Neck Space

Infections

Dr. Vishal Sharma

Fascial layers of neck

A. Superficial cervical fascia: encloses platysma

B. Deep cervical fascia

1. Superficial or Investing layer

2. Middle layer 3. Deep layer

a. Muscular division a. Alar fascia

b. Visceral division b. Pre-vertebral

fascia

Deep Cervical Fascia

Investing layer: Encloses trapezius & SCM; parotid,

submandibular gland & carotid sheath

Visceral layer: Surrounds strap muscles, pharynx,

larynx, esophagus, trachea, thyroid

Deep layer: Covers deep neck muscles, cervical

plexus, phrenic nerve & brachial plexus. Cervical

sympathetic chain lies superficial to this fascia.

Classification of neck spaces

A. Involves entire neck B. Spaces above hyoid

1. Superficial neck space 1. Submental

2. Deep neck spaces 2. Submandibular

a. Carotid sheath a. Sublingual

b. Retro-pharyngeal b. Submaxillary

c. Danger space 3. Masticator

d. Pre-vertebral 4. Parotid

C. Below Hyoid 5. Parapharyngeal

1. Pre-tracheal space 6. Peri-tonsillar

Masticator spaces

Formed around muscles

of mastication (masseter,

pterygoids, insertion of

temporalis) & covered by

investing layer of deep

cervical fascia

Classification of neck

space infections

A. Involves entire neck B. Supra-hyoid abscess

1. Superficial space Sub-mental

Necrotizing fascitis Masticator

2. Deep space abscess Parotid

Carotid sheath Ludwig’s angina

Retro-pharyngeal Para-pharyngeal

Danger space Peri-tonsillar (quinsy)

Pre-vertebral C. Infra-hyoid abscess

Pre-tracheal

Necrotizing fasciitis

Rare infection of superficial neck space causing

necrosis of fascia + subcutaneous tissue,

initially sparing skin & muscle

Term coined in 1952 by Wilson

Etiology: Dental infections, skin trauma, quinsy

& parapharyngeal abscess

Bacteriology: β-hemolytic streptococcus,

Staphylococcus aureus, anaerobes

Clinical Presentation Outer zone of erythema, intermediate zone of

tender ecchymosis & central zone of vesiculation

+ black necrosis + ulceration

Fascial necrosis extends beyond skin necrosis

Skin anesthesia (damage of cutaneous nerves)

Soft tissue crepitus due to gas formation

Hypocalcemia, hyponatremia & dehydration

Necrotizing fasciitis of chest

CT scan showing gas formation

Treatment Early correction of fluid & electrolyte imbalance

I.V. Ampicillin + Gentamicin + Clindamycin

Immediate radical debridement of necrotic tissue

(in presence of subcutaneous air, progressive

infection despite 48 hours of medical therapy,

obvious fluctuation or skin necrosis)

Skin grafting after debridement

Wound debridement

Skin grafting

Healed wound

Poor prognostic factors: Diabetes mellitus,

atherosclerosis, chronic renal failure, obesity,

immuno-suppression, malnutrition

Complications: necrosis of chest wall fascia,

mediastinitis, pleural effusion, pericardial

effusion, empyema, airway obstruction, arterial

erosion, jugular vein thrombophlebitis, septic

shock, lung abscess, carotid artery thrombosis

Ludwig’s Angina

Rapidly progressing poly-microbial cellulitis of

sublingual & submaxillary spaces with potentially

life-threatening airway compromise

Submandibular spaceBoundaries: Anterior & lateral: mandible

Medial: anterior belly of digastric

Posterior: submandibular gland

Inferior: level of hyoid bone

Subdivisions:

1. Sublingual space: above mylohyoid muscle

2. Submaxillary space: below mylohyoid muscle

Contents: Submandibular salivary gland, lymph nodes

Etiology of Ludwig’s angina

A. Lower dental or periodontal infection (80%):

1. Poor dental hygiene (caries & abscess)

2. Tooth extraction (lower molars & premolars)

Roots of premolars & 1st molar lie above

mylohyoid sublingual space infection

Roots of 2nd & 3rd molars lie below mylohyoid

submaxillary space infection

B. Others (20%): submandibular sialadenitis, floor of

mouth trauma, mandibular fractures

Mixed aerobic & anaerobic infection

Streptococcus pyogenes

Streptococcus viridans

Streptococcus pneumoniae

Staphylococcus

Fusobacterium

Bacteroides

Peptostreptococcus

Causative organisms

Toothache, fever, odynophagia, drooling

Floor of mouth swelling + tongue elevation in

sublingual space infection

Brawny / woody tender swelling below chin in

submaxillary space infection

Trismus

Stridor: falling back of tongue, laryngeal edema

Initial cellulitis delayed pus formation

Clinical Features

Elevation of tongue

Submandibular swelling

Submandibular swelling

X-ray soft tissue neck lateral

assess degree

of soft tissue

swelling &

airway

obstruction

C.T. scan

Treatment of Ludwig’s angina

1. I.V. antibiotics: Cefuroxime / Ceftriaxone

+ Metronidazole / Clindamycin

2. Airway: endotracheal intubation / tracheostomy

3. Incision & drainage of serous fluid / pus

a. Intra-oral: for sublingual space infection

b. Extra-oral: for submaxillary space infection

Transverse incision from one angle of

mandible to opposite angle of mandible

4. IV fluid for adequate hydration

5. Periodic assessment for disease progression &

airway compromise

Incision drainage + Tracheostomy

Incision drainage + Tracheostomy

Parapharyngeal abscess

Retropharyngeal abscess

Acute airway obstruction (within hours): due to

pushing back of tongue, laryngeal edema

Aspiration pneumonia

Septicemia

Death

Complications

Retropharyngeal abscess

Retropharyngeal Space

Superior: Base of skull

Inferior: Mediastinum (till tracheal bifurcation)

Anterior: Buccopharyngeal fascia

Posterior: Alar fascia

Lateral: Parapharyngeal spaces

Divided into two lateral compartments (space of

Gillette) by midline fibrous raphe

Retropharyngeal abscess

Collection of pus in retropharyngeal space

Classification:

1. Acute

2. Chronic

Acute abscess is common in children below 3-5 yrs

as retropharyngeal nodes of Rouviere regress later

Acute Retropharyngeal

Abscess

Etiology Suppuration of retropharyngeal lymph node of

Rouviere from upper respiratory tract infection

Penetrating injury of posterior pharyngeal wall

(e.g.. fish bone, vertebral fracture)

Following endoscopic trauma to pharynx

Acute mastoitis: pus tracking under petrous bone

Symptoms H/o upper respiratory tract infection

Dysphagia / odynophagia

Difficulty in breathing

Croupy cough

Hot potato voice

Neck stiffness

Signs

Febrile, ill-looking, child with drooling

Tender neck swelling + fistula

Torticollis (twisted neck) on side of abscess

followed by hyperextension of neck

U/L bulge on posterior pharyngeal wall

Posterior pharyngeal wall swelling on left side

Endoscopic view of posterior pharyngeal wall bulge

X-ray soft tissue neck (lateral)1. Widened pre-vertebral soft tissue shadow

a. > 7 mm at C2 vertebra

b. > 14 mm at C6 vertebra below 14 years

c. > 22 mm at C6 vertebra above 14 years

2. Presence of air-fluid level & / gas (acute cases)

3. Homogenous pre-vertebral shadow (chronic)

4. Straightening of cervical spine curve due to

spasm of pre-vertebral muscles

High retropharyngeal abscess

Air-fluid level & gas shadow

CT scan axial cuts

Treatment1. IV antibiotics: Ceftriaxone + Metronidazole

2. Incision & drainage:

No anesthesia (as it may rupture abscess) or

very careful endotracheal intubation

Supine with head hanging low from table

Vertical or horizontal incision on fluctuant area

Incision + immediate suction of pus

3. Tracheostomy for airway obstruction

Chronic Retropharyngeal

Abscess

Etiology Caries of cervical spine: presents as central

posterior pharyngeal wall swelling

Tubercular infection of retropharyngeal lymph

nodes from infected deep cervical nodes:

presents as lateral posterior pharyngeal wall

swelling true retropharyngeal abscess

Post traumatic: vertebral fracture

Spread from parapharyngeal abscess

Clinical Features Chronic mild dysphagia

Pain is absent due to cold abscess

Bulge of posterior pharyngeal wall with fluctuant

swelling (central or lateral)

Investigations

As in acute retropharyngeal abscess

Ziehl Neelsen stain of pus after aspiration

X-ray soft tissue neck (lateral): homogenous opacity

Tuberculosis

of cervical spine

with

chronic

retropharyngeal

abscess

Treatment1. I.V. antibiotics: Ceftriaxone + Metronidazole

2. Incision & drainage:

Low abscess: along anterior border of

sternocleidomastoid muscle

High abscess: along posterior border of

sternocleidomastoid muscle

3. Anti-tubercular therapy for 9 - 12 months

Complications

1. Airway obstruction: mechanical obstruction

laryngeal edema

2. Spread of abscess to other neck spaces

3. Spontaneous rupture of abscess

4. Septicemia

5. Death

Parapharyngeal abscess

Parapharyngeal spaceBase & superior limit: Skull Base

Apex: Lesser cornu of hyoid

Lateral: Mandible ramus, Medial Pterygoid, Parotid

Medial: Bucco-pharyngeal fascia, superior constrictor

Anterior: Pterygo-mandibular raphe

Posterior: Pre-vertebral fascia

Inferior: Deep cervical fascia lateral to mandible angle

ContentsPre-styloid

Deep lobe of parotid

Internal maxillary artery

Inferior alveolar nerve

Lingual nerve

Auriculo-temporal nerve

Lymph nodes

Styloid: Styloid process, its 3 muscles + 2 ligaments

Post-styloid

Internal carotid artery

Internal jugular vein

Last 4 cranial nerves

Sympathetic chain

Glomus system

Lymph nodes

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

Clinical Features1. Fever, sore throat, odynophagia, torticollis

2. Anterior compartment involvement:

a. Tonsils pushed medially

b. Trismus

c. Neck swelling behind angle of mandible

3. Posterior compartment involvement:

a. Medial bulge behind posterior pillar of tonsil

b. Paralysis of IX, X, XI, XII & sympathetic chain

CT scan neck: axial cuts

Treatment1. IV antibiotics: Ceftriaxone + Metronidazole

2. Incision & drainage:

Under GA with endotracheal intubation

Horizontal incision made 3 cm below angle of

mandible

Trans-oral drainage avoided to prevent injury to

carotid artery & internal jugular vein

3. Tracheostomy for airway obstruction / trismus

Peritonsillar abscess (Quinsy)

Etio-pathogenesis Pus present between tonsillar capsule &

superior constrictor muscle

Pathology: aerobic + anaerobic organisms

1. Acute tonsillitis blockage of crypts intra

tonsillar abscess peritonsillitis quinsy

2. Abscess of Weber's salivary gland in supra

tonsillar fossa quinsy

Clinical features

Symptoms: Young adult with severe odynophagia,

fever, halitosis & muffled voice

Signs: 1. Para-tonsil area swollen & congested

2. U/L tonsil ed, pushed medially, congested

3. Jugulo-digastric lymph node tender, enlarged

4. Trismus

5. Torticollis

Peri-tonsillitis & Quinsy

Management

Diagnosis:

Needle aspiration reveals pus

Medical treatment:

1. Urgent admission, I.V. fluids

2. I.V. Cefotaxime + Metronidazole

3. Antihistamine - decongestant + analgesic

4. Betadine gargle

Needle aspiration

Incision

Incision line & quinsy forceps

Alternate incision site at maximum bulge

Abscess drainage

Incision & drainage Incision made with # 11 blade or Thilenius

peritonsillar abscess drainage forceps

Nick made above & lateral to junction of 2

imaginary lines. Horizontal along base of uvula,

vertical along anterior tonsillar pillar.

Incision widened with sinus forceps & pus

drained. No anesthesia is required.

Surgical treatment

1. Interval tonsillectomy after 4 – 6 wk.

2. Hot tonsillectomy or abscess tonsillectomy is

avoided as it leads to:

more bleeding

septicemia

Complications of quinsy

1. Parapharyngeal abscess

2. Retropharyngeal abscess

3. Laryngitis & laryngeal edema

4. Lung abscess

5. Internal jugular vein thrombosis

6. Septicemia

Parotid abscess

Parotid SpaceFormed due to splitting of investing layer of deep

cervical fascia around parotid salivary gland

Etiology

Ascent of bacterial infection (Staphylococcus,

Haemophillus, Streptococcus) to a dehydrated

parotid gland along parotid duct from oral cavity

Suppuration of intra-parotid lymph nodes

Spread of infection from EAC via cartilaginous

fissures of Santorini or bony foramen of Huschke

Causes of parotid dehydration

1. Post-operative patient (surgical mumps)

2. Medications that decrease salivary flow:

Antihistamines

Tricyclic antidepressants

Barbiturates

Diuretics

Parasympathomimetics

Parotid abscess Pain + induration over parotid

gland

Pitting edema of parotid area

differentiates parotid abscess

from simple parotitis

Parotid massage expresses

pus from parotid duct into oral

cavity (opposite upper 2nd

molar)

Investigation

C.B.P.: Leukocytosis

Needle aspiration

with 18 G needle

Ultrasonography

C.T. scan

M.R.I.

C.T. scan & M.R.I.

Parotid anatomy

Treatment1. IV fluid for dehydration

2. IV Ampicillin + Gentamicin

+ Metronidazole

3. Incision drainage:

a. Blair’s incision made

b. Multiple incisions made

through fascia, parallel to

facial nerve branches

c. Blunt dissection to evacuate

pus. Drains placed.

Thank You