耳鼻咽喉頭頸外科學(xué)：06 頸深部間隙及感染

1、Deep Neck Spaces and Infections,解剖 頸筋膜the Cervical Fascia 頸深部間隙the Deep Neck Spaces 頸深部間隙感染 扁桃體周圍膿腫Paratonsillar abscesses 咽旁膿腫Parapharyngeal abscesses 咽后膿腫Retropharyngeal abscesses 膿性頜下炎 Ludwigs angina,頸深部間隙及感染,Superficial Layer淺層 Platysma頸闊肌 Deep Layer深層 Superficial Middle Deep,頸筋膜,Superficial Lay

2、er of the Deep Cervical Fascia Muscles Sternocleidomastoid胸鎖乳突肌 Trapezius斜方肌 Glands Submandibular頜下腺 Parotid腮腺,頸筋膜,Middle Layer of the Deep Cervical Fascia Muscular Division Infrahyoid Strap Muscles舌骨下帶狀肌 Visceral Division Pharynx,咽 Larynx喉, Esophagus食管, Trachea氣管, Thyroid甲狀腺 Buccopharyngeal Fascia頰

3、咽筋膜,頸筋膜,Deep Layer of Deep Cervical Fascia Alar Layer翼狀層 Posterior to visceral layer of middle fascia Anterior to prevertebral layer Prevertebral Layer椎前層 Vertebral bodies Deep muscles of the neck,頸筋膜,Cervical Fascia,Carotid sheath,頸深深層,頸深中層,頸深淺層,頸淺筋膜,Peritonsillar Space扁桃體周圍間隙 Medialcapsule of pala

4、tine tonsil扁桃體被摸 Lateralsuperior pharyngeal constrictor上咽縮肌,頸深部間隙,Deep Neck Spaces,Peritonsillar space 扁桃體周圍間隙,前面,Retropharyngeal Space咽后間隙 咽和食管的后方 頸深筋膜深層的前方 從顱底到T1-T2,頸深部間隙,Entire Length of Neck: Prevertebral Space椎前間隙 椎前筋膜后方 椎體前方 Extends along entire length of vertebral column,頸深部間隙,Danger space,R

5、etro-pharyngeal space,Pre-vertebral space,頸深部間隙,Cervical Fascia,Prevertebral Space,Danger space,Retro-pharyngeal space,Parapharyngeal Space咽旁間隙 前界翼下頜縫 后界椎前筋膜 內(nèi)界頰咽筋膜 外界頸深筋膜淺層 上界顱底 下界舌骨,頸深部間隙,Parapharyngeal Space Prestyloid莖突前 Contains fat, connective tissue, nodes Poststyloid莖突后 Carotid sheath頸動(dòng)脈鞘 Cr

6、anial nerves顱神經(jīng)IX, X, XII,頸深部間隙,Deep Neck Spaces,Styloid process莖突,前面,咽旁間隙,Carotid Sheath頸動(dòng)脈鞘 Formed by all three layers of deep fascia 頸動(dòng)脈 頸內(nèi)靜脈 迷走神經(jīng),頸深部間隙,Entire Length of Neck:,Carotid Sheath 頸動(dòng)脈鞘,頸深部間隙,Sublingual Space舌下間隙 口底黏膜 下頜舌骨肌 內(nèi)含： 蜂窩組織 舌骨舌肌 舌下神經(jīng)和舌神經(jīng) 舌下腺 頜下腺導(dǎo)管,頸深部間隙,extension from tonsillit

7、is Symptoms : Severe sore throat on one side, drooling, dysphagia 咽喉疼痛，流涎，吞咽困難 Otalgia耳痛on the affected side trismus牙關(guān)緊閉 lymphadenopathy淋巴結(jié)病, torticollis斜頸, nasal regurgitation鼻反流,扁桃體周圍膿腫,bulging of superior tonsil pole and soft palate 軟腭和扁桃體上極膨出 deviation of uvula 懸雍垂偏移,扁桃體周圍膿腫,扁桃體周圍膿腫,鑒別診斷 咽旁膿腫 智齒

8、冠周炎 膿性頜下炎 扁桃體惡性腫瘤,扁桃體周圍膿腫,Pediatrics suppurative process in lymph nodes Nose, adenoids, nasopharynx, sinuses,Adults Trauma Instrumentation Foreign body,咽后膿腫,病因:,96% occur before 6 years of age Symptoms : 發(fā)熱，易怒 咽痛，流涎，吞咽困難 頸部淋巴結(jié)腫大，斜頸 呼吸困難，打鼾 腭咽反流,咽后膿腫,Lateral neck plain film Normal: 7mm at C-2, 4mm at

9、 C-6 for kids, 2mm at C-6 for adults,咽后膿腫,咽后膿腫,咽后膿腫,Nasal endoscopy,咽后膿腫,infection of pharynx, tonsil,adenoids, dentition, parotid, mastoid, suppurative lymphadenitis, extension from other deep neck spaces,咽旁膿腫,Fever Pain, dysphagia, trismus Medial bulge內(nèi)側(cè)隆起 of lateral pharyngeal wall,咽旁膿腫,CT scan C

10、T vs. PE Accuracy of diagnosis: CT = 77%, PE = 63% Sensitivity: CT = 95%, PE = 55% -Miller, et al:,咽旁膿腫,膿性頜下炎,病因: 牙源性感染 厭氧菌多見,Cellulitis蜂窩組織炎, not abscess 發(fā)熱、中毒癥狀 口底、頦下、頜下腫脹，觸痛,不伴波動(dòng) 言語不清, 流涎 呼吸困難, 喘鳴,膿性頜下炎,Ludwigs angina 膿性頜下炎,膿性頜下炎,治療及轉(zhuǎn)歸,Airway protection氣道維護(hù) Observation觀察 Intubation氣管插管 Direct lar

11、yngoscopy: possible risk of rupture and aspiration Flexible fiberoptic Tracheostomy氣管切開 Ideally = planned, awake, local anesthesia Abscess may overlie trachea Distorted anatomy and tissue planes,治療及轉(zhuǎn)歸,LUDWIGS ANGINA = PERILOUS 危險(xiǎn)AIRWAY,治療及轉(zhuǎn)歸,氣管切開術(shù),Antibiotic Therapy抗生素 足程聯(lián)合用藥 監(jiān)測(cè)細(xì)菌培養(yǎng) 必要時(shí)感染科會(huì)診 治療效果不佳要

12、考慮： Abscess? drug-resistance bacteria?超級(jí)細(xì)菌？ Diabetes等全身情況？,治療及轉(zhuǎn)歸,Surgical Drainage外科引流 Preoperative CT 膿腫是否形成 膿腫與大血管的關(guān)系,治療及轉(zhuǎn)歸,Surgical Drainage 反復(fù)細(xì)針穿刺引流根據(jù)患者一般情況，膿腫位置和形態(tài)等選擇性進(jìn)行 Transoral經(jīng)口切開引流 穿刺 鈍性分離 External approach 外進(jìn)路切開引流 EXPOSURE, EXPOSURE, EXPOSURE,治療及轉(zhuǎn)歸,Surgical Drainage,治療及轉(zhuǎn)歸,扁桃體周圍膿腫的切開引流,Surgical Drainage,治療及轉(zhuǎn)歸,咽旁膿腫的切開引流,Surgical Drainage,治療及轉(zhuǎn)歸,咽后膿腫的切開引流,咽后壁切開引流,治療及轉(zhuǎn)歸,治療