Transcript Neck space infections

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 neck
B. 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 space
6. 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 neck
B. 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-vertebral
C. 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
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
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
Subdivisions:
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 &
airway
obstruction
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
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 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
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
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
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Acute mastoitis: pus tracking under petrous bone
Symptoms

H/o upper respiratory tract infection

Dysphagia / odynophagia

Difficulty in breathing

Croupy cough

Hot potato voice

Neck stiffness
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
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
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
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 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
Tuberculosis
of cervical spine
with
chronic
retropharyngeal
abscess
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
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 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
Post-styloid
 Deep lobe of parotid
 Internal carotid artery
 Internal maxillary artery
 Internal jugular vein
 Inferior alveolar nerve
 Last 4 cranial nerves
 Lingual nerve
 Sympathetic chain
 Auriculo-temporal nerve
 Glomus system
 Lymph nodes
 Lymph nodes
Styloid: Styloid process, its 3 muscles + 2 ligaments
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, 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
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)
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 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
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
Incision
Incision line & quinsy forceps
Alternate incision site at
maximum bulge
Abscess drainage
Incision & drainage

Incision made with # 11 blade or Thilenius
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
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 cartilaginous
fissures 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)
Investigation

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
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