deep neck infection

Deep neck space infection

Dr ramesh parajuli, MSChitwan Medical College, Bharatpur-

10, Chitwan, Nepal

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

(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

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

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

Subdivisions of submandibular space

1. Sublingual space: above mylohyoid muscle

2. Submaxillary space: below mylohyoid muscle

Contents: Submandibular salivary gland, lymph nodes

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

Causative agentsCausative agents

Mixed aerobic & anaerobic infection

Streptococcus pyogenes

Streptococcus viridans

Streptococcus pneumoniae

Staphylococcus

Fusobacterium

Bacteroides

Peptostreptococcus

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)

Parapharyngeal abscess

Retropharyngeal abscess

Acute airway obstruction (within

hours):

due to falling back of tongue

Aspiration pneumonia

Septicemia

Death

ComplicationsComplications

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

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

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

Symptoms

H/o upper respiratory tract infection

Dysphagia / odynophagia

Difficulty in breathing

Neck stiffness/ torticollis

Signs

Febrile, ill-looking, child with

drooling

Tender neck swelling

Torticollis (twisted neck)

Bulge on posterior pharyngeal wallTorticollis

Widened pre-vertebral soft tissue shadow

Air-fluid level & gas shadow

Tuberculosis of cervical spine with retropharyngeal abscess

Complications

1. Airway obstruction:

2. Spread of abscess to other neck spaces

3. Spontaneous rupture of abscess

4. Septicemia

5. Death

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

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

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

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

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 features

1. Fever, sore throat, odynophagia, torticollis2. Tonsils pushed medially3. Trismus4. Neck swelling behind angle of mandible

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

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)

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

Complications of quinsy

1. Parapharyngeal abscess

2. Retropharyngeal abscess

3. Laryngitis & laryngeal edema

4. Lung abscess

5. Internal jugular vein thrombosis

6. Septicemia

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

Incision & drainage site

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

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

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

Thank youThank you