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Deep neck space infections

Deep neck space infections. Dr. Sheetal Rai Assistant Professor Dept of ENT Yenepoya Medical College Mangalore. Anatomy of deep neck spaces. Neck is divided into 4 compartments by the deep fascia 2 neurovascular compartments Visceral compartment Musculoskeletal compartment

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Deep neck space infections

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  1. Deep neck space infections Dr. SheetalRai Assistant Professor Dept of ENT Yenepoya Medical College Mangalore

  2. Anatomy of deep neck spaces

  3. Neck is divided into 4 compartments by the deep fascia • 2 neurovascular compartments • Visceral compartment • Musculoskeletal compartment • Deep fascia of the neck can be divided into three layers • Investing layer • Pretracheal layer • Prevertebral layer

  4. Investing layer of DCF • Attachments • Superior, inferior, anterior & posterior • Spaces: parotid & masticator • Submental space

  5. Middle layer or pre-tracheal layer • Encloses viscera, strap muscles, neurovascular structures • Attachments superior: base of skull Inferior: continues with fibrous pericardium • Buccopharyngeal fascia • Surgical importance

  6. Carotid sheath • Superior: base of skull • Inferior : merges around arch of aorta & pericardium • CONTENTS • Carotid artery • Vagus nerve • IJV • Cervical sympathetic trunk

  7. Deep layer of DCF • Arises from spinous processes & ligamentumnuchae • Splits into 2 layers 1. ALAR superior: base of skull inferior: upper mediastinum T1 – T2 2. PREVERTEBRAL skull base to coccyx Extends as axillary sheath

  8. DEEP NECK SPACE INFECTIONS

  9. Source of infection • Dental infection • Isolated nodal abscesses • Peritonsillar cellulitis or abscess • Upper aerodigestive trauma • Retropharyngeal lymphadenitis • Pott’s disease • Sialadenitis • Bezold’s abscess • Congenital cysts and fistulae • Subcuteneous or IV drug abuse

  10. Microbiology • Mixed microbial flora • α and β hemolytic streptococcus • Staphylococcus • Peptostreptococcus • Bacteroides melanogenica • B.oralis • Veillonella • Actinomyces • Spirochaetes • Ekinella corrodens

  11. Clinical manifestations • Pain • Fever • Trismus and limitation of neck movements OTHERS Dysphagia Odynophagia Change in voice Dyspnoea

  12. General work up • Careful history • Complete physical examination • Investigations • CBC, Blood Culture • X-rays : Lateral neck X-ray • Non invasive techniques : CT or MRI

  13. Specific Deep Neck Infections

  14. Ludwig’s Angina • Infection of Submandibular space • Origin in submaxillary space  sublingual space

  15. Submandibular space • Divided by mylohyoid into two spaces-submaxillary and sublingual. • Boundaries-sup,inf,lat,floor. • Contents- submandibular gland, Wharton’s duct, lingual & hypoglossal nerve, branch of facial artery and lymphatics

  16. Ludwig’s Angina Criteria for Diagnosis • Rapidly progressing cellulitis; no tendency to form abscess • Involvement of submaxillary & sublingual space • Spread along fascial planes • Involvement of muscle & facsia but not submandibular gland & LN

  17. Clinical features • Fever • Increasing oral or neck pain & swelling • Neck rigidity • Trismus, odynophagia • Drooling of saliva • Dyspnoea & stridor

  18. On examination • Floor of the mouth swollen and inflammed, tense, indurated • Tongue displaced upwards & backwards towards the palatal vault • Woody induration • X-ray : shows soft tissue edema airway encroachment

  19. Treatment • Early stage : IV antibiotics, supportive measures, extraction of inciting tooth • Advanced stage : Surgery • Secure Airway : Tracheostomy under LA • Surgical Drainage : Incision – Median horizontal incision 2 ½ breadths below the mandibular margin • Drainage : Multiple drains placed & wound left open.

  20. Complications • Airway obstruction • Spread of infection to carotid sheath or retropharyngeal space  mediastinal extension

  21. Parapharyngeal abscess

  22. Parapharyngeal space • Inverted pyramidal shape • Boundaries base-petrous temporal bone apex- hyoid bone med-BP fascia post-prevertebral fascia lat-med pterygoidmuscle,mandible,deep parotid gland

  23. Divided into anterior & post compartment by styloid process and muscles attached • Contents-carotid art, IJV, 9th,10th,11th and 12th C N, sympathetic trunk & upper deep cervical nodes

  24. Aetiology: • pharynx: acute & chronic tonsillitis, adenoiditis, peritonsillar abscess • Teeth: infn. from lower last molar tooth • Ear: Bezold’s abscess, petrositis • Other spaces: infn from parotid, Retropharyngeal space, submaxillary space • External trauma: penetrating neck injuries

  25. Clinical features Anterior compartment involvement: • Anterior & medial displacement of the tonsil • Trismus • External swelling behind the angle of the jaw Posterior compartment involvement: • Swelling of the palate & lat pharyngeal wall behind the posterior pillar • Paralysis of cranial nerves 9,10,11,12 & cervical sympathetic chain[HORNER’S SYNDROME] • Swelling of the parotid region

  26. Common to both compartments: • Fever • Odynophagia • Sore throat • Torticollis • Signs of toxemia

  27. Treatment • Early stage:IV antibiotics, fluid replacement, close observation • Late stage:surgical drainage • Approaches:intraoral or extraoral • Extraoral :submandibular incision two & half finger breadths inferior to mandibular margin from ant. limit of submandibular gland to just past the angle of the mandible • Vertical incision at the ant.border of SCM along with transverse for carotid sheath exploration[Mosher]

  28. Complications • Airway compromise • IJV thrombosis • Mediastinitis • Carotid artery h’ge

  29. Retropharyngeal abscess

  30. Retropharyngeal space • Lies b/w pharynx, oesophagus & alar layer of DCF • Boundaries sup-base of skull inf-T2 vertebra ant- B P fascia post- alar layer

  31. Aetiology: Abscessed LNs draining ear, nose & throat. Regional trauma: FB ingestion oral endotracheal intubation endoscopic procedures Retropharngeal space

  32. Children Irritability, poor appetite, fever Neck rigidity, tenderness, muffled cry, drooling, dyspnoea. Adults Fever, sore throat, odynophagia, neck tenderness. U/L swelling of posterior pharyngeal wall pushing the soft palate forwards. DD: Pott’s abscess. Inv: X ray lat view of neck. CXR: Mediastinal involvement Clinical features

  33. Management • Initial : IV antibiotics/ Fluid replacement. • Surgical: Incision & Drainage per oral (Rose’s position) • Inferior extension: Anterior cervical approach or DEAN approach. • Incision along SCM from hyoid to cricoid. • Complications: Haemorrhage, aspiration, Danger space infection

  34. Peritonsillar abscess

  35. Peritonsillar space • Between capsule of the tonsil and superior constrictor muscle. • Importance –spread of infection to para pharyngeal space, carotid sheath and mediastinum. • posterior spread to retropharyngeal space.

  36. Peritonsillar abscess • Aetiology : Follows acute tonsillitis • Bacteriology: Mixed growth • Clinical Features : young adults, Unilateral • General symptoms : Fever, chills, malaise • Local: Severe throat pain , odynophagia, drooling of saliva, hot patato voice, foul breath, ipsilateral ear ache, trismus

  37. On examination: • tonsil pillars and soft palate, congested & swollen • Uvula oedematous, pushed to opposite side • Bulging of soft palate & anterior pillar above the tonsil • Tender enlarged JD nodes Torticollis

  38. Treatment • Hospitalisation • Aspiration of pus with a wide bore needle • Analgesics & IV antibiotics • Incision & Drainage • Quinsy forceps is used • Incision made at the point of maximum bulge or at the point where two imaginary lines meet – one drawn along the base of the uvula and the other drawn vertically along the anterior pillar.(shown in asterix in the picture above) • Interval tonsillectomy

  39. Complications: • Respiratory obstruction • Parapharyngeal abscess • IJV thrombosis • Carotid artery H’ge • Septicemia, pneumonitis

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