Deep neck Deep neck infectionsinfections가천의과대학 길병원

구강악안면외과 김 현민

차례차례1) facial spaces2) each spaces ; buccal masticator sublingual & submandibular parapharyngeal retropharyngeal 3) case report 1.2 4) summary5) references

Fascial spaces of clinical signifFascial spaces of clinical significanceicance

Face ; buccal canine masticator – masseter , pterygoid , zygomaticotemporal parotid Suprahyoid ; sublingual submandibular – submaxillary , submental lateral pharyngeal(pharyngomaxillary) peritonsillar Infrahyoid ; pretracheal (anterovisceral) Spaces of total neck ; retropharyngeal danger space space of carotid sheath by Topazian & Goldberg

Fascial anatomyFascial anatomy

Fascial anatomy 1Fascial anatomy 1

Fascial anatomy 2Fascial anatomy 2

Fascial anatomy 3Fascial anatomy 3

Fascial anatomy 4Fascial anatomy 4

Fascial anatomy 5Fascial anatomy 5

Fascial anatomy 6Fascial anatomy 6

Cellulitis versus abscess on CCellulitis versus abscess on CT imagiesT imagies

Abscess ; single or multilocated low density masses, peripheral irregular rim enhancement, fluid collections

contrast injections (a)before (b)after on RPA/PPA

Cellulitis ; without a low density collection, no fluid collections hypodensity with(a),without(b) complete ring enhancement

Buccal space infectionsBuccal space infections Symptoms ; round dome shape swelling, trismus, 원인치의 동요 및

타진 반응 , 상하안검 swelling Anatomy ;

Masticator space Masticator space infectionsinfections

Symptoms; trismus, painful swelling, dysphagia etc Anatomy ;

Masticator space Masticator space infectionsinfections

* Mn 에서 야기된 odontogenic infections 은 upward 되며 masseter m 감염은 PS , temporalis, lat.pterygoid m 로 spread ,

med. Pterygoid m 감염은 PPS , lat. Pterygoid m 로 spread 된다 . Downward 되어 sublingual, submn spaces 로 spread 된다 . * Mx 에서 야기된 inf 은 downward 되지 않고 superficially temporal,

MS, deeply lat. / med. Pterygoid m 을 involve 한다 . MS 는 mn inf. 의 primary site 이고 PS & pharyngeal space 는 MS 의

2nd site 이며 mn inf. 은 sublingual & submn 으로 직접 전파된다 . By Koichi Yonetsu

Submandibular space infectioSubmandibular space infectionsns

Symptoms ; neck rigidity, trismus, dysphagia, respiratory distress, sialorrhea, pyrexia,

Anatomy ;

Submandibular space infectionSubmandibular space infectionss

*Schematic drawing of the 3 types of pathways type 1; beyond mylohyoid ridge & posterioly from adjacent sublingual space ; with mylohyoid m enlarge

type 2 ; from inflammatory periostitis of mn ; no or rare PPS,MS involvement mild symptoms without trismus & dysphagia

Submandibular space infectionSubmandibular space infectionss

* 만약 감염이 PPS 로 spread 되면 dysphagia 발생되며 PPS 는 med. Pterygoid m 같은 MS 감염시 자주 spread 된다 . 그런데 ,Submn space inf 시 PPS 사이에 fasciaL barrier 가 얇아서 전이가 용이하다 . 이는 med. Pterygoid m involvment 없이도 동시에 감염이 일어나는 것으로 확인 될 수 있다 .

type 3 ; downward from MS

Type1(57.6%) > type2(15.2%) > type3(12.1%) by Y.Ariji et al

Parapharyngeal space infectiParapharyngeal space infectionsons

Symptoms ; fever(38.5), chill, throat swelling, odynophagia, dysphagia, neck pain & stiffness, respiratory distress, sialorrhea, trismus ( PPS swelling+ & trismus- = peritonsillar abscess)

Cause ; most common cause - peritonsillar abscess odontogenic sourse(20-39%) by Larry J. Peterson Anatomy ; ant prestyloid compartment- fat filled post retrostyloid compartment-major neurovascular bundle (h

ard palate- upper PPS, lower PPS)

Parapharyngeal space infectioParapharyngeal space infectionsns

Anatomy – MS,PS(lateral) , CS(post) , RPS(posteromedial) PPS 의 displacement direction 은 origin of lesion 을 sugge

st 한다 . By VFH Chong et al

Parapharyngeal space infectioParapharyngeal space infections imagiesns imagies

Retropharyngeal space Retropharyngeal space infectionsinfections

Symptoms ; fever, decrease oral intake, odynophagia, malaise, torticollis, neck pain, trismus, otalgia, headache, neck swelling,

Anatomy ;

Retrppharyngeal space infectiRetrppharyngeal space infectionsons

Lateral neck x-ray 는 first imaging test 되어야 한다 . Air sign 이 보이는 경우 specific 하다 . CT scan 은 RPS abscess manage 시 중요하지만 cellulitis 와 abscess 를 구분하는 데 한계가 있다 .

by Carl Boucher RPS abscess – lat. Neck x-ray – air sign+- drainage (with CT) air sign—IV anti –no improvement-CT scan improvement-IV continue Young children 에서 neck plain films 는 true lat, orientation(neck exten

sion, full inspiration, swallowing& expiratory crying 을 avoid 하여야 RPS thicken 을 방지할 수 있다 .by P.Bradley Brechtelsbauer

Lat. Neck x-ray diagnosis ; 1)smooth lordotic curve of cervical vertebra-C2,C3 7mm wide 적어야 , 평균 3mm, C6 14mm 소아 , 22mm 성인 soft tissue shadow 가 정상

Retropharyngeal space Retropharyngeal space infectionsinfections

2) presence of gas 3) straight cervical spine or reversed kyphotic curve loss of the lordotic curve by Larry J. Peterson

Retropharyngeal space Retropharyngeal space infectionsinfections

Case report 1Case report 1Pt ; 38/F

CC ; 내원 5 일 전 개인치과 발치 후 우측 swelling으로 내원

PI ; mouth opening limitation, dysphagia, Rt buccal & sub mn swelling / Td/ redness

Dx ; masticatory spce, lat. Pharyngeal space abscess Tx ; I & D X 2 (submn & submental, deep neck carotid sheath

area) anti theraphy ( aug + micronomycin + flagyl) fluid etc supplementary tx (O2 etc) 초진 lab ; WBC 30260, segmental neutrophil 85.9%, C

RP 36.5

초진 모습초진 모습

치료 임상 사진치료 임상 사진 1) 초기 I&D (02.9.13), 2 차 I&D(02.9.14)

2)3 차 I&D(02,9.17)

치료 후 사진치료 후 사진 02. 9.27

초진 초진 CT (02.9.14)CT (02.9.14)

22 회 회 CT(02.9.17)CT(02.9.17)

33 회 회 CT(02.9.19)CT(02.9.19)

44 회 회 CT(02.9.25)CT(02.9.25)

Case report 2Case report 2 Pt ; 30/M CC ;transfer from ENT d/t deep neck infection from

dental origin Hx ; 02.5.20 #38 ext 후 ENT 로 입원 PI ; both submn swelling & Td mouth opening limit, dysphagia, dyspnea, neck Td & redness, #38 area pus DX ; submn & mental space abscess pretracheal space abscess descending necrotizing mediastinitis Tx ; I & D 3 회 (local 1, general 2 with TS)

초진모습초진모습 초진 lab ; WBC 16120, segmental neut92.7%,

ESR119, CRP25.1

치료 임상 사진치료 임상 사진

치료 후 사진치료 후 사진

초진 초진 CT(02.5.25)CT(02.5.25)

22 회 회 CT(02.5.29)CT(02.5.29)

33 회 회 CT(02.6.3)CT(02.6.3)

44 회 회 CT(02.6.12)CT(02.6.12)

SummarySummary

Deep neck infections 의 치료는 early radiologic Dx, medical management(effective antitherapy), intensive surgical management & airway control 등 요소가 필수적이다 .

Culture 를 시행하는 것이 중요하지만 감수성검사가 시행되기 전까지 penicillin derivatives & clindamycin 과 같은 항생제로 early intervention을 시행하여야 하고 cellulitic stage 에서는 항생제만으로도 가능하지만 abscess 가 확진 되면 surgical intervention 이 시행되어야 한다 . CT 및 MRI 등의 이용은 임상증상의 한계를 보이는 deep neck infection 시 고려되어야 한다 .

만약 초기 항생제 치료 48 시간내 증상의 호전이 보이지 않거나 abscess 가 임상적으로 확인가능 하다면 I & D 는 충분히 고려되어야 한다 .

AIR way 확보는 RPA, Submn A 시 tracheostomy 가 필요로 하는 경우도 있으므로 충분한 환자의 monitoring 이 중요하다고 하겠다 .

ReferencesReferences 1.Y.Ariji et al.odontogenic inf. Pathway to the submn space; imaging assessment.

Int.J.Oral Maxillofac.Surg.2002;31;165 2.VHF Chong & YF Fan. Radiology of the PPS.Australasian radiology.1998;42;278 3.Larry J. Peterson.L.contemporary management of deep infections of the neck.J.

Oral Maxillofac.Surg.1993;51;226-231 4.Carl Boucher et al.RPS abscess; a clinical & radiologic correction;J.of Otolaryng

ology,1999;28;134 5. Per-Lennart Westesson; contemporary maxillofacial imaging OMFS clinics of no

th america,1992 6. Topazian & Goldberg; oral & maxillofacial infections, 3rd edition 7. 김여갑 ; 임상구강악안면감염학 ,1995 8. Koichi Yonetsu et al; deep fascial inf. Of odontogenic origin: CT assessment of

pathways of space involvment. AM J Neuroradiology,1998;19;123