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Anne, Clara, Jewel || Engada K Page 1 of 8 Dr. Calavera Odontogenic and Deep Neck Mass September 12, 2012 Outline 1. Fascial Layers of the Neck 2. Neck Spaces 3. Diseases a. Necrotizing Fasciculitis b. Ludwig’s Angina c. Retropharyngeal Abscess d. Parapharyngeal Abscess e. Peritonsilar Abcess f. Parotid Abscess o Fascial layers divide the neck into true and potential spaces. o The two main fascial divisions of the neck are the superficial cervical fascia and the deep cervical fascia, which further divides into three layers. [Cummings] Superficial Cervical Fascia o Deep to the dermis o Envelops the platysma and muscles of facial expression o Deep to the platysma, a potential space separates the superficial and deep cervica; fasciae. This space houses adipose tissue, sensory nerves and blood vessels such as the anterior and external jugular veins and facilitates free movement of the skin [Cummings] o Underlies platysma and subcutaneous fat; encases sternocleidomastoid and trapezius o Attached to hyoid bone and stretches superiorly to mandibular bone and inferiorly to sternum and clavicle [Probst] Deep Cervical Fascia o Arises from the spinous process of cervical vertebrae and forms rigid tube around deep neck muscles that is adherent posteriorly to the superficial cervical fascia encasing trapezius muscles. o Part of fascial system that extends continuously from skull base to the lower end of spinal column (prevertebral gravitation abscesses) [Probst] o Divided into three layers [Cummings] A. Superficial or investing layer- surrounds the neck B. Middle layer-visceral division i. Muscular division- surrounds the strap muscles ii. Visceral division- thyroid, great vessels, carotid cyst C. Deep layer (aka prevertebral fascia)- encloses deep muscles of neck and vertebrae i. Alar fascia ii. Pre-vertebral fascia Neck Spaces Classification o The above fasciae and the structures within the neck form real and potential spaces. Many of these compartments openly communicate with each other and some spaces are contiguous with distant regions of the body, offering a route of rapid transit for infections. [Cummings] Superficial Space [2013B] o Surrounds the platysma o Contains areolar tissue, nodes, nerves and vessels o subplatysmal flaps o involved with cellulitis and superficial abscess, usually treated with incision along Langers’s lines, drainage, and antibiotics o example: Necrotizing fasciitis Deep Space o Carotid sheath The carotid or visceral vascular space is the potential space within the carotid sheath containing carotid artery, IJV, vagus nerve and sympathetic plexus. Infection from the surrpunding parapharyngeal space, penetrating trauma or IV drug use may potentiate spread into this space o Retro-pharyngeal posterior to the pharynx and esophagus, anterior to alar layer of deep fascia, posterior border is prevertebral layer [2013B] extends from skull base to diaphragm at the tracheal bifurcation. refers to the lymph node and connective tissue containing potential space between the middle and deep layers of deep cervical fascia [Cummings] carotid sheath is lateral to the space-involved by direct spread from the parapharyngeal space, or lymphatic spread from the paranasal sinuses or nasopharyngeal region, primarily in children [Cummings] o Danger space anterior border is alar layer of deep fascia, posterior border is prevertebral layer [2013B] between the retropharyngeal and prevertebral spaces potential for rapid inferior spread of infection to the posterior mediastinum through its loose areolar tissue, extends from the skull base to the diaphragm [Cummings] o Pre-vertebral anterior border is prevertebral space , posterior border are vertebral bodies and deep neck muscles, extends along the entire length of vertebral column [2013B] compact potential space, contains dense areolar tissue and lies posterior to the danger space contains paraspinous, prevertebral, and scalene muscles, vertebral artery and vein, brachial plexus, and phrenic nerve main pathways of spread to the prevertebral space are from infection of the vertebral bodies and penetrating injuries [Cummings] Suprahyoid Abscesses o Above hyoid bone Submental Masticator Parotid Ludwig’s Angina Para-pharyngeal Peri-tonsillar (quinsy) Infrahyoid Abscesses o Pre-tracheal NECROTIZING FASCILITIS o Rare infection of superficial neck space causing necrosis of fascia (initially) + subcutaneous tissue (fat) , initially sparing skin and muscle o Etiology: Dental infections, skin trauma, Quinsy (discussed later) and parapharyngeal abscess o Bacteriology: B-hemolytic streptococcus , Staphylococcus aureus, anaerobes o Necrotizing Fascilitis is a severe form of deep neck infection that occurs more often in older age groups (age older than 60 years) and immunocompromised patients, especially patients with poorly controlled diabetes. The origin of the infection is commonly odontogenic [Cummings] FASCIAL LAYERS OF THE NECK
