------------------------------------------------------------------------------- TITLE: NECK SPACE INFECTIONS: 1994 SOURCE: Dept. of Otolaryngology, UTMB, Grand Rounds DATE: May 12, 1993 RESIDENT PHYSICIAN: M. D. Bryan, M.D. FACULTY: F. B. Quinn, M.D. DATABASE ADMINISTRATOR: Melinda McCracken, M.S. ------------------------------------------------------------------------------- "This material was prepared by resident physicians in partial fulfillment of educational requirements established for the Postgraduate Training Program of the UTMB Department of Otolaryngology/Head and Neck Surgery and was not intended for clinical use in its present form. It was prepared for the purpose of stimulating group discussion in a conference setting. No warranties, either express or implied, are made with respect to its accuracy, completeness, or timeliness. The material does not necessarily reflect the current or past opinions of members of the UTMB faculty and should not be used for purposes of diagnosis or treatment without consulting appropriate literature sources and informed professional opinion." INTRODUCTION The deep neck spaces are actually potential spaces between fascial planes that surround and invest the structures in the neck. The path of spread by neck infections is along and directed by these planes. These connective tissues can frequently confine and limit the spread of suppurative processes, but they are imperfect barriers. Communication can occur between the spaces as well as outside the confines of the neck itself, leading to life-threatening complications. The anatomical relationships of the fascial planes, spaces, and lymphatic drainage are the basis for understanding the pathology of deep neck space infections. The Major Fascial Layers - Specific Spaces: Superficial Cervical Fascia This fascial layer encircles the entire neck subcutaneously, invests the platysma, and plays no direct role in the development or management of deep neck space infections. Deep Cervical Fascia The DCF is divided into three layers, the superficial layer, the middle layer, and the deep layer. Superficial layer - Originates along the nuchal line and extends circumferentially to encircle the neck. It is contiguous with the SMAS of the face, and splits to enclose the trapezius, sternocleinomastoid, and major salivary glands. It extends inferiorly to attach to the clavicle, sternum, and hyoid bone. It combines with the other two layers of the DCF to contribute to the carotid sheath. Middle layer - The middle layer is contiguous with the superficial layer anteriorly as the superficial layer comes off of the SCM. This layer is further subdivided into visceral and muscular component layers. The muscular division is of little clinical relevance, as it merely surrounds the strap muscles other than the SCM (sternohyoid, sternothyroid, thyrohyoid, & omohyoid). The visceral division is contiguous with the posterior aspect of the muscular division and extends posteriorly to surround the thyroid gland, trachea, & esophagus below the hyoid. It attaches to the thyroid cartilage and hyoid bone. Posteriosuperiorly, it attaches to the skull base behind the nasopharynx. Most importantly, it extends along the viscera to the mediastinum where it is contiguous with the pericardium as it travels with the thoracic esophagus and trachea. Deep layer - The deep layer also has two divisions, the alar layer and the prevertebral layer. The prevertebral layer approximates the anterior periostium of the vertebral bodies, extending to attach laterally to the transverse processes of the vertebra. It continues posteriorly to enclose the paraspinous muscles, meeting the superficial layer of the DCF as they converge on the spinous processes to attach there. The alar fascia simply attaches to the transverse processes of the vertebral bodies, passing anterior to the prevertebral fascia between their common attachments. The prevertebral fascia continues inferiorly to the coccyx, but the alar fascia descends to about the T1 level where it fuses with and becomes indistinguishable from the visceral layer of the middle layer of the DCF. Superiorly, both divisions attach to the skull base. Regional Lymphatic Drainage The lymphatics of the head and neck can be divided into 10 groups of nodes supplying regional drainage. The first 6 groups (occipital, post-auricular, parotid, submandibular, submental, and facial) form more or less a collar at the junction of the head and neck. These nodes drain the skin and superficial underlying structures in the proximal areas. The retropharyngeal and sublingual nodes drain primarily mucosal surfaces, specifically the nose, sinuses, pharynx, tongue, and oral cavity. The submandibular nodes receive drainage from the submandibular gland itself, the tongue, floor of mouth, and mandibular teeth. These and other rostral groups (except the occipital) drain to the lateral cervical nodes which can be divided into superficial and deep groups. The superficial nodes lie between the superficial fascia and the superficial layer of the deep cervical fascia, and drain to the deep nodes. The deep nodes are separated into chains; the internal jugular, the spinal accessory, the transverse cervical, and a large deep chain along the carotid sheath. Spread of infection and suppuration of lymph nodes can lead to infections of the surrounding tissues/spaces. ETIOLOGY OF INFECTIONS The incidence of deep neck space infections has decreased with the increasing use and availability of antibiotics. The use of antibiotics has also resulted in a statistical change in the etiology of the infectious process, in most authors opinions. In the pre-antibiotic era, the prevailing etiology was mucosal oropharyngitis that progressed to neck infection and abscess. With the widespread use of potent antibiotics, the proportion of these infections originating from simple pharyngitis has declined. Curent thinking is that odontogenic sources now rival simple mucosal infections as the most common source. Salivary gland infections are also a significant cause of deep neck infections. However, the source is considered unknown in a significant number of patients (approximately 20% in one large series). The pathogenic process in the case of a local infection that results in spread to a deep neck space is typically lymphatic spread to regional nodes and subsequent suppuration of the nodes. Local cellulitis progresses to phlegmon and if untreated to abscess. Other causes of infection include penetrating trauma with direct innoculation of skin or oropharyngeal flora (MVAs, GSW, stabbings, instrumentation, etc.), and congenital deformities (branchial cleft sinuses and thyroglossal duct cysts). An increasingly commmon cause is the use of dirty needles and/or non-sterile technique by IV drug abusers injecting into the veins of the neck. BACTERIOLOGY The bacteria responsible for most deep neck infections are normal components of the oropharyngeal flora. They become virulent when mucosal barriers are violated. Mucosal barriers are typically violated as a result of local inflammation, or less frequently from physical penetration. As expected, the result is usually a mixed anaerobic/aerobic infection. Multiple isolates are typically found from culture of deep neck space infections. In retrospective studies where few or no anaerobes have been found, the authors themselves were critical of transport and culture techniques employed. In studies (usually prospective) where careful anaerobic techniques were employed, the three most commonly found anaerobes found were Peptostreptococcus, Fusobacterium, and Bacteroides (usually B. melaninogenicus) . The predominant aerobic organisms are streptococci species. Gram negative rods are not thought to commonly be involved in deep neck space infections, but when they are found they are most commonly E. coli, Klebsiella pneumoniae, Haemophilus influenzae, and Pseudomonas aeruginosa. The Gram negative roods are more likely to be found in the aged and/or immunologically compromised patient population. Fungi, TB, and Actinomyces are occasionally responsible for deep neck space infections. TB should be suspected in prevertebral space infections arising from spinal osteomyelitis. Of interest are a few reports of Eikenella corrodens causing deep neck space infections. The reason that this bears mention is the fact that this anaerobe is resistent to clindamycin, an otherwise useful antibiotic agent in these types of infections. As a result of increased I.V. drug abuse, a increasing incidence of deep neck space infections secondary to non-sterile injection technique has been documented. Not surprisingly the bacteriology of these infections is more related to the skin flora, with staphylococci the predominant organism. DIAGNOSIS History - highly variable. A significant portion of patients do not report the anticipated history of recent URI. The time of onset of symptoms until the time of presentation is also variable, but is usually in the range of 2 days to 2 weeks. The use of antibiotics can mask the findings that one would expect to see and this can lead to delay in diagnosis and appropriate treatment. This should be specifically explored in the history. I.V. drug abuse should be specifically asked about. Presenting symptoms - specific symptoms depend on the space involved, but for general review, the following data was derived from analysis of 51 neck space infection cases at the Los Angeles County - USC Medical Center (Tom, et. al., 1988): Pain 76% Fever 64% Swelling 62% Dysphagia/odynophagia 42% Trismus 14% Respiratory distress 14% Dental problems 8% Physical findings - again, dependent on the space involved, but form the same USC study, the following clinical data is useful: Swelling 90% Dental abnormality 29% Fluctuance 27% Oropharyngeal abnormality 22% Trismus 18% Laryngeal abnormality 18% (pooling of secretions, edema, etc.) The physical exam should include survey for track marks on the arms, groin, etc. Radiographic Studies - Plain films: AP & lateral neck films are useful in delineating the course and caliber of the airway as well as the degree of soft tissue edema. Also useful for detecting and localizing radiopaque foreign bodies. CXR is a useful adjunctive study, especially if you suspect mediastinal involvement. In patients with no obvious source of infection, a routine CXR should be used to screen for hilar adenopathy or masses. Ultrasound: The usefulness of USG in neck mass/abscess evaluation is still debated. Studies have resulted in some disagreement as to the sensitivity of this modality in detecting pathology. It is relatively inexpensive and can be used to follow the clinical course of a patient with an abscess that can be seen by USG. It is not considered to be the study of choice by most authors. CT: This is the current "gold standard" imaging study in the evaluation of neck space infections. Sensitivity and specificity are excellent in the delineation of involved spaces and contrast allows enhancement of abscess walls. Air/fluid interfaces and fluid-filled cavities are clearly demonstrated. Superior to MRI in the evaluation of the cervical spine when osteomyelitis is suspected as a cause for prevertebral space involvement. This is the study of choice. MRI: Offers better soft tissue resolution and contrast (ie. - normal vs. inflamed) . It does allow recostruction in any plane and can therefore offer views that are difficult or impossible to see with routine CT. Additionally, for patients with allergies to contrast material it does offer comparable information to a contrast enhanced CT without exposure to contrast. There is no radiation exposure. However, it is still expensive by comparison to CT, and in most institutions, still more difficult to get on a timely basis. In summary, in selected cases it may be advocated, but it is not routinely needed. Laboratory - There will almost always be an elevated WBC and sedimentation rate. Blood cultures are typically negative unless septic thrombophlebitis occurs. TREATMENT Airway assessment and control is the paramount initial concern Tracheotomy is occasionally required Intubation Humidified O2 Immediate parenteral antibiotics High dose PCN - considered the drug of choice in the past, it is still widely recommended. Semi-synthetic penicillins are a good but more expensive alternative. Continuous PCN infusion has been used effectively in the treatment of mediastinal extension of deep neck infection. Nafcillin would be a good choice in the treatment of neck abscess secondary to I.V. drug abuse. Clindamycin - some controversy in the literature with respect to the necessity of this agent in non-penicillin-allergic patients, but the trend toward penicillase producing anaerobic organisms would favor its inclusion. Of note is the resistance of Eikenella corrodens (an anaerobe) to Clindamycin. It is generally exquisitely sensitive to PCN however, but this illustrates the potential problems with the use of single agent clindamycin. Most authors do not feel that gram negative coverage is inherently necessary unless culture and sensitivity data indicate otherwise. Needle Aspiration Diagnostic - If surgical drainage is not planned immediately, a needle aspiration of the suspect area, even in a cellulitic picture, is advocated to obtain material for Gram's stain and culture. Anaerobic cultures are important. Return of purulent material also helps in confirming the diagnosis Therapeutic - A growing number of authorities believe that neck space infections can be treated by aspiration of the infected material, serially if necessary. CT or USG guidance of aspiration is optional. Surgical Drainage Growing trend is away from immediate surgical drainage. Most advocate a 24-48 hour period of observation while IV antibiotic treatment is ongoing. If improvement is not evident, or if deterioration occurs, surgical intervention is performed. However, clinical judgement is the best guide to timing of surgical treatment, and in the case of clear abscess formation, incision and drainage can not be easily faulted. Early intervention is typically preferred in the treatment of anterior visceral abscess/infection. DISCUSSION OF SPECIFIC SPACES Submandibular Space - actually consists of two spaces, the sublingual space and the submylohyoid space, separated by, and freely communicating around the posterior border of, the mylohyoid muscle. Boundaries Anterior: mandible Lateral: mandible Anterioinferior: superficial layer of the DCF Posterioinferior: hyoid bone Superior: floor of mouth mucosa Contents: Sublingual and submandibular glands Geniohyoid, genioglossus, myelohyoid, anterior digastric muscles Pathology: Odontogenic and submandibular gland infections are the rule. The odontogenic source is usually the second or third mandibular molar in the case of the submylohyoid area, and the first molar in the case of a sublingual space infection. Other factors to consider are lacerations and fractures. Clinical: Early infections will present characteristically based on the space they involve. Submylohyoid space infections typically present as hard, "woody" induration of the submental area, with warmth, tenderness, and erythema of the overlying skin. Fluctuance is uncommon because of the fascial and muscular planes involved. The sublingual space is less confined because of the pliant floor of mouth mucosa, and will present as swelling and erythema of this area, with elevation of the tongue, and occasionally fluctuance. Unilateral involvement is not uncommon because of the natural barrier provided by the septum of the tongue. Ludwig's angina can result from spread of infection from sublingual or submylohyoid areas into the other space. Ludwig's requires involvement of both submandibular spaces. The floor of mouth will be distended and firm, the tongue markedly elevated and pushed posteriorly, with potential oral airway compromise. They will have a hot potato voice if they can still talk, complain of stiff neck, mouth pain, will be drooling, and dysphagic. Fluctuance is rare. Fever, chills, and systemic toxicity are typical. Trismus indicates spread to lateral pharyngeal space and involvement of masticatory muscles. Dyspnea represents an advanced stage and requires immediate airway intervention. Treatment: Assess and control airway if necessary Start I.V. antibiotics Sublingual infections/abscesses can be drained intra orally or externally Submylohyoid infections can be drained via a horizontal submental incision. The mylohyoid muscle MUST be divided to effect proper drainage in cases of Ludwig's angina that ultimately require surgical intervention. Culture and sensitivities dictate changes in antibiotics. Complications: Spread to other neck spaces - a dangerous connection exists between the submandibular and lateral pharyngeal spaces known as the buccopharyngeal gap. The styloglossus courses through this gap on its way from the tongue to the styloid process. Infection can spread along this route to the lateral pharyngeal space and beyond. Asphyxia - obstruction of airway most common cause of death in fatal cases of Ludwig's angina. Mandibular osteomyelitis. Lateral Pharyngeal Space - Cone shaped space with apex inferiorly at the hyoid, divided into pre-styloid and post-styloid spaces. Boundaries - Superior: skull base (sphenoid) Inferior: hyoid bone Medial: lateral pharyngeal wall Posterior: prevertebral, alar, visceral DCF Anteriosuperior: pterygomandibular raphe; Anterioinferior: junction of the buccopharyngeal and muscular division of the middle layer of the DCF Lateral: parotid, mandible, and internal pterygoid. Contents: The post-styloid compartment contains cranial nerves 9 through 12, the carotid sheath and its contents, and the cervical sympathetic chain. The pre-styloid compartment contains only fat, areolar tissue, lymph nodes, and muscles (stylohyoid, digastric, styloglossus, and stylopharyngeous muscles). Pathology: Infections in the lateral pharyngeal space can arise from multiple sources. The pharynx, teeth, tonsils, adenoids, parotid, submandibular space, retropharyngeal space, masticator space, and lymph nodes draining the nose and pharynx may all be sites of origin. Extension from peritonsillar abscesses can occur by dissection through the pharyngeal wall, lymphatic spread, perivascular extension, or septic thrombosis of the peritonsillar veins. Bezold's abscesses can rarely suppurate and erode through the mastoid tip and reach the lateral pharyngeal space. Clinical: Symptoms differ according to whether the pre- or post-styloid space is involved. Common features include fever, otalgia, and odynophagia. The cardinal signs of pre-styloid involvement are trismus, lateral pharyngeal wall fullness, induration, swelling & tenderness at the angle of the mandible, and systemic toxicity. Fluctuance is rare. Post-styloid involvement usually is accompanied by marked sepsis, little or no trismus, and sometimes cranial nerve palsy and/or, Horner's syndrome. Treatment: Airway assessment and management I.V. antibiotics Needle aspirate for Gram's stain and culture If known abscess (vs. phelgmon), surgical incision and drainage. Use transcervical approach. Do not use intraoral drainage. The surgical approach of choice is usually a horizontal incision parallel to the border of the mandible, with a vertical incision (creating a "T") along the anterior border of the SCM. The carotid sheath and the anterior belly of the digastric are the primary landmarks. The dissection follows the digastric, from under the submandibular gland toward the styloid process. Drains are placed both inferiorly and superiorly. Complications: Airway obstruction Jugular thrombophlebitis Descending suppurative mediastinitis Septic pulmonary foci (dissemination) Carotid rupture Aspiration pneumonia Extension to adjacent neck space Retropharyngeal Space - terminology is commonly confused in discussions about this area, with three spaces all referred to as "retrophayngeal": (1) retropharyngeal (visceral) space, (2) alar or "danger" space, and the (3) prevertebral space. Most commonly involved is the visceral retropharyngeal space. The alar space is almost always a secondarily infected space when it is involved, and the prevertebral space is usually infected secondary to osteomyelitis or injury and subsequent infection of the spine. Focus will be on the visceral retrophahyngeal space. Boundaries: Superior: skull base Anterior: pharyngeal constrictors and their fascial covering Posterior: alar fascia Inferior: point of fusion of alar and anterior visceral fascia at about the level of the tracheal bifurcation. Lateral: the carotid sheath, at its points of fusion with the deep layer of the DCF and the middle layer of the DCF. Contents: loose areolar tissue and lymphatics; midline raphe Pathology: Most commonly affected are children, with infection thought to be the result of suppuration of the lymph nodes draining the nose, sinuses, and pharynx. Most common age < 12 months. Adults affected much less often, with etiology less clear. Lymph node atrophy by age 3 to 5 years thought to the reason for fewer adult infections. Spread from other neck spaces is the more common source in adults, as well as penetrating trauma. Clinical: Children: fever, swollen neck, dysphagia, muffled voice, and hyperextension of the neck are the most common. The most common physical finding is cervical adenopathy, with posterior pharyngeal bulge seen in about half of the afflicted patients. Although tonsillitis, and otitis media are the most common coincident diagnoses, retropharyngeal infection may mimic croup, epiglottitis, supraglottitis, tracheitis, pharyngitis, or uvulitis. Surprisingly, there is no report of significant coincident or preceding illness in the majority of patients. The WBC count is elevated and a left shift is seen in almost all cases; WBC count of about 20,000 is typical. Adults: fever, sialorrhea, stiff neck, stridor, lateral neck swelling & erythema, odynophagia, and dysphagia are common signs and symptoms. Coincident neck space infections or spinal osteomyelitis should be suspected and sought if diagnosis of retropharyngeal infection is considered in an adult. WBC are elevated similarly in children and adults. In all cases, the diagnosis is confirmed with radiological studies. Lateral neck soft issue plain films are considered sufficient for diagnostic confirmation by most authors, but CT scan is recommended by all. The posterior pharyngeal soft tissues have characteristic thicknesses at different levels of the cervical spine for diferent age groups. Hay (1930), and Wholey (1958), each reviewed lateral neck films of a large number of patients and characterized their findings. The widely used parameters of 1.0 to 7.0 mm at the C2 level, or 9.0 to 22.0 mm for adults & 6.0 to 14.0 mm for children at the C6 level are considered the normal ranges and come from these studies. Swischuk has characterized the normal soft tissue thickness of the pediatric (and adult) population as a fraction of the thickness of the C4 vertebral body. For ages 6 years and up, the soft tissues should not exceed 0.3 times the C4 vertebral body width. For 1 to 6 year olds, the ratio is 0.4 to 0.5, and for ages less than 1 year, 1.5 times the C4 body width is the upper limit of normal posterior pharyngeal soft tissue thickness. Obvious deviation from this range is considered pathologic. Treatment: Airway assessment/management I. V. antibiotics should be broad spectrum and anaerobic coverage is important, especially in adults, or when a sinus, odontogenic, or middle ear source is suspected. Surgical drainage is recommended in the event of abscess. The route of incision and drainage is not mandated. Intraoral drainage has been use successfully, but some authors believe inadequate drainage is too high a risk and recommend a transcervical external approach. If intraoral approach is used, it is done under general anesthesia with airway protection to reduce the risk of aspiration and subsequent pneumonia. If surrounding spaces are involved, the external approach is always used. The external approach can be from anterior or posterior to the SCM. Tracheostomy is occasionally required. Complications: Spread to mediastinum, "danger space",lateral pharyngeal space, etc. Usually this manifests as chest pain, with respiratory distress occasionally, and high fever. Look for tenderness with sternal compression and widened mediastinum on CXR. Airway obstruction Aspiration pneumonia can occur, especially if spontaneous or iatrogenic rupture of the abscess occurs without sufficient airway protections. Parotid space - the potential space surrounding the parotid gland Boundaries: Formed by the split in the superficial layer of the DCF as it envelopes the parotid gland. The fascia is incomplete at the superior medial surface of the gland, allowing direct communication to the lateral pharyngeal space if infection spreads this far Contents: Parotid gland and nodes. CN VII External carotid artery and posterior facial veins Pathology: Acute parotitis secondary to obstruction of the parotid duct by stones, neoplasms, inspissated secretions, etc., is the most common cause of infection Poor oral hygiene with subsequent infection. Postoperative infection. Recurrent acute parotitis in children. This is cryptogenic and usually doesn't lead to serious infection. Episodes typically subsides near puberty. Clinical: Local swelling, pain, erythema. Debilitated and/or severely dehydrated patients are affected more frequently. Trismus is absent unless spread to involve masticator space or lateral pharyngeal space has occurred. Treatment: I. V. antibiotics Hydration Sialogogues Oral hygiene Surgical treatment is used in the event of clear abscess formation, or clinical deterioration occurs. In the event of a well defined very superficial abscess, a small incision at the site of maximum prominence is used. It is recommended that incisions be parallel with the expected course of facial nerve branches. If a large abscess or indistinctly defined abscess is suspected, a Furstenberg incision is used to access the parotid fascia. The fascia is incised and bluntly explored, again with care taken to avoid injury to the facial nerve. Drains are inserted after drainage and irrigation. Parotidectomy is rarely neccesary. Complications: Spread to lateral pharyngeal space or the masticator space. Scarring of the ducts with chronic obstruction. Masticator space - the muscles of mastication are the pterygoids and the masseter, which are enclosed in fascial sheaths that derive from the superficial layer of the DCF as it splits to enclose the mandible. The superficial or lateral layer goes on to enclose the masseter and attach to the zygoma, with the deeper layer encasing the pterygoids and attaching to the skullbase. Boundaries: The muscle fascia defines the space boundaries, except that there is communication with the supratemporal and infratemporal spaces superiorly. The ramus and posterior body of the mandible forms a subdividing line, being the medial border of the submasseteric space, and the lateral border of the pterygomandibular space. Contents: Pterygoids, masseter, temporalis tendon, inferior alveolar nerve. Pathology: infection is almost always secondary to spread form odontogenic source. Mandibular molars most commonly involved. The bacteriology reflects this, with mixed aerobic/anaerobic flora typically. Less frequently, infection of infratemporal ,parotid, pharyngomaxillary, or lateral pharyngeal spaces spreads to involve the masticator space. Clinical: Onset is usually acute. Trismus is always present, usually extreme.Dysphagia is common. Swelling, induration and tenderness over the masseter, without fluctuance. May be confused with deep parotid infection. The swelling can extend below the angle of the mandible and extends to the opposite side of the neck. The posteriolateral floor of mouth is usually swollen and tender on the involved side. May look like early Ludwig's angina. Panorex is recommended,in addition to CT scan. Treatment: I. V. antibiotics Surgical intervention if indicated by non-improvement or deterioration. The external approach is commonly used with the incision parallel to the mandible at the angle. The incision is carried down through the periosteum. Some authors recommend an intraoral approach through the posterior mucobuccal sulcus for cosmetic reasons. Complications: Osteomyelitis of the mandible, especially if there is a delay in treatment. Spread to the parotid, temporal, or lateral pharyngeal spaces. Anterior visceral space - Boundaries: Completely surrounded by visceral fascia Anterior - middle layer of the DCF as it surrounds the strap muscles Posterior - the middle layer of the DCF "splits" to cover the musculature of the esophagus, leaving the anterior surface of the esophagus as the posterior boundary of the anterior visceral space Superior - the fascia extents and attaches to the thyroid cartilage and hyoid bone Inferior - the space extends along the trachea to anterior superior mediastinum Pathology: The majority of infections of third space originate secondary to a perforating injury of the esophagus (trauma, foreign body, instrumentation.) Surprisingly, rare to have infection here as result of thyroiditis Clinical: Subcutaneous emphysema, Fullness, induration,pain, erythema of the anterior neck commonly Dysphagia and odynophagia Hypopharynx may appear narrowed with prominent bulging of anterior wall (endoscopic) Dyspnea; can progress to airway obstruction May have chest pain, or pleuritic pain as infection extends into the mediastinum Treatment: Airway assessment/management I. V. antibiotics Surgical intervention early because of ease of spread to the mediastinum, and/or airway threat Complications: Obtruction/asphyxia Mediastinitis Pleuritis/empyema Extension to lateral or retropharyngeal spaces --------------------------------------------------------------------------- BIBLIOGRAPHY Scott, B., Stiernberg, C. M. "Deep Neck Space Infections", Department of Otolaryngology Grand Rounds, April 11, 1990 Johnson, J. T. "Abscesses and deep neck space infections of the head and neck." 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