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Deep neck space infection
Dr ramesh parajuli, MS
Chitwan Medical College, Bharatpur-10,
Chitwan, Nepal
Fascial layers of the neck
 Fascia is an investing fibrous tissue related to muscles &
major neck structures.
A. Superfic...
(I)Superficial cervical fascia: encloses platysma
(II) Deep cervical fascia
(i)Investing layer: Encloses strap muscles, SC...
Deep neck spaces
 Potential neck spaces
 Contain loose areolar tissue
 Spread of tumor and infection
 Submental space
...
Ludwig’s angina:
 Rapidly progressing cellulitis of submandibular space
(i.e. sublingual & submaxillary space)
 Mixed fl...
Subdivisions of submandibular space
1. Sublingual space: above mylohyoid muscle
2. Submaxillary space: below mylohyoid mus...
Etiology:
1. Dental infection: 80% cases
Tooth (lower molars & premolars)
Roots of premolars lie above mylohyoid ⇒ subling...
Causative agentsCausative agents
Mixed aerobic & anaerobic infection
 Streptococcus pyogenes
 Streptococcus viridans
 S...
Clinical featuresClinical features
 Toothache, fever, odynophagia, drooling of saliva
 Floor of mouth swelling + tongue ...
 Parapharyngeal abscess
 Retropharyngeal abscess
 Acute airway obstruction (within
hours):
due to falling back of tongu...
Management:
1. I.V. antibiotics: Ceftriaxone + Metronidazole / Clindamycin
2. IV fluid for adequate hydration
3. Monitor v...
Retropharyngeal space
It lies behind the pharynx
Superior: Base of skull
Inferior: Mediastinum (till tracheal bifurcation)...
Retropharyngeal abscess
 Collection of pus in retropharyngeal space
 In children: Suppuration of retropharyngeal lymph
n...
Symptoms
 H/o upper respiratory tract infection
 Dysphagia / odynophagia
 Difficulty in breathing
 Neck stiffness/ tor...
Signs
 Febrile, ill-looking, child with drooling
 Tender neck swelling
 Torticollis (twisted neck)
 Bulge on posterior...
Widened pre-vertebral soft tissue
shadow
Air-fluid level & gas shadow
Tuberculosis of cervical spine with
retropharyngeal abscess
Complications
1. Airway obstruction:
2. Spread of abscess to other neck spaces
3. Spontaneous rupture of abscess
4. Septic...
Treatment
1. Broad spectrum intravenous antibiotics:
Ceftriaxone + Metronidazole
2. Incision & drainage: without anesthesi...
Parapharyngeal space
Base & superior limit: Skull Base
Apex: hyoid
Lateral: Ramus of mandible, Medial Pterygoid
deep lobe ...
Styloid process divides into two
compartments:-
Prestyloid
◦ Deep lobe of parotid
◦ Contains fat, connective
tissue, nodes...
Contents of parapharyngeal space
Pre-styloid
• Deep lobe of parotid
•Lymph nodes
•Fat
•Connective tissue
Post-styloid
• In...
Etiology
 Pharynx: acute tonsillitis, peritonsillar abscess
 Teeth: dental infection (esp. lower last molar)
 Ear: Bezo...
Clinical features
1. Fever, sore throat, odynophagia, torticollis
2. Tonsils pushed medially
3. Trismus
4. Neck swelling b...
Management
1. IV antibiotics: Ceftriaxone + Metronidazole
2. Incision & drainage:
 Under GA with endotracheal intubation
...
Peritonsillar abscess (quinsy)
 Pus present in the peritonsillar space i.e. between tonsillar
capsule & superior pharynge...
Clinical features
Symptoms: odynophagia, fever, halitosis & muffled voice
Signs:
1.Unilateral tonsil enlarged (infection i...
Complications of quinsy
1. Parapharyngeal abscess
2. Retropharyngeal abscess
3. Laryngitis & laryngeal edema
4. Lung absce...
Management
Diagnosis: Peritonsillitis vs Peritonsillar
abscess
Needle aspiration → reveals pus i.e. quinsy
1. Broad spectu...
Incision & drainage site
 Incision and drainage of quinsy:
1. I & D with quinsy forceps
2. I & D with No.11 surgical blade
3. Repeated pus aspirat...
Parotid abscess
 Debilitated & dehydrated pts (decreased salivary
flow)
 Causative organism: Staph. aureus, Streptococci...
 Painful parotid region swelling
 Trismus
 Parotid massage expresses pus
from parotid duct opening
 Rx: Broad spectrum...
Thank youThank you
Deep neck infection
Deep neck infection
Deep neck infection
Deep neck infection
Deep neck infection
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Deep neck infection

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Deep neck infection

  1. 1. Deep neck space infection Dr ramesh parajuli, MS Chitwan Medical College, Bharatpur-10, Chitwan, Nepal
  2. 2. Fascial layers of the neck  Fascia is an investing fibrous tissue related to muscles & major neck structures. A. Superficial cervical fascia: B. Deep cervical fascia: 1. Superficial or investing layer 2. Middle layer or visceral fascia 3. Deep layer or pre-vertebral fascia
  3. 3. (I)Superficial cervical fascia: encloses platysma (II) Deep cervical fascia (i)Investing layer: Encloses strap muscles, SCM, trapezius Parotid &submandibular glands, carotid sheath (ii)Middle or Visceral layer: encircles esophagus, trachea, thyroid (iii)Deep or pre-vertebral layer: Covers deep neck muscles i.e. prevertebral muscles
  4. 4. Deep neck spaces  Potential neck spaces  Contain loose areolar tissue  Spread of tumor and infection  Submental space  Submandibular space  Parotid  Peritonsillar  Parapharyngeal  Retropharyngeal  Pretracheal space  Prevertebral space
  5. 5. Ludwig’s angina:  Rapidly progressing cellulitis of submandibular space (i.e. sublingual & submaxillary space)  Mixed flora (poly-microbial)  May result into life-threatening airway obstruction
  6. 6. Subdivisions of submandibular space 1. Sublingual space: above mylohyoid muscle 2. Submaxillary space: below mylohyoid muscle Contents: Submandibular salivary gland, lymph nodes
  7. 7. Etiology: 1. Dental infection: 80% cases Tooth (lower molars & premolars) Roots of premolars lie above mylohyoid ⇒ sublingual space infection Roots of molars lie below mylohyoid ⇒ submaxillary space infection 2. Injury to floor of mouth 3. Submandibular sialadenitis
  8. 8. Causative agentsCausative agents Mixed aerobic & anaerobic infection  Streptococcus pyogenes  Streptococcus viridans  Streptococcus pneumoniae  Staphylococcus  Fusobacterium  Bacteroides  Peptostreptococcus
  9. 9. Clinical featuresClinical features  Toothache, fever, odynophagia, drooling of saliva  Floor of mouth swelling + tongue elevation  submental swelling: Brawny induration  Trismus  Stridor: falling back of tongue causing upper airway obstn  Initially cellulitis (no frank pus) ⇒ pus formation (only at late stage)
  10. 10.  Parapharyngeal abscess  Retropharyngeal abscess  Acute airway obstruction (within hours): due to falling back of tongue  Aspiration pneumonia  Septicemia  Death ComplicationsComplications
  11. 11. Management: 1. I.V. antibiotics: Ceftriaxone + Metronidazole / Clindamycin 2. IV fluid for adequate hydration 3. Monitor vital signs regularly eg. assessment for disease progression & airway compromise 4. Airway obstruction: Intubation / tracheostomy 5. Incision & drainage Transverse incision from one angle of mandible to opposite angle of mandible
  12. 12. Retropharyngeal space It lies behind the pharynx Superior: Base of skull Inferior: Mediastinum (till tracheal bifurcation) Anterior: Buccopharyngeal fascia Posterior: pre-vertebral fascia Contains lymph nodes (of Rouviere) which usually disappear at 3-4 years of age
  13. 13. Retropharyngeal abscess  Collection of pus in retropharyngeal space  In children: Suppuration of retropharyngeal lymph node of Rouviere from URTI  In adults:  Tubercular infection of retropharyngeal lymph nodes/cervical spinepresents as posterior pharyngeal wall swelling
  14. 14. Symptoms  H/o upper respiratory tract infection  Dysphagia / odynophagia  Difficulty in breathing  Neck stiffness/ torticollis
  15. 15. Signs  Febrile, ill-looking, child with drooling  Tender neck swelling  Torticollis (twisted neck)  Bulge on posterior pharyngeal wall Torticollis
  16. 16. Widened pre-vertebral soft tissue shadow
  17. 17. Air-fluid level & gas shadow
  18. 18. Tuberculosis of cervical spine with retropharyngeal abscess
  19. 19. Complications 1. Airway obstruction: 2. Spread of abscess to other neck spaces 3. Spontaneous rupture of abscess 4. Septicemia 5. Death
  20. 20. Treatment 1. Broad spectrum intravenous antibiotics: Ceftriaxone + Metronidazole 2. Incision & drainage: without anesthesia, supine with head hanging down from the table, I & D at most bulging part of posterior pharyngeal wall bulge, two powerful suctions to suck out pus thus preventing aspiration General anesthesia(GA) is contraindicated for fear of rupture of abscess during intubationaspiration 3. Anti-tubercular therapy
  21. 21. Parapharyngeal space Base & superior limit: Skull Base Apex: hyoid Lateral: Ramus of mandible, Medial Pterygoid deep lobe of parotid Medial: Bucco-pharyngeal fascia Anterior: Pterygo-mandibular raphe Posterior: Pre-vertebral fascia
  22. 22. Styloid process divides into two compartments:- Prestyloid ◦ Deep lobe of parotid ◦ Contains fat, connective tissue, nodes Poststyloid ◦ Neurovascular compartment ◦ Carotid sheath (ICA,IJV) ◦ Cranial nerves (IX, X, XI, XII) ◦ Sympathetic chain
  23. 23. Contents of parapharyngeal space Pre-styloid • Deep lobe of parotid •Lymph nodes •Fat •Connective tissue Post-styloid • Internal carotid artery • Internal jugular vein • Cranial nerves(IX,X,XI,XII) • Sympathetic chain • Lymph nodes •Styloid process divides into two spaces
  24. 24. 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
  25. 25. Clinical features 1. Fever, sore throat, odynophagia, torticollis 2. Tonsils pushed medially 3. Trismus 4. Neck swelling behind angle of mandible
  26. 26. Management 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
  27. 27. Peritonsillar abscess (quinsy)  Pus present in the peritonsillar space i.e. between tonsillar capsule & superior pharyngeal constrictor muscle  Causative agents: aerobic + anaerobic organisms  Infection of Weber's gland (Minor salivary gland in supra tonsillar fossa) → quinsy  Following acute tonsilitis (Less commonly)
  28. 28. Clinical features Symptoms: odynophagia, fever, halitosis & muffled voice Signs: 1.Unilateral tonsil enlarged (infection in paratonsillar spacepseudohypertrophy), pushed medially 2. Congested tonsil,tonsillar pillars, soft palate 3. Jugulo-digastric lymph node tender, enlarged 4. Trismus
  29. 29. Complications of quinsy 1. Parapharyngeal abscess 2. Retropharyngeal abscess 3. Laryngitis & laryngeal edema 4. Lung abscess 5. Internal jugular vein thrombosis 6. Septicemia
  30. 30. Management Diagnosis: Peritonsillitis vs Peritonsillar abscess Needle aspiration → reveals pus i.e. quinsy 1. Broad spectum IV antibiotics:Ceftriaxone +Metronidazole 2. I.V. fluids & analgesics 3. Antiseptic mouth gargle 4. Repeated needle aspiration 5. Incision and drainage
  31. 31. Incision & drainage site
  32. 32.  Incision and drainage of quinsy: 1. I & D with quinsy forceps 2. I & D with No.11 surgical blade 3. Repeated pus aspiration with wide bore needle
  33. 33. Parotid abscess  Debilitated & dehydrated pts (decreased salivary flow)  Causative organism: Staph. aureus, Streptococci, Haemophilus & other organisms  Ascending bacterial infection from oral cavity through the duct to the gland  Predisposing conditions: DM, Immunocompromised, poor oro-dental hygeine
  34. 34.  Painful parotid region swelling  Trismus  Parotid massage expresses pus from parotid duct opening  Rx: Broad spectrum antibiotics (Inj. Ampicillin plus cloxacillin, and clindamycin)  I & D: Modified Blair’s incision
  35. 35. Thank youThank you

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