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Deep neck and mediastinal necrotizing infection secondary to a traumatic intubation: Report of a case
CASE REPORTS J Oral Maxillofac 46:76&791,
Surg
1966
Deep Neck and Mediastinal Necrotizing Infection Secondary to a Trauma tic In tuba tion: Report of a Case JOSHUA URAM DMD,* AND MICHAEL S. HAUSER DMD, MDt
pression with multiple suicide attempts. The patient was stabilized in the emergency room and transferred to the medical intensive care unit. She became alert the following day and was extubated. She was transferred to the medical floor two days after admission. While in the medical intensive care unit, the patient developed a fever of unknown origin. Physical examination, radiographs of the chest, blood cultures. and urine cultures were negative. On the third hospital day, she complained of a severe sore throat and demonstrated dysphagia and right neck tenderness. The Oral and Maxillofacial Surgery service was consulted on the fourth hospital day. At that time the patient had an erythematous oropharynx in addition to some swelling and erythema of the anterior neck and superior sternum. The patient’s temperature was 102” F and the white blood cell count was 11,700. An initial diagnosis of an infected pharyngeal abrasion was made, and empirically the patient was administered penicillin-G, 2 million units every four hours. A CT scan of the head-neck-chest was ordered to rule out possible abscess formation. The patient was instructed to stop chain smoking cigarettes, which she refused, and to begin oral rinsing. On the fifth hospital day, the patient’s complaint of neck and throat tenderness increased. She was too uncooperative to allow a CT scan of the neck to be taken. During the following two days, the patient’s sore throat improved, although there was no improvement of the neck tenderness or superior chest erythema. Her temperature remained at 103” F. On the eighth hospital day, her condition deteriorated, and she showed torticollis of the right neck, increased trismus, dyspnea, and cervical and supraclavicular tenderness. The patient was in much distress and appeared toxic. She was taken to the operating room for examination of the pharynx, exploration of the neck, and drainage of probable deep neck infection. Once the patient was anesthetized and intubated, direct laryngoscopy of the pharynx revealed no perforations. However, the right pharyngeal wall was erythematous and contused, this being the probable site of perforation or trauma from the emergent intubation eight days earlier. Needle aspiration deep to the sternocleidomastoid muscles bilaterally easily produced pus. A collar incision was made extending from the right posterior head of the sternocleidomastoid to the left posterior head, about 1 cm above the clavicles. When the anterior skin flap and superficial fascia was raised, some of the inferior heads of the sternocleidomastoid muscles were found to be ne-
Introduction Deep infections of the neck can be lifethreatening in both children and adults because of involvement of the upper airway, major vessels, and mediastinal communication. They can be classified as being localized within a contained fascial space, or nonlocalized with diffuse soft tissue infection and/or widespread tissue necrosis. The causes of these problems are usually infections of the structures in the upper aerodigestive tract or visceral neck organs (teeth, tonsils, thryoid), and trauma to the neck.’ Most of these infections of the deep neck are polymicrobial in nature, usually involving the oropharyngeal flora.2 The state of the patient’s health and their immune system also play an important role.3 This article presents an unusual case in which a traumatic intubation resulted in a severe, widespread neck infection.
Report of a Case A 39-year-old woman was brought to the emergency room in an unconscious state following an overdose of digoxin, phenobarbital, and alcohol. She was emergently intubated by paramedics at her home because of severe respiratory depression. The patient’s past medical history included ischemic and alcoholic cardiomyopathy with a left ventricular ejection fraction less than 30%, paroxysmal atria1 tachycardia, intravenous drug and alcohol abuse, chronic obstructive pulmonary disease, and deReceived from the Department of Oral and Maxillofacial Surgery, Mt. Sinai Medical Center, Cleveland, Ohio. * Resident. t Chief. Address correspondence and reprint requests to Dr. Uram: Department of Oral and Maxillofacial Surgery, Mt. Sinai Medical Center, One Mt. Sinai Drive, Cleveland. OH 44106-4198. 0 1988 American geons
Association
027%2391/88/4609-0009
of Oral and Maxillofacial
Sur-
$3.00/O
788
789
URAM AND HAUSER
erotic. The sternocleidomastoids were separated 2 cm above the clavicles, and necrotic muscle and fascia were debrided as necessary. Once these muscles were elevated, copius amounts of foul smelling pus began to drain from around the carotid sheaths. Much of the lymphatic tissue in this region was necrotic; some of the strap muscles and the omohyoids were also necrotic, requiring extensive debridement (Fig. 1). Loculations of pus were also found along the retropharyngeal and visceral spaces extending into the superior mediastinum, where more pus was evacuated. Loculations of pus were also found extending up to the right lateral pharyngeal wail deep to the internal pterygoid, and inferiorly deep to the right trapezius muscle. Following tissue debridement and evacuation of several hundred ml of purulent fluid, Jackson Pratt drains were placed into the mediastinum to create an afferent and efferent drain system. Penrose drains were placed into many of the abscess pockets, followed by a loose closure of the skin (Fig. 2). During the surgery, Gram stains were made and material for aerobic and anaerobic cultures was obtained. The majority of aerobic organisms found were group F beta-hemolytic and alpha-hemolytic Streptococci. Anaerobes cultured were Bacteroides melaninogenicus and a bacteroides species producing p-lactamase. The patient’s antibiotic regimen was changed to gentamycin (80 mg, 6 times daily) and chloramphenicol (1 g, 6 times daily), intravenously. Following surgery, the patient remained intubated for ventilatory support and airway patency. Hemo’dynamic support with dopamine and neosynephrine was necessary to maintain acceptable mean arterial pressures and cardiac output. She remained febrile and hypotensive, and there was continued drainage from her neck; she also developed a left lower lobe infiltrate. The patient was taken back to the operating room 3 days after the initial surgery for further debridement and placement of a chest tube in the left pleural space. During the second debridement, abscess cavities were found and drained over her right and left suprascapular spaces. The patient had a rapid recovery following the second procedure. The neck edema decreased, and she was extubated two days following surgery. Her vital signs were normal without the use of cardiovascular supporting drugs. The patient was transferred out of the surgical intensive care unit, with the neck wound open and dressed with 0.25% acetic acid soaked gauze. She was returned to the operating room 17 days after the second procedure (29
FIGURE 1. Dissection of the right neck. Note the area of necrotic sternocleidomastoid muscle and cervical lymph node overlying the carotid sheath (arrow)
days after admission) for a delayed primary closure of the neck wound. The superior and inferior portions of the neck wound were extensively underminded and closed without tension. Her early postoperative course following delayed primary closure of the neck was uneventful; however as a result of the infection and the extensive inflammatory reaction in the pharyngeal musculature, the patient had great difficulty swallowing despite continuous physiotherapy. She would cough violently when attempting to swallow liquids. A tracheal-esophageal fistula was suspected. An esophagram was obtained that showed poor pharyngeal muscular coordination with aspiration, but no evidence of a fistula. The patient had a gastrostomy tube placed using a percutaneous endoscopic gastrostomy technique. On follow-up evaluation, she still had difficulty swallowing, although the situation was improving (Fig. 3).
Discussion This case demonstrates the course of a lifethreatening infection in the neck and mediastinum from an oropharyngeal source, specifically resulting from a traumatic intubation in a compromised host. An appreciation of the anatomy of the deep neck is necessary to understand the path by which this infection spread. In general, infections will spread by direct, lymphatic, and hematogenous extension.4 In this case, the spread of infection was by both direct and lymphatic extension. Direct extension involves the movement of bacteria and infection in the path of least resistance, which is usually along the fascia1 planes and potential spaces of the neck. The cervical fascial planes consist of fibrous connective tissues that sheath organs, muscles, and vessels. This results in the division of the neck into distinct fascial regions with the formation of potential spaces between and within these regions. It is generally agreed that four major fascia1 sheaths are found in the neck. These form two major fascia1 groups, the single superficial and three deep cervical fascia layers. The deep cervical layers consist of the superficial or investing fascia, the middle or viscera1 fascia, and the deep layer of the deep cervical fascia (Fig. 4).- Not included in this group of four fascia1 layers is the carotid sheath, also called the viscera1 vascular sheath. It is formed bv the contributions of the three deer, neck fascia1 -The potential spaces formed by these facial planes can be divided into three basic groups based on their relationship to the hyoid bone. The hyoid bone plays an important role in that it limits the direct extension of infection due to its position in the neck with the specific muscle and fascial group attachments.5q638 The first group of spaces are those that run the entire length of the neck. These are comprised of the retropharyngeal, prevertebral,
DEEP NECK NECROTIZING
790
INFECTION
FIGURE 2. View of the initial wound closure. Note the bilateral Jackson Pratt drains used for afferent and efferent lavage/drainage of the superior mediastinum. The Penrose drains were placed in sites of pus formation.
alar, and the spaces surrounding the carotid sheaths. Infection in these spaces can extend uninhibited into the mediastinum, because only a loose areolar connective tissue is present. Common symptoms of infection running the length of the neck include pain, dysphagia, adenopathy, torticollis, and dyspnea. Symptoms of mediastinal involvement include severe dyspnea, brawny induration of the neck or chest, and radiologic appearance of a widening mediastinum.5*6*10 The second group of spaces are those in which infection is limited to areas above the hyoid bone. These include the submandibular, sublingual, lateral pharyngeal, masticator, parotid, and peritonsilar spaces. Infection in the submandibular, sublingual, and masticator spaces are commonly of dental
or periodontal origin. The submandibular and sublingual spaces freely communicate along the path provided by the submandibular gland. A severe infection of these two spaces could result in elevation of the tongue creating an obstructed airway, historically referred to as Ludwig’s angina. The lateral pharyngeal or pharyngomaxillary space is cone shaped, with the base of the cone at the skull base, and the apex at the hyoid bone. It is essential between the lateral pharyngeal wall and the internal pterygoid muscle. Infections in this space usually arise from the pharynx, tonsils/ adenoids, dentition, or trauma of the lateral pharyngeal walls. Symptoms of a lateral pharyngeal space infection include trismus from irritation to the internal pterygoids, induration at the mandibular angle, dysphagia, and swelling of the pharyngeal wall in the oropharynx. Lateral pharyngeal infections cannot extend below the suprahyoid muscle attachments to the hyoid bone. However, if the organisms
>,
l.,l,
,“S b%
,,
it,,,.,
I
,,,,I
..”
FIGURE 3. tial surgery.
Appearance of the wound 2 months following ini-
/I
I”
,,
FIGURE 4. Diagram of a crossection at C-6 level demonstrating the cervical fascial planes and deep neck spaces.
791
URAM AND HAUSER
causing this space infection are sufftciently virulent to penetrate into the retropharyngeal space, then extension below the hyoid can occur. The third group of spaces are those in which infections are limited to the region below the hyoid bone, and within the middle cervical visceral fascia. These infections involve the visceral space, which surrounds the thyroid gland, strap muscles, trachea, and esophagus. This space also extends into the superior mediastinum ending at the upper border of the aortic arch.’ Infections in this space are usually due to trauma to the hypopharynx, esophagus, and cervical trachea. Clinical symptoms include dysphagia, severe dyspnea, and hoarseness. The cervical lymphatic tissue also provides a pathway for the extension of deep neck infections. A virulent necrotizing infection from the pharynx will extend inferiorly through the lymphatic chain into the neck. Retropharyngeal space infections are more common in children before puberty than in adults because of the greater number of lymph channels and nodes in the retropharyngeal area in young persons.4 In this case, the initial emergent intubation at the patient’s home probably abraded or lacerated the right pharyngeal wall, allowing the oropharyngeal flora to enter the right lateral pharyngeal space. Because of the patient’s compromised health and depressed immunologic state, the infection did not remain localized. The infection spread by cervical lymphatic drainage and through rapid direct extension from the right pharyngeal space to the retropharyngeal space, then bilaterally around the carotid sheaths into the visceral space and also into the superior mediastinum. Because of the virulent nature of the bacteria, some lymphatic and muscle/ fascia tissue underwent necrosis. This patient was in critical condition due to septic shock, impending airway obstruction, and the mediastinitis that had developed in the face of her severe cardiomyopathy and chronic obstructive pulmonary disease. Deep neck necrotizing infections cannot be managed by antimicrobial therapy alone. These infections require surgical debridement of dead tissue and drainage of pus collections.“” Once drainage has been established, antimicrobial therapy can be effective. The most common bacterial species in deep neck infections are the group A Streptococci and anaerobic Bacteroides groups, except for B. frugilis, which are usually found in the abdomen. These organisms are members of the normal oropharyngeal flora, and were the key organisms involved in this infection case report. Following the initial surgical debridement and Gram stain results in this case, the patient was placed on gentamycin and chloramphenicol. This combination provided a broad spectrum coverage
for aerobic and anaerobic organisms as .well as increased protection against the Gram-negative enteric nosocomial infections, sometimes seen in debilitated patients. Other antibiotic agents that could be useful in these mixed flora infections are clindamycin, ticarcillin/clavulanic Acid (Timentin*), the combination of penicillin and metronidazole, and cefoxitin. For serious infections a two or three drug regimen is often employed initially until cultures provide a guide for specific antimicrobial chemotherapy. An early CT scan of the neck in this case could have prevented the degree of extension of the infection by demonstrating the need for drainage two days prior to the initial surgery. The appearance of a deep neck abscess on CT scan can easily be defined. Characteristic of these abscesses are low density zones of fluid centers, tissue edema, and changes in the fascial anatomy.” Summary This article describes a patient who developed a deep neck and mediastinal necrotizing infection that was initiated by a traumatic intubation. The history of the patient’s illness and the surgical procedures are reviewed and anatomic and microbial considerations of deep neck infections are discussed. The combination of aggressive and extensive surgical drainage of the neck, multiple antibiotic therapy, airway management, and treatment for septic shock, arrhythmia, and cardiomyopathy resulted in survival of the patient. References 1. Beck HJ, McCaffrey TV: Life-threatening neck infections. Postgrad Med 76:69, 1984 2. Bartlett JG. Gorbach SL: Anaerobic infections of the head and neck. Otolaryngol Clin North Am 9:655, 1976 3. Topazian RG, Goldberg MH: Management of Infections of the Oral and Maxillofacial Regions. Philadelphia, W.B. Saunders, 1981, pp l-39 4. Paonessa CF. Godstein JC: Anatomy and physiology of head and neck infections (with emphasis on the fascia of the head and neck). Otolaryngol Clin North Am 9561, 1976 5. Levitt GW: Cervical fascia and deep neck infections. Laryngoscope 80:409, 1970 6. Levitt GW: Cervical fascia and deep neck infections. Otolarvnnol Clin North Am 9:703. 1976 7. White B’: Deep neck infections and respiratory distress in children. Ear Nose Throat J 64:30, 1985 8. Levitt GW: The surgical treatment of deep neck infection. Laryngoscope 81:403, 1971 9. Romanes GT: Cunningham’s Textbook of Anatomy, 12th ed. London, Oxford-University Press 1981, pp 307-310 10. Rubin MM. Cozzi GM: Fatal necrotizing mediastinitis as a complication of an odotogenic infection. J Oral Maxillofac Sur 45~529, 1987 11. Kisch AL: Principles of the antimicrobial therapy of head and neck infections. Otolaryngol Clin North Am 9:751, 1976 12. Halt GR, McManus K, Newman RK, et al: Computed tomography in the diagnosis of deep neck infections. Arch Otolarvneol 108:693. 1982
Surg
1966
Deep Neck and Mediastinal Necrotizing Infection Secondary to a Trauma tic In tuba tion: Report of a Case JOSHUA URAM DMD,* AND MICHAEL S. HAUSER DMD, MDt
pression with multiple suicide attempts. The patient was stabilized in the emergency room and transferred to the medical intensive care unit. She became alert the following day and was extubated. She was transferred to the medical floor two days after admission. While in the medical intensive care unit, the patient developed a fever of unknown origin. Physical examination, radiographs of the chest, blood cultures. and urine cultures were negative. On the third hospital day, she complained of a severe sore throat and demonstrated dysphagia and right neck tenderness. The Oral and Maxillofacial Surgery service was consulted on the fourth hospital day. At that time the patient had an erythematous oropharynx in addition to some swelling and erythema of the anterior neck and superior sternum. The patient’s temperature was 102” F and the white blood cell count was 11,700. An initial diagnosis of an infected pharyngeal abrasion was made, and empirically the patient was administered penicillin-G, 2 million units every four hours. A CT scan of the head-neck-chest was ordered to rule out possible abscess formation. The patient was instructed to stop chain smoking cigarettes, which she refused, and to begin oral rinsing. On the fifth hospital day, the patient’s complaint of neck and throat tenderness increased. She was too uncooperative to allow a CT scan of the neck to be taken. During the following two days, the patient’s sore throat improved, although there was no improvement of the neck tenderness or superior chest erythema. Her temperature remained at 103” F. On the eighth hospital day, her condition deteriorated, and she showed torticollis of the right neck, increased trismus, dyspnea, and cervical and supraclavicular tenderness. The patient was in much distress and appeared toxic. She was taken to the operating room for examination of the pharynx, exploration of the neck, and drainage of probable deep neck infection. Once the patient was anesthetized and intubated, direct laryngoscopy of the pharynx revealed no perforations. However, the right pharyngeal wall was erythematous and contused, this being the probable site of perforation or trauma from the emergent intubation eight days earlier. Needle aspiration deep to the sternocleidomastoid muscles bilaterally easily produced pus. A collar incision was made extending from the right posterior head of the sternocleidomastoid to the left posterior head, about 1 cm above the clavicles. When the anterior skin flap and superficial fascia was raised, some of the inferior heads of the sternocleidomastoid muscles were found to be ne-
Introduction Deep infections of the neck can be lifethreatening in both children and adults because of involvement of the upper airway, major vessels, and mediastinal communication. They can be classified as being localized within a contained fascial space, or nonlocalized with diffuse soft tissue infection and/or widespread tissue necrosis. The causes of these problems are usually infections of the structures in the upper aerodigestive tract or visceral neck organs (teeth, tonsils, thryoid), and trauma to the neck.’ Most of these infections of the deep neck are polymicrobial in nature, usually involving the oropharyngeal flora.2 The state of the patient’s health and their immune system also play an important role.3 This article presents an unusual case in which a traumatic intubation resulted in a severe, widespread neck infection.
Report of a Case A 39-year-old woman was brought to the emergency room in an unconscious state following an overdose of digoxin, phenobarbital, and alcohol. She was emergently intubated by paramedics at her home because of severe respiratory depression. The patient’s past medical history included ischemic and alcoholic cardiomyopathy with a left ventricular ejection fraction less than 30%, paroxysmal atria1 tachycardia, intravenous drug and alcohol abuse, chronic obstructive pulmonary disease, and deReceived from the Department of Oral and Maxillofacial Surgery, Mt. Sinai Medical Center, Cleveland, Ohio. * Resident. t Chief. Address correspondence and reprint requests to Dr. Uram: Department of Oral and Maxillofacial Surgery, Mt. Sinai Medical Center, One Mt. Sinai Drive, Cleveland. OH 44106-4198. 0 1988 American geons
Association
027%2391/88/4609-0009
of Oral and Maxillofacial
Sur-
$3.00/O
788
789
URAM AND HAUSER
erotic. The sternocleidomastoids were separated 2 cm above the clavicles, and necrotic muscle and fascia were debrided as necessary. Once these muscles were elevated, copius amounts of foul smelling pus began to drain from around the carotid sheaths. Much of the lymphatic tissue in this region was necrotic; some of the strap muscles and the omohyoids were also necrotic, requiring extensive debridement (Fig. 1). Loculations of pus were also found along the retropharyngeal and visceral spaces extending into the superior mediastinum, where more pus was evacuated. Loculations of pus were also found extending up to the right lateral pharyngeal wail deep to the internal pterygoid, and inferiorly deep to the right trapezius muscle. Following tissue debridement and evacuation of several hundred ml of purulent fluid, Jackson Pratt drains were placed into the mediastinum to create an afferent and efferent drain system. Penrose drains were placed into many of the abscess pockets, followed by a loose closure of the skin (Fig. 2). During the surgery, Gram stains were made and material for aerobic and anaerobic cultures was obtained. The majority of aerobic organisms found were group F beta-hemolytic and alpha-hemolytic Streptococci. Anaerobes cultured were Bacteroides melaninogenicus and a bacteroides species producing p-lactamase. The patient’s antibiotic regimen was changed to gentamycin (80 mg, 6 times daily) and chloramphenicol (1 g, 6 times daily), intravenously. Following surgery, the patient remained intubated for ventilatory support and airway patency. Hemo’dynamic support with dopamine and neosynephrine was necessary to maintain acceptable mean arterial pressures and cardiac output. She remained febrile and hypotensive, and there was continued drainage from her neck; she also developed a left lower lobe infiltrate. The patient was taken back to the operating room 3 days after the initial surgery for further debridement and placement of a chest tube in the left pleural space. During the second debridement, abscess cavities were found and drained over her right and left suprascapular spaces. The patient had a rapid recovery following the second procedure. The neck edema decreased, and she was extubated two days following surgery. Her vital signs were normal without the use of cardiovascular supporting drugs. The patient was transferred out of the surgical intensive care unit, with the neck wound open and dressed with 0.25% acetic acid soaked gauze. She was returned to the operating room 17 days after the second procedure (29
FIGURE 1. Dissection of the right neck. Note the area of necrotic sternocleidomastoid muscle and cervical lymph node overlying the carotid sheath (arrow)
days after admission) for a delayed primary closure of the neck wound. The superior and inferior portions of the neck wound were extensively underminded and closed without tension. Her early postoperative course following delayed primary closure of the neck was uneventful; however as a result of the infection and the extensive inflammatory reaction in the pharyngeal musculature, the patient had great difficulty swallowing despite continuous physiotherapy. She would cough violently when attempting to swallow liquids. A tracheal-esophageal fistula was suspected. An esophagram was obtained that showed poor pharyngeal muscular coordination with aspiration, but no evidence of a fistula. The patient had a gastrostomy tube placed using a percutaneous endoscopic gastrostomy technique. On follow-up evaluation, she still had difficulty swallowing, although the situation was improving (Fig. 3).
Discussion This case demonstrates the course of a lifethreatening infection in the neck and mediastinum from an oropharyngeal source, specifically resulting from a traumatic intubation in a compromised host. An appreciation of the anatomy of the deep neck is necessary to understand the path by which this infection spread. In general, infections will spread by direct, lymphatic, and hematogenous extension.4 In this case, the spread of infection was by both direct and lymphatic extension. Direct extension involves the movement of bacteria and infection in the path of least resistance, which is usually along the fascia1 planes and potential spaces of the neck. The cervical fascial planes consist of fibrous connective tissues that sheath organs, muscles, and vessels. This results in the division of the neck into distinct fascial regions with the formation of potential spaces between and within these regions. It is generally agreed that four major fascia1 sheaths are found in the neck. These form two major fascia1 groups, the single superficial and three deep cervical fascia layers. The deep cervical layers consist of the superficial or investing fascia, the middle or viscera1 fascia, and the deep layer of the deep cervical fascia (Fig. 4).- Not included in this group of four fascia1 layers is the carotid sheath, also called the viscera1 vascular sheath. It is formed bv the contributions of the three deer, neck fascia1 -The potential spaces formed by these facial planes can be divided into three basic groups based on their relationship to the hyoid bone. The hyoid bone plays an important role in that it limits the direct extension of infection due to its position in the neck with the specific muscle and fascial group attachments.5q638 The first group of spaces are those that run the entire length of the neck. These are comprised of the retropharyngeal, prevertebral,
DEEP NECK NECROTIZING
790
INFECTION
FIGURE 2. View of the initial wound closure. Note the bilateral Jackson Pratt drains used for afferent and efferent lavage/drainage of the superior mediastinum. The Penrose drains were placed in sites of pus formation.
alar, and the spaces surrounding the carotid sheaths. Infection in these spaces can extend uninhibited into the mediastinum, because only a loose areolar connective tissue is present. Common symptoms of infection running the length of the neck include pain, dysphagia, adenopathy, torticollis, and dyspnea. Symptoms of mediastinal involvement include severe dyspnea, brawny induration of the neck or chest, and radiologic appearance of a widening mediastinum.5*6*10 The second group of spaces are those in which infection is limited to areas above the hyoid bone. These include the submandibular, sublingual, lateral pharyngeal, masticator, parotid, and peritonsilar spaces. Infection in the submandibular, sublingual, and masticator spaces are commonly of dental
or periodontal origin. The submandibular and sublingual spaces freely communicate along the path provided by the submandibular gland. A severe infection of these two spaces could result in elevation of the tongue creating an obstructed airway, historically referred to as Ludwig’s angina. The lateral pharyngeal or pharyngomaxillary space is cone shaped, with the base of the cone at the skull base, and the apex at the hyoid bone. It is essential between the lateral pharyngeal wall and the internal pterygoid muscle. Infections in this space usually arise from the pharynx, tonsils/ adenoids, dentition, or trauma of the lateral pharyngeal walls. Symptoms of a lateral pharyngeal space infection include trismus from irritation to the internal pterygoids, induration at the mandibular angle, dysphagia, and swelling of the pharyngeal wall in the oropharynx. Lateral pharyngeal infections cannot extend below the suprahyoid muscle attachments to the hyoid bone. However, if the organisms
>,
l.,l,
,“S b%
,,
it,,,.,
I
,,,,I
..”
FIGURE 3. tial surgery.
Appearance of the wound 2 months following ini-
/I
I”
,,
FIGURE 4. Diagram of a crossection at C-6 level demonstrating the cervical fascial planes and deep neck spaces.
791
URAM AND HAUSER
causing this space infection are sufftciently virulent to penetrate into the retropharyngeal space, then extension below the hyoid can occur. The third group of spaces are those in which infections are limited to the region below the hyoid bone, and within the middle cervical visceral fascia. These infections involve the visceral space, which surrounds the thyroid gland, strap muscles, trachea, and esophagus. This space also extends into the superior mediastinum ending at the upper border of the aortic arch.’ Infections in this space are usually due to trauma to the hypopharynx, esophagus, and cervical trachea. Clinical symptoms include dysphagia, severe dyspnea, and hoarseness. The cervical lymphatic tissue also provides a pathway for the extension of deep neck infections. A virulent necrotizing infection from the pharynx will extend inferiorly through the lymphatic chain into the neck. Retropharyngeal space infections are more common in children before puberty than in adults because of the greater number of lymph channels and nodes in the retropharyngeal area in young persons.4 In this case, the initial emergent intubation at the patient’s home probably abraded or lacerated the right pharyngeal wall, allowing the oropharyngeal flora to enter the right lateral pharyngeal space. Because of the patient’s compromised health and depressed immunologic state, the infection did not remain localized. The infection spread by cervical lymphatic drainage and through rapid direct extension from the right pharyngeal space to the retropharyngeal space, then bilaterally around the carotid sheaths into the visceral space and also into the superior mediastinum. Because of the virulent nature of the bacteria, some lymphatic and muscle/ fascia tissue underwent necrosis. This patient was in critical condition due to septic shock, impending airway obstruction, and the mediastinitis that had developed in the face of her severe cardiomyopathy and chronic obstructive pulmonary disease. Deep neck necrotizing infections cannot be managed by antimicrobial therapy alone. These infections require surgical debridement of dead tissue and drainage of pus collections.“” Once drainage has been established, antimicrobial therapy can be effective. The most common bacterial species in deep neck infections are the group A Streptococci and anaerobic Bacteroides groups, except for B. frugilis, which are usually found in the abdomen. These organisms are members of the normal oropharyngeal flora, and were the key organisms involved in this infection case report. Following the initial surgical debridement and Gram stain results in this case, the patient was placed on gentamycin and chloramphenicol. This combination provided a broad spectrum coverage
for aerobic and anaerobic organisms as .well as increased protection against the Gram-negative enteric nosocomial infections, sometimes seen in debilitated patients. Other antibiotic agents that could be useful in these mixed flora infections are clindamycin, ticarcillin/clavulanic Acid (Timentin*), the combination of penicillin and metronidazole, and cefoxitin. For serious infections a two or three drug regimen is often employed initially until cultures provide a guide for specific antimicrobial chemotherapy. An early CT scan of the neck in this case could have prevented the degree of extension of the infection by demonstrating the need for drainage two days prior to the initial surgery. The appearance of a deep neck abscess on CT scan can easily be defined. Characteristic of these abscesses are low density zones of fluid centers, tissue edema, and changes in the fascial anatomy.” Summary This article describes a patient who developed a deep neck and mediastinal necrotizing infection that was initiated by a traumatic intubation. The history of the patient’s illness and the surgical procedures are reviewed and anatomic and microbial considerations of deep neck infections are discussed. The combination of aggressive and extensive surgical drainage of the neck, multiple antibiotic therapy, airway management, and treatment for septic shock, arrhythmia, and cardiomyopathy resulted in survival of the patient. References 1. Beck HJ, McCaffrey TV: Life-threatening neck infections. Postgrad Med 76:69, 1984 2. Bartlett JG. Gorbach SL: Anaerobic infections of the head and neck. Otolaryngol Clin North Am 9:655, 1976 3. Topazian RG, Goldberg MH: Management of Infections of the Oral and Maxillofacial Regions. Philadelphia, W.B. Saunders, 1981, pp l-39 4. Paonessa CF. Godstein JC: Anatomy and physiology of head and neck infections (with emphasis on the fascia of the head and neck). Otolaryngol Clin North Am 9561, 1976 5. Levitt GW: Cervical fascia and deep neck infections. Laryngoscope 80:409, 1970 6. Levitt GW: Cervical fascia and deep neck infections. Otolarvnnol Clin North Am 9:703. 1976 7. White B’: Deep neck infections and respiratory distress in children. Ear Nose Throat J 64:30, 1985 8. Levitt GW: The surgical treatment of deep neck infection. Laryngoscope 81:403, 1971 9. Romanes GT: Cunningham’s Textbook of Anatomy, 12th ed. London, Oxford-University Press 1981, pp 307-310 10. Rubin MM. Cozzi GM: Fatal necrotizing mediastinitis as a complication of an odotogenic infection. J Oral Maxillofac Sur 45~529, 1987 11. Kisch AL: Principles of the antimicrobial therapy of head and neck infections. Otolaryngol Clin North Am 9:751, 1976 12. Halt GR, McManus K, Newman RK, et al: Computed tomography in the diagnosis of deep neck infections. Arch Otolarvneol 108:693. 1982