Deep Neck Space Infections. Michael D. Puricelli, M.D. Jeffrey B. Jorgensen, M.D.

Transcription

1 Deep Neck Space Infections Michael D. Puricelli, M.D. Jeffrey B. Jorgensen, M.D.

2 Goals Review fascia and fascial spaces to facilitate understanding of how infections move through the neck. Provide current data on appropriate work-up and management of deep neck space infections. Review key complications of deep neck space infections.

3 Background Dividing the extracranial head and neck into different spaces dates back to the 1800s Arose to resolve the inexplicable extension of infections of the extracranial head and neck to other areas These studies led to detailed descriptions of the cervical fascia and the numerous soft tissue spaces that were contained within the fascial layers.

4 History Highly nuanced and complex "the cervical fascia appear in a new form under the pen of each author who attempts to describe them, French anatomist Malgaigne in Definition of fascia a band of connective tissue that surrounds structures (such as enveloping muscles), giving rise to potential tissue spaces and pathways that allow for infection to spread. Niel S. Norton. Netter s Head and Neck Anatomy for Dentistry. 2007

5 Deep Neck Space Infections

6 Deep Neck Space Infections

7 My Goal Mukherji SK, Castillo M. A simplified approach to the spaces of the suprahyoid neck. Radiol Clin North Am Sep;36(5):761-80, v. Review. PubMed PMID:

8 Overview Case Presentation Fascial Planes of the Head and Neck Deep Neck Spaces Microbiology Management Complications of Infections

9 Case ER consult 4 y/o female several days fever and neck stiffness What additional information would you like?

10 History HPI Inflammatory symptoms Pain, fever, swelling, and redness Onset and duration Localizing symptoms Dysphagia, odynophagia, drooling, hot potato voice, hoarseness, dyspnea, trismus, and ear pain Risk Factors (source) Peds - travel, pets, rodents, unpasturized milk, uncooked meat, tuberculosis exposure Adult - recent dental work, upper airway surgery or intubation, intravenous drug use, sinusitis, pharyngitis, otitis, or blunt or penetrating soft tissue trauma Lymphoma B-symptoms PMH Antibiotic allergies Recent antibiotic therapy Immunodeficiency HIV, hepatitis, diabetes, collagen vascular diseases, hematologic malignancy, and recent chemotherapy or steroid Cummings otolaryngology 5 th Ed. Chapter 14 deep neck space infections

11 Case Onset 4 days ago Associated symptoms: purulent rhinorrhea, reduced oral intake, pain with swallowing. Denies hoarseness or voice changes. No trismus or ear pain. No skin erythema/crepitus. No recent choking episodes. No recent tonsillitis. No prior episodes. No recent dental work, intubation/upper airway procedures, penetrating trauma. No chest pain/dyspnea. No Rx to date. No immunodeficiency. What are the most important things to look for on exam?

12 Physical Examination Full examination, as in all patients. High points: Difficulty with mouth opening indicates inflammation spread Parapharyngeal, pterygoid, or masseteric spaces. Alveolar swelling and decayed, loose, tender, or broken teeth. Floor of the mouth Ludwig s angina. Stensen's and Wharton's ducts Upper dentition, paranasal sinuses, facial soft tissues Facial and ophthalmic venous drainage EOM and pupillary light reflex Cummings otolaryngology 5 th Ed. Chapter 14 deep neck space infections

13 Case T: 38.9, respirations 24/min No stridor/stertor. CN 2-12 WNL. Normal dentition. No facial pain. Nasal crusting. Pain with palpation of the neck. Diffuse minimally enlarged lymphadenopathy. EOMI, vision normal What do you want to do next?

14 Case WBC 18.2, 88% neutrophils Mild prerenal azotemia

15 Case 2 cm

16 Case Management? Medical Surgical

17 Overview Case Presentation Fascial Planes of the Head and Neck Deep Neck Spaces Microbiology Management Complications of Infections

18 Fascia Planes of the Neck Superficial Cervical Fascia Deep Cervical Fascia Superficial layer Middle layer Deep layer Carotid Sheath Mukherji SK, Castillo M. A simplified approach to the spaces of the suprahyoid neck. Radiol Clin North Am Sep;36(5):761-80, v. Review. PubMed PMID:

19 Vieira F, Allen SM, Stocks RM, Thompson JW. Deep neck infection. Otolaryngol Clin North Am Jun;41(3):459-83, vii. doi: /j.otc Review. PubMed PMID:

20 Superficial Cervical Fascia Vieira F, Allen SM, Stocks RM, Thompson JW. Deep neck infection. Otolaryngol Clin North Am Jun;41(3):459-83, vii. doi: /j.otc Review. PubMed PMID:

21 Superficial Cervical Fascia Deep to the dermis Envelops Platysma and muscles of facial expression Incorporates musculoaponeurotic system Boundaries Superior: zygomatic process Inferior: clavicle, axillae, deltopectoral region Cummings otolaryngology 5 th Ed. Chapter 14 deep neck space infections

22 Vieira F, Allen SM, Stocks RM, Thompson JW. Deep neck infection. Otolaryngol Clin North Am Jun;41(3):459-83, vii. doi: /j.otc Review. PubMed PMID:

23 Superficial Layer of Deep Cervical Fascia Vieira F, Allen SM, Stocks RM, Thompson JW. Deep neck infection. Otolaryngol Clin North Am Jun;41(3):459-83, vii. doi: /j.otc Review. PubMed PMID:

24 Deep Cervical Fascia Superficial layer Investing fascia Envelopes Trapezius, sternocleidomastoid, muscles of mastication (masseter, pterygoids, temporalis) Encloses parotid gland and covers the submandibular gland Forms stylomandibular ligament: separates the parotid from the submandibular gland Contributes to the lateral aspect of the carotid sheath Extent Superior Zygomatic arch and mandible Inferior Attaches to the clavicle, acromion, and spine of the scapula Deeply Extends along the temporal bone to the carotid canal Cummings otolaryngology 5 th Ed. Chapter 14 deep neck space infections Anderson JC, Homan JA. Radiographic correlation with neck anatomy. Oral Maxillofac Surg Clin North Am Aug;20(3): doi: /j.coms Review. PubMed PMID:

25 Vieira F, Allen SM, Stocks RM, Thompson JW. Deep neck infection. Otolaryngol Clin North Am Jun;41(3):459-83, vii. doi: /j.otc Review. PubMed PMID:

26 Middle Layer of Deep Cervical Fascia muscular division Vieira F, Allen SM, Stocks RM, Thompson JW. Deep neck infection. Otolaryngol Clin North Am Jun;41(3):459-83, vii. doi: /j.otc Review. PubMed PMID:

27 Vieira F, Allen SM, Stocks RM, Thompson JW. Deep neck infection. Otolaryngol Clin North Am Jun;41(3):459-83, vii. doi: /j.otc Review. PubMed PMID:

28 Middle Layer of Deep Cervical Fascia visceral division Vieira F, Allen SM, Stocks RM, Thompson JW. Deep neck infection. Otolaryngol Clin North Am Jun;41(3):459-83, vii. doi: /j.otc Review. PubMed PMID:

29 Deep Cervical Fascia Middle layer Envelopes Muscular division Surrounds the strap muscles (sternohyoid, sternothyroid, thyrohyoid, omohyoid) Visceral division Surrounds the pharyngeal constrictor muscles, buccinator, larynx, trachea, esophagus, thyroid, and parathyroid glands Extent Superior Base of skull Inferior Mediastinum Cummings otolaryngology 5 th Ed. Chapter 14 deep neck space infections Anderson JC, Homan JA. Radiographic correlation with neck anatomy. Oral Maxillofac Surg Clin North Am Aug;20(3): doi: /j.coms Review. PubMed PMID:

30 Vieira F, Allen SM, Stocks RM, Thompson JW. Deep neck infection. Otolaryngol Clin North Am Jun;41(3):459-83, vii. doi: /j.otc Review. PubMed PMID:

31 Deep Layer of Deep Cervical Fascia Vieira F, Allen SM, Stocks RM, Thompson JW. Deep neck infection. Otolaryngol Clin North Am Jun;41(3):459-83, vii. doi: /j.otc Review. PubMed PMID:

32 Deep Cervical Fascia Deep layer Prevertebral fascia Two layers: alar and pre-vertebral Envelopes Paraspinous muscles, cervical vertebrae Extent: Alar layer: skull base to mediastinum Pre-vertebral layer: skull base to the coccyx Cummings otolaryngology 5 th Ed. Chapter 14 deep neck space infections Anderson JC, Homan JA. Radiographic correlation with neck anatomy. Oral Maxillofac Surg Clin North Am Aug;20(3): doi: /j.coms Review. PubMed PMID:

33 Vieira F, Allen SM, Stocks RM, Thompson JW. Deep neck infection. Otolaryngol Clin North Am Jun;41(3):459-83, vii. doi: /j.otc Review. PubMed PMID:

34 Carotid Sheath Vieira F, Allen SM, Stocks RM, Thompson JW. Deep neck infection. Otolaryngol Clin North Am Jun;41(3):459-83, vii. doi: /j.otc Review. PubMed PMID:

35 Overview Case Presentation Fascial Planes of the Head and Neck Deep Neck Spaces Microbiology Management Complications of Infections

36 Fascial Spaces Compartments regions of loose connective tissue that fill the areas between the fascial layers Interconnectedness of these areas is debated Some interconnect according to Cummings No universally accepted naming system Som, PM et. al Head and Neck Imaging 5 th Ed.

37 Osborn TM, Assael LA, Bell RB. Deep space neck infection: principles of surgical management. Oral Maxillofac Surg Clin North Am Aug;20(3): doi: /j.coms Review. PubMed PMID:

38 Osborn TM, Assael LA, Bell RB. Deep space neck infection: principles of surgical management. Oral Maxillofac Surg Clin North Am Aug;20(3): doi: /j.coms Review. PubMed PMID:

39 Masticator Retropharyngeal Prevertebral Parapharyngeal Parotid Carotid STATDX.COM

40 Deep Neck Spaces Anatomical Suprahyoid Infrahyoid Transhyoid Pathophysiologic Sources Sequential spread Key Spaces Parapharyngeal Submandibular/sublingual Retropharyngeal, danger, prevertebral, carotid

41 Parapharyngeal Space Skull base Hyoid Stambuk, HE. Patel, SG. Imaging of the Parapharyngeal Space. Otolaryngologic Clinics of North America. Vol 41. Iss

42 Parapharyngeal Space Anterior: pterygomandibular raphe and medial pterygoid muscle Lateral: parotid gland, mandible, and lateral pterygoid muscle Medial: superior constrictor, tensor, and levator veli palatini muscles STATDX.COM Posterior: prevertebral

43 Parapharyngeal space Central connection for the suprahyoid spaces Medially peritonsillar space Inferiorly submandibular space Laterally masticator space Carotid sheath courses through this space Posteromedially retropharyngeal space

44 Hartmann, RW. Ludwig s Angina in Children. Am Fam Physician 1999 July 1;60(1) Superior: Oral mucosa Sublingual Space Posterior: Digastric and stylomandibular ligament Inferior: Mylohyoid

45 Superior: Mylohyoid Submandibular Space Posterior: Digastric and stylomandibular ligament Anterior: Digastric Inferior: Hyoid Hartmann, RW. Ludwig s Angina in Children. Am Fam Physician 1999 July 1;60(1) Lateral: Platysma and mandible

46 Hartmann, RW. Ludwig s Angina in Children. Am Fam Physician 1999 July 1;60(1) Submandibular and Sublingual Spaces Functionally comprise a single space Clinical significance: The mylohyoid line Tooth apices anterior to second molar: sublingual space Second and third molars: submandibular Ludwig described indurated edema of the submandibular and sublingual areas with minimal throat inflammation but without lymph node involvement or suppuration. At that time, the condition was almost always fatal. Hartmann

47 Google images: mylohyoid line

48 Submandibular and Sublingual Spaces Hartmann, RW. Ludwig s Angina in Children. Am Fam Physician 1999 July 1;60(1)

49 Retropharyngeal Space Boundaries: Superior: skull base Inferior: mediastinum (fusion of middle cervical fascia with alar fascia, near T4) Anterior: Buccopharyngeal fascia Posterior: Alar fascia Lateral: Carotid sheath Cummings otolaryngology 5 th Ed. Chapter 14 deep neck space infections

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51 Retropharyngeal Space Clinical Significance Direct spread from the parapharyngeal space Lymphatic spread from the paranasal sinuses/nasopharyngeal region

52 Danger Space Boundaries: Superior: skull base Inferior: diaphragm Anterior: alar fascial layer of deep cervical fascia Posterior: prevertebral fascial layer of deep cervical fascia Lateral: Transverse processes of vertebral Cummings otolaryngology 5 th Ed. Chapter 14 deep neck space infections

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54 Danger Space Clinical significance: Potential for rapid inferior spread Loose areolar tissue Infectious infiltration from the retropharyngeal, parapharyngeal, or prevertebral spaces are the primary routes to the danger space

55 Cummings otolaryngology 5 th Ed. Chapter 14 deep neck space infections Osborn TM, Assael LA, Bell RB. Deep space neck infection: principles of surgical management. Oral Maxillofac Surg Clin North Am Aug;20(3): doi: /j.coms Review. PubMed PMID: Prevertebral Space Boundaries: Anterior: prevertebral fascia Superior: Clivus Inferior: Coccyx

56 Prevertebral Space Clinical significance: Dense areolar tissue Mechanisms of spread Infection of the vertebral bodies Penetrating injuries.

57 Masticator Space Enclosed by superficial layer of deep cervical fascia Boundaries: Anterior buccal fat pad Medial: Fascia medial to pterygoid muscles Lateral: Fascia lateral to masseter Superior temporal fossa Subspaces: Mandible Temporalis muscle Cummings otolaryngology 5 th Ed. Chapter 14 deep neck space infections STATDX.COM

58 Masticator Space Clinical significance: Anterolateral to parapharyngeal space Most commonly from the third mandibular molars May involve temporal space with maxillary molar infection STATDX.COM Cummings otolaryngology 5 th Ed. Chapter 14 deep neck space infections

59 Peritonsillar Space Boundaries: Medial: capsule of the palatine tonsil Lateral: superior constrictor muscle. Anterior/posterior: anterior and posterior tonsillar pillars Inferior: posterior tongue Cummings otolaryngology 5 th Ed. Chapter 14 deep neck space infections

60 Wikipedia: Peritonsillar abscess Peritonsillar Space Clinical significance Loose connective tissue Readily spread to the parapharyngeal space.

61 Parotid Space Boundaries: Lateral: superficial layer of deep cervical fascia Medial: fascia, which does not enclose the superomedial aspect of the gland Cummings otolaryngology 5 th Ed. Chapter 14 deep neck space infections STATDX.COM

62 Parotid Space Clinical significance Parotid space is lateral to the parapharyngeal space. Incomplete superomedial border permits communication with the prestyloid compartment of the parapharyngeal space.

63 Carotid Space Borders: Carotid sheath Cummings otolaryngology 5 th Ed. Chapter 14 deep neck space infections

64 Wikipedia: Lincoln highway Carotid Space Clinical significance: Infection from the surrounding parapharyngeal space, penetrating trauma, or intravenous drug use may potentiate spread into this space. Lincoln highway of the neck Coined by Harris B. Mosher in 1929

65 Anterior Visceral Space Boundaries: The visceral division of the middle layer of deep cervical fascia encloses the anterior visceral space, or pretracheal space Superior: thyroid cartilage Inferior: mediastinum Cummings otolaryngology 5 th Ed. Chapter 14 deep neck space infections

66 Anterior Visceral Space Clinical significance Perforation of the anterior esophageal wall by endoscopic instrumentation, foreign bodies, or trauma may introduce infection to this space. Direct spread from submandibular space

67 Matching Mechanism Acute tonsillitis Rhinosinusitis Dental infection (upper) Dental infection (lower) 2 nd /3 rd molar Dental infection (lower) anterior Esophagoscopy Space Retropharyngeal/ Parapharyngeal Sublingual Submandibular Masticator space Retropharyngeal Peritonsillar space

68 Matching Mechanism Acute tonsillitis Rhinosinusitis Dental infection (upper) Dental infection (lower) 2 nd /3 rd molar Dental infection (lower) anterior Esophagoscopy Space Retropharyngeal/ Parapharyngeal Sublingual Submandibular Masticator space Retropharyngeal Peritonsillar space

69 Overview Case Presentation Fascial Planes of the Head and Neck Deep Neck Spaces Microbiology Management Complications of Infections

70 Microbiology Usually mixed aerobic and anaerobic organisms, predominance of oral flora. Group A beta-hemolytic streptococcal species, alpha-hemolytic streptococcal species, Staphylococcus aureus, Fusobacterium nucleatum, Bacteroides melaninogenicus, Bacteroides oralis, and Spirochaeta, Peptostreptococcus, and Neisseria species Pseudomonas species, Escherichia coli, and Haemophilus influenzae are occasionally encountered. Increasing documentation of MRSA, especially within pediatric patient populations Higher gram negative incidence in diabetics Thomason TS, Brenski A, McClay J, Ehmer D. The rising incidence of methicillin-resistant Staphylococcus aureus in pediatric neck abscesses. Otolaryngol Head Neck Surg Sep;137(3): PubMed PMID: Murray, AD et. Al. Deep Neck infections. Emedicine. Mar 12, 2012

71 Overview Case Presentation Fascial Planes of the Head and Neck Deep Neck Spaces Microbiology Management Complications of Infections

72 Vieira, F. Allen, SM. Etal. Deep Neck Infection. Otolaryngol Clini N Am. 41 (2008) Cummings otolaryngology 5 th Ed. Chapter 14 deep neck space infections Imaging CT scan is indicated in cases of a suspected deep neck space infection It has been suggested that size (>2 cm) is more predictive of a deep neck abscess than the presence of a ring-enhancing lesion. Lateral neck radiographs are less sensitive that CT and are not recommended Presence of an air-fluid level or greater than 5 mm of thickening in a child or greater than 7 mm of thickening in an adult of the prevertebral tissue at C2 indicate retropharyngeal infection until proven otherwise Ultrasound is more accurate than CECT in differentiating a drainable abscess from cellulitis May not visualize deeper lesions Does not provide anatomic information necessary for planning surgery

73 5 year retrospective review of suspected deep neck space infections 89 patients identified, 13 excluded Of 76, all had CT scans. fluid collection was present in 65 people. 57 taken to surgery, rest treated with antibiotics Negative if no pus or responded to antibiotics All false positives were all less than 3.5 cm Negative predictive value of CT 100% Freling N, Roele E, Schaefer-Prokop C, Fokkens W. Prediction of deep neck abscesses by contrast-enhanced computerized tomography in 76 clinically suspect consecutive patients. Laryngoscope Sep;119(9): doi: /lary PubMed PMID:

74 Medical Management Airway, Airway, Airway Loss of airway is a major source of mortality from deep neck infection Aggressive management Dyspnea, stridor, retractions Impending airway compromise Consider tracheostomy over intubation Shorter overall hospital stay (4.8 vs 5.9 days) did not reach significance Reduced cost by 60% Fewer lost airways Antibiotics Steroids Advocated by some Felt to worsen hyperglycemia etc. by others Cummings otolaryngology 5 th Ed. Chapter 14 deep neck space infections Potter JK, Herford AS, Ellis E 3rd. Tracheotomy versus endotracheal intubation for airway management in deep neck space infections. J Oral Maxillofac Surg Apr;60(4):349-54; discussion Review. PubMed PMID:

75 Recommended Antibiotics Cummings otolaryngology 5 th Ed. Chapter 14 deep neck space infections

76 Surgical Management Indicated (1) air-fluid level in the neck or evidence of gas-producing organisms; (2) abscess visualized in the fascial spaces of the head and neck; (3) threatened airway compromise from abscess or phlegmon; (4) failure to respond to 48 to 72 hours of empiric intravenous antibiotic therapy. Needle Aspiration Transoral Incision and Drainage Transcervical Incision and Drainage The guiding principle of surgery for deep neck infection is obtaining adequate access and drainage of the infected space while minimizing risk to normal structures. Cummings otolaryngology 5 th Ed. Chapter 14 deep neck space infections

77 Cheng J, Elden L. Children with deep space neck infections: our experience with 178 children. Otolaryngol Head Neck Surg Jun;148(6): doi: / Epub 2013 Mar 21. PubMed PMID:

78 Overview Case Presentation Fascial Planes of the Head and Neck Deep Neck Spaces Microbiology Management Complications of Infections

79 Complications Lemierre's Syndrome Carotid Artery Pseudoaneurysm or Rupture Mediastinitis Necrotizing Fasciitis Cummings otolaryngology 5 th Ed. Chapter 14 deep neck space infections

80 Vieira, F. Allen, SM. Etal. Deep Neck Infection. Otolaryngol Clini N Am. 41 (2008) Cummings otolaryngology 5 th Ed. Chapter 14 deep neck space infections Lemierre's Syndrome Definition Thrombophlebitis of the internal jugular vein Origin Carotid space infection Microbiology Gram-negative bacillus Fusobacterium necrophorum Endotoxin induces platelet aggregation and septic thrombus formation. Symptoms Swelling and tenderness at the angle of the jaw and along the SCM, along with signs of sepsis with pulmonary emboli Imaging Filling defect in the internal jugular system. Treatment Prolonged antimicrobial treatment +/- anticoagulation Surgery limited to worsening clinical course despite appropriate medical therapy

81 Vieira, F. Allen, SM. Etal. Deep Neck Infection. Otolaryngol Clini N Am. 41 (2008) Cummings otolaryngology 5 th Ed. Chapter 14 deep neck space infections Carotid Artery Pseudoaneurysm or Rupture Origin Retropharyngeal or parapharyngeal spaces Symptoms Sentinel hemorrhages Hemodynamic compromise Protracted course Hematoma Other: pulsating neck mass, Horner's syndrome, palsies of cranial nerves IX through XII Treatment Proximal control and ligation of the carotid artery.?role for interventional radiology

82 Corsten, MJ, Shamji, FM etal. Optimal treatment of descending necrotising mediastinitis. Thorax. 1997; 52: Vieira, F. Allen, SM. Etal. Deep Neck Infection. Otolaryngol Clini N Am. 41 (2008) Cummings otolaryngology 5 th Ed. Chapter 14 deep neck space infections Mediastinitis Origin Retropharyngeal, danger and prevertebral spaces Anterior visceral space Symptoms Dyspnea, pleuritic chest pain, tachycardia, pleural effusion, mediastinal widening/air Management Broad-spectrum intravenous antibiotics Drainage Surgical Drainage Optimal approach is somewhat debated Bilateral cervical approach advocated by some with infection limited to the anterior-superior mediastinum Thoracotomy in cases that extend beyond the upper mediastinum or that involve more than one mediastinal compartment Corsten: analysis ofpatients with mediastinitis from cervical abscess showing mortality rate was 19% among patients who underwent both cervical and thoracic drainage and 47% among those who underwent cervical drainage alone

83 Necrotizing Fasciitis Definition Infection that spreads along fascial planes and causes necrosis of connective tissue Microbiology Mixed including S pyogenes, Clostridium perfringens, others MRSA Symptoms Fevers, skin changes (tender, edematous, erythematous), soft tissue crepitation Later developing pale, anesthetic, dusky and blistering skin Management IV antibiotics Aggressive and frequent debridement of necrotic tissue Hyperbaric oxygen Flanagan et al show that hyperbaric oxygen may decrease hospital stay 10 patient (9 received 1 did not due to hemodynamic instability). Multiple studies in other specialties literature showing no difference in amputation rate or mortality Mortality 20% to 30% in treated patients Vieira, F. Allen, SM. Etal. Deep Neck Infection. Otolaryngol Clini N Am. 41 (2008) Cummings otolaryngology 5 th Ed. Chapter 14 deep neck space infections Wolf, H, R M. Necrotizing Fasciitis of the Head and Neck. Head and Neck. December 2010 Flanagan, CE. Daramola, OO. Surgical debridement and adjunctive hyperbaric oxygen in cervical necrotizing fasciitis. Otolaryngology Heada dn Neck Surgery : 730.

84 Acknowledgement I would like to thank Dr. Sindhwani of the Department of Radiology for assistance in obtaining some of the images used in this presentation The images obtained from STATDX.COM are meant for educational purposes only.

85 References Anderson JC, Homan JA. Radiographic correlation with neck anatomy. Oral Maxillofac Surg Clin North Am Aug;20(3): doi: /j.coms Review. PubMed PMID: Biron VL, Kurien G, Dziegielewski P, Barber B, Seikaly H. Surgical vs ultrasound-guided drainage of deep neck space abscesses: a randomized controlled trial: surgical vs ultrasound drainage. J Otolaryngol Head Neck Surg Feb 26;42(1):18. doi: / PubMed PMID: ; PubMed Central PMCID: PMC Cheng J, Elden L. Children with deep space neck infections: our experience with 178 children. Otolaryngol Head Neck Surg Jun;148(6): doi: / Epub 2013 Mar 21. PubMed PMID: Corsten, MJ, Shamji, FM etal. Optimal treatment of descending necrotising mediastinitis. Thorax. 1997; 52: Cummings otolaryngology 5 th Ed. Chapter 14 deep neck space infections Flanagan, CE. Daramola, OO. Surgical debridement and adjunctive hyperbaric oxygen in cervical necrotizing fasciitis. Otolaryngology Heada dn Neck Surgery : 730 Freling N, Roele E, Schaefer-Prokop C, Fokkens W. Prediction of deep neck abscesses by contrast-enhanced computerized tomography in 76 clinically suspect consecutive patients. Laryngoscope Sep;119(9): doi: /lary PubMed PMID: Hartmann, RW. Ludwig s Angina in Children. Am Fam Physician 1999 July 1;60(1) Miller WD, Furst IM, Sàndor GK, Keller MA. A prospective, blinded comparison of clinical examination and computed tomography in deep neck infections. Laryngoscope Nov;109(11): PubMed PMID: Mukherji SK, Castillo M. A simplified approach to the spaces of the suprahyoid neck. Radiol Clin North Am Sep;36(5):761-80, v. Review. PubMed PMID: Murray, AD et. Al. Deep Neck infections. Emedicine. Mar 12, 2012 Osborn TM, Assael LA, Bell RB. Deep space neck infection: principles of surgical management. Oral Maxillofac Surg Clin North Am Aug;20(3): doi: /j.coms Review. PubMed PMID: Potter JK, Herford AS, Ellis E 3rd. Tracheotomy versus endotracheal intubation for airway management in deep neck space infections. J Oral Maxillofac Surg Apr;60(4):349-54; discussion Review. PubMed PMID: Som, PM et. al Head and Neck Imaging 5 th Ed. Stambuk, HE. Patel, SG. Imaging of the Parapharyngeal Space. Otolaryngologic Clinics of North America. Vol 41. Iss STATDX.COM Thomason TS, Brenski A, McClay J, Ehmer D. The rising incidence of methicillin-resistant Staphylococcus aureus in pediatric neck abscesses. Otolaryngol Head Neck Surg Sep;137(3): PubMed PMID: Vieira F, Allen SM, Stocks RM, Thompson JW. Deep neck infection. Otolaryngol Clin North Am Jun;41(3):459-83, vii. doi: /j.otc Review. PubMed PMID: Wolf, H, R M. Necrotizing Fasciitis of the Head and Neck. Head and Neck. December 2010