Neck space infections
This presentation is the property of its rightful owner.
Sponsored Links
1 / 99

Neck Space Infections PowerPoint PPT Presentation


  • 1017 Views
  • Uploaded on
  • Presentation posted in: General

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

Download Presentation

Neck Space Infections

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -

Presentation Transcript


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.


Classification of neck spaces

Classification of neck spaces


Neck space infections

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


Classification of neck space infections

Classification of neck space infections


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

Necrotizing fasciitis


Neck space infections

  • 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

  • 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


Ct scan showing gas formation

CT scan showing gas formation


Treatment

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


Wound debridement

Wound debridement


Skin grafting

Skin grafting


Healed wound

Healed wound


Neck space infections

  • 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

Ludwig’s Angina


Neck space infections

Rapidly progressing poly-microbial cellulitis of

sublingual & submaxillary spaces with potentially

life-threatening airway compromise


Submandibular space

Submandibular space

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


Neck space infections

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

Causative organisms

Mixed aerobic & anaerobic infection

  • Streptococcus pyogenes

  • Streptococcus viridans

  • Streptococcus pneumoniae

  • Staphylococcus

  • Fusobacterium

  • Bacteroides

  • Peptostreptococcus


Clinical features

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

Elevation of tongue


Submandibular swelling

Submandibular swelling


Submandibular swelling1

Submandibular swelling


X ray soft tissue neck lateral

X-ray soft tissue neck lateral

assess degree

of soft tissue

swelling &

airway

obstruction


C t scan

C.T. scan


Treatment of ludwig s angina

Treatment of Ludwig’s angina


Neck space infections

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


Incision drainage tracheostomy1

Incision drainage + Tracheostomy


Complications

Complications

  • 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


Retropharyngeal space

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 abscess1

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


Acute retropharyngeal abscess

Acute Retropharyngeal Abscess


Etiology

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


Symptoms

Symptoms

  • H/o upper respiratory tract infection

  • Dysphagia / odynophagia

  • Difficulty in breathing

  • Croupy cough

  • Hot potato voice

  • Neck stiffness


Signs

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


Posterior pharyngeal wall swelling on left side

Posterior pharyngeal wall swelling on left side


Endoscopic view of posterior pharyngeal wall bulge

Endoscopic view of posterior pharyngeal wall bulge


X ray soft tissue neck lateral1

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

High retropharyngeal abscess


Air fluid level gas shadow

Air-fluid level & gas shadow


Ct scan axial cuts

CT scan axial cuts


Treatment1

Treatment

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


Etiology1

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


Clinical features1

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


X ray soft tissue neck lateral homogenous opacity

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


Neck space infections

Tuberculosis

of cervical spine with

chronic

retropharyngeal

abscess


Treatment2

Treatment

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

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


Parapharyngeal space

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


Contents

Pre-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

Contents


Etiology2

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 features2

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

CT scan neck: axial cuts


Treatment3

Treatment

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)


Etio pathogenesis

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


Clinical features3

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

Peri-tonsillitis & Quinsy


Management

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


Needle aspiration

Needle aspiration


Incision

Incision


Incision line quinsy forceps

Incision line & quinsy forceps


Alternate incision site at maximum bulge

Alternate incision site at maximum bulge


Abscess drainage

Abscess drainage


Incision 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

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

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 abscess


Parotid space

Parotid Space

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


Etiology3

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 cartilaginousfissures of Santorini or bony foramen of Huschke


Causes of parotid dehydration

Causes of parotid dehydration

1. Post-operative patient (surgical mumps)

2. Medications that decrease salivary flow:

  • Antihistamines

  • Tricyclic antidepressants

  • Barbiturates

  • Diuretics

  • Parasympathomimetics


Parotid abscess1

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)


Investigation

Investigation

  • 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.


Parotid anatomy

Parotid anatomy


Treatment4

Treatment

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


  • Login