neck space infections dr. vishal sharma. fascial layers of neck a. superficial cervical fascia:...
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Neck Space
Infections
Dr. Vishal Sharma
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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
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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.
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Classification of neck spaces
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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
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Masticator spaces
Formed around muscles
of mastication (masseter,
pterygoids, insertion of
temporalis) & covered by
investing layer of deep
cervical fascia
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Classification of neck
space infections
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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
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Necrotizing fasciitis
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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
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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
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Necrotizing fasciitis of chest
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CT scan showing gas formation
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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
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Wound debridement
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Skin grafting
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Healed wound
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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
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Ludwig’s Angina
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Rapidly progressing poly-microbial cellulitis of
sublingual & submaxillary spaces with potentially
life-threatening airway compromise
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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
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Etiology of Ludwig’s angina
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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
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Mixed aerobic & anaerobic infection
Streptococcus pyogenes
Streptococcus viridans
Streptococcus pneumoniae
Staphylococcus
Fusobacterium
Bacteroides
Peptostreptococcus
Causative organisms
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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
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Elevation of tongue
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Submandibular swelling
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Submandibular swelling
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X-ray soft tissue neck lateral
assess degree
of soft tissue
swelling &
airway
obstruction
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C.T. scan
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Treatment of Ludwig’s angina
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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
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Incision drainage + Tracheostomy
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Incision drainage + Tracheostomy
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Parapharyngeal abscess
Retropharyngeal abscess
Acute airway obstruction (within hours): due to
pushing back of tongue, laryngeal edema
Aspiration pneumonia
Septicemia
Death
Complications
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Retropharyngeal abscess
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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
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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
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Acute Retropharyngeal
Abscess
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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
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Symptoms H/o upper respiratory tract infection
Dysphagia / odynophagia
Difficulty in breathing
Croupy cough
Hot potato voice
Neck stiffness
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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
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Posterior pharyngeal wall swelling on left side
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Endoscopic view of posterior pharyngeal wall bulge
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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
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High retropharyngeal abscess
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Air-fluid level & gas shadow
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CT scan axial cuts
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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
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Chronic Retropharyngeal
Abscess
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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
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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
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X-ray soft tissue neck (lateral): homogenous opacity
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Tuberculosis
of cervical spine
with
chronic
retropharyngeal
abscess
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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
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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
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Parapharyngeal abscess
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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
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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
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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 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
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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
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Peritonsillar abscess (Quinsy)
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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
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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
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Peri-tonsillitis & Quinsy
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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
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Needle aspiration
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Incision
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Incision line & quinsy forceps
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Alternate incision site at maximum bulge
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Abscess drainage
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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.
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Surgical treatment
1. Interval tonsillectomy after 4 – 6 wk.
2. Hot tonsillectomy or abscess tonsillectomy is
avoided as it leads to:
more bleeding
septicemia
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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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Parotid abscess
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Parotid SpaceFormed due to splitting of investing layer of deep
cervical fascia around parotid salivary gland
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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
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Causes of parotid dehydration
1. Post-operative patient (surgical mumps)
2. Medications that decrease salivary flow:
Antihistamines
Tricyclic antidepressants
Barbiturates
Diuretics
Parasympathomimetics
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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)
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Investigation
C.B.P.: Leukocytosis
Needle aspiration
with 18 G needle
Ultrasonography
C.T. scan
M.R.I.
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C.T. scan & M.R.I.
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Parotid anatomy
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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.
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Thank You