Etiopathology of deep neck spaces :
Patients at risk : immunocompromised ,diabetic ,infants , IV drug abusers
Precipitating factors :
salivary gland infections
Spaces of neck :
A) spaces involving the entire neck :
Deep space : retropharyngeal ,prevertebral
B) suprahyoid spaces:
Mandibular space : submandibular,submental,sublingual
C) infrahyoid space
It is suppuration of the parotid space.
Deep cervical fascia splits into two layers, superficial and deep, to
enclose the parotid gland and its associated structures.
Parotid space lies deep to its superficial layer.
Contents of parotid space : parotid gland , parotid lymph
nodes, facial nerve, external carotid artery and retromandibular vein.
post-surgical cases and debilitated patients
stasis of salivary flow
Infection from the oral cavity travels via the
Stenson's duct to invade the parotid gland
Multiple small abscesses may form in the
parenchyma. They may then coalesce to form a single
Most common organism is Staph. aureus but Streptococci, anaerobic
organisms and rarely the gram negative organisms have been
Usually follows 5-7 days after operation.
There is swelling, redness, indurations and tenderness in the parotid area
and at the angle of mandible.
Parotid abscess is usually unilateral, but bilateral abscesses may occur.
Fluctuation is difficult to elicit due to thick capsule.
Opening of the Stenson's duct becomes congested and may exude pus
on pressure over the parotid.
Patient is toxic, running high fever and dehydrated.
Diagnosis of the abscess can be made by ultrasound or CT scan. More
than one loculi of pus may be seen.
Aspiration of abscess can be done for culture and sensitivity of the
Correct the dehydration, improve oral hygiene and promote
Intravenous antibiotics are instituted.
Surgical drainage under local or general anaesthesia is carried
out by a preauricular incision as employed for parotidectomy.
Skin flap is raised to expose surface of the gland, and the abscess
or abscesses are bluntly opened working parallel to the branches
of the VIIth nerve.
It is a collection of pus in the peritonsillar space which lies between
the capsule of tonsil and the superior constrictor muscle.
Peritonsillar abscess usually follows acute tonsillitis though it may
arise de novo without previous history of sore throats.
First, one of the tonsillar crypts, usually the crypta magna, gets
infected and sealed off.
It forms an intratonsillar abscess which then bursts through the tonsillar
capsule to set up peritonsillitis and then an abscess.
Culture of pus from the abscess may reveal pure growth of Strept.
pyogenes, Staph. aureus or anaerobic organisms.
More often the growth is mixed, with both aerobic and anaerobic
Peritonsillar abscess mostly affects adults and rarely the children
though acute tonsillitis is more common in children.
Usually, it is unilateral though occasionally bilateral abscesses are
recorded. Clinical features are divided into:
1.General. They are due to septicaemia and resemble any acute
They include fever (up to 104°F), chills and rigors, general malaise,
body aches, headache, nausea and constipation.
(i) Severe pain in throat. Usually unilateral.
(ii) Odynophagia. It is so marked that the patient cannot even
swallow his own saliva which dribbles from the angle of his mouth.
Patient is usually dehydrated.
(iii) Muffled and thick speech, often called "Hot potato voice".
(iv) Foul breath due to sepsis in the oral cavity and poor hygiene.
(v) Ipsilateral earache. This is referred pain via CN IX which supplies
both the tonsil and the ear.
(vi) Trismus due to spasm of pterygoid muscles which are in close
proximity to the superior constrictor.
2. Intravenous fluids to combat dehydration.
3. Antibiotics. Suitable antibiotics in large i.v. doses to cover both
aerobic and anaerobic organisms.
4. Analgesics like paracetamol is given for relief of pain and to lower the
temperature. Sometimes, stronger analgesics like pethidine may be
required. Aspirin is avoided because of the danger of bleeding.
5. Oral hygiene should be maintained by hydrogen peroxide or saline
The above conservative measures may cure peritonsillitis. If a frank
abscess has formed, incision and drainage will be required.
Interval tonsillectomy :
Tonsils are removed four to six weeks following an attack of quinsy.
Abscess or hot tonsillectomy :
Some people prefer to do 'hot'tonsillectomy instead of incision and
Abscess tonsillectomy has the risk of rupture of the abscess during
anaesthesia, and excessive bleeding at the time of operation.
It lies behind the pharynx between the buccopharyngeal fascia
covering pharyngeal constrictor muscles and the prevertebral
It extends from the base of skull to the bifurcation of trachea.
The space is divided into two lateral compartments (spaces of
Gillette) by a fibrous raphe .
Each lateral space contains retropharyngeal nodes which usually
disappear at 3-4 years of age. Parapharyngeal space
communicates with the retropharyngeal space. Infection of
retropharyngeal space can pass down behind the oesophagus
into the mediastinum.
It lies between the vertebral bodies posteriorly and the prevertebral
It extends from the base to skull of coccyx. Infection of this space
usually comes from the caries of spine
Common in infants (below 3 yrs) Common in adults
Suppuration of retropharyngeal
Infection from nasopharynx and
Caries of cervical spine.
1.Dysphagia & difficulty in breathing Patient may c/o discomfort in throat.
2.Stridor and croupy cough Dysphagia.
3.torticollis Tuberculous lymphnodes
4. Bulge in posterior pharyngeal wall
1.Incision and drainage of abscess. 1.Incision and drainage of abscess.
2.Systemic antibiotics. 2.Full course of antitubercular drugs.
Also called Abscess of pharyngomaxillary or lateral
Parapharyngeal space is pyramidal in shape with its base
at the base of skull and its apex at the hyoid bone.
Infection of parapharyngeal space can occur from:
1. Pharynx. Acute and chronic infections of tonsil and adenoid,
bursting of peritonsillar abscess.
2. Teeth. Dental infection usually comes from the lower last molar
3. Ear. Bezold's abscess, petrositis.
4. Other spaces. Infections of parotid, retropharyngeal and
5. External trauma. Penetrating injuries of neck, injection of local
anaesthetic for tonsillectomy or mandibular nerve block.
Anterior compartment infections produce a triad of symptoms:
(i)prolapse of tonsil and tonsillar fossa,
(ii) trismus (due to spasm of medial pterygoid muscle) and
(iii) external swelling behind the angle of jaw. There is marked
odynophagia associated with it.
Posterior compartment involvement produces
(i)bulge of pharynx behind the posterior pillar,
(ii)paralysis of CN IX, X, XI, and XII and sympathetic chain,
(iii)swelling of parotid region. There is minimal trismus or tonsillar
1. Acute oedema of larynx with respiratory obstruction.
2. Thrombophlebitis of jugular vein with septicaemia.
3. Spread of infection to retropharyngeal space.
4. Spread of infection to mediastinum along the carotid space.
5. Mycotic aneurysm of carotid artery from weakening of its wall by
purulent material. It may involve common carotid or internal carotid
6. Carotid blow out with massive haemorrhage
Systemic antibiotics. Intravenous antibiotics may become necessary to
Drainage of abscess. This is usually done under general anaesthesia. If
the trismus is marked, pre-operative tracheostomy becomes
Abscess is drained by a horizontal incision, made 2-3 cm below the
angle of mandible.
Blunt dissection along the inner surface of medial pterygoid
muscle towards styloid process is carried out and abscess
evacuated. A drain is inserted.
Transoral drainage should never be done due to danger of injury
to great vessels which pass through this space
It is the infection of the submandibular sapce .
Described by Wilheim Friedrich Von Ludwig in 1836.
Submandibular space :
lies between mucous membrane of the floor of mouth and
tongue on one side and superficial layer of deep cervical fascia extending
between the hyoid bone and mandible on the other .
It is divided into two compartments by the mylohyoid muscle:
(a) sublingual compartment (above the mylohyoid)
(b) submaxillary and submental compartment (below the mylohyoid).
1. Dental infections. They account for 80% of the cases. Roots of
premolars often lie above the attachment of mylohyoid and
cause sublingual space infection while roots of the molar teeth
extend up to or below the mylohyoid line and primarily cause
submaxillary space infection.
2. Submandibular sialadenitis, injuries of oral mucosa and
fractures of the mandible account for other cases.
Criteria for diagnosis of ludwig’s angina:
•Rapidly progressive cellulitis;not an abscess.
•Develops along fascial planes with direct extension,does
not involve lymphatic spread.
•Does not involve submandibular gland or lymphnodes.
•Involves both sublingual and submaxillary spaces and is
Clinical features :
There is marked difficulty in swallowing (odynophagia) with varying degrees of
When infection is localised to the sublingual space, structures in the floor of
mouth are swollen and tongue seems to be pushed up and back.
When infection spreads to submaxillary space, submental and submandibular
regions become swollen and tender, and impart woody-hard feel.
Usually, there is cellulitis of the tissues rather than frank abscess.
Tongue is progressively pushed upwards and backwards threatening the
Laryngeal oedema may appear.
1. Systemic antibiotics.
2. Incision and drainage of abscess.
(a) Intraoral-if infection is still localised to sublingual space.
(b) External-if infection involves submaxillary space. A transverse
incision extending from one angle of mandible to the other is made
with vertical opening of midline musculature of tongue with a blunt
haemostat. Very often it is serous fluid rather than frank pus that is
3. Tracheostomy, if airway is endangered.