Taking heed of the 'danger space': acute descending necrotising mediastinitis secondary to primary odontogenic infection

The Alar Fascia and Danger Space: A Modern Review

PURPOSE

Given the advancements in dissection modalities over the last decade, what is the current understanding of the alar fascia and its clinical implications as an access point into the danger space (DS)? The aim of the study is to provide an updated review of the alar fascia and danger space.

METHODS

A comprehensive search of the alar fascia and danger space was performed through PubMed databases up to August 2022. Thirty-two sagittal E12 sheet plastination slices of the head and neck were analyzed under a stereomicroscope to assess the morphology and continuity of the retropharyngeal, alar, and prevertebral fasciae (PVF and their respective potential spaces).

RESULTS

Recent advancements have provided evidence that the alar fascia is a true fascial layer between the retropharyngeal and danger spaces within the deep cervical region. Although its composition, histological features, and borders remain topics of controversy, the alar fascia is comprised of dense connective tissue and may serve as a physical barrier to prevent the spread of infection into the danger space. Complications arising from deep neck infections that invade the danger space include mediastinitis, necrotizing fasciitis, and empyema.

CONCLUSION

A proper understanding of the anatomy, structure, function, and potential spaces is crucial to assessing the alar fascia and danger space routinely in clinical practice, especially when imaging.

Odontogenic Head and Neck Region Infections Requiring Hospitalization: An 18-Month Retrospective Analysis

The aim of this study was to comprehensively review our experience with odontogenic infections in the head and neck region requiring treatment at a national referral center. We retrospectively reviewed 85 patients treated at the Chair and Clinic of Maxillofacial Surgery of the University Hospital in Wrocław between January 2018 and June 2019. We excluded patients with nonondontogenic infections or other than purulent clinical forms of dentivitis in the head and neck region. Several demographic, clinicopathological, and treatment variables were assessed. The majority of patients were men who were referred for inpatient treatment by a dentist or family doctor, presented to the Hospital Emergency Ward (SOR) by themselves, or transported to the SOR by paramedics SOR from their home or another hospital. All patients were treated in accordance with the current guidelines for head and neck region odontogenic infections. An incision was made and the abscess was drained. The odontogenic cause was removed followed by the collection of tissue for microbiological examination. The course of infection was monitored by means of laboratory parameters such as leukocyte counts and c-reactive protein levels. Odontogenic infections in the head and neck region are a persistent and common problem. Rapid, accurate diagnosis and treatment minimizes the risk of life-threatening complications, shortens the hospitalization period, and lowers treatment costs.

Airway Compromise due to Retropharyngeal Emphysema-A Rare Complication of an Extravasated Peripherally Inserted Central Venous Catheter

A 48-year-old woman was scheduled for flexible bronchoscopy, video-assisted thoracoscopic surgery and mediastinal washout. She had developed voice changes, difficulty swallowing, shortness of breath with a fever and increased respiratory rate in intensive care unit 12 days after a double liver and kidney transplantation. Computerised tomography of neck and chest demonstrated extensive retropharyngeal and subcutaneous emphysema, laryngeal distortion and pneumo-mediastinum; however, the causative factors were not immediately obvious. Intraoperatively, an un-anticipated diagnosis of extravasated peripherally inserted central venous cannula (PICC) was made. Total parenteral nutrition had extravasated into the mediastinum and thorax. Subsequent inflammation and infection resulted in air pocket formation. The retropharyngeal air pockets were caused by mediastinal emphysema tracking through the tissue planes to the anterior and posterior larynx. Awareness of the tip position and accompanying clinical and radiological enquiry, must be performed prior to use of PICC lines in critically ill patients.

Hyperbaric oxygen therapy in a case of cervical abscess extending to anterior mediastinum, with isolation of Prevotella corporis

We present a case of an odontogenic abscess, first spreading at the lateral cervical level and then in mediastinum. We isolated an anaerobic bacterium, Prevotella corporis, rarely documented in literature. The mortality rates of cervical abscesses secondary to odontogenic infections and complicated by mediastinitis vary from 10% to 40%. Treatment of descending mediastinitis involves multidisciplinary teams such as otorhinolaryngology, thoracic surgeons, infectious disease physicians, anesthetists and intensivists. Due to the combined treatment with surgical drainage within 48 hours of hospitalisation, antibiotics and subsequent hyperbaric oxygen therapy, we have achieved complete recovery of the patient.