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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

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Neck Space Infections

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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 neckB. 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 space6. 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 neckB. 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-vertebralC. 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


  • 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 space

Boundaries:Anterior & lateral:mandible

Medial: anterior belly of digastric

Posterior:submandibular gland

Inferior: level of hyoid bone


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

Causative organisms

Mixed aerobic & anaerobic infection

  • Streptococcus pyogenes

  • Streptococcus viridans

  • Streptococcus pneumoniae

  • Staphylococcus

  • Fusobacterium

  • Bacteroides

  • Peptostreptococcus

Clinical Features

  • 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

Elevation of tongue

Submandibular swelling

Submandibular swelling

X-ray soft tissue neck lateral

assess degree

of soft tissue

swelling &



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

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


1. Acute

2. Chronic

Acute abscess is common in children below 3-5 yrs

as retropharyngeal nodes of Rouviere regress later

Acute Retropharyngeal Abscess


  • 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


  • H/o upper respiratory tract infection

  • Dysphagia / odynophagia

  • Difficulty in breathing

  • Croupy cough

  • Hot potato voice

  • Neck stiffness


  • 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


1. 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


  • 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)


  • As in acute retropharyngeal abscess

  • Ziehl Neelsen stain of pus after aspiration

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


of cervical spine with





1. 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


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 space

Base & 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


 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


 Internal carotid artery

 Internal jugular vein

 Last 4 cranial nerves

 Sympathetic chain

 Glomus system

 Lymph nodes



  • 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, 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


1. 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)


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



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 line & quinsy forceps

Alternate incision site at maximum bulge

Abscess drainage

Incision & drainage

  • Incision made with # 11 blade orThilenius 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 Space

Formed due to splitting of investing layer of deep cervical fascia around parotid salivary gland


  • 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 cartilaginousfissures 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)


  • 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


1. 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

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