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4. Cervical Fascia
Superficial Layer
Deep Layer
Subdivisions not
histologically separate
Superficial
Middle
Enveloping layer
Investing layer
Visceral fascia
Prethyroid fascia
Pretracheal fascia
Deep
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5. Superficial Layer
Superior attachment –
zygomatic process
Inferior attachment –
thorax, axilla.
Similar to
subcutaneous tissue
Ensheathes platysma
and muscles of facial
expression
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6. Superficial Layer of the Deep Cervical
Fascia
Completely surrounds the
neck.
Arises from spinous
processes.
Superior border – nuchal line,
skull base, zygoma, mandible.
Inferior border – chest and
axilla
Splits at mandible and covers
the masseter laterally and the
medial surface of the medial
pterygoid.
Envelopes
SCM
Trapezius
Submandibular
Parotid
Forms floor of submandibular
space
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8. Middle Layer of the Deep Cervical Fascia
Visceral Division
Superior border
Anterior – hyoid and thyroid cartilage
Posterior – skull base
Inferior border – continuous with
fibrous pericardium in the upper
mediastinum.
Buccopharyngeal fascia
Muscular Division
Superior border – hyoid and
thyroid cartilage
Inferior border – sternum, clavicle
and scapula
Envelopes infrahyoid strap
muscles
Name for portion that covers the
pharyngeal constrictors and
buccinator.
Envelopes
Thyroid
Trachea
Esophagus
Pharynx
Larynx
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9. Middle Layer of the Deep Cervical Fascia
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10. Deep Layer of Deep Cervical Fascia
Arises from spinous processes and ligamentum
nuchae.
Splits into two layers at the transverse
processes:
Alar layer
Superior border – skull base
Inferior border – upper mediastinum at T1-T2
Prevertebral layer
Superior border – skull base
Inferior border – coccyx
Envelopes vertebral bodies and deep muscles of the neck.
Extends laterally as the axillary sheath.
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11. Deep Layer of Deep Cervical Fascia
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12. Carotid Sheath
Formed by all three layers of deep fascia
Anatomically separate from all layers.
Contains carotid artery, internal jugular vein, and vagus nerve
“Lincoln’s Highway”
Travels through pharyngomaxillary space.
Extends from skull base to thorax.
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13. Deep Neck Spaces
Described in relation to the hyoid.
Entire length of neck
Suprahyoid
Superficial space
Retropharyngeal
Danger
Prevertebral
Vascular visceral
Submandibular
Pharyngomaxillary (Parapharyngeal)
Parotid
Peritonsillar
Temporal
Masticator
Infrahyoid
Anterior visceral
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14. Superficial Space
Entire length of neck
Surrounds platysma
Contains areolar tissue,
nodes, nerves and vessels
Subplatysmal Flaps
Involved with cellulitis and
superficial abscesses
Treat with incision along
Langer’s lines, drainage
and antibiotics
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15. Retropharyngeal Space
Entire length of neck.
Anterior border - pharynx and
esophagus (buccopharyngeal
fascia)
Posterior border - alar layer of
deep fascia
Superior border - skull base
Inferior border – superior
mediastinum
Combines with buccopharyngeal
fascia at level of T1-T2
Midline raphe connects superior
constrictor to the deep layer of
deep cervical fascia.
Contains retropharyngeal nodes.
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16. Space
Entire length of
neck
Anterior border alar layer of deep
fascia
Posterior border prevertebral layer
Extends from skull
base to diaphragm
Contains loose
areolar tissue.
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17. Prevertebral Space
Entire length of neck
Anterior border prevertebral fascia
Posterior border vertebral bodies and
deep neck muscles
Lateral border –
transverse processes
Extends along entire
length of vertebral column
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18. Visceral Vascular Space
Entire length of neck
Carotid Sheath
“Lincoln Highway”
Lymphatic vessels can
receive drainage from
most of lymphatic
vessels in head and
neck.
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19. Submandibular Space
Suprahyoid
2 compartments
Superior – oral mucosa
Inferior - superficial layer
of deep fascia
Anterior border –
mandible
Lateral border - mandible
Posterior - hyoid and
base of tongue
musculature
Sublingual space
Areolar tissue
Hypoglossal and lingual
nerves
Sublingual gland
Wharton’s duct
Submaxillary space
Anterior bellies of digastrics
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Submental compartment
Submaxillary
compartments
Submandibular gland
21. Pharyngomaxillary space
Suprahyoid
aka – Parapharyngeal space
Superior—skull base
Inferior—hyoid
Anterior—ptyergomandibular
raphe
Posterior—prevertebral fascia
Medial—buccopharyngeal
fascia
Lateral—superficial layer of
deep fascia
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22. Pharyngomaxillary space
Prestyloid
Poststyloid
Muscular compartment
Medial—tonsillar fossa
Lateral—medial pterygoid
Contains fat, connective
tissue, nodes
Neurovascular compartment
Carotid sheath
Cranial nerves IX, X, XI, XII
Sympathetic chain
Stylopharyngeal aponeurosis
of Zuckerkandel and Testut
Alar, buccopharyngeal and
stylomuscular fascia.
Prevents infectious spread
from anterior to posterior.
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25.
Masticator and Temporal
Spaces
Suprahyoid
Formed by superficial layer of deep
cervical fascia
Masticator space
Antero-lateral to pharyngomaxillary
space.
Contains
Masseter
Pterygoids
Body and ramus of the mandible
Inferior alveolar nerves and vessels
Tendon of the temporalis muscle
Temporal space
Continuous with masticator space.
Lateral border – temporalis fascia
Medial border – periosteum of
temporal bone
Superficial and deep spaces divided
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by temporalis muscle
26. Parotid Space
Suprahyoid
Superficial layer of deep fascia
Dense septa from capsule into
gland
Direct communication to
parapharyngeal space
Contains
External carotid artery
Posterior facial vein
Facial nerve
Lymph nodes
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27. Anterior Visceral Space
Infrahyoid
aka – pretracheal space
Enclosed by visceral division of
middle layer of deep fascia
Contains thyroid
Surrounds trachea
Superior border - thyroid
cartilage
Inferior border - anterior
superior mediastinum down to
the arch of the aorta.
Posterior border – anterior wall
of esophagus
Communicates laterally with
the retropharyngeal space
below the thyroid gland.
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28. Epidemiology
All patients
Avg age b/w 40-50.
More predominant in pts
over 50 years.
Pediatric pts
Infants to teens.
Male predilection in some
case series.
Most common age group:
3-5 years.
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30. Clinical presentation
Most common symptoms
Most common symptoms (exluding peritonsillar abscesses)
Sore throat (72%)
Odynophagia (63%)
Neck swelling (70%)
Neck Pain (63%)
Pediatric
Fever
Decreased PO
Odynophagia
Malaise
Torticollis
Neck pain
Otalgia
HA
Trismus
Neck swelling
Vocal quality change
Worsening of snoring, sleep apnea
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31. Imaging
Lateral neck plain film
Screening exam
No benefit in pts with
DNI based on strong
clinical suspicion.
Normal:
Technique dependent
7mm at C-2
14mm at C-6 for kids
22mm at C-6 for adults
Extension
Inspiration
Sensitivity 83%,
compared to CT 100%
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32. Imaging
MRI
Pros
CT with contrast
MRI superior to CT in
initial assessment
More precise identification
of space involvement
(multiplanar)
Better detection of
underlying lesion
Less dental artifact
Better for floor of mouth
No radiation
Non iodine contrast
Pros
Cons
Cons
Widely available
Faster (5-15 minutes)
Abscess vs cellulitis
Less expensive
Cost
Pt cooperation
Slower (19 to 35 minutes)
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Contrast
Radiation
Uniplanar
Dental artifacts
35. Antibiotic Therapy
Initial therapy
Cover Gram positive cocci and anaerobes
If pt is diabetic, should consider covering
gram negatives empirically.
Unasyn, Clindamycin, 2nd generation
cephalosporin.
PCN, gentamicin and flagyl - developing
nations.
IV abx alone (based on retro and
parapharyngeal infections)
Patient stability and nature of lesion.
Cellulitis/phlegmon by CT.
Abscesses in clinically stable patient.
If no clinical improvement in 24 - 48 hours
proceed to surgical intervention.
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38. Who gets complications?
Older pts
Systemic dz
Immunodeficient pts
HIV
Myelodysplasia
Cirrhosis
DM
Most common systemic
Mbio – Klebsiella pneum. (56%)
33% with complications
Higher mortality rate
Prolonged hospital stay
20 days vs. 10 days
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39. Descending Necrotizing
Mediastinitis
Definition – mediastinal infection in which pathology originates in
fascial spaces of head and neck and extends down.
Criteria for diagnosis
1.
2.
3.
Retropharyngeal and Danger Space – 71%
Visceral vascular – 20%
Anterior visceral – 7-8%
Clinical manifestation of severe infection.
Demonstration of the characteristic imaging features of mediastinitis.
Features of necrotizing mediastinal infection at surgery.
1960-89 – 43 published cases
Mortality rate 14-40%
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43. Bibliography
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Scott, BA, Stiernberg, CM, Driscoll, BP. Deep Neck Space Infections. In: Head and Neck Surgery—Otolaryngology, 2nd ed., Bailey,
BJ ed. Philadelphia, Lippincott-Raven Publishers, 1998; 819-35
Kirse, DJ, Roberson,DW. Surgical Management of Retropharyngeal Space Infections in Children. Laryngoscope, 111: 1413-1422,
2000.
Stalfors, J, Adielsson, A, Ebenfelt, A, Nethander, G, Westin, T. Deep Neck Space Infections Remain a Surgical Challenge. A Study
of 72 Patients. Acta Otolaryngol 2004; 124: 1191-1196.
Meher, R, Jain, A, Sabharwal, A, Gupta, B, Singh, I, Agarwal, AK. Deep Neck Abscess: A Prospective Study of 54 Cases. The
Journal of Laryngology and otology. April 2005. Vol 119, 299-302.
Nagy, M, Pizzuto, M, Backstrom, J, Brodsky, L. Deep Neck Infections in Children: A New Approach to Diagnosis and Treatment.
Laryngoscope. 1997; 107 (12): 1627-1634.
Huang, TT, Liu, TC, Chen, PR, Tseng, FY, Yeh, TH, Chen, YS. Deep Neck Infection: Analysis of 185 Cases. Head and Neck. 26:
854-860. 2004.
Parhiscar, A, Har-El, G. Deep neck abscess: A retrospective review of 210 cases. Annals of Otology, Rhinology and Laryngology,
2001; 110 (11): 1051-54.
Huang, TT, Tseng, FY, Lie, TC, Hsu, CJ, Chen ,YS. Deep Neck Infection in Diabetic Patients: Comparison of Clinical Picture and
Outcomes with Nondiabetic Patients. Otolaryngol Head Neck Surg 2005;13:943-7.
Munoz, A, Castillo, M, Melchor, MA, Gutierrez, R. Acute Neck Infections: Prospective Comparison Between CT and MRI in 47
Patients. Journal of Comp Ass Tomography. 2001. 25 (5): 733-741.
McClay, JE, Murray, AD, Booth, TB. Intravenous Antibiotic Therapy for Deep Neck Abscesses Defined by Computed Tomography.
Arch Otolaryngol Head Neck Surg. 2003;129:1207 – 1212.
Nagy, M, Backstrom, J. Comparison of the sensitivity of lateral neck radiographs and computed tomography scanning in pediatric
deep-neck infections. Laryngoscope, 1999; 109 (5): 775-779.
Chaudhary, N, Agrawal, S, Rai, A. Descending Necrotizing Mediastinitis: Trends in a Developing Country. Ear Nose Throat. 2005
84(4); 242-50.
Harar, R, Cranston, C, Warwick-Brown, N. Descending necrotizing mediastinitis: report of a case following steroid neck injection.
Journal Laryngol Otol. Oct 2002, vol 116; 862 – 64.
Kiernan, PD, Hernandez, A, Byrne, W, Bloom, R, Dicicco,B, Hetrick, V, Graling, P, Vaughan, B. Descending Cervical Mediastinitis.
Ann Thorac Surg 1998; 65:1483-8.
Akman, C, Kantarci, F, Cetinkaya, S. Imaging in mediastinitis: a systematic review based on aetiology. Clinical radiology (2004) 59,
573-85.
Baqain, Z, Neman, L, Hyde, N. How Serious are Oral Infections? Journ Laryngol Otol. July 2004 (118). 561-65.
Netters, F. Atlas of Human Anatomy 2nd Ed.
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Rosen, EJ, Bailey, B, Quinn, FB. Deep Neck Spaces and Infections: Grand Rounds Presentation. Dr. Quinn’s Online Textbook of
Otolaryngology Grand Rounds Archive. 2002. http://www.utmb.edu/otoref/Grnds/Deep-Neck-Spaces-2002-04/Deep-neck-spaces2002-04.doc
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44. Thank you
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