s.Balaji16

Etiopathology of deep neck spaces :Patients at risk : immunocompromised ,diabetic ,infants , IV drug abusers

Precipitating factors : salivary gland infectionsURTITraumaForeign bodyInstrumentationPotts diseaseRetropharyngeal lymphadenitisPeritonsillar cellulitis

Spaces of neck :A) spaces involving the entire neck :Superficial space Deep space : retropharyngeal ,prevertebralB) suprahyoid spaces:Mandibular space : submandibular,submental,sublingualMasicatorLateral pharyngeal Parotid spaceC) infrahyoid spacePretracheal space

It is suppuration of the parotid space.

Deep cervical fascia splits into two layers, superficial and deep, to enclose the parotid gland and its associated structures.

Parotid space lies deep to its superficial layer.

Contents of parotid space : parotid gland , parotid lymph nodes, facial nerve, external carotid artery and retromandibular vein.

PAROTID ABSCESS

Dehydration post-surgical cases and debilitated patients stasis of salivary flow Infection from the oral cavity travels via the Stenson's duct to invade the parotid gland Multiple small abscesses may form in the parenchyma. They may then coalesce to form a single abscess.

ETIOLOGY

Most common organism is Staph. aureus but Streptococci, anaerobic organisms and rarely the gram negative organisms have been cultured.

Bacteriology

Usually follows 5-7 days after operation.

There is swelling, redness, indurations and tenderness in the parotid area and at the angle of mandible.

Parotid abscess is usually unilateral, but bilateral abscesses may occur.

Clinical Features

Fluctuation is difficult to elicit due to thick capsule.

Opening of the Stenson's duct becomes congested and may exude pus on pressure over the parotid.

Patient is toxic, running high fever and dehydrated.

Diagnosis of the abscess can be made by ultrasound or CT scan. More than one loculi of pus may be seen.

Aspiration of abscess can be done for culture and sensitivity of the causative organisms.

Diagnosis

Correct the dehydration, improve oral hygiene and promote salivary flow.

Intravenous antibiotics are instituted.

Surgical drainage under local or general anaesthesia is carried out by a preauricular incision as employed for parotidectomy.

Skin flap is raised to expose surface of the gland, and the abscess or abscesses are bluntly opened working parallel to the branches of the VIIth nerve.

Treatment

It is a collection of pus in the peritonsillar space which lies between the capsule of tonsil and the superior constrictor muscle.

Peritonsillar abscess usually follows acute tonsillitis though it may arise de novo without previous history of sore throats.

First, one of the tonsillar crypts, usually the crypta magna, gets infected and sealed off.

PERITONSILLAR ABSCESS (QUINSY)

Aetiology

It forms an intratonsillar abscess which then bursts through the tonsillar capsule to set up peritonsillitis and then an abscess.

Culture of pus from the abscess may reveal pure growth of Strept. pyogenes, Staph. aureus or anaerobic organisms.

More often the growth is mixed, with both aerobic and anaerobic organisms.

Peritonsillar abscess mostly affects adults and rarely the children though acute tonsillitis is more common in children.

Usually, it is unilateral though occasionally bilateral abscesses are recorded. Clinical features are divided into:

1.General. They are due to septicaemia and resemble any acute infection. They include fever (up to 104°F), chills and rigors, general malaise, body aches, headache, nausea and constipation.

2. Local

(i) Severe pain in throat. Usually unilateral. (ii) Odynophagia. It is so marked that the patient cannot even swallow his own saliva which dribbles from the angle of his mouth. Patient is usually dehydrated. (iii) Muffled and thick speech, often called "Hot potato voice". (iv) Foul breath due to sepsis in the oral cavity and poor hygiene. (v) Ipsilateral earache. This is referred pain via CN IX which supplies both the tonsil and the ear. (vi) Trismus due to spasm of pterygoid muscles which are in close proximity to the superior constrictor.

1. Hospitalisation. 2. Intravenous fluids to combat dehydration. 3. Antibiotics. Suitable antibiotics in large i.v. doses to cover both aerobic and anaerobic organisms. 4. Analgesics like paracetamol is given for relief of pain and to lower the temperature. Sometimes, stronger analgesics like pethidine may be required. Aspirin is avoided because of the danger of bleeding. 5. Oral hygiene should be maintained by hydrogen peroxide or saline mouth washes.

The above conservative measures may cure peritonsillitis. If a frank abscess has formed, incision and drainage will be required.

Treatment

Interval tonsillectomy :Tonsils are removed four to six weeks following an attack of quinsy.

Abscess or hot tonsillectomy :

Some people prefer to do 'hot'tonsillectomy instead of incision and drainage.

Abscess tonsillectomy has the risk of rupture of the abscess during anaesthesia, and excessive bleeding at the time of operation.

RETROPHARYNGEAL ABSCESS

Retropharyngeal space It lies behind the pharynx between the buccopharyngeal fascia covering pharyngeal constrictor muscles and the prevertebral fascia.

It extends from the base of skull to the bifurcation of trachea. The space is divided into two lateral compartments (spaces of Gillette) by a fibrous raphe .

Each lateral space contains retropharyngeal nodes which usually disappear at 3-4 years of age. Parapharyngeal space communicates with the retropharyngeal space. Infection of retropharyngeal space can pass down behind the oesophagus into the mediastinum.

Prevertebral space

It lies between the vertebral bodies posteriorly and the prevertebral fascia anteriorly. It extends from the base to skull of coccyx. Infection of this space usually comes from the caries of spine

Acute ChronicCommon in infants (below 3 yrs) Common in adultsEtiology:Suppuration of retropharyngeal lymphnodes.Infection from nasopharynx and oropharynxCommonly streptococcusPenetrating injury

Etiology:Tuberculosis Caries of cervical spine.

Acute ChronicClinical features:1.Dysphagia & difficulty in breathing Patient may c/o discomfort in throat.

2.Stridor and croupy cough Dysphagia.

3.torticollis Tuberculous lymphnodes

4. Bulge in posterior pharyngeal wall

Treatment:

1.Incision and drainage of abscess. 1.Incision and drainage of abscess.

2.Systemic antibiotics. 2.Full course of antitubercular drugs.3.tracheostomy.

PARAPHARYNGEAL ABSCESS Also called Abscess of pharyngomaxillary or lateral pharyngeal space.

Applied Anatomy

Parapharyngeal space is pyramidal in shape with its base at the base of skull and its apex at the hyoid bone.

Aetiology

Infection of parapharyngeal space can occur from:

1. Pharynx. Acute and chronic infections of tonsil and adenoid, bursting of peritonsillar abscess. 2. Teeth. Dental infection usually comes from the lower last molar tooth. 3. Ear. Bezold's abscess, petrositis. 4. Other spaces. Infections of parotid, retropharyngeal and submaxillary spaces. 5. External trauma. Penetrating injuries of neck, injection of local anaesthetic for tonsillectomy or mandibular nerve block.

Clinical Features

Anterior compartment infections produce a triad of symptoms: (i)prolapse of tonsil and tonsillar fossa, (ii) trismus (due to spasm of medial pterygoid muscle) and (iii) external swelling behind the angle of jaw. There is marked odynophagia associated with it.

Posterior compartment involvement produces (i)bulge of pharynx behind the posterior pillar,(ii)paralysis of CN IX, X, XI, and XII and sympathetic chain, (iii)swelling of parotid region. There is minimal trismus or tonsillar prolapse.

Complications:

1. Acute oedema of larynx with respiratory obstruction. 2. Thrombophlebitis of jugular vein with septicaemia. 3. Spread of infection to retropharyngeal space. 4. Spread of infection to mediastinum along the carotid space. 5. Mycotic aneurysm of carotid artery from weakening of its wall by purulent material. It may involve common carotid or internal carotid artery. 6. Carotid blow out with massive haemorrhage

Treatment

Systemic antibiotics. Intravenous antibiotics may become necessary to combat infection.

Drainage of abscess. This is usually done under general anaesthesia. If the trismus is marked, pre-operative tracheostomy becomes mandatory.

Abscess is drained by a horizontal incision, made 2-3 cm below the angle of mandible.

Blunt dissection along the inner surface of medial pterygoid muscle towards styloid process is carried out and abscess evacuated. A drain is inserted.

Transoral drainage should never be done due to danger of injury to great vessels which pass through this space

It is the infection of the submandibular sapce .Described by Wilheim Friedrich Von Ludwig in 1836.Submandibular space : lies between mucous membrane of the floor of mouth and tongue on one side and superficial layer of deep cervical fascia extending between the hyoid bone and mandible on the other . It is divided into two compartments by the mylohyoid muscle: (a) sublingual compartment (above the mylohyoid) (b) submaxillary and submental compartment (below the mylohyoid).

LUDWIG’S ANGINA

1. Dental infections. They account for 80% of the cases. Roots of premolars often lie above the attachment of mylohyoid and cause sublingual space infection while roots of the molar teeth extend up to or below the mylohyoid line and primarily cause submaxillary space infection.

2. Submandibular sialadenitis, injuries of oral mucosa and fractures of the mandible account for other cases.

Aetiology:

Criteria for diagnosis of ludwig’s angina:•Rapidly progressive cellulitis;not an abscess.

•Develops along fascial planes with direct extension,does not involve lymphatic spread.

•Does not involve submandibular gland or lymphnodes.

•Involves both sublingual and submaxillary spaces and is usually bilateral.

Clinical features :There is marked difficulty in swallowing (odynophagia) with varying degrees of trismus.

When infection is localised to the sublingual space, structures in the floor of mouth are swollen and tongue seems to be pushed up and back.

When infection spreads to submaxillary space, submental and submandibular regions become swollen and tender, and impart woody-hard feel.

Usually, there is cellulitis of the tissues rather than frank abscess.

Tongue is progressively pushed upwards and backwards threatening the airway.

Laryngeal oedema may appear.

1. Systemic antibiotics.

2. Incision and drainage of abscess. (a) Intraoral-if infection is still localised to sublingual space. (b) External-if infection involves submaxillary space. A transverse incision extending from one angle of mandible to the other is made with vertical opening of midline musculature of tongue with a blunt haemostat. Very often it is serous fluid rather than frank pus that is encountered.

3. Tracheostomy, if airway is endangered.

Treatment: