinitisMortalityof40 Increasingdyspnea chestpainCXR widenedmediastinumTreatmentEARLYRECOGNITIONANDINTERVENTIONAggressiveIVantibiotictherapySurgicaldrainageTranscervicalapproachChesttubevs thoracotomy SpecialConsideration RecurrentDeepNeckSpaceInfectionTHINKCONGENITALABNORMALITYImagingshouldhelpmakethediagnosisNusbaum etal 12casesofrecurrentdeepneckinfectionMostCommon secondbranchialcleftcystOthers first third fourthbranchialcleftcysts lymphangiomas thyroglossalductcysts cervicalthymiccyst CasePresentation 43y omanpresentstotheERcomplainingofmouthandneckpain hefindsitdifficulttoswallowandhasbeenspittingouthissaliva Healsoreportsprogressiveswellinginhisneckthatittendertotouch