Deep Neck Space Infections
INDIAN
ACADEMY

DENTAL

Leader in continuing dental education
www.indiandentalacademy.com

www....
Outline
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Anatomy
 Fascial planes
 Spaces
Epidemiology
Etiology
Clinical presentation
Imaging
Bacteriol...
ανατομία

www.indiandentalacademy.com
Cervical Fascia

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Superficial Layer
Deep Layer
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Subdivisions not
histologically separate
Superficial
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Middl...
Superficial Layer
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Superior attachment –
zygomatic process
Inferior attachment –
thorax, axilla.
Similar to
sub...
Superficial Layer of the Deep Cervical
Fascia
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Completely surrounds the
neck.
Arises from spinous
processes....
Superficial Layer of the Deep Cervical
Fascia

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Middle Layer of the Deep Cervical Fascia
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Visceral Division
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Superior border
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Anterior – hyoid and thyroi...
Middle Layer of the Deep Cervical Fascia

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Deep Layer of Deep Cervical Fascia
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Arises from spinous processes and ligamentum
nuchae.
Splits into two layers at the...
Deep Layer of Deep Cervical Fascia

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Carotid Sheath
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Formed by all three layers of deep fascia
Anatomically separate from all layers.
Contains caro...
Deep Neck Spaces
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Described in relation to the hyoid.
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Entire length of neck
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Suprahyoid
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...
Superficial Space
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Entire length of neck
Surrounds platysma
Contains areolar tissue,
nodes, nerves and vess...
Retropharyngeal Space
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Entire length of neck.
Anterior border - pharynx and
esophagus (buccopharyngeal
fascia)...
Space
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Entire length of
neck
Anterior border alar layer of deep
fascia
Posterior border prevertebral layer
Ext...
Prevertebral Space
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Entire length of neck
Anterior border prevertebral fascia
Posterior border vertebral bodie...
Visceral Vascular Space
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Entire length of neck
Carotid Sheath
“Lincoln Highway”
Lymphatic vessels can
receive dra...
Submandibular Space
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Suprahyoid



2 compartments
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

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Superior – oral mucosa
Inferior - superficial layer
of ...
Submandibular Space

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Pharyngomaxillary space


Suprahyoid



aka – Parapharyngeal space






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Superior—skull base
Inferior—hyoid
Ante...
Pharyngomaxillary space
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Prestyloid
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Poststyloid
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Muscular compartment
Medial—tonsillar fossa
Late...
Pharyngomaxillary Space
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Communicates
with several deep
neck spaces.
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Parotid
Masticator
Peritonsillar
Submand...
Peritonsillar Space
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Suprahyoid
Medial—capsule of
palatine tonsil
Lateral—superior
pharyngeal constrictor
Su...


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Masticator and Temporal
Spaces
Suprahyoid
Formed by superficial layer of deep
cervical fascia
Masticator space

...
Parotid Space
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Suprahyoid

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Superficial layer of deep fascia
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Dense septa from capsule into
gland
Direct commu...
Anterior Visceral Space
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Infrahyoid

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aka – pretracheal space

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Enclosed by visceral division of
middle la...
Epidemiology
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All patients

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Avg age b/w 40-50.
More predominant in pts
over 50 years.

Pediatric pts
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Infa...
Etiology
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Odontogenic
Tonsillitis
IV drug injection
Trauma
Foreign body
Sialoadenitis
Parotitis
...
Clinical presentation

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Most common symptoms



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Most common symptoms (exluding peritonsillar abscesses)





Sor...
Imaging


Lateral neck plain film





Screening exam
No benefit in pts with
DNI based on strong
clinical suspicion.
N...
Imaging


MRI
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Pros
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
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CT with contrast


MRI superior to CT in
initial assessment
More precise ide...
Imaging




Regular cavity wall with
ring enhancement (RE)
 Sensitivity - 89%
 Specificity - 0%

Irregular wall
(scall...
Aerobic

 

 

 

G (+)

n

%

 

Total

645

87.4
0

 

Strep sp.

229

Staph sp.

Bacteriology

 

 

 

 

Anaerobic

 ...
Antibiotic Therapy


Initial therapy







Cover Gram positive cocci and anaerobes
If pt is diabetic, should consid...
Surgery


External drainage


Landmarks







Transoral drainage


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Tip of greater horn of hyoid
Cricoid ca...
Complications
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Airway obstruction
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Mediastinitis – 2.7%
UGI bleeding
Sepsis
Pneumonia
IJV thrombo...
Who gets complications?
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Older pts
Systemic dz
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Immunodeficient pts
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HIV
Myelodysplasia

Cirrhosis
DM
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...
Descending Necrotizing
Mediastinitis
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Definition – mediastinal infection in which pathology originates in
fascial spaces...
Clinical Presentation
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Symptoms
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Respiratory difficulty
Tachycardia
Erythema/edema
Skin necrosis
Crep...
Mediastinitis Imaging
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Plain films
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Widened mediastinum
(superiorly)
Mediastinal emphysema
Pleural effusions
...
Treatment
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IV antibiotics
Cervical drainage
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Transthoracic drainage
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Abscesses below T4

Subxyphoid approa...
Bibliography
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Scott, BA, Stiernberg, CM, Driscoll, BP. ...
Thank you
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Deep neck-infection-051005 /certified fixed orthodontic courses by Indian dental academy

  1. 1. Deep Neck Space Infections INDIAN ACADEMY DENTAL Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
  2. 2. Outline         Anatomy  Fascial planes  Spaces Epidemiology Etiology Clinical presentation Imaging Bacteriology Therapy  Medical  Surgical Complications  Mediastinitis www.indiandentalacademy.com
  3. 3. ανατομία www.indiandentalacademy.com
  4. 4. Cervical Fascia   Superficial Layer Deep Layer   Subdivisions not histologically separate Superficial    Middle     Enveloping layer Investing layer Visceral fascia Prethyroid fascia Pretracheal fascia Deep www.indiandentalacademy.com
  5. 5. Superficial Layer     Superior attachment – zygomatic process Inferior attachment – thorax, axilla. Similar to subcutaneous tissue Ensheathes platysma and muscles of facial expression www.indiandentalacademy.com
  6. 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 www.indiandentalacademy.com
  7. 7. Superficial Layer of the Deep Cervical Fascia www.indiandentalacademy.com
  8. 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 www.indiandentalacademy.com
  9. 9. Middle Layer of the Deep Cervical Fascia www.indiandentalacademy.com
  10. 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. www.indiandentalacademy.com
  11. 11. Deep Layer of Deep Cervical Fascia www.indiandentalacademy.com
  12. 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. www.indiandentalacademy.com
  13. 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 www.indiandentalacademy.com
  14. 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 www.indiandentalacademy.com
  15. 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. www.indiandentalacademy.com
  16. 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. www.indiandentalacademy.com
  17. 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 www.indiandentalacademy.com
  18. 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. www.indiandentalacademy.com
  19. 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    www.indiandentalacademy.com Submental compartment Submaxillary compartments Submandibular gland
  20. 20. Submandibular Space www.indiandentalacademy.com
  21. 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 www.indiandentalacademy.com
  22. 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. www.indiandentalacademy.com
  23. 23. Pharyngomaxillary Space  Communicates with several deep neck spaces.      Parotid Masticator Peritonsillar Submandibular Retropharyngeal www.indiandentalacademy.com
  24. 24. Peritonsillar Space      Suprahyoid Medial—capsule of palatine tonsil Lateral—superior pharyngeal constrictor Superior—anterior tonsil pillar Inferior—posterior tonsil pillar www.indiandentalacademy.com
  25. 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 www.indiandentalacademy.com by temporalis muscle
  26. 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 www.indiandentalacademy.com
  27. 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. www.indiandentalacademy.com
  28. 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. www.indiandentalacademy.com
  29. 29. Etiology              Odontogenic Tonsillitis IV drug injection Trauma Foreign body Sialoadenitis Parotitis Osteomyelitis Epiglottitis URI Iatrogenic Congenital anomalies Idiopathic www.indiandentalacademy.com
  30. 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 www.indiandentalacademy.com
  31. 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% www.indiandentalacademy.com
  32. 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) www.indiandentalacademy.com Contrast Radiation Uniplanar Dental artifacts
  33. 33. Imaging   Regular cavity wall with ring enhancement (RE)  Sensitivity - 89%  Specificity - 0% Irregular wall (scalloped)    Sensitivity - 64% Specificity - 82% PPV - 94% www.indiandentalacademy.com
  34. 34. Aerobic       G (+) n %   Total 645 87.4 0   Strep sp. 229 Staph sp. Bacteriology         Anaerobic   G (-) n %     n % Total 137 18.5 6   Total 201 27.24 31.03 Klebsiella sp. 90 12.20 Peptostreptococcus 43 5.83 112 15.18 Neisseria sp. 20 2.71 Bacteroides sp. 50 6.78 B-hemolytic Strep 80 10.84 Acinebacter sp. 7 0.95 Unidentified 46 6.23 Strep viridans 71 9.62 Enterobacter sp. 7 0.95 Bacteroides melaninogenicus 13 1.76 Staph aureus 57 7.72 Proteus sp. 4 0.54 Propionibacterium 9 1.22 Coagulase neg. Staph sp. 55 7.45 E coli 3 0.41 Provotella sp. 7 0.95 Strep pneum 13 1.76 Citrobacter sp 2 0.27 Fusobacterium 7 0.95 Enterococcus 10 1.36 M. Catarrhalis 2 0.27 Bacteroidies fragilis 6 0.81 Mycobacterium tub.* 10 1.36 Pseudomonas sp. 1 0.14 Eubacterium 6 0.81 Micrococcus 8 1.08 H. Parainfluenza 1 0.14 Peptococcus 6 0.81 Diptheroids 7 0.95 H influenzae 1 0.14 Veillonella parvula 5 0.68 Bacillus sp. 6 0.81 Salmonella sp. 1 0.14 Clostridium sp. 4 0.54 Actinomycosis israelii 3 0.41 Lactobacillus 4 0.54 Bifidobacterium sp. 3 0.41 Polymicrobial 181 24.5 3   Sterile 71   9.62 Modified and combined data from 738 patients (1, 2, 3, 4, 5, 6, 7). www.indiandentalacademy.com
  35. 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. www.indiandentalacademy.com
  36. 36. Surgery  External drainage  Landmarks      Transoral drainage     Tip of greater horn of hyoid Cricoid cartilage Styloid process SCM Parapharyngeal, retropharyngeal abscesses Great vessels lateral to abscess Tonsillectomy for exposure Needle aspiration www.indiandentalacademy.com
  37. 37. Complications  Airway obstruction            Mediastinitis – 2.7% UGI bleeding Sepsis Pneumonia IJV thrombosis Skin defect Vocal cord palsy Pleural effusion Hemorrhage   Trach 10 – 20% Ludwig’s angina - 75% 20 - 80% mortality Multiple space involvement www.indiandentalacademy.com
  38. 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 www.indiandentalacademy.com
  39. 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% www.indiandentalacademy.com
  40. 40. Clinical Presentation  Symptoms          Respiratory difficulty Tachycardia Erythema/edema Skin necrosis Crepitus Chest pain Back pain Shock Important to have a low threshold for further workup www.indiandentalacademy.com
  41. 41. Mediastinitis Imaging  Plain films      Widened mediastinum (superiorly) Mediastinal emphysema Pleural effusions Changes appear late in the disease. CT neck and thorax.      Esophageal thickening Obliterated normal fat planes Air fluid levels Pleural effusions CT helps establish dx and surgical plan www.indiandentalacademy.com
  42. 42. Treatment   IV antibiotics Cervical drainage    Transthoracic drainage   Abscesses below T4 Subxyphoid approach   Cervical abscesses Superior mediastinal abscesses above T4 (tracheal bifurcation) Anterior mediastinal drainage Thoracostomy tubes www.indiandentalacademy.com
  43. 43. Bibliography 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 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. Lee, KJ. Essentials of Otolaryngology. 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 www.indiandentalacademy.com
  44. 44. Thank you For more details please visit www.indiandentalacademy.com www.indiandentalacademy.com

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