Journ al of the Korean Radiological Society 1995 : 33(6) : 853-860
Odontogenic Versus Nonodontogenic Deep Neck Space Infections: CT Manifestations1
Hyung-Jin Kim, M.D. , Eui Dong Park, M.D., Jung Hee Kim, M.D. ,
Jae Hyoung Kim, M.D. , Eui Gee Hwang, M.D.2, Sung Hoon Chung, M.D.
Purpose : The purpose of this study was to evaluate computed tomographic (CT) findings of deep neck space infection(DNSI) with particular attentionto the differences in the spaces involved and in complications between odontogenic and nonodontogenic groups.
Materials and Methods: Forty-four patients(21 odontogenic and 23 nonodontogenic) were included in this study. Among odontogenic DNSls, 15 had the dental infection in the second or third mandibular molar. We compared the CT features betw een odontogenic and nonodontogenic DNSls with special emphasis on the differences in the spaces involved and in the rate and type of complications.
Results: In all patients, CT clearly differentiated abscess from cellulitis. The most common spaces involved in 21 patients with odontogenic DNSI were the parapharyngeal(n=18}, the submandibular( n=18}, the anterior viscera l(n=13},
꾀침 the masticator( n=9}, and the sublingua l(n=7) spaces. In contrast, in 23 patients with nonodontogenic DNSI, the anterior visceral space(n=14) was most frequently involved. The parapharyngeal, the submandib비ar, and the masticator spaces were statistically more frequently involved in odontogenic than in nonodontogenic DNSl(p < .05) . Twenty-two patients had one or more com미 i
cationsshown by CT, ofwhich airwaycompromisewas morefrequentand severe in odontogenicthan in nonodontogenic DNSI.
Conclusion : We conclude that the parapharyngeal , the submandibular, and the masticator spaces are more significantly vulnerable in odontogenic DNSI than in nonodontogenic DNSI. The predilection for certain spaces of the neck in odontogenic DNSI seems to originate from the intimate relationship of the mandibular molars to the adjacent deep neck spaces.
Index Words: Neck, infections Neck, CT Teeth
A thorough knowledge of the anatomy of the deep fascial layers and spaces of the neck is ess~ntial to understand the passageway of deep neck space infection(DNSI) , because serious life - threatening complicatons such as airway compromise , jugular vein thrombosis , mediastinal involvement, pericarditis , pneumonia , empyema, arterial erosion , or intracranial ex-
'Departmenl ofD iagnoslic Radiology, Gyeongsan Nalional Unversily Hospilal 2Departmenl olOlorhi nolaryngology, Gyeongsang Nalional Universily Hospilal Received Oclober 6, 1995; Accepled November 3, 1995 Address reprinl requesls 10 : Hyung-Jin Kim, M.D., Deparlmenl 01 Diagnoslic Radiology, Gyeongsang Nalional Unversily Hospilal ~ 92, Chi lam-dong, Chinju 660- 702, Korea
Te l. 82-591- 50-8202 Fax. 82-591- 758- 1568
tension may ensue if the diagnosis and the treatment are delayed. Recently , dental infection has become one of the most important sources of DNSI(1 , 2). It often has been described that the particular spaces of the neck tend to be involved in odontogen ic DNSI. This mainly results from the close relationship between the position of the dental roots and the origi n or insertion of the adjacent muscles of the jaw and the mouth floor(2 , 3). Although there have been many descriptions concerning the usefulness ofcomputed tomography(CT) in the evaluation of DNSI(4-14) , less attention has been paid on the different modes of spread between odontogen ic and nonodontogenic DNSls in the radiologic literature(7 , 10, 14). However , because of the reported
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Journal of the Korean Radiological Society 1995: 33(6) : 853-860
predilection of the certain spaces involvement in odontogenic DNSI , its early detection by CT may lead one to search for an odontogenic source and help one direct to the appropriate management without delay. Accordingly , the purpose of this study was to evaluate the usefulness of CT in patients with DNSI with special emphasis on the differences in the spaces involved and in complications between odontogenic and nonodontogenic DNSls.
MATERIALS and METHODS
We reviewed the CT scans of 60 patients with DNSI examined between March 1989 and May 1993 in our institution. Of the 60 patients , the cause of DNSI could be identified by the medical history or physical examination in 44 patients who formed the basis of this study. There were 28 men and 16 women with their ages ranging from 3 to 78 years(mean , 42 years). The diagnosis was established by surgery in 31 patients and by the clinical signs and symptoms in 13 patients. The specific microorganisms were isolated from the culture in 26 patients , among whom Streptococcus species was the most common aerobe demonstrated in 17 patients.
Among the causes of DNSI identified , dental infection was the most frequent etiology(n=21) , followed by trauma including surgery and foreign body injury (n=10) , upper respiratory tract or tonsillar infection (n=8) , sep- ticemia(n=2) , skin furuncle(n=1) , erysipelas(n =1) , and spread of infection by the infected second branchial cleft cyst(n=1). Among the 10 patients with trauma, there were three patients with fishbone injury , two in the cervical esophagus and one in the mouth floor , and one patient with acupuncture in the posterior neck, hematoma in the posterior neck following blunt injury, mandibular fracture , and hypopharyngeal perforation by blunt trauma each. In the remaining three patients , DNSI developed after surgery , two in the anterior neck and one in the posterior neck.
We classified the cause into odontogenic only if all of the following three criteria were met : (1) the presence of the dental infection should be documented by a dentist; (2) there should be an appropriate cause -and-ef
10
a b
fect chronological sequence between the dental problem and the clinical manifestations ; and(3) other causes could be excluded clinically. Of the 21 patients with the dental infection , the specific teeth infected were the second or third mandibular molar in 15 patients , the fi rst mandibul ar mol ar with or without the teeth anterior to it in four patients , and the second maxillary molar in one patien t. In the remaining one patient, there were widespread caries in the mandibular teeth.
CT was performed with a GE 9800 scanner( GE Medical System , Milwaukee, Wis) after the IV administraton of the contrast material. Axial scans were obtained in all patients with a 5-10mm slice thickness and table incrementation through the region of interest. The additional coronal scans were obtained in some patients. If necessary , the gantry angle was modified to minimize artifacts from metallic dental reconstructions.
We reviewed CT scans, paying partic비ar attention to the location and extent of the infectious process , the presence of an abscess to be drained , and the complication(s) associated with DNSI. Two radiologists interpreted the CT scans and reached a consensus. I nvolvement of each space by the infectious process was documented only on a present-or -absent basis. Abscess was considered to be present , ifthere was discrete low density area with peripheral rim enhancement at CT. If there was only soft tissue swelling or infiltration which 。bliterated the fascial plane(s) at CT, cellulitis was considered. When abscess in one space was accompanied by the infiltration in the contiguous space(s) at CT, we considered the patient to have both abscess and cellu litis. We then compared the CT features between odontogenic and nonodontogenic DNSls with special emphasis on the differences in the spaces involved and in the rate and type of compl ications.
According to the various authors , different terms have been applied to describe the fasciae and spaces of the deep neck. Among those , we largely adopted the terminology described by Harnsberger(15) in this paper.
Fig . 1. A 74-year-old woman with the right third mandibular molar infection CT scans at the level of the ramus (a) and the body (b) of the mandible show multiple abscesses in the right masticato r( arrow in a) , submandibular(arr。WS In 비 , and sublingual (arrowheads in b) spaces. Note the higher attenuation (open arrow in a) in the right parapharyngeal space fat in comparison with the contralateral normal side
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Hyung-Jin Kim, et al : Odontogenic Versus Nonodontogenic Deep Neck Space Infections
lection without significant complication were treated
with trial of needle aspiration followed by medication
without single case of failure. AII of seven patients
whose CT showed cellulitis alone improved with medi
cation only. Of the 37 patients who had abscess , gas
bubbles within abscess were noted in 18 patients.
RESULTS
Abscess versus Cellulitis
Of the 44 patients, seven patients were judged to
have cellulitis alone and 37 patients to have both cellu
litis and abscess based on C T. Incision and drainage
procedure was performed in 31 out of 37 patients with
abscess(es) and confirmed the CT findings. Six pati
ents in whom CT showed a minimal amount offluid col-
Differences in the Spaces Involved between
Odontogenic and Nonodontogenic DNSls
In general , in the patients with a more obvious clini-
Table 1 . Differences in the Spaces Involved between Odontogenic and Nonodontogenic Deep Neck Space Inlections (DNSls)
No. 01 Patients
Anatomic Spaces Involved
Parapharyngeal space
Submandibular space
Anterior visceral space
Masticator space
Sublingual space
Carotid space
Retropharyngeal space
Posterior cervical space
Parotid space
Paraspi nal space
SpaceolBurns
Superlicial space
"Signilicant at p<.05 by X2 analysis
Odontogenic DNSI (n=21)
18"
18a
13
9a
7" 끼4 끼/L 끼/L
o 17
를 ! μ a b
a b
- 855 -
N。nodontogenic DNSI (n=23)
5
9
14
2
3
2
8
6
2
3
3
18
Fig. 2. A 79-year-old woman with the
right second maxillary molar inlection
CT scans at the level 01 the ramus (a)
and the angle (b) 01 the mandible show
multiple abscesses with air-Iluid level in
the right superlicial(arrows) and deep
(arrowheads in a) masticator , and pa
rapharyngeal(open arrows) spaces
Fig. 3. Nonodontogenic deep neck sp
ace inlection. a. CT scan 01 a 68-year-old woman with
the upper respi ratory tract inlection
shows an abscess in the right anterior
visceral space b. CT scan 01 a 60-year-old woman with
the upper respiratory tract inlection
shows an abscess in the retropharyn
geal space.
Journal of the Korean Radiological Society 1995: 33(6) : 853-860
cal history such as trauma, tonsillitis , skin furuncle , or
the underlying neck cyst, it was easy to interpret CT findings concerning the primary site of infection. How
ever, the massive involvement of the contiguous neck
spaces seen in many patients in our study prevented us
from telling the exact pathways of the spread of infection or the initial site of infection by CT with confidence.
In many patients , infection seemed to violate the adjac
ent neck spaces without respecting the fascial barrier Nevertheless, certain spaces of the neck were more
frequently involved in odontogenic DNSI than in nono
dontogenic DNSI. The differences in the spaces invol
ved between odontogenic and nonodontogenic DNSls are summarized in Table 1. Of the 21 patients with od
ontogenic DNSI , the parapharyngeal and the subman
dibular spaces were the two most common spaces
involved seen in 18 patients each , followed by the anterior visceral , the masticator , and the sublingual sp
aces(Fig. 1 and 2). In contrast , of the 23 patients with
nonodontogenic DNSI , the anterior visceral space(Fig.
Table 2. Differences in Complications between Odontogenic and Nonodontogenic Deep Neck Space Infections (DNSls)
랩
n”
뼈
빠 -5
4
얘
-
m
빼
N Total
N0.ofPatients(n=44)
17
6
No. of Patients
Compl ications
Airway compromise
Mediastinitis/
mediastinal abscess
Jugular vein thrombosis
Empyema
Pericarditis
Aortic pseudoaneurysm
aSignilicant at p< .05 by X2 analysis.
Odontogenic DNSI (n=21)
12a
2
nu
nu
nU
2
“1훌 -... ‘ ~훌 ‘ ....... if* f li요↓‘~",...훌률톨빼b
a
c
Fig. 4. Complications of deep neck space infection. a. Mediastinal abscess: CT scan of a 39-year-old man with a traumatic injury to the hypopharynx shows a gas-containing abscess involving the mediastinum b. Jugular vein thrombosis: CT scan of a 44-year-old man with the left second mandibular molar inlection shows an abscess containing gas bubbles within the left carotid sheath , The laterally displaced internal jugular vein is severely compressed and appears in crescentic shape(arrows) , Surgery conlirmed the partially eroded and thrombosed jugular vein ,
c. Pseudoaneurysm lormation : CT scan 01 a 52-year 이 d woman with the fishbone injury to the hypopharynx shows a large abnormal vascular structure(arrow) beneath the aortic arch , accompanied by the mediastinal inlection. At surgery , inadvertent dissection of the mediastinum caused massive uncontrolled hemorrahge
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Hyung -Jin Kim, et al: Odontogen ic Versus Nonodontogen ic Deep Neck Space Infections
3a) was most 1requently involved seen in 14 patients , followed by the submandibular , the retropharyngeal (Fig. 3b) , the posterior cervical , and the parapharyngeal spaces. The parapharyngeal , the submandibular , and the masticator spaces were statistically more frequently involved in odontogenic than in nonodontogenic DNSI(p< .05). According to the specific teeth in1ected , there was no significant difference in the spaces involvement among the patients with odontogenic DNSI.
Complications of DNSI Twenty - two patients had one or more complications
shown by CT(Table 2). These were airway compromise, mediastinal involvement(Fig. 4a) , jugular vein thrombosis(Fig. 4b) , empyema, pericarditis , and pseudoaneurysm 01 the aortic arch(Fig. 4c). Among the various complications , airway compromise was statistically more frequent in odontogenic than in nonodontogenic DNSI((p < .05).
DISCUSSION
Deep neck space infection involves the spaces 01 the head and neck which are surrounded and compartmentalized by the three layers of the deep cervical fascia. It can spread via Iymphatic vessels , blood vessels , or direct extension , leading to multiple contiguous spaces involvement, and thus be categorized into transpatial disease(16). Since the advent of antibiotics, the incidence of DNSI has continuously declined , but it still occasionally causes serious life - threatening complications. For the early diagnosis and the appropriate treatment to reduce a morbidity and mor-
Buccalspace
tality , a comprehensive understanding of the pertinent cervical anatomy is crucial , described elsewhere(1 , 13, 17 -19).
Etiology of DNSI In the preantibiotic era, pharyngeal infection was the
most common cause of DNSI. However, with the introduction of antibiotics, various other portals of entry have been recognized more importantly than before(1 , 11 -13, 20) ; these are intravenous drug abuse, odontogenic in1ection , skin infection , ear infection , cervical adenitis , trauma, and so forth. It has also been reported that the cause 01 DNSI could not be found up to 50% of the cases(20). Concerning odontogenic infection , the prevalence has been reported in 9-34%(1 , 12, 20). If we include the 16 patients with unknown etiology in our study, odontogenic infection comprises 35%(21/6이 01 the etiology of DNSI.
Abscess versus Cellulitis There are different opinions about the optimal timing
of surgical therapy for DNSI. While recent investigators advocate early incision and drainage during the cellulitis stage(20) , the more or less prevailing traditional thought is that no drainage should be attempted during the stage of cellulitis(5 , 9). It is often difficult to determine clinically whether a patient with a pain1ul tender and swollen neck has an abscess or has cell비 itis
alone, because the characteristic fluctuation of an abscess frequently cannot be felt in the region 01 the deep neck(12, 13). In the study 0151 patients with neck abscess , Tom and Rice(12) reported that 11uctuation was noted only in 27%. One of the most important values 01 CT in the evaluation of DNSI is its high reliability on the
Mylohyoid
Fig . 5. Diagram demonstrating the different pathways 01 the den- Fig. 6. Diagram demonstrating the different pathways 01 the den-tal inlection according to the relationship between the buccinator tal inlection according to the relationship between the mylohy이 d
muscle attachment to the alveolar process and the position ofthe muscle attachment to the mandible and the position of the root root apices ofthe molar teeth. If a maxillary molar with a long root apices of the mandibular teeth. If a mandibular teeth with a long extending beyond the buccinator attachment is infected , inlection root extending beyond the mylohyoid ridge is infected as shown can reach the buccal space with ease, from which it can spread on the right side of the diagram, infection can directly spread to into the masticator or submandibular space. On the contrary , if a the submandibular space. In contrast, if a mandibular teeth with a mandibular molar with a short root above the buccinator attach- short root above the mylohyoid ridge is inlected as shown on the ment is infected , inlection is preponderantly directed to the oral left side of the diagram, infection tends to involve the sublingal vestibule. spaceinitially
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Journal of the Korean Radiological Society 1995 ; 33(6 ) : 853-860
differentiation between abscess and cellulitis , thus it is useful for treatment planning and management of the patients. The distinguishing feature of abscess vs ce-11 비 itis on CT scan is the enhancing rim that represents the wall of abscess. 1 n our study , surgery confirmed the CT findings in all of 31 patients whose CT showed a considerable amount of abscess fluid. In six patients in whom CT showed a minimal amount of abscess fluid , we simply aspirated the fluid followed by medication instead of incision and drainage. With this method , we could achieve the favorable clinical outcome in most of the cases
Differences in the Spaces Involved between Odontogenic and Nonodontogenic DNSls
Although the massive involvement of the contiguous neck spaces often made it difficult to make sure about the exact pathways of the spread of infection in this study, our results showed that there is a different tendency of the space involvement between odontogenic and nonodontogenic DNSls. This knowledge of the predilection sites involved in odontogenic DNSI is important because it may lead a radiologist to warn the cl inician to search for an underlying or hidden odontogenic source and help guide to remove it without delay. In our study , the parapharyngeal , the submandibular, and the masticator spaces were statistically more frequently involved in odontogenic than in nonodontogenic DNSI. Although the sublingual space was also more frequently involved in odontogenic(7/21) than in nonodontogenic(3/23) DNSI , it was not statistically significan t.
More than one anatomical relationships between the mandibular or maxillary molars and the adjacent deep neck spaces may result in the different spaces involvement between the two groups. Several important anatomic details are described below. First , in the region of the mandibular and maxillary molars, it is the attachment of the buccinator muscle to the base of the alveolar process that directs the path of the dental infection(3). If there is an infection of the mandibular or maxillary molars which have long roots extending beyond the buccinator attachment, as in the second or third mandibular and maxillary molars, it can reach the buccal space with ease , from which it can spread into the masticator or submandibular space(3 , 19) (Fig. 5). Second, infection from a mandibular molar that directly perforates the buccal or lingual plate of the mandible can invade the superficial or deep masticator space, respectively(3). Third , the relation of the apices of the mandibular teeth to the mandibular attachment of the mylohy이 d muscle is such that, in general , the roots of the second and third mandibular molars extend beyond the mylohyoid ridge , while the roots of the anterior ones never reach so far. Consequently , dental infections anterior to the second mandibular molar tend first to involve the sublingal space , while those of the second or third mandibular molar can directly involve the
submandibular space(2 , 3, 19, 22) (Fig. 6). Fourth , once the submandibular space is involved , there is more chances of the spread of infection to the parapharyngeal space because the fascial barrier between the parapharyngeal space and the submylohoid space is the thinnest providing the path of least resistance(3) . Last, although the sublingual and submandibular spaces are separated by the mylohy이 d muscle, they are freely communicating posteriorly to each other , making the infection of one space involve the other space with ease(13).
Our original thought was that there should be a different pattern of the spaces i nvolvement regardi ng the specific tooth i nfected. Unfortunately , however , we could not prove it in our study. The great part of this nonspecificity may be attributed to the subjects included in our study. In the patients who have infection in the anterior teeth , the clinical detection and the treatment usually can be made more promptly without the aid ofthe sophisticated imaging study such as CT. Most of the serious odontogenic infection requiring CT arise from the mandibular molars. Li kewise , if we exclude the one patient who had widespread caries in the mandibular teeth , all patients except one who had infection in the second maxillary molar had an infection focus in the mandibular molars , 15 patients in the second or third molar , and four patients in the first molar. Widespread infection seen in many patients in our study also masked the primary site of infection. Interestingly, although it was not included in the results , among the four patients who had infection in the first mandibular molar, the sublingual space was involved in only one patien t. The other three patients had the submandibular space involvement sparing the sublingual space. This finding suggests that the relation of the apex of the first mandibular molar to the mandibular attachment of the mylohy이 d muscle may be subject to the individual variation . In cases where it extends below the mylohyoid ridge , the submandibular space can be directly involved ; on the other hand , in cases where it lies above the mylohy이d ridge , the sublingual space is involved first(Fig. 6).
Complications of DNSI The most important role of CT in the evaluation of
DNSI is probably the identification of serious complications. A variety of complications associated with DNSI have been reported ; airway compromise , jugular vein thrombosis , mediastinal involvement , pericarditis , pneumonia, empyema, arterial erosion , intracranial extension , or necrotizing fasciitis(5 , 8, 9, 23 -25). Recognition of these potentially life -threatening complications as soon as possible should lessen morbidity and mortality by the prompt surgical procedures. In ou r study , airway compromise and mediastinal involvement were the two most frequent complications of DNSI. Although the reason is not clear , the ai rway com-
858 -
Hyung-Jin Kim , et al: Odontogenic Versus Nonodontogenic Deep Neck Space Infections
promise was more frequent and severe in odontogenic
than in nonodontogenic DNSI , similar to the results of
Tom and Rice(12). Mediastinal involvement was less
prevalent in odontogenic DNSI in our study. The spread
of DNSI into the mediastinum can occur via the anterior
visceral space or the retropharyngeal space , either of
which has components that cross the thoracic inlet(13)
In addition , mediastinitis can also result from suppu
ration in the parapharyngeal space spreading down
through the carotid sheath(11) . A single mortality case
in our series occurred in a patient with fishbone i 미 ury
to the cervical esophagus. In this patient, the medias
tinal extension of DNSI caused the erosion of the aortic
arch resulting in the formation of a pseudoaneurysm
(Fig.4c)
We conclude that somewhat different modes of sp
read of infection exist between odontogenic and nono
dontogenic DNSls and this difference originates from
the intimate relationship of the mandibular molars to
the adjacent deep neck spaces. CT should be used as
the principal diagnostic tool in the evaluation and man
agement of DNSI.
REFERENCES
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폈
Journal of the Korean Radiological Society 1995 : 33(6) : 853-860
대 한 방사 선 의 학 회 지 1995 : 33( 6) : 853-860
CT를 이용한 치성과 비치성 심부 경부 감염의 비교: 파급된 경부 공간을 중심으로1
1 경상대학교의과대학진단방사선과학교실
2경상대학교 의과대학 이비인후과학교실
김형진 · 박의동 · 김정희 · 김재형 · 황으171 2 . 정성훈
목 적 :본 논문의 목적은 CT를 이용하여 치성과 비치성 심부 경부 감염에 있어서 침범된 경부 곰간과 합병증의 차이를 알
아보기 위힘이다.
대상 및 방법 :심부 경부 갑염으로 확진되고 임상적으로 그 원인을 파악할 수 있었던 44명의 환자를 대상으로 하였으며 이
중 치성 감염자가 21 명, 비치성 감염자가 23명이었다.21명의 치성 감염자중 15명에서 선행이 된 치아 병변은 제 2 또는 제 3
하악 대구치에 있었다. 저자들은 치성과 비치성 심부 경부 감염의 두 군에서 침범된 심부 경부 공간과 합병증의 앙상에 상이
한 점이 있는지에 주안점을 두고 CT 소견을 분석하였다.
결 과 : 전예에서 CT로 농앙과 봉와직염의 구분이 가능하였다. 21 명의 치성 감염자군에서 가장 흔히 침범되는 심부 경부
공간은 각각 18명에서 관찰된 부인두강과 하악하강이었고 내장강이 13명, 저작강이 9명, 설하강이 7멸에서 침범되었다. 반면
23명의 비치성 감염자군에서는 내장강이 14명으로 가장 흔히 침범되었다. 부인두강, 하악하강과 저작근강은 치성 감염자군
에서 비치성 감염자군보다 통계학적으로 유의하게 더 흔히 침범되었다. 전체 환자중 22명에서 하나 또는 그 이상의 함병증
이 CT에서 관찰되었는데 이중 기도 압박의 소견은 치성 감염자군에서 통계학적으로 유의하게 더 흔하였다.
결 론.치성 감염시 심부 경부 공간들중 부인두강, 하악하강과 저작근강은 비치성 감엽때보다 쉽게 침범되며 치성 감염에
의한 이러한 특정 공간의 침범은 하악 대구치와 그에 인접한 경부 곰간틀간의 긴밀한 해부학적 관계에 기인한 것으로 사료
된다.
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