颈深间隙感染合并上纵隔脓肿的临床分析
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摘要
背景
颈深间隙感染(infection of the deep neck interf ascial space)是指颈深筋膜浅层深面的深部组织感染性疾病,常继发于头、面、颈部及上呼吸道感染,亦可为全身感染性疾病的延续,抗生素的广泛应用虽降低了颈深间隙感染发病率,但其在临床上仍时有发生。此感染位于颈深部软组织,其原发病灶器官的位置亦较深,通常为：牙、咽部、扁桃体、唾液腺、食管、气管等。颈深筋膜解剖复杂,各层筋膜包绕颈部的血管、肌肉、神经及器官,将颈部分隔形成多个潜在的间隙,这些腔隙内为疏松的结缔组织,抵抗力弱,感染易在此处沿解剖途径播散,脓液易在该间隙中积聚,因此颈深筋膜间隙感染不易局限,病情发展快,若不及时控制,可形成脓肿并引起严重的全身中毒症状。抗生素应用之前,该病的致病菌多为链球菌,而应用抗生素之后,金黄色葡萄球菌的感染明显增加。据文献报道,颈深间隙感染多为需氧菌与厌氧菌的混合感染,即厌氧菌感染也有增多趋势。
颈深间隙中的咽后间隙(retropharyngeal space)、椎前间隙(prevertebral space)、气管前间隙(pretracheal space)、咽旁间隙(parapharyngeal space)、颈动脉鞘(carotid sheath)通过解剖途径直接或间接相通,并向下扩展至纵隔。颈深间隙感染加重且未及时控制的患者,炎症易向下蔓延引起纵隔感染或脓肿。纵隔内包含心脏、气管、食管、神经、胸内大血管和淋巴组织,结构疏松薄弱,此处的炎症或脓肿临床症状极重,可出现胸痛、吞咽困难、呼吸困难,甚至窒息、大血管破裂而死亡。
有文献报道,颈深间隙感染的患者抗生素治疗后,仍有88%的患者需联合手术治疗。合理应用抗生素控制颈深间隙感染,虽安全而有益,但临床上证实形成颈深间隙脓肿的患者仍应及早行手术切开引流。
目的
分析总结颈深间隙感染合并上纵隔脓肿患者的病因、临床特点、影像学特征、微生物学特点,探讨颈深间隙感染合并上纵膈脓肿的诊断和有效治疗方案。
方法
回顾性分析2009年1月至2012年9月郑州大学第一附属医院耳鼻咽喉头外科收治的11例颈深间隙感染合并上纵隔脓肿患者,其中男8例,女3例,年龄为5～71岁,中位年龄为36岁,入院后行胸部X线、颈部彩超、颈胸部增强CT检查,及时抗感染和对症支持治疗,10例患者在感染局限时行颈侧切开引流手术。
结果
11例患者除1例患者死亡,余10例均经过积极治疗治愈出院,住院时间为13-109天。其中9例患者在术后10天左右拔出颈部引流管,1例术后2周拔出引流管,1例于术后先后3次重置引流管；术后患者均可正常饮食。
结论
食管破裂穿孔、糖尿病、急性化脓性扁桃体炎可引起颈深间隙感染合并上纵隔脓肿,该病病情严重,发展迅速。早诊断、有效的抗感染治疗、尽早手术切开引流并充分的营养支持是治疗成功的关键。
Background
Infection of the deep neck interfascial space is the infection of deep tissue,which is under the superficical layer of deep cervical fascia. It is often secondary to the head,neck, and upper respiratory tract infection, also the continuation of infection diseases for the whole body. Although the incidence of infection of the deep neck interfascial space was reduced after antibiotics widely used, it is also see more quite in clinic. The infection is in deep neck. The location of its primary lesions also is in deep, usually the tooth, throat, tonsils, salivary glands, esophagus, trachea and so on. The anatomy of the deep neck interfascial space is complicated. Each layer of the deep neck interfascial space package the blood vessels, muscles, nerves and organs, and divide the neck form multiple potential gaps. There is loose connective tissue with weak resistance in the potential gaps. In the clearance,infection spread easily along the way of the anatomy, and pus also easily accumulate in here, so the infection of the deep neck interfascial space is not easy to be limited. Because of the rapid progression of the disease, if the infection could not get to control just in time, it is easy to form abscess and cause severe systemic symptoms of poisoning. Before Antibiotic application, the commonest pathogenic bacteria of the infection of the deep cervical fascial space is streptococcic; but after antibiotic application, staphylococcus aureus infection is increased significantly. According to reports in the literature, the deep neck interfascial space is a mix of aerobic and anaerobic bacteria infection,that's to say, there is a tendency of gradually increasing of anaerobic bacteria infection in recent years.
The retropharyngeal space, prevertebral space, pretracheal space, parapharyngeal space, carotid sheath are directly or indirectly associated with each other through anatomy way, and they can extend down to the mediastinum. If the infection of the deep neck interfascial space can not be controled in time, it is easy to spread down and cause mediastinum infection or mediastinum abscess. Mediastinum contains the heart, trachea, esophagus, nerves, large blood vessels within the chest and lymphatic organization, however,these structures are looser and weak. The clinical symptoms of the mediastinum infection or mediastinum abscess are more severe, such as chest pains, dysphagia, dyspnea, even suffocation, great vessels rupture to die and so on.
According to the report, after antibiotic application,88%of the patients,with infection of the deep neck interfascial space, still need to combine with surgery. Although it is safe and beneficial of the reasonable antibiotic application to control infection of the deep neck interfascial space, it is clinically proven that early surgical incision drainage is necessary for the patients with infection of the deep neck interfascial space.
Objective
To analysis and summarize on the etiology, clinical features, imaging examination, microbiology of infection of the deep neck interfascial space with mediastinal abscess.The purpose of this thesis was to discuss the diagnosis and effective treatments about infection of the deep neck interfascial space with mediastinal abscess.
Methods
A retrospective analysis was undertaken for11patients with infection of the deep neck interfascial space with mediastinal abscess from January2009to September2009at Department of Otolaryngology, the first Affiliated Hospital of Zhengzhou University.This section included a total of11patients,8were male and3 were female,age ranged from5to71, the median age was36. After admission,they all received chest X-ray, the color ultrasound of neck, neck and chest enhanced CT examination, anti-infection and symptomatic support treatment,Ten of the patients received surgical incision and drainage through lateral neck incision.
Results
In these group of11cases with infection of the deep neck interfascial space with mediastinal abscess,one died,10cases were cured after active treatments,the days in hospital ranged from13to109days.9patients were pulled out the drainage tube at the10th after surgery.1at the14th after surgery,1reset the drainage tub three times after surgery. All of the patients can have normal diet.
Conclusions
Rupture of the esophagus perforation, diabetes, acute suppurative tonsillitis can cause infection of the deep neck interfascial space with mediastinal abscess.The disease was seriously ill and had a rapidly progresses, the early diagnosis, effective antibiotics,Reasonable surgical incision and drainage, sufficient nutritional support treatments are key methods to the treatment of infection of the deep neck interfascial space with mediastinal abscess.
颈深间隙感染(infection of the deep neck interf ascial space)是指颈深筋膜浅层深面的深部组织感染性疾病,常继发于头、面、颈部及上呼吸道感染,亦可为全身感染性疾病的延续,抗生素的广泛应用虽降低了颈深间隙感染发病率,但其在临床上仍时有发生。此感染位于颈深部软组织,其原发病灶器官的位置亦较深,通常为：牙、咽部、扁桃体、唾液腺、食管、气管等。颈深筋膜解剖复杂,各层筋膜包绕颈部的血管、肌肉、神经及器官,将颈部分隔形成多个潜在的间隙,这些腔隙内为疏松的结缔组织,抵抗力弱,感染易在此处沿解剖途径播散,脓液易在该间隙中积聚,因此颈深筋膜间隙感染不易局限,病情发展快,若不及时控制,可形成脓肿并引起严重的全身中毒症状。抗生素应用之前,该病的致病菌多为链球菌,而应用抗生素之后,金黄色葡萄球菌的感染明显增加。据文献报道,颈深间隙感染多为需氧菌与厌氧菌的混合感染,即厌氧菌感染也有增多趋势。
颈深间隙中的咽后间隙(retropharyngeal space)、椎前间隙(prevertebral space)、气管前间隙(pretracheal space)、咽旁间隙(parapharyngeal space)、颈动脉鞘(carotid sheath)通过解剖途径直接或间接相通,并向下扩展至纵隔。颈深间隙感染加重且未及时控制的患者,炎症易向下蔓延引起纵隔感染或脓肿。纵隔内包含心脏、气管、食管、神经、胸内大血管和淋巴组织,结构疏松薄弱,此处的炎症或脓肿临床症状极重,可出现胸痛、吞咽困难、呼吸困难,甚至窒息、大血管破裂而死亡。
有文献报道,颈深间隙感染的患者抗生素治疗后,仍有88%的患者需联合手术治疗。合理应用抗生素控制颈深间隙感染,虽安全而有益,但临床上证实形成颈深间隙脓肿的患者仍应及早行手术切开引流。
目的
分析总结颈深间隙感染合并上纵隔脓肿患者的病因、临床特点、影像学特征、微生物学特点,探讨颈深间隙感染合并上纵膈脓肿的诊断和有效治疗方案。
方法
回顾性分析2009年1月至2012年9月郑州大学第一附属医院耳鼻咽喉头外科收治的11例颈深间隙感染合并上纵隔脓肿患者,其中男8例,女3例,年龄为5～71岁,中位年龄为36岁,入院后行胸部X线、颈部彩超、颈胸部增强CT检查,及时抗感染和对症支持治疗,10例患者在感染局限时行颈侧切开引流手术。
结果
11例患者除1例患者死亡,余10例均经过积极治疗治愈出院,住院时间为13-109天。其中9例患者在术后10天左右拔出颈部引流管,1例术后2周拔出引流管,1例于术后先后3次重置引流管；术后患者均可正常饮食。
结论
食管破裂穿孔、糖尿病、急性化脓性扁桃体炎可引起颈深间隙感染合并上纵隔脓肿,该病病情严重,发展迅速。早诊断、有效的抗感染治疗、尽早手术切开引流并充分的营养支持是治疗成功的关键。
Background
Infection of the deep neck interfascial space is the infection of deep tissue,which is under the superficical layer of deep cervical fascia. It is often secondary to the head,neck, and upper respiratory tract infection, also the continuation of infection diseases for the whole body. Although the incidence of infection of the deep neck interfascial space was reduced after antibiotics widely used, it is also see more quite in clinic. The infection is in deep neck. The location of its primary lesions also is in deep, usually the tooth, throat, tonsils, salivary glands, esophagus, trachea and so on. The anatomy of the deep neck interfascial space is complicated. Each layer of the deep neck interfascial space package the blood vessels, muscles, nerves and organs, and divide the neck form multiple potential gaps. There is loose connective tissue with weak resistance in the potential gaps. In the clearance,infection spread easily along the way of the anatomy, and pus also easily accumulate in here, so the infection of the deep neck interfascial space is not easy to be limited. Because of the rapid progression of the disease, if the infection could not get to control just in time, it is easy to form abscess and cause severe systemic symptoms of poisoning. Before Antibiotic application, the commonest pathogenic bacteria of the infection of the deep cervical fascial space is streptococcic; but after antibiotic application, staphylococcus aureus infection is increased significantly. According to reports in the literature, the deep neck interfascial space is a mix of aerobic and anaerobic bacteria infection,that's to say, there is a tendency of gradually increasing of anaerobic bacteria infection in recent years.
The retropharyngeal space, prevertebral space, pretracheal space, parapharyngeal space, carotid sheath are directly or indirectly associated with each other through anatomy way, and they can extend down to the mediastinum. If the infection of the deep neck interfascial space can not be controled in time, it is easy to spread down and cause mediastinum infection or mediastinum abscess. Mediastinum contains the heart, trachea, esophagus, nerves, large blood vessels within the chest and lymphatic organization, however,these structures are looser and weak. The clinical symptoms of the mediastinum infection or mediastinum abscess are more severe, such as chest pains, dysphagia, dyspnea, even suffocation, great vessels rupture to die and so on.
According to the report, after antibiotic application,88%of the patients,with infection of the deep neck interfascial space, still need to combine with surgery. Although it is safe and beneficial of the reasonable antibiotic application to control infection of the deep neck interfascial space, it is clinically proven that early surgical incision drainage is necessary for the patients with infection of the deep neck interfascial space.
Objective
To analysis and summarize on the etiology, clinical features, imaging examination, microbiology of infection of the deep neck interfascial space with mediastinal abscess.The purpose of this thesis was to discuss the diagnosis and effective treatments about infection of the deep neck interfascial space with mediastinal abscess.
Methods
A retrospective analysis was undertaken for11patients with infection of the deep neck interfascial space with mediastinal abscess from January2009to September2009at Department of Otolaryngology, the first Affiliated Hospital of Zhengzhou University.This section included a total of11patients,8were male and3 were female,age ranged from5to71, the median age was36. After admission,they all received chest X-ray, the color ultrasound of neck, neck and chest enhanced CT examination, anti-infection and symptomatic support treatment,Ten of the patients received surgical incision and drainage through lateral neck incision.
Results
In these group of11cases with infection of the deep neck interfascial space with mediastinal abscess,one died,10cases were cured after active treatments,the days in hospital ranged from13to109days.9patients were pulled out the drainage tube at the10th after surgery.1at the14th after surgery,1reset the drainage tub three times after surgery. All of the patients can have normal diet.
Conclusions
Rupture of the esophagus perforation, diabetes, acute suppurative tonsillitis can cause infection of the deep neck interfascial space with mediastinal abscess.The disease was seriously ill and had a rapidly progresses, the early diagnosis, effective antibiotics,Reasonable surgical incision and drainage, sufficient nutritional support treatments are key methods to the treatment of infection of the deep neck interfascial space with mediastinal abscess.
引文
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[2]黄选兆,汪吉宝主编.实用耳鼻咽喉科学[M].北京：人民卫生出版社,1998：375-376.
[3]Estrera AS,Landay MJ,et al,Descending necronzing mediastinitis[J].Surg Gynecol obstet.1983,157:545-552.
[4]李俊义,毕京玉,孟新宇,等.颈深部感染76例临床分析[J].中国现代医药杂志,2009,11(04),45-47.
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