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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

Neck Space Infections

Dr. Vishal Sharma


Fascial layers of neck
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
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.



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
Masticator spaces

Formed around muscles

of mastication (masseter,

pterygoids, insertion of

temporalis) & covered by

investing layer of deep

cervical fascia



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



  • 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
Clinical Presentation fascia + subcutaneous tissue, initially sparing skin & muscle

  • 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
Necrotizing fasciitis of chest fascia + subcutaneous tissue, initially sparing skin & muscle


Ct scan showing gas formation
CT scan showing gas formation fascia + subcutaneous tissue, initially sparing skin & muscle


Treatment
Treatment fascia + subcutaneous tissue, initially sparing skin & muscle

  • 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
Wound debridement fascia + subcutaneous tissue, initially sparing skin & muscle


Skin grafting
Skin grafting fascia + subcutaneous tissue, initially sparing skin & muscle


Healed wound
Healed wound fascia + subcutaneous tissue, initially sparing skin & muscle


  • Poor prognostic factors: fascia + subcutaneous tissue, initially sparing skin & muscleDiabetes 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

Ludwig’s Angina fascia + subcutaneous tissue, initially sparing skin & muscle


Rapidly progressing poly-microbial cellulitis of fascia + subcutaneous tissue, initially sparing skin & muscle

sublingual & submaxillary spaces with potentially

life-threatening airway compromise


Submandibular space
Submandibular space fascia + subcutaneous tissue, initially sparing skin & muscle

Boundaries: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


Etiology of ludwig s angina

Etiology of Ludwig’s angina fascia + subcutaneous tissue, initially sparing skin & muscle


A. Lower dental or periodontal infection (80%): fascia + subcutaneous tissue, initially sparing skin & muscle

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
Causative organisms fascia + subcutaneous tissue, initially sparing skin & muscle

Mixed aerobic & anaerobic infection

  • Streptococcus pyogenes

  • Streptococcus viridans

  • Streptococcus pneumoniae

  • Staphylococcus

  • Fusobacterium

  • Bacteroides

  • Peptostreptococcus


Clinical features
Clinical Features fascia + subcutaneous tissue, initially sparing skin & muscle

  • 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
Elevation of tongue fascia + subcutaneous tissue, initially sparing skin & muscle


Submandibular swelling
Submandibular swelling fascia + subcutaneous tissue, initially sparing skin & muscle


Submandibular swelling1
Submandibular swelling fascia + subcutaneous tissue, initially sparing skin & muscle


X ray soft tissue neck lateral
X-ray soft tissue neck lateral fascia + subcutaneous tissue, initially sparing skin & muscle

assess degree

of soft tissue

swelling &

airway

obstruction


C t scan
C.T. scan fascia + subcutaneous tissue, initially sparing skin & muscle


Treatment of ludwig s angina

Treatment of Ludwig’s angina fascia + subcutaneous tissue, initially sparing skin & muscle


1. I.V. antibiotics: fascia + subcutaneous tissue, initially sparing skin & muscleCefuroxime / 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 fascia + subcutaneous tissue, initially sparing skin & muscle


Incision drainage tracheostomy1
Incision drainage + Tracheostomy fascia + subcutaneous tissue, initially sparing skin & muscle


Complications
Complications fascia + subcutaneous tissue, initially sparing skin & muscle

  • Parapharyngeal abscess

  • Retropharyngeal abscess

  • Acute airway obstruction (within hours): due to

    pushing back of tongue, laryngeal edema

  • Aspiration pneumonia

  • Septicemia

  • Death


Retropharyngeal abscess

Retropharyngeal abscess fascia + subcutaneous tissue, initially sparing skin & muscle


Retropharyngeal space
Retropharyngeal Space fascia + subcutaneous tissue, initially sparing skin & muscle

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 abscess1
Retropharyngeal abscess fascia + subcutaneous tissue, initially sparing skin & muscle

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


Acute retropharyngeal abscess

Acute Retropharyngeal Abscess fascia + subcutaneous tissue, initially sparing skin & muscle


Etiology
Etiology fascia + subcutaneous tissue, initially sparing skin & muscle

  • 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


Symptoms
Symptoms fascia + subcutaneous tissue, initially sparing skin & muscle

  • H/o upper respiratory tract infection

  • Dysphagia / odynophagia

  • Difficulty in breathing

  • Croupy cough

  • Hot potato voice

  • Neck stiffness


Signs
Signs fascia + subcutaneous tissue, initially sparing skin & muscle

  • 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
Posterior pharyngeal wall swelling on left side fascia + subcutaneous tissue, initially sparing skin & muscle


Endoscopic view of posterior pharyngeal wall bulge
Endoscopic view of posterior pharyngeal wall bulge fascia + subcutaneous tissue, initially sparing skin & muscle


X ray soft tissue neck lateral1
X-ray soft tissue neck (lateral) fascia + subcutaneous tissue, initially sparing skin & muscle

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
High retropharyngeal abscess fascia + subcutaneous tissue, initially sparing skin & muscle


Air fluid level gas shadow
Air-fluid level & gas shadow fascia + subcutaneous tissue, initially sparing skin & muscle


Ct scan axial cuts
CT scan axial cuts fascia + subcutaneous tissue, initially sparing skin & muscle


Treatment1
Treatment fascia + subcutaneous tissue, initially sparing skin & muscle

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

Chronic Retropharyngeal Abscess fascia + subcutaneous tissue, initially sparing skin & muscle


Etiology1
Etiology fascia + subcutaneous tissue, initially sparing skin & muscle

  • 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 features1
Clinical Features fascia + subcutaneous tissue, initially sparing skin & muscle

  • 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


X ray soft tissue neck lateral homogenous opacity
X-ray soft tissue neck (lateral): homogenous opacity fascia + subcutaneous tissue, initially sparing skin & muscle


Tuberculosis fascia + subcutaneous tissue, initially sparing skin & muscle

of cervical spine with

chronic

retropharyngeal

abscess


Treatment2
Treatment fascia + subcutaneous tissue, initially sparing skin & muscle

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


Complications1
Complications fascia + subcutaneous tissue, initially sparing skin & muscle

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 abscess fascia + subcutaneous tissue, initially sparing skin & muscle


Parapharyngeal space
Parapharyngeal space fascia + subcutaneous tissue, initially sparing skin & muscle

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


Contents

Pre-styloid fascia + subcutaneous tissue, initially sparing skin & muscle

 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

Contents


Etiology2
Etiology fascia + subcutaneous tissue, initially sparing skin & muscle

  • 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 features2
Clinical Features fascia + subcutaneous tissue, initially sparing skin & muscle

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
CT scan neck: axial cuts fascia + subcutaneous tissue, initially sparing skin & muscle


Treatment3
Treatment fascia + subcutaneous tissue, initially sparing skin & muscle

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

Peritonsillar abscess (Quinsy) fascia + subcutaneous tissue, initially sparing skin & muscle


Etio pathogenesis
Etio-pathogenesis fascia + subcutaneous tissue, initially sparing skin & muscle

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 features3
Clinical features fascia + subcutaneous tissue, initially sparing skin & muscle

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
Peri-tonsillitis & Quinsy fascia + subcutaneous tissue, initially sparing skin & muscle


Management
Management fascia + subcutaneous tissue, initially sparing skin & muscle

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


Needle aspiration
Needle aspiration fascia + subcutaneous tissue, initially sparing skin & muscle


Incision
Incision fascia + subcutaneous tissue, initially sparing skin & muscle


Incision line quinsy forceps
Incision line & quinsy forceps fascia + subcutaneous tissue, initially sparing skin & muscle


Alternate incision site at maximum bulge
Alternate incision site at maximum bulge fascia + subcutaneous tissue, initially sparing skin & muscle


Abscess drainage
Abscess drainage fascia + subcutaneous tissue, initially sparing skin & muscle


Incision drainage
Incision & drainage fascia + subcutaneous tissue, initially sparing skin & muscle

  • 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
Surgical treatment fascia + subcutaneous tissue, initially sparing skin & muscle

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
Complications of quinsy fascia + subcutaneous tissue, initially sparing skin & muscle

1. Parapharyngeal abscess

2. Retropharyngeal abscess

3. Laryngitis & laryngeal edema

4. Lung abscess

5. Internal jugular vein thrombosis

6. Septicemia


Parotid abscess

Parotid abscess fascia + subcutaneous tissue, initially sparing skin & muscle


Parotid space
Parotid Space fascia + subcutaneous tissue, initially sparing skin & muscle

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


Etiology3
Etiology fascia + subcutaneous tissue, initially sparing skin & muscle

  • 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
Causes of parotid dehydration fascia + subcutaneous tissue, initially sparing skin & muscle

1. Post-operative patient (surgical mumps)

2. Medications that decrease salivary flow:

  • Antihistamines

  • Tricyclic antidepressants

  • Barbiturates

  • Diuretics

  • Parasympathomimetics


Parotid abscess1
Parotid abscess fascia + subcutaneous tissue, initially sparing skin & muscle

  • 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)


Investigation
Investigation fascia + subcutaneous tissue, initially sparing skin & muscle

  • C.B.P.: Leukocytosis

  • Needle aspiration with 18 G needle

  • Ultrasonography

  • C.T. scan

  • M.R.I.


C t scan m r i
C.T. scan & M.R.I. fascia + subcutaneous tissue, initially sparing skin & muscle


Parotid anatomy
Parotid anatomy fascia + subcutaneous tissue, initially sparing skin & muscle


Treatment4
Treatment fascia + subcutaneous tissue, initially sparing skin & muscle

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
Thank You fascia + subcutaneous tissue, initially sparing skin & muscle


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