耳鼻喉科Otolaryngology topic five: Deep neck infection

Deep neck infection

***high mortality if diagnosis & treatment delayed***

***beware of air way***

1. Etiology: 

-- past: from tonsils and pharynx

-- now: odontogenic 

2. Anatomy: 

-- superficial cervical fascia*1+ deep cervical fascia*4 (if including carotid sheath)

Deep cervical fascia- superficial layer

-- rule of two's

Deep cervical fascia- middle layer

-- posterior midline raphe (=pharyngeal raphe) and pterygomandibular raphe

Deep cervical fascia- deep layer

-- alar portion

-- prevertebral portion

Spaces

-- retropharyngeal space:  between middle layer visceral division and alar ; nodes of Rouviere, drainage from sinus, infection more common in children

-- danger space: between alar  and prevertebral;  cervical sympathetic trunk

-- prevertebral space: phrenic nerve,  brachial plexus

-- carotid space:  vagus nerve

-- parapharyngeal space(pic below): common pathway for other cervical spaces; inverted pyramid, poststyloid compartment, prestyloid compartment

3. Infection source: odontogenic, sinusitis, pharyngitis, otitis 

-- Gram (+), consider MRSA

-- anaerobics

-- Gram (-) if immunocompromised, consider pseudomonas

-- atypical

4. Special symptoms

-- dyspnea

-- dsyphagia 

-- odynophagia  

-- voice changes

-- drooling 

-- trismus 

-- otalgia

5. Complications

--  neurovascular :carotid artery pseudoaneurysm and rupture, Lemierre’s syndrome or IJV thrombophlebitis

--  mediastinitis 

--  necrotizing cervical fasciitis 

6. Submandibular space and Ludwig angina 

-- between submandibular(posterior molar infection) and sublingual(anterior molar infection)

-- affect range from hyoid muscle to parapharngeal space

-- symptoms: rigid, trismus, voice change, dyspnea

-- need tracheotomy