Deep neck infection
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Deep neck space infection
Dr ramesh parajuli, MSChitwan Medical College, Bharatpur-
10, Chitwan, Nepal
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Fascial layers of the neck Fascia is an investing fibrous tissue related to muscles & major
neck structures.
A. Superficial cervical fascia:
B. Deep cervical fascia:
1. Superficial or investing layer
2. Middle layer or visceral fascia
3. Deep layer or pre-vertebral fascia
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(I)Superficial cervical fascia: encloses platysma
(II) Deep cervical fascia
(i)Investing layer: Encloses strap muscles, SCM, trapezius
Parotid &submandibular glands, carotid sheath
(ii)Middle or Visceral layer: encircles esophagus, trachea,
thyroid
(iii)Deep or pre-vertebral layer: Covers deep neck muscles i.e.
prevertebral muscles
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Deep neck spaces Potential neck spaces Contain loose areolar tissue Spread of tumor and
infection
Submental space Submandibular space Parotid Peritonsillar Parapharyngeal Retropharyngeal Pretracheal space Prevertebral space
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Ludwig’s angina: Rapidly progressing cellulitis of submandibular space
(i.e. sublingual & submaxillary space) Mixed flora (poly-microbial) May result into life-threatening airway obstruction
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Subdivisions of submandibular space
1. Sublingual space: above mylohyoid muscle
2. Submaxillary space: below mylohyoid muscle
Contents: Submandibular salivary gland, lymph nodes
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Etiology: 1. Dental infection: 80% cases
Tooth (lower molars & premolars)
Roots of premolars lie above mylohyoid sublingual space
infection
Roots of molars lie below mylohyoid submaxillary space
infection
2. Injury to floor of mouth
3. Submandibular sialadenitis
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Causative agentsCausative agents
Mixed aerobic & anaerobic infection
Streptococcus pyogenes
Streptococcus viridans
Streptococcus pneumoniae
Staphylococcus
Fusobacterium
Bacteroides
Peptostreptococcus
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Clinical featuresClinical features Toothache, fever, odynophagia, drooling of saliva
Floor of mouth swelling + tongue elevation
submental swelling: Brawny induration
Trismus
Stridor: falling back of tongue causing upper airway obstn
Initially cellulitis (no frank pus) pus formation (only
at late stage)
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Parapharyngeal abscess
Retropharyngeal abscess
Acute airway obstruction (within
hours):
due to falling back of tongue
Aspiration pneumonia
Septicemia
Death
ComplicationsComplications
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Management:
1. I.V. antibiotics: Ceftriaxone + Metronidazole / Clindamycin
2. IV fluid for adequate hydration
3. Monitor vital signs regularly eg. assessment for disease progression & airway compromise
4. Airway obstruction: Intubation / tracheostomy
5. Incision & drainage
Transverse incision from one angle of mandible to opposite angle of mandible
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Retropharyngeal space
It lies behind the pharynx
Superior: Base of skull
Inferior: Mediastinum (till tracheal bifurcation)
Anterior: Buccopharyngeal fascia
Posterior: pre-vertebral fasciaContains lymph nodes (of Rouviere) which usually disappear at 3-4 years of age
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Retropharyngeal abscess
Collection of pus in retropharyngeal space
In children: Suppuration of retropharyngeal
lymph node of Rouviere from URTI In adults:Tubercular infection of retropharyngeal
lymph nodes/cervical spinepresents as posterior pharyngeal wall swelling
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Symptoms
H/o upper respiratory tract infection
Dysphagia / odynophagia
Difficulty in breathing
Neck stiffness/ torticollis
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Signs
Febrile, ill-looking, child with
drooling
Tender neck swelling
Torticollis (twisted neck)
Bulge on posterior pharyngeal wallTorticollis
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Widened pre-vertebral soft tissue shadow
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Air-fluid level & gas shadow
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Tuberculosis of cervical spine with retropharyngeal abscess
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Complications
1. Airway obstruction:
2. Spread of abscess to other neck spaces
3. Spontaneous rupture of abscess
4. Septicemia
5. Death
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Treatment
1. Broad spectrum intravenous antibiotics:
Ceftriaxone + Metronidazole
2. Incision & drainage: without anesthesia, supine with head hanging down from the table, I & D at most bulging part of posterior pharyngeal wall bulge, two powerful suctions to suck out pus thus preventing aspiration
General anesthesia(GA) is contraindicated for fear of rupture of abscess during intubationaspiration
3. Anti-tubercular therapy
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Parapharyngeal space
Base & superior limit: Skull Base
Apex: hyoid
Lateral: Ramus of mandible, Medial Pterygoid
deep lobe of parotid
Medial: Bucco-pharyngeal fascia
Anterior: Pterygo-mandibular raphe
Posterior: Pre-vertebral fascia
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Styloid process divides into two compartments:-
Prestyloid ◦ Deep lobe of parotid◦ Contains fat, connective
tissue, nodes
Poststyloid ◦ Neurovascular compartment◦ Carotid sheath (ICA,IJV)◦ Cranial nerves (IX, X, XI, XII)◦ Sympathetic chain
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Contents of parapharyngeal space
Pre-styloid
Deep lobe of parotid Lymph nodesFat Connective tissue
Post-styloid Internal carotid artery Internal jugular vein Cranial
nerves(IX,X,XI,XII) Sympathetic chain Lymph nodes
•Styloid process divides into two spaces
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Etiology
Pharynx: acute tonsillitis, peritonsillar abscess
Teeth: dental infection (esp. lower last molar)
Ear: Bezold’s abscess
Spread from other neck abscess: parotid, retropharyngeal, submandibular
Penetrating neck injuries
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Clinical features
1. Fever, sore throat, odynophagia, torticollis2. Tonsils pushed medially3. Trismus4. Neck swelling behind angle of mandible
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Management1. IV antibiotics: Ceftriaxone + Metronidazole2. Incision & drainage:Under GA with endotracheal intubationHorizontal incision made 3 cm below angle of
mandibleTrans-oral drainage avoided to prevent injury
to carotid artery & internal jugular vein3. Tracheostomy for airway obstruction
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Peritonsillar abscess (quinsy)
Pus present in the peritonsillar space i.e. between tonsillar capsule & superior pharyngeal constrictor muscle
Causative agents: aerobic + anaerobic organisms Infection of Weber's gland (Minor salivary gland in supra
tonsillar fossa) quinsyFollowing acute tonsilitis (Less commonly)
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Clinical features
Symptoms: odynophagia, fever, halitosis & muffled voice
Signs:
1.Unilateral tonsil enlarged (infection in paratonsillar spacepseudohypertrophy), pushed medially
2. Congested tonsil,tonsillar pillars, soft palate
3. Jugulo-digastric lymph node tender, enlarged
4. Trismus
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Complications of quinsy
1. Parapharyngeal abscess
2. Retropharyngeal abscess
3. Laryngitis & laryngeal edema
4. Lung abscess
5. Internal jugular vein thrombosis
6. Septicemia
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ManagementDiagnosis: Peritonsillitis vs Peritonsillar
abscess
Needle aspiration reveals pus i.e. quinsy
1. Broad spectum IV antibiotics:Ceftriaxone +Metronidazole
2. I.V. fluids & analgesics
3. Antiseptic mouth gargle
4. Repeated needle aspiration
5. Incision and drainage
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Incision & drainage site
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Incision and drainage of quinsy:
1. I & D with quinsy forceps
2. I & D with No.11 surgical blade
3. Repeated pus aspiration with wide bore needle
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Parotid abscessDebilitated & dehydrated pts (decreased
salivary flow)Causative organism: Staph. aureus,
Streptococci, Haemophilus & other organismsAscending bacterial infection from oral cavity
through the duct to the gland Predisposing conditions: DM,
Immunocompromised, poor oro-dental hygeine
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Painful parotid region swelling Trismus Parotid massage expresses
pus from parotid duct opening Rx: Broad spectrum
antibiotics (Inj. Ampicillin plus cloxacillin, and clindamycin)
I & D: Modified Blair’s incision
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Thank youThank you