Infections of the Head and Neck: Anatomical Considerations -<= /title> <o:SmartTagType namespaceuri=3D"urn:schemas-microsoft-com:office:smarttags" name=3D"place"/> <o:SmartTagType namespaceuri=3D"urn:schemas-microsoft-com:office:smarttags" name=3D"City"/>  <link rel=3DthemeData href=3D"HN-anat-2011-11-30_files/themedata.thmx"> <link rel=3DcolorSchemeMapping href=3D"HN-anat-2011-11-30_files/colorschememapping.xml">  <style>  </style>  </head> <body lang=3DEN-US link=3Dblue vlink=3Dpurple style=3D'tab-interval:.5in'> <div class=3DWordSection1> <a name=3D"OLE_LINK2"></a= ><a name=3D"OLE_LINK1">TITLE: Infections= of the Head and Neck: Anatomical Considerations SOURCE: Grand Rounds Presentation, The University of Texas Medical Branch (utmb Health), Department of Otolaryngology DATE: November 30, 2011 RESIDENT PHYSICIAN: Angelia Natali, M.D. FACULTY PHYSICIAN: Susan McCammon, M.D. DISCUSSANT: SERIES EDITOR: Francis B. Quinn, Jr., M.D. ARCHIVIST: Melinda Stoner Quinn, M= SICS</a> <div style=3D'mso-element:para-border-div;border:solid windowtext 1.0pt; mso-border-alt:solid windowtext .5pt;padding:1.0pt 4.0pt 1.0pt 4.0pt'> "This material was prepared by resident physicians in partial fulfillment of educational requirements established f= or 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 sho= uld not be used for purposes of diagnosis or treatment without consulting appropriate literature sources and informed professional opinion." <o:= p></o:p> </div> <h1>Introduction: </h1> Infections are one of the most commonly occurring head= and neck pathologies. Spread of infect= ion can be predicted by anatomic boundaries. Mortality from head and neck infections has decreased significantly since the advent of antibiotics, but resistant organisms are spreading into= the community. Diagnosis and treatment= will not be focus of this discussion. The spaces in the head and neck that will be discussed= are: Sinuses, Orbits, Peritonsillar, Parapharyngeal, Submandibular, Retropharyng= eal, Danger Space, Prevertebral, Mastica= tor, Ear. <h1>Sinuses:</h1> <h2>First the = nasal borders:<o:p></o:p></h2> <![if !supp= ortLists]>· <![endif]>Medially - the nasal septum (perpendicular p= late of the ethmoid bone, the vomer bone, and the septal cartilage) <o:p></o:p> <![if !supp= ortLists]>· <![endif]>Laterally - the nasal conchae; superior and middle (ethmoid bone derivation), inferior (a bone itself), and contributio= ns from the lacrimal bone, the perpendicular plate of the palatine bone, and t= he maxillary bone <o:p></o:p> <![if !supp= ortLists]>· <![endif]>Inferiorly - the horizontal plate of the maxillary bone (anterior two thirds of the hard palate) and the horizontal plate of the palatine bone (posterior third of the hard palate) <o:p></o:p> <![if !supp= ortLists]>· <![endif]>Superiorly - the cribiform plate of the ethm= oid bone (where the nerve endings of the Olfactory Nerve (CN1) open to the environment) <o:p></o:p> <![if !supp= ortLists]>· <![endif]>Posterior - none, the nasal cavity opens to the nasopharynx via the c</spa= n>hoanae<o:p></o:p> <h1>Sinus drainage patterns:</h1> <![if !supp= ortLists]>· <![endif]>Maxillary Sinus - The largest sinus, is found lateral and inferior to the lateral nasal wall below the orbit. This sinus drains, superiorly, to the middle meatus just below the ethmoidal bulla. </= p> <![if !supp= ortLists]>· <![endif]>Sphenoidal Sinus - This sinus is located in = the posterior wall of the nasal cavity and opens to the sphenoethmoidal recess which is superior to the superior concha. Superior to this sinus is the pituitary gland (hypophysis) in the sella turcica of the sphenoid bone. <![if !supp= ortLists]>· <![endif]>Frontal Sinus - The frontal sinuses are loca= ted in the frontal bone of the cranium and extend across the forehead. These sinuses drain down to the middle meatus via the frontonasal duct into the anterior portion of the semilunar hiatus. <![if !supp= ortLists]>· <![endif]>Ethmoidal Sinus - These sinuses resemble bub= bles and are located behind the superior lateral nasal wall. They are divided in= to anterior, middle and posterior cells on the basis of their drainage. The anterior cells drain to the middle meatus in the posterior portion of the semilunar hiatus. The middle sinuses empty to the center of the ethmoidal bulla. The posterior sinuses empty to the superior meatus. <h1>Sinusitis:</h1> This is a complex disease process resulting in blockag= e of sinus drainage and accumulation of fluid leading to bacterial overgrowth.<s= pan style=3D'mso-spacerun:yes'> It may be treated medically or surgical= ly, with the goal of surgery to alleviate anatomic obstructions. <h2>Orbits: The <st1:place w:st=3D= "on"><st1:City w:st=3D"on">Chandler</st1:City></st1:place> Classification</h2> <![if !supp= ortLists]>· <![endif]>Periorbital (Preseptal) Cellulitis: eyelid edema, erythema, tenderness; no vision changes, chemosis, proptosis, or restriction of ocular muscles <![if !supp= ortLists]>· <![endif]>Orbital Cellulitis: proptosis, chemosis, may cause vision changes (anterior pupillary defect), may limit extraocular mus= cles <![if !supp= ortLists]>· <![endif]>Subperiosteal Abscess: collection of pus bet= ween bone and periosteum, chemosis, may have proptosis, restrict extraocular mot= ion, and affect vision, requires urgent surgical decompression <![if !supp= ortLists]>· <![endif]>Orbital Abscess: collection of pus in orbital soft tissue, proptosis, chemosis, restricted extraocular motion, may have no light perception (may be reversible), requires urgent surgical decompressio= n <![if !supp= ortLists]>· <![endif]>Cavernous Sinus Thrombosis: Pathophysiology: perinasal sinus infection ➝ orbital extension ➝ mural thrombus forms in vessel wall (thrombophlebitis) ➝ propagates distally as clot softens and begins= to seed <h1>Pathogens: S. aureus, hemolytic Streptococcus and Pneumococcus</h1> SSx: “picket fence” spiking fevers, toxemia, papilledema, paralysis of extraocular muscles (CN III, IV, and V), proptosis, chemosis, eyelid edema <o:p> </o:p> A word about the cavernous sinus: The cavernous sinuses are paire= d, venous structures located on either side of the sella turcica. They receive venous tributaries from the superior and inferior orbital veins and drain i= nto the superior and inferior petrosal sinuses. The cavernous sinus contains the carotid artery, its sympathetic plexus, and the oculomotor nerves (third, fourth, and sixth cranial nerves). In addition, the ophthalmic branch and occasionally the maxillary branch of the fifth nerve traverse the cavernous sinus. The nerves pass through the wall of the sinus while the carotid arte= ry passes through the sinus itself. <o:p> </o:p> <h1>Peritonsillar space:</h1> The peritonsillar space consists of loose connective t= issue between the capsule of the palatine tonsil and the superior constrictor mus= cle. The anterior and posterior tonsillar pillars contribute to its anterior and posterior borders, respectively. The posterior tongue forms the inferior boundary. Peritonsillar infections may readily spread to the parapharyngeal space. <h1>Parapharyngeal space</h1> <![if !supp= ortLists]>· <![endif]>Other names: lateral pharyngeal or pharyngomaxillary space <![if !supp= ortLists]>· <![endif]>Shape: </s= pan>inverted pyramid <![if !supp= ortLists]>· <![endif]>Superior boundary: skull base <![if !supp= ortLists]>· <![endif]>Inferior boundary: junction of the posterior belly of the digastric muscle and greater cornu of the hyoid bone <![if !supp= ortLists]>· <![endif]>Anterior boundary: pterygomandibular raphe and medial ptery= goid muscle bound the space <![if !supp= ortLists]>· <![endif]>Posterior: prevertebral fasci <![if !supp= ortLists]>· <![endif]>Medialboundary: superior constrictor, tensor, and levato= r veli palatini muscle <![if !supp= ortLists]>· <![endif]>Lateral boundary: parotid gland, mandible, a= nd lateral pterygoid muscle <![if !supp= ortLists]>· <![endif]>Compartments: prestyloid (anterior): contains fat, styloglossus and stylopharyngeus, lymph nodes, deep lobe of the paroti= d, internal maxillary artery, inferior alveolar, lingual, and auriculotemporal nerves <![if !supp= ortLists]>· <![endif]>Poststyloid (posterior): contains carotid artery, internal jugular vein, sympathetic chain, and cranial nerves IX, X,= XI, and XII. <![if !supp= ortLists]>· <![endif]>Connections to other deep spaces: <![if !supp= ortLists]>· <![endif]>posteromedially: retropharyngeal space <![if !supp= ortLists]>· <![endif]>inferiorly: submandibular space <![if !supp= ortLists]>· <![endif]>laterally: masticator space <![if !supp= ortLists]>· <![endif]>medially: peritonsillar space <o:p>&n= bsp;</o:p> <h1>Submandibular Space</h1> <![if !supp= ortLists]>· <![endif]>Boundaries: <![if !supp= ortLists]>· <![endif]>Superior: mucosa of the floor of the mouth</= p> <![if !supp= ortLists]>· <![endif]>Inferior: digastrics muscle and hyoid bone</= p> <![if !supp= ortLists]>· <![endif]>Anterior: mylohyoid muscle and anterior bell= y of digastrics <![if !supp= ortLists]>· <![endif]>Posterior: posterior belly of the digastric = and stylomandibular ligament <![if !supp= ortLists]>· <![endif]>Medial: hyoglossus, mylohyoid, styloglossus, genioglossus, and geniohyoid muscles <![if !supp= ortLists]>· <![endif]>Lateral: platysma and mandible The mylohyoid muscle divides the submandibular space i= nto a superior sublingual space and an inferior submaxillary space (for clarity, = this is also referred to as the submandibular space). Sublingual space: lateral to the geniohyoid and genioglossus muscles, contains = the sublingual gland and Wharton’s duct. Teeth apices anterior to the second mo= lar lie superior to the mylohyoid line and thus involve the sublingual space. <= /p> <h1>Submaxillary space: contains submandibular glands and lymph nodes. Infections of the second and third molars initially involve the submandibular or parapharyngeal space, because their roots extend below the mylohyoid line.<o:p></o:p></h1> <h1>Retropharyngeal space</h1> <ul style=3D'margin-top:0in' type=3Ddisc> <li class=3DMsoNormal style=3D'margin-bottom:0in;margin-bottom:.0001pt;tex= t-indent: -.25in;mso-list:l21 level1 lfo20'>Potential space</li> <li class=3DMsoNormal style=3D'margin-bottom:0in;margin-bottom:.0001pt;tex= t-indent: -.25in;mso-list:l21 level1 lfo20'>Boundaries:</li> <li class=3DMsoNormal style=3D'margin-bottom:0in;margin-bottom:.0001pt;tex= t-indent: -.25in;mso-list:l21 level1 lfo20'>Upper: skull base </li> <li class=3DMsoNormal style=3D'margin-bottom:0in;margin-bottom:.0001pt;tex= t-indent: -.25in;mso-list:l21 level1 lfo20'>Lower: mediastinum at the tracheal bifurcation <o:p></o:p></li> <li class=3DMsoNormal style=3D'margin-bottom:0in;margin-bottom:.0001pt;tex= t-indent: -.25in;mso-list:l21 level1 lfo20'>Anterior: buccopharyngeal fascia </li> <li class=3DMsoNormal style=3D'margin-bottom:0in;margin-bottom:.0001pt;tex= t-indent: -.25in;mso-list:l21 level1 lfo20'>Posterior: alar fascia<o:p></o:p></li> <li class=3DMsoNormal style=3D'margin-bottom:0in;margin-bottom:.0001pt;tex= t-indent: -.25in;mso-list:l21 level1 lfo20'>Contains: lymph node and connective tissue </li> <li class=3DMsoNormal style=3D'margin-bottom:0in;margin-bottom:.0001pt;tex= t-indent: -.25in;mso-list:l21 level1 lfo20'>Routes of entry: direct spread from = the parapharyngeal space, or lymphatic spread from the paranasal sinuses o= r nasopharyngeal region</li> </ul> <o:p> </o:p> <h1>Danger Space</h1> Potential Space, named for the potential for rapid inferior spread of infection to the posterior mediastin= um through its loose areolar tissue <![if !supportLists]>· <![endif]>Boundaries: <![if !supportLists]>· <![endif]>Superior: skull base <![if !supportLists]>· <![endif]>Inferior: diaphragm <![if !supportLists]>· <![endif]>Anterior: alar fascia, retropharyngeal space= <![if !supportLists]>· <![endif]>Posterior: prevertebral fascia <![if !supportLists]>· <![endif]>Lateral: transverse processes of vertebrae</= p> <![if !supportLists]>· <![endif]>Contains: sympathetic trunk <![if !supportLists]>· <![endif]>Routes of entry: retropharyngeal, parapharyngeal, or prevertebral spaces <o:p> </o:p> <h1>Prevertebral space</h1> <![if !supportLists]>· <![endif]>Potential space <![if !supportLists]>· <![endif]>Boundaries: <![if !supportLists]>· <![endif]>Superior: clivus of the skull base <![if !supportLists]>· <![endif]>Inferior: coccyx <![if !supportLists]>· <![endif]>Anterior: prevertebral fascia <![if !supportLists]>· <![endif]>Posterior: vertebral bodies <![if !supportLists]>· <![endif]>Lateral: transverse processes <![if !supportLists]>· <![endif]>Contains: paraspinous, prevertebral, and sca= lene muscles, it contains the vertebral artery and vein, brachial plexus, and ph= renic nerve <![if !supportLists]>· <![endif]>Routes of entry: infection of the vertebral bodies and penetrating injuries <o:p= > </o:p> <h1>Masticator space</h1> <![if !supportLists]>· <![endif]>Boundaries: <![if !supportLists]>· <![endif]>Superior: skull base <![if !supportLists]>· <![endif]>Inferior: submandibular space <![if !supportLists]>· <![endif]>Lateral: masseter, superficial temporal fasc= ia <![if !supportLists]>· <![endif]>Medial: medial pterygoid, parapharyngeal spa= ce <![if !supportLists]>· <![endif]>Anterior: posterior wall of maxillary sinus, buccal space <![if !supportLists]>· <![endif]>Posterior: parotid <![if !supportLists]>· <![endif]>Contains: mandible and muscles of mastication (masseter, temporalis, medial pterygoid, lateral pterygoid), the third port= ion of the trigeminal nerve, which enters through the foramen ovale, the intern= al maxillary artery, and much of the buccal fat pad <![if !supportLists]>· <![endif]>Subspaces: <![if !supportLists]>· <![endif]>Masseteric: between the masseter muscle and ramus of mandible <![if !supportLists]>· <![endif]>Pterygoid: between the pterygoid muscles and ramus <![if !supportLists]>· <![endif]>Superficial temporal: superficial temporal fascia and temporalis muscle <![if !supportLists]>· <![endif]>Deep temporal: between the deep temporal fas= cia and temporal bone <![if !supportLists]>· <![endif]>Route of entry: most commonly from the third mandibular molars <o:p> </o:p> <span style=3D'font-size:11.0pt;mso-bidi-font-size:16.0pt;font-family:"A= rial","sans-serif"; mso-fareast-font-family:"Times New Roman";mso-bidi-font-family:"Times New R= oman"; mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA'= > <h1>Ear</h1> Malignant otitis externa is an aggressive and potentia= lly fatal infection originating in the external canal, with progressive spread along the soft tissues and bone of the skull base, ultimately involving intracranial structures. It is also (more accurately) known as necrotizing otitis externa. Posterior invasion of P. aeruginosa leads to clouding = of the mastoid air cells. With medial invasion, displacement and erosion of ossicl= es occur, while anterior invasion may produce temporomandibular joint arthritis and mandibular condyle osteomyelitis. Intracranial invasion may result in meningitis, brain abscess or cavernous sinus thrombosis. <h1>Conclusion:</h1> Understanding anatomical boundaries can help clinicians manage head and neck infections by predicting their spread. Mortality has decreased significantly i= n the postantibiotic era, but resistant organisms are spreading. <div style=3D'mso-element:para-border-div;border:none;border-bottom:solid w= indowtext 1.0pt; mso-border-bottom-alt:solid windowtext .5pt;padding:0in 0in 1.0pt 0in'> <o:p> </o:p> </div> <h1>DR. PINE'S DISCUSSION OF Dr. NATILI'S GRAND ROUNDS 2011/11/30</h1> The peritonsillar one is a great example where I bet a bunch of them probably w= ould get better medically, but since we're there ready to open them up and that's not such a good example in an adult where you can do something there right = in the ER but in a kid its potentially a big deal because it means bringing someone to the operating room when you might get away with antibiotics, so = I'm always looking for things you can point to and say, well, look, it's less than one centimeter and= so statistically we're going to win w= ith a trial of antibiotics and let's try that first versus just saying, "Loo= k, there's an abscess there that could be drained."<o:p></o:p> <div style=3D'mso-element:para-border-div;border:none;border-bottom:solid w= indowtext 1.0pt; mso-border-bottom-alt:solid windowtext .5pt;padding:0in 0in 1.0pt 0in'> <h1 style=3D'border:none;mso-border-bottom-alt:solid windowtext .5pt;paddin= g: 0in;mso-padding-alt:0in 0in 1.0pt 0in'><o:p> </o:p></h1> </div> <o:p> </o:p> <h1>References</h1> <![if !supportLists]>¢ <![endif]><a href=3D"http://iris3.med.tufts.edu/headne= ck">http://iris3.med.tufts.edu/headneck</a> <![if !supportLists]>¢ <![endif]><a href=3D"http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/a= llergy/rhino-sinusitis/">http://www.clevelandclinicmeded.com/medicalpubs/di= seasemanagement/allergy/rhino-sinusitis/</a> <![if !supportLists]>¢ <![endif]><a href=3D"http://doctorcayoo.blogspot.com/2009/12/peritonsiler-abscess-pta-qu= insy-1.html">http://doctorcayoo.blogspot.com/2009/12/peritonsiler-abscess-p= ta-quinsy-1.html</a> <![if !supportLists]>¢ <![endif]><a href=3D"http://www.merckmanuals.com/professional/eye_disorders/orbital_dise= ases/preseptal_and_orbital_cellulitis.html">www.merckmanuals.com/profession= al/eye_disorde...</a> <![if !supportLists]>¢ <![endif]><a href=3D"http://iris3.med.tufts.edu/dentgross/labguide/Homepage.html">http:/= /iris3.med.tufts.edu/dentgross/labguide/Homepage.html</a> <![if !supportLists]>¢ <![endif]>Cummings Otolaryngology Head and Neck Surger= y, 5th ed. <![if !supportLists]>¢ <![endif]>Lee KJ, Essential Otolaryngology Head and Ne= ck Surgery <![if !supportLists]>¢ <![endif]>Pasha R, Otolaryngology Head and Neck Surgery Clinical Reference Guide <![if !supportLists]>¢ <![endif]>Herr RD, Serious Soft Tissue Infections of t= he Head and Neck, American Family Physician, September 1991, Vol 44, no 3, 878= -888 <![if !supportLists]>¢ <![endif]>Hartmann RW Jr. Ludwig's angina in children.= Am Fam Physician. 1999 Jul;60(1):109-12. <![if !supportLists]>¢ <![endif]>Netter FH Atlas of Human Anatomy 3rd</s= up> Ed. <![if !supportLists]>¢ <![endif]>The masticator space: From anatomy to pathol= ogy, N. Faye et al, Journal of Neuroradiology Volume 36, numéro 3pages 121-130 (= juin 2009) <o:p>&nb= sp;</o:p> </div> </body> </html> ------=_NextPart_01CCDE88.9B711620 Content-Location: file:///C:/9D293A90/HN-anat-2011-11-30_files/themedata.thmx Content-Transfer-Encoding: base64 Content-Type: application/vnd.ms-officetheme UEsDBBQABgAIAAAAIQDp3g+//wAAABwCAAATAAAAW0NvbnRlbnRfVHlwZXNdLnhtbKyRy07DMBBF 90j8g+UtSpyyQAgl6YLHjseifMDImSQWydiyp1X790zSVEKoIBZsLNkz954743K9Hwe1w5icp0qv 8kIrJOsbR12l3zdP2a1WiYEaGDxhpQ+Y9Lq+vCg3h4BJiZpSpXvmcGdMsj2OkHIfkKTS+jgCyzV2 JoD9gA7NdVHcGOuJkTjjyUPX5QO2sB1YPe7l+Zgk4pC0uj82TqxKQwiDs8CS1Oyo+UbJFkIuyrkn 9S6kK4mhzVnCVPkZsOheZTXRNajeIPILjBLDsAyJX89nIBkt5r87nons29ZZbLzdjrKOfDZezE7B /xRg9T/oE9PMf1t/AgAA//8DAFBLAwQUAAYACAAAACEApdan58AAAAA2AQAACwAAAF9yZWxzLy5y ZWxzhI/PasMwDIfvhb2D0X1R0sMYJXYvpZBDL6N9AOEof2giG9sb69tPxwYKuwiEpO/3qT3+rov5 4ZTnIBaaqgbD4kM/y2jhdj2/f4LJhaSnJQhbeHCGo3vbtV+8UNGjPM0xG6VItjCVEg+I2U+8Uq5C 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style=3D'mso-element:para-border-div;border:none;border-bottom:solid #= 622423 3.0pt; padding:0in 0in 1.0pt 0in'> Infections of the Head and Neck: Anatomical Considerations.<o:p></o:p> </div> </div> <div style=3D'mso-element:footer' id=3Df1> <table class=3DMsoNormalTable border=3D1 cellspacing=3D0 cellpadding=3D0 wi= dth=3D"100%" style=3D'width:100.0%;border-collapse:collapse;border:none;mso-border-top-= alt: solid gray 2.25pt;mso-yfti-tbllook:1184;mso-padding-alt:0in 5.4pt 0in 5.4p= t; mso-border-insidev:2.25pt solid gray'> <tr style=3D'mso-yfti-irow:0;mso-yfti-firstrow:yes;mso-yfti-lastrow:yes'> <td width=3D61 valign=3Dtop style=3D'width:45.9pt;border-top:solid gray 2= .25pt; border-left:none;border-bottom:none;border-right:solid gray 2.25pt; padding:0in 5.4pt 0in 5.4pt'> 1<o:p></o:p> </td> <td width=3D529 valign=3Dtop style=3D'width:396.9pt;border:none;border-to= p:solid gray 2.25pt; mso-border-left-alt:solid gray 2.25pt;padding:0in 5.4pt 0in 5.4pt'> <o:p> </o:p> </td> </tr> 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MIME-Version: 1.0 Content-Type: multipart/related; boundary="----=_NextPart_01CCDE88.9B711620" This document is a Single File Web Page, also known as a Web Archive file. If you are seeing this message, your browser or editor doesn't support Web Archive files. Please download a browser that supports Web Archive, such as Windows® Internet Explorer®. ------=_NextPart_01CCDE88.9B711620 Content-Location: file:///C:/9D293A90/HN-anat-2011-11-30.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="windows-1252" Infections of the Head and Neck: Anatomical Considerations -<= /title> <o:SmartTagType namespaceuri=3D"urn:schemas-microsoft-com:office:smarttags" name=3D"place"/> <o:SmartTagType namespaceuri=3D"urn:schemas-microsoft-com:office:smarttags" name=3D"City"/>  <link rel=3DthemeData href=3D"HN-anat-2011-11-30_files/themedata.thmx"> <link rel=3DcolorSchemeMapping href=3D"HN-anat-2011-11-30_files/colorschememapping.xml">  <style>  </style>  </head> <body lang=3DEN-US link=3Dblue vlink=3Dpurple style=3D'tab-interval:.5in'> <div class=3DWordSection1> <a name=3D"OLE_LINK2"></a= ><a name=3D"OLE_LINK1">TITLE: Infections= of the Head and Neck: Anatomical Considerations SOURCE: Grand Rounds Presentation, The University of Texas Medical Branch (utmb Health), Department of Otolaryngology DATE: November 30, 2011 RESIDENT PHYSICIAN: Angelia Natali, M.D. FACULTY PHYSICIAN: Susan McCammon, M.D. DISCUSSANT: SERIES EDITOR: Francis B. Quinn, Jr., M.D. ARCHIVIST: Melinda Stoner Quinn, M= SICS</a> <div style=3D'mso-element:para-border-div;border:solid windowtext 1.0pt; mso-border-alt:solid windowtext .5pt;padding:1.0pt 4.0pt 1.0pt 4.0pt'> "This material was prepared by resident physicians in partial fulfillment of educational requirements established f= or 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 sho= uld not be used for purposes of diagnosis or treatment without consulting appropriate literature sources and informed professional opinion." <o:= p></o:p> </div> <h1>Introduction: </h1> Infections are one of the most commonly occurring head= and neck pathologies. Spread of infect= ion can be predicted by anatomic boundaries. Mortality from head and neck infections has decreased significantly since the advent of antibiotics, but resistant organisms are spreading into= the community. Diagnosis and treatment= will not be focus of this discussion. The spaces in the head and neck that will be discussed= are: Sinuses, Orbits, Peritonsillar, Parapharyngeal, Submandibular, Retropharyng= eal, Danger Space, Prevertebral, Mastica= tor, Ear. <h1>Sinuses:</h1> <h2>First the = nasal borders:<o:p></o:p></h2> <![if !supp= ortLists]>· <![endif]>Medially - the nasal septum (perpendicular p= late of the ethmoid bone, the vomer bone, and the septal cartilage) <o:p></o:p> <![if !supp= ortLists]>· <![endif]>Laterally - the nasal conchae; superior and middle (ethmoid bone derivation), inferior (a bone itself), and contributio= ns from the lacrimal bone, the perpendicular plate of the palatine bone, and t= he maxillary bone <o:p></o:p> <![if !supp= ortLists]>· <![endif]>Inferiorly - the horizontal plate of the maxillary bone (anterior two thirds of the hard palate) and the horizontal plate of the palatine bone (posterior third of the hard palate) <o:p></o:p> <![if !supp= ortLists]>· <![endif]>Superiorly - the cribiform plate of the ethm= oid bone (where the nerve endings of the Olfactory Nerve (CN1) open to the environment) <o:p></o:p> <![if !supp= ortLists]>· <![endif]>Posterior - none, the nasal cavity opens to the nasopharynx via the c</spa= n>hoanae<o:p></o:p> <h1>Sinus drainage patterns:</h1> <![if !supp= ortLists]>· <![endif]>Maxillary Sinus - The largest sinus, is found lateral and inferior to the lateral nasal wall below the orbit. This sinus drains, superiorly, to the middle meatus just below the ethmoidal bulla. </= p> <![if !supp= ortLists]>· <![endif]>Sphenoidal Sinus - This sinus is located in = the posterior wall of the nasal cavity and opens to the sphenoethmoidal recess which is superior to the superior concha. Superior to this sinus is the pituitary gland (hypophysis) in the sella turcica of the sphenoid bone. <![if !supp= ortLists]>· <![endif]>Frontal Sinus - The frontal sinuses are loca= ted in the frontal bone of the cranium and extend across the forehead. These sinuses drain down to the middle meatus via the frontonasal duct into the anterior portion of the semilunar hiatus. <![if !supp= ortLists]>· <![endif]>Ethmoidal Sinus - These sinuses resemble bub= bles and are located behind the superior lateral nasal wall. They are divided in= to anterior, middle and posterior cells on the basis of their drainage. The anterior cells drain to the middle meatus in the posterior portion of the semilunar hiatus. The middle sinuses empty to the center of the ethmoidal bulla. The posterior sinuses empty to the superior meatus. <h1>Sinusitis:</h1> This is a complex disease process resulting in blockag= e of sinus drainage and accumulation of fluid leading to bacterial overgrowth.<s= pan style=3D'mso-spacerun:yes'> It may be treated medically or surgical= ly, with the goal of surgery to alleviate anatomic obstructions. <h2>Orbits: The <st1:place w:st=3D= "on"><st1:City w:st=3D"on">Chandler</st1:City></st1:place> Classification</h2> <![if !supp= ortLists]>· <![endif]>Periorbital (Preseptal) Cellulitis: eyelid edema, erythema, tenderness; no vision changes, chemosis, proptosis, or restriction of ocular muscles <![if !supp= ortLists]>· <![endif]>Orbital Cellulitis: proptosis, chemosis, may cause vision changes (anterior pupillary defect), may limit extraocular mus= cles <![if !supp= ortLists]>· <![endif]>Subperiosteal Abscess: collection of pus bet= ween bone and periosteum, chemosis, may have proptosis, restrict extraocular mot= ion, and affect vision, requires urgent surgical decompression <![if !supp= ortLists]>· <![endif]>Orbital Abscess: collection of pus in orbital soft tissue, proptosis, chemosis, restricted extraocular motion, may have no light perception (may be reversible), requires urgent surgical decompressio= n <![if !supp= ortLists]>· <![endif]>Cavernous Sinus Thrombosis: Pathophysiology: perinasal sinus infection ➝ orbital extension ➝ mural thrombus forms in vessel wall (thrombophlebitis) ➝ propagates distally as clot softens and begins= to seed <h1>Pathogens: S. aureus, hemolytic Streptococcus and Pneumococcus</h1> SSx: “picket fence” spiking fevers, toxemia, papilledema, paralysis of extraocular muscles (CN III, IV, and V), proptosis, chemosis, eyelid edema <o:p> </o:p> A word about the cavernous sinus: The cavernous sinuses are paire= d, venous structures located on either side of the sella turcica. They receive venous tributaries from the superior and inferior orbital veins and drain i= nto the superior and inferior petrosal sinuses. The cavernous sinus contains the carotid artery, its sympathetic plexus, and the oculomotor nerves (third, fourth, and sixth cranial nerves). In addition, the ophthalmic branch and occasionally the maxillary branch of the fifth nerve traverse the cavernous sinus. The nerves pass through the wall of the sinus while the carotid arte= ry passes through the sinus itself. <o:p> </o:p> <h1>Peritonsillar space:</h1> The peritonsillar space consists of loose connective t= issue between the capsule of the palatine tonsil and the superior constrictor mus= cle. The anterior and posterior tonsillar pillars contribute to its anterior and posterior borders, respectively. The posterior tongue forms the inferior boundary. Peritonsillar infections may readily spread to the parapharyngeal space. <h1>Parapharyngeal space</h1> <![if !supp= ortLists]>· <![endif]>Other names: lateral pharyngeal or pharyngomaxillary space <![if !supp= ortLists]>· <![endif]>Shape: </s= pan>inverted pyramid <![if !supp= ortLists]>· <![endif]>Superior boundary: skull base <![if !supp= ortLists]>· <![endif]>Inferior boundary: junction of the posterior belly of the digastric muscle and greater cornu of the hyoid bone <![if !supp= ortLists]>· <![endif]>Anterior boundary: pterygomandibular raphe and medial ptery= goid muscle bound the space <![if !supp= ortLists]>· <![endif]>Posterior: prevertebral fasci <![if !supp= ortLists]>· <![endif]>Medialboundary: superior constrictor, tensor, and levato= r veli palatini muscle <![if !supp= ortLists]>· <![endif]>Lateral boundary: parotid gland, mandible, a= nd lateral pterygoid muscle <![if !supp= ortLists]>· <![endif]>Compartments: prestyloid (anterior): contains fat, styloglossus and stylopharyngeus, lymph nodes, deep lobe of the paroti= d, internal maxillary artery, inferior alveolar, lingual, and auriculotemporal nerves <![if !supp= ortLists]>· <![endif]>Poststyloid (posterior): contains carotid artery, internal jugular vein, sympathetic chain, and cranial nerves IX, X,= XI, and XII. <![if !supp= ortLists]>· <![endif]>Connections to other deep spaces: <![if !supp= ortLists]>· <![endif]>posteromedially: retropharyngeal space <![if !supp= ortLists]>· <![endif]>inferiorly: submandibular space <![if !supp= ortLists]>· <![endif]>laterally: masticator space <![if !supp= ortLists]>· <![endif]>medially: peritonsillar space <o:p>&n= bsp;</o:p> <h1>Submandibular Space</h1> <![if !supp= ortLists]>· <![endif]>Boundaries: <![if !supp= ortLists]>· <![endif]>Superior: mucosa of the floor of the mouth</= p> <![if !supp= ortLists]>· <![endif]>Inferior: digastrics muscle and hyoid bone</= p> <![if !supp= ortLists]>· <![endif]>Anterior: mylohyoid muscle and anterior bell= y of digastrics <![if !supp= ortLists]>· <![endif]>Posterior: posterior belly of the digastric = and stylomandibular ligament <![if !supp= ortLists]>· <![endif]>Medial: hyoglossus, mylohyoid, styloglossus, genioglossus, and geniohyoid muscles <![if !supp= ortLists]>· <![endif]>Lateral: platysma and mandible The mylohyoid muscle divides the submandibular space i= nto a superior sublingual space and an inferior submaxillary space (for clarity, = this is also referred to as the submandibular space). Sublingual space: lateral to the geniohyoid and genioglossus muscles, contains = the sublingual gland and Wharton’s duct. Teeth apices anterior to the second mo= lar lie superior to the mylohyoid line and thus involve the sublingual space. <= /p> <h1>Submaxillary space: contains submandibular glands and lymph nodes. Infections of the second and third molars initially involve the submandibular or parapharyngeal space, because their roots extend below the mylohyoid line.<o:p></o:p></h1> <h1>Retropharyngeal space</h1> <ul style=3D'margin-top:0in' type=3Ddisc> <li class=3DMsoNormal style=3D'margin-bottom:0in;margin-bottom:.0001pt;tex= t-indent: -.25in;mso-list:l21 level1 lfo20'>Potential space</li> <li class=3DMsoNormal style=3D'margin-bottom:0in;margin-bottom:.0001pt;tex= t-indent: -.25in;mso-list:l21 level1 lfo20'>Boundaries:</li> <li class=3DMsoNormal style=3D'margin-bottom:0in;margin-bottom:.0001pt;tex= t-indent: -.25in;mso-list:l21 level1 lfo20'>Upper: skull base </li> <li class=3DMsoNormal style=3D'margin-bottom:0in;margin-bottom:.0001pt;tex= t-indent: -.25in;mso-list:l21 level1 lfo20'>Lower: mediastinum at the tracheal bifurcation <o:p></o:p></li> <li class=3DMsoNormal style=3D'margin-bottom:0in;margin-bottom:.0001pt;tex= t-indent: -.25in;mso-list:l21 level1 lfo20'>Anterior: buccopharyngeal fascia </li> <li class=3DMsoNormal style=3D'margin-bottom:0in;margin-bottom:.0001pt;tex= t-indent: -.25in;mso-list:l21 level1 lfo20'>Posterior: alar fascia<o:p></o:p></li> <li class=3DMsoNormal style=3D'margin-bottom:0in;margin-bottom:.0001pt;tex= t-indent: -.25in;mso-list:l21 level1 lfo20'>Contains: lymph node and connective tissue </li> <li class=3DMsoNormal style=3D'margin-bottom:0in;margin-bottom:.0001pt;tex= t-indent: -.25in;mso-list:l21 level1 lfo20'>Routes of entry: direct spread from = the parapharyngeal space, or lymphatic spread from the paranasal sinuses o= r nasopharyngeal region</li> </ul> <o:p> </o:p> <h1>Danger Space</h1> Potential Space, named for the potential for rapid inferior spread of infection to the posterior mediastin= um through its loose areolar tissue <![if !supportLists]>· <![endif]>Boundaries: <![if !supportLists]>· <![endif]>Superior: skull base <![if !supportLists]>· <![endif]>Inferior: diaphragm <![if !supportLists]>· <![endif]>Anterior: alar fascia, retropharyngeal space= <![if !supportLists]>· <![endif]>Posterior: prevertebral fascia <![if !supportLists]>· <![endif]>Lateral: transverse processes of vertebrae</= p> <![if !supportLists]>· <![endif]>Contains: sympathetic trunk <![if !supportLists]>· <![endif]>Routes of entry: retropharyngeal, parapharyngeal, or prevertebral spaces <o:p> </o:p> <h1>Prevertebral space</h1> <![if !supportLists]>· <![endif]>Potential space <![if !supportLists]>· <![endif]>Boundaries: <![if !supportLists]>· <![endif]>Superior: clivus of the skull base <![if !supportLists]>· <![endif]>Inferior: coccyx <![if !supportLists]>· <![endif]>Anterior: prevertebral fascia <![if !supportLists]>· <![endif]>Posterior: vertebral bodies <![if !supportLists]>· <![endif]>Lateral: transverse processes <![if !supportLists]>· <![endif]>Contains: paraspinous, prevertebral, and sca= lene muscles, it contains the vertebral artery and vein, brachial plexus, and ph= renic nerve <![if !supportLists]>· <![endif]>Routes of entry: infection of the vertebral bodies and penetrating injuries <o:p= > </o:p> <h1>Masticator space</h1> <![if !supportLists]>· <![endif]>Boundaries: <![if !supportLists]>· <![endif]>Superior: skull base <![if !supportLists]>· <![endif]>Inferior: submandibular space <![if !supportLists]>· <![endif]>Lateral: masseter, superficial temporal fasc= ia <![if !supportLists]>· <![endif]>Medial: medial pterygoid, parapharyngeal spa= ce <![if !supportLists]>· <![endif]>Anterior: posterior wall of maxillary sinus, buccal space <![if !supportLists]>· <![endif]>Posterior: parotid <![if !supportLists]>· <![endif]>Contains: mandible and muscles of mastication (masseter, temporalis, medial pterygoid, lateral pterygoid), the third port= ion of the trigeminal nerve, which enters through the foramen ovale, the intern= al maxillary artery, and much of the buccal fat pad <![if !supportLists]>· <![endif]>Subspaces: <![if !supportLists]>· <![endif]>Masseteric: between the masseter muscle and ramus of mandible <![if !supportLists]>· <![endif]>Pterygoid: between the pterygoid muscles and ramus <![if !supportLists]>· <![endif]>Superficial temporal: superficial temporal fascia and temporalis muscle <![if !supportLists]>· <![endif]>Deep temporal: between the deep temporal fas= cia and temporal bone <![if !supportLists]>· <![endif]>Route of entry: most commonly from the third mandibular molars <o:p> </o:p> <span style=3D'font-size:11.0pt;mso-bidi-font-size:16.0pt;font-family:"A= rial","sans-serif"; mso-fareast-font-family:"Times New Roman";mso-bidi-font-family:"Times New R= oman"; mso-ansi-language:EN-US;mso-fareast-language:EN-US;mso-bidi-language:AR-SA'= > <h1>Ear</h1> Malignant otitis externa is an aggressive and potentia= lly fatal infection originating in the external canal, with progressive spread along the soft tissues and bone of the skull base, ultimately involving intracranial structures. It is also (more accurately) known as necrotizing otitis externa. Posterior invasion of P. aeruginosa leads to clouding = of the mastoid air cells. With medial invasion, displacement and erosion of ossicl= es occur, while anterior invasion may produce temporomandibular joint arthritis and mandibular condyle osteomyelitis. Intracranial invasion may result in meningitis, brain abscess or cavernous sinus thrombosis. <h1>Conclusion:</h1> Understanding anatomical boundaries can help clinicians manage head and neck infections by predicting their spread. Mortality has decreased significantly i= n the postantibiotic era, but resistant organisms are spreading. <div style=3D'mso-element:para-border-div;border:none;border-bottom:solid w= indowtext 1.0pt; mso-border-bottom-alt:solid windowtext .5pt;padding:0in 0in 1.0pt 0in'> <o:p> </o:p> </div> <h1>DR. PINE'S DISCUSSION OF Dr. NATILI'S GRAND ROUNDS 2011/11/30</h1> The peritonsillar one is a great example where I bet a bunch of them probably w= ould get better medically, but since we're there ready to open them up and that's not such a good example in an adult where you can do something there right = in the ER but in a kid its potentially a big deal because it means bringing someone to the operating room when you might get away with antibiotics, so = I'm always looking for things you can point to and say, well, look, it's less than one centimeter and= so statistically we're going to win w= ith a trial of antibiotics and let's try that first versus just saying, "Loo= k, there's an abscess there that could be drained."<o:p></o:p> <div style=3D'mso-element:para-border-div;border:none;border-bottom:solid w= indowtext 1.0pt; mso-border-bottom-alt:solid windowtext .5pt;padding:0in 0in 1.0pt 0in'> <h1 style=3D'border:none;mso-border-bottom-alt:solid windowtext .5pt;paddin= g: 0in;mso-padding-alt:0in 0in 1.0pt 0in'><o:p> </o:p></h1> </div> <o:p> </o:p> <h1>References</h1> <![if !supportLists]>¢ <![endif]><a href=3D"http://iris3.med.tufts.edu/headne= ck">http://iris3.med.tufts.edu/headneck</a> <![if !supportLists]>¢ <![endif]><a href=3D"http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/a= llergy/rhino-sinusitis/">http://www.clevelandclinicmeded.com/medicalpubs/di= seasemanagement/allergy/rhino-sinusitis/</a> <![if !supportLists]>¢ <![endif]><a href=3D"http://doctorcayoo.blogspot.com/2009/12/peritonsiler-abscess-pta-qu= insy-1.html">http://doctorcayoo.blogspot.com/2009/12/peritonsiler-abscess-p= ta-quinsy-1.html</a> <![if !supportLists]>¢ <![endif]><a href=3D"http://www.merckmanuals.com/professional/eye_disorders/orbital_dise= ases/preseptal_and_orbital_cellulitis.html">www.merckmanuals.com/profession= al/eye_disorde...</a> <![if !supportLists]>¢ <![endif]><a href=3D"http://iris3.med.tufts.edu/dentgross/labguide/Homepage.html">http:/= /iris3.med.tufts.edu/dentgross/labguide/Homepage.html</a> <![if !supportLists]>¢ <![endif]>Cummings Otolaryngology Head and Neck Surger= y, 5th ed. <![if !supportLists]>¢ <![endif]>Lee KJ, Essential Otolaryngology Head and Ne= ck Surgery <![if !supportLists]>¢ <![endif]>Pasha R, Otolaryngology Head and Neck Surgery Clinical Reference Guide <![if !supportLists]>¢ <![endif]>Herr RD, Serious Soft Tissue Infections of t= he Head and Neck, American Family Physician, September 1991, Vol 44, no 3, 878= -888 <![if !supportLists]>¢ <![endif]>Hartmann RW Jr. Ludwig's angina in children.= Am Fam Physician. 1999 Jul;60(1):109-12. <![if !supportLists]>¢ <![endif]>Netter FH Atlas of Human Anatomy 3rd</s= up> Ed. <![if !supportLists]>¢ <![endif]>The masticator space: From anatomy to pathol= ogy, N. Faye et al, Journal of Neuroradiology Volume 36, numéro 3pages 121-130 (= juin 2009) <o:p>&nb= sp;</o:p> </div> </body> </html> ------=_NextPart_01CCDE88.9B711620 Content-Location: file:///C:/9D293A90/HN-anat-2011-11-30_files/themedata.thmx Content-Transfer-Encoding: base64 Content-Type: application/vnd.ms-officetheme UEsDBBQABgAIAAAAIQDp3g+//wAAABwCAAATAAAAW0NvbnRlbnRfVHlwZXNdLnhtbKyRy07DMBBF 90j8g+UtSpyyQAgl6YLHjseifMDImSQWydiyp1X790zSVEKoIBZsLNkz954743K9Hwe1w5icp0qv 8kIrJOsbR12l3zdP2a1WiYEaGDxhpQ+Y9Lq+vCg3h4BJiZpSpXvmcGdMsj2OkHIfkKTS+jgCyzV2 JoD9gA7NdVHcGOuJkTjjyUPX5QO2sB1YPe7l+Zgk4pC0uj82TqxKQwiDs8CS1Oyo+UbJFkIuyrkn 9S6kK4mhzVnCVPkZsOheZTXRNajeIPILjBLDsAyJX89nIBkt5r87nons29ZZbLzdjrKOfDZezE7B /xRg9T/oE9PMf1t/AgAA//8DAFBLAwQUAAYACAAAACEApdan58AAAAA2AQAACwAAAF9yZWxzLy5y ZWxzhI/PasMwDIfvhb2D0X1R0sMYJXYvpZBDL6N9AOEof2giG9sb69tPxwYKuwiEpO/3qT3+rov5 4ZTnIBaaqgbD4kM/y2jhdj2/f4LJhaSnJQhbeHCGo3vbtV+8UNGjPM0xG6VItjCVEg+I2U+8Uq5C 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style=3D'mso-element:para-border-div;border:none;border-bottom:solid #= 622423 3.0pt; padding:0in 0in 1.0pt 0in'> Infections of the Head and Neck: Anatomical Considerations.<o:p></o:p> </div> </div> <div style=3D'mso-element:footer' id=3Df1> <table class=3DMsoNormalTable border=3D1 cellspacing=3D0 cellpadding=3D0 wi= dth=3D"100%" style=3D'width:100.0%;border-collapse:collapse;border:none;mso-border-top-= alt: solid gray 2.25pt;mso-yfti-tbllook:1184;mso-padding-alt:0in 5.4pt 0in 5.4p= t; mso-border-insidev:2.25pt solid gray'> <tr style=3D'mso-yfti-irow:0;mso-yfti-firstrow:yes;mso-yfti-lastrow:yes'> <td width=3D61 valign=3Dtop style=3D'width:45.9pt;border-top:solid gray 2= .25pt; border-left:none;border-bottom:none;border-right:solid gray 2.25pt; padding:0in 5.4pt 0in 5.4pt'> 1<o:p></o:p> </td> <td width=3D529 valign=3Dtop style=3D'width:396.9pt;border:none;border-to= p:solid gray 2.25pt; mso-border-left-alt:solid gray 2.25pt;padding:0in 5.4pt 0in 5.4pt'> <o:p> </o:p> </td> </tr> 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