1、复旦大学耳鼻咽喉科系复旦大学耳鼻咽喉科系华山医院耳鼻咽喉科华山医院耳鼻咽喉科孙广滨孙广滨Deep Neck Spaces and Infectionsw 解剖解剖n颈筋膜颈筋膜the Cervical Fasciathe Cervical Fascian颈深部间隙颈深部间隙the Deep Neck Spacesthe Deep Neck Spacesw 颈深部间隙感染颈深部间隙感染n扁桃体周围脓肿扁桃体周围脓肿Paratonsillar abscessesParatonsillar abscessesn咽旁脓肿咽旁脓肿Parapharyngeal abscessesParapharyngea
2、l abscessesn咽后脓肿咽后脓肿Retropharyngeal abscessesRetropharyngeal abscessesn脓性颌下炎脓性颌下炎 Ludwigs angina Ludwigs anginaDeep Neck Spaces and Infectionsw Superficial LayerSuperficial Layer浅层浅层PlatysmaPlatysma颈阔肌颈阔肌w Deep LayerDeep Layer深层深层nSuperficialSuperficialnMiddleMiddlenDeepDeepDeep Neck Spaces and Infe
3、ctionsw Superficial LayerSuperficial Layer of the Deep Cervical of the Deep Cervical FasciaFascianMuscles SternocleidomastoidMuscles Sternocleidomastoid胸锁乳突肌胸锁乳突肌 Trapezius Trapezius斜方肌斜方肌nGlands SubmandibularGlands Submandibular颌下腺颌下腺 Parotid Parotid腮腺腮腺Deep Neck Spaces and Infectionsw Middle Layer
4、Middle Layer of the Deep Cervical Fascia of the Deep Cervical FascianMuscular DivisionMuscular DivisionlInfrahyoid Strap MusclesInfrahyoid Strap Muscles舌骨下带状肌舌骨下带状肌nVisceral DivisionVisceral DivisionlPharynx,Pharynx,咽咽 Larynx Larynx喉喉,Esophagus,Esophagus食管食管,Trachea,Trachea气管气管,Thyroid,Thyroid甲状腺甲状腺
5、lBuccopharyngeal FasciaBuccopharyngeal Fascia颊咽筋膜颊咽筋膜Deep Neck Spaces and Infectionsw Deep LayerDeep Layer of Deep Cervical Fascia of Deep Cervical FascianAlar LayerAlar Layer翼状层翼状层lPosterior to visceral layer of middle Posterior to visceral layer of middle fasciafascialAnterior to prevertebral laye
6、rAnterior to prevertebral layernPrevertebral LayerPrevertebral Layer椎前层椎前层lVertebral bodiesVertebral bodieslDeep muscles of the neckDeep muscles of the neck颈深深层颈深深层颈深中层颈深中层颈深浅层颈深浅层颈浅筋膜颈浅筋膜Deep Neck Spaces and Infectionsw Peritonsillar SpacePeritonsillar Space扁桃体周围间隙扁桃体周围间隙nMedialcapsule of palatine
7、tonsilMedialcapsule of palatine tonsil扁桃体被摸扁桃体被摸nLateralsuperior pharyngeal Lateralsuperior pharyngeal constrictorconstrictor上咽缩肌上咽缩肌Deep Neck Spaces and Infectionsw Retropharyngeal SpaceRetropharyngeal Spacen咽和食管的后方咽和食管的后方n颈深筋膜深层的前方颈深筋膜深层的前方n从颅底到从颅底到T1-T2T1-T2Deep Neck Spaces and Infectionsw Entire
8、 Length of Neck:Prevertebral Entire Length of Neck:Prevertebral SpaceSpacen椎前筋膜后方椎前筋膜后方n椎体前方椎体前方nExtends along entire length of Extends along entire length of vertebral columnvertebral columnDeep Neck Spaces and InfectionsDeep Neck Spaces and Infectionsw Parapharyngeal SpaceParapharyngeal Space咽旁间隙咽
9、旁间隙n前界前界翼下颌缝翼下颌缝n后界后界椎前筋膜椎前筋膜n内界内界颊咽筋膜颊咽筋膜n外界外界颈深筋膜浅层颈深筋膜浅层n上界上界颅底颅底n下界下界舌骨舌骨Deep Neck Spaces and Infectionsw Parapharyngeal SpaceParapharyngeal SpacenPrestyloidPrestyloid茎突前茎突前lContains fat,connective tissue,Contains fat,connective tissue,nodesnodesnPoststyloidPoststyloid茎突后茎突后lCarotid sheathCaroti
10、d sheath颈动脉鞘颈动脉鞘lCranial nervesCranial nerves颅神经颅神经IX,X,XIIIX,X,XIIDeep Neck Spaces and Infectionsw Carotid SheathCarotid Sheath颈动脉鞘颈动脉鞘nFormed by all three layers of deep Formed by all three layers of deep fasciafascian颈动脉颈动脉n颈内静脉颈内静脉n迷走神经迷走神经Deep Neck Spaces and Infectionsw Entire Length of Neck:E
11、ntire Length of Neck:Deep Neck Spaces and InfectionsSublingual SpaceSublingual Space舌下间隙舌下间隙w 口底黏膜口底黏膜w 下颌舌骨肌下颌舌骨肌内含：内含：n蜂窝组织蜂窝组织n舌骨舌肌舌骨舌肌n舌下神经和舌神经舌下神经和舌神经n舌下腺舌下腺n颌下腺导管颌下腺导管Deep Neck Spaces and Infectionsnextension from tonsillitisextension from tonsillitisnSymptoms:Symptoms:lSevere sore throat on o
12、ne side,drooling,Severe sore throat on one side,drooling,dysphagia dysphagia 咽喉疼痛，流涎，吞咽困难咽喉疼痛，流涎，吞咽困难lOtalgiaOtalgia耳痛耳痛on the affected sideon the affected sideltrismustrismus牙关紧闭牙关紧闭llymphadenopathylymphadenopathy淋巴结病淋巴结病,torticollis,torticollis斜颈斜颈,lnasal regurgitationnasal regurgitation鼻反流鼻反流Deep
13、 Neck Spaces and Infectionsbulging of bulging of superior tonsil superior tonsil pole and soft pole and soft palatepalate软腭和扁桃体上极膨出软腭和扁桃体上极膨出deviation of deviation of uvulauvula悬雍垂偏移悬雍垂偏移Deep Neck Spaces and InfectionsDeep Neck Spaces and Infections智齿冠周炎智齿冠周炎脓性颌下炎脓性颌下炎扁桃体恶性肿瘤扁桃体恶性肿瘤Deep Neck Spaces
14、and Infectionsw Pediatrics Pediatrics nsuppurative process suppurative process in lymph nodesin lymph nodeslNose,adenoids,Nose,adenoids,nasopharynx,nasopharynx,sinusessinusesw AdultsnTraumanInstrumentationnForeign body咽后脓肿咽后脓肿Deep Neck Spaces and Infectionsn96%occur before 6 years of age96%occur bef
15、ore 6 years of agenSymptoms:Symptoms:l发热，易怒发热，易怒l咽痛，流涎，吞咽困难咽痛，流涎，吞咽困难l颈部淋巴结肿大，斜颈颈部淋巴结肿大，斜颈l呼吸困难，打鼾呼吸困难，打鼾l腭咽反流腭咽反流咽后脓肿咽后脓肿Deep Neck Spaces and Infectionsw Lateral neck plain Lateral neck plain filmfilmnNormal:Normal:n7mm at C-2,7mm at C-2,n4mm at C-6 for 4mm at C-6 for kids,kids,n2mm at C-6 for 2mm
16、at C-6 for adultsadults咽后脓肿咽后脓肿Deep Neck Spaces and Infections咽后脓肿咽后脓肿Deep Neck Spaces and Infections咽后脓肿咽后脓肿Deep Neck Spaces and InfectionsNasalNasal endoscopyendoscopy咽后脓肿咽后脓肿Deep Neck Spaces and Infectionsinfection ofinfection of pharynx,pharynx,tonsil,adenoids,tonsil,adenoids,dentition,parotid,d
17、entition,parotid,mastoid,mastoid,suppurative suppurative lymphadenitis,lymphadenitis,extension fromextension from other deep neck other deep neck spacesspaces咽旁脓肿咽旁脓肿Deep Neck Spaces and InfectionsnFeverFevernPain,dysphagia,trismusPain,dysphagia,trismusnMedial bulgeMedial bulge内侧隆起内侧隆起 of lateral of
18、 lateral pharyngeal wallpharyngeal wall咽旁脓肿咽旁脓肿Deep Neck Spaces and Infectionsw CT scanCT scannCT vs.PECT vs.PElAccuracy of diagnosis:Accuracy of diagnosis:CT=77%,CT=77%,PE=63%PE=63%lSensitivity:Sensitivity:CT=95%,CT=95%,PE=55%PE=55%-Miller,et al:-Miller,et al:咽旁脓肿咽旁脓肿Deep Neck Spaces and Infections
19、脓性颌下炎脓性颌下炎Deep Neck Spaces and InfectionsCellulitisCellulitis蜂窝组织炎蜂窝组织炎,not abscess,not abscessw 发热、中毒症状发热、中毒症状w 口底、颏下、颌下肿胀，触痛口底、颏下、颌下肿胀，触痛,不伴波动不伴波动w 言语不清言语不清,流涎流涎w 呼吸困难呼吸困难,喘鸣喘鸣脓性颌下炎脓性颌下炎Deep Neck Spaces and InfectionsLudwigs anginaLudwigs angina脓性颌下炎脓性颌下炎脓性颌下炎脓性颌下炎Deep Neck Spaces and Infections治疗
20、及转归治疗及转归 处理处理监控监控气道维护气道维护呼吸困难程度的评估呼吸困难程度的评估抗生素抗生素足程联合足程联合 培养培养+药敏药敏糖皮质激素糖皮质激素咽喉水肿程度的评估咽喉水肿程度的评估感染性休克感染性休克血压、肝肾功能等的监控血压、肝肾功能等的监控DIC处理处理DIC全套检查全套检查对症处理对症处理电解质、血糖、蛋白等检查电解质、血糖、蛋白等检查外科引流外科引流B超、超、CT、MRI等等相关科室会诊相关科室会诊病情进展治疗效果不佳病情进展治疗效果不佳Deep Neck Spaces and InfectionswAirway protectionAirway protection气道维护
21、气道维护nObservationObservation观察观察nIntubationIntubation气管插管气管插管lDirect laryngoscopy:possible risk of Direct laryngoscopy:possible risk of rupture and aspirationrupture and aspirationlFlexible fiberopticFlexible fiberopticnTracheostomyTracheostomy气管切开气管切开lIdeally=planned,awake,local anesthesiaIdeally=pl
22、anned,awake,local anesthesialAbscess may overlie tracheaAbscess may overlie trachealDistorted anatomy and tissue planesDistorted anatomy and tissue planes治疗及转归治疗及转归Deep Neck Spaces and Infectionsw LUDWIGS ANGINA=LUDWIGS ANGINA=PERILOUS PERILOUS 危险危险AIRWAYAIRWAY治疗及转归治疗及转归Deep Neck Spaces and Infectio
23、nswAntibiotic TherapyAntibiotic Therapy抗生素抗生素n足程联合用药足程联合用药n监测细菌培养监测细菌培养n必要时感染科会诊必要时感染科会诊l治疗效果不佳要考虑：治疗效果不佳要考虑：wAbscess?Abscess?wdrug-resistance bacteria?drug-resistance bacteria?超级细菌？超级细菌？wDiabetesDiabetes等全身情况？等全身情况？治疗及转归治疗及转归Deep Neck Spaces and Infectionsl脓肿是否形成脓肿是否形成l脓肿与大血管的关系脓肿与大血管的关系治疗及转归治疗及转归D
24、eep Neck Spaces and InfectionswSurgical DrainageSurgical Drainagen反复细针穿刺引流反复细针穿刺引流根据患者一般情况，脓肿位置和形态等选择性进行经口切开引流经口切开引流l穿刺穿刺l钝性分离钝性分离nExternal approach External approach 外进路切开引流外进路切开引流lEXPOSURE,EXPOSURE,EXPOSUREEXPOSURE,EXPOSURE,EXPOSURE治疗及转归治疗及转归Deep Neck Spaces and InfectionsSurgical DrainageSurgical
25、 Drainage治疗及转归治疗及转归Deep Neck Spaces and InfectionsSurgical DrainageSurgical Drainage治疗及转归治疗及转归Deep Neck Spaces and InfectionsSurgical DrainageSurgical Drainage治疗及转归治疗及转归Deep Neck Spaces and Infections治疗及转归治疗及转归Deep Neck Spaces and Infections治疗及转归治疗及转归Deep Neck Spaces and Infections治疗及转归治疗及转归Deep Nec
26、k Spaces and InfectionswAirway obstructionAirway obstruction气道阻塞气道阻塞wRuptured abscessRuptured abscess脓肿破裂脓肿破裂wInternal Jugular Vein ThrombosisInternal Jugular Vein Thrombosis颈内静脉血栓形成颈内静脉血栓形成wCarotid Artery RuptureCarotid Artery Rupture颈动脉破裂颈动脉破裂wMediastinitisMediastinitis纵隔炎纵隔炎wInfectious shockInfec
27、tious shock感染性休克，感染性休克，DICDIC治疗及转归治疗及转归Deep Neck Spaces and InfectionsDeep Neck Spaces and InfectionsDeep Neck Spaces and InfectionsDeep Neck Spaces and InfectionsDeep Neck Spaces and InfectionsDeep Neck Spaces and InfectionsDeep Neck Spaces and InfectionsDeep Neck Spaces and InfectionsDeep Neck Spaces and InfectionsDeep Neck Spaces and InfectionsDeep Neck Spaces and Infections
