Deep neck space infections

1. Clinical Anatomy and infection of
deep neck spaces
Dr. Sundar Dhungana
MS (ORL-HNS)
1st year
GMS Memorial Academy of ENT & HNS
MMC-TUTH,IOM

2. Roadmap
• Clinical Anatomy
• Common deep neck space infection
• Etiology
• Clinical presentation
• Diagnosis
• Management
– Medical
– Surgical
• Complications

3. Fascia of neck
• Structures in neck are compartmentalised by layers of
cervical fascia
– Superficial Layer
– Deep Layer
1. Superficial
Investing layer
2. Middle
Pretracheal fascia
3. Deep
Prevertebral

5. Superficial Layer
• Superior attachment –
Zygomatic process
• Inferior attachment –
Thorax, axilla.
• Similar to subcutaneous tissue
• Ensheathes platysma and
muscles of facial expression
• Contains
– Cutaneous nerves
– Blood and lymphatics vessels
– Superficial lymph node
– Variable amount of fat
– Platysma muscle

6. Deep Cervical Fascia
• Supports the viscera(eg thyroid),muscles,vessels and
deep lymph nodes.
• Facial layers form natural clevage plane through which
tissue may be seperated during surgery
• They limits the spread of abscess
• Protect vitals structures from penetrating injury
• 3 deep layers
1. Superficial Layer(Investing)
2. Middle Layer(Pretracheal)
3. Deep Layer
– Alar
– Prevertebral

7. Superficial Layer of the Deep Cervical
Fascia
• Completely surrounds the neck.
• Origin: spinous processes.
• Superiorly :
– superior nuchal line of occipital bone
– Mastoid process of temporal bone
– Zygomatic arches
– Inferior border of mandible
• Inferiorly:
– Manubrium of sternum
– Clavicle
– Acromion and spine of the scapula

8. Superficial Layer of the Deep Cervical
Fascia
• Splits at mandible and covers the masseter laterally and
the medial surface of the medial pterygoid.
• Body of hyoid bone to mandible to form floor of
submandibular space
• Posterior to mandible it splits to form fibrous capsule of
parotid gland
• Envelopes
Muscle - SCM
Trapezius
Glands Submandibular
Parotid
Spaces Suprasternal space of burn
Supraclavicular space
Parotid space
Floor of submandibular space

9. Middle Layer of the Deep Cervical
Fascia
 Visceral division
• Limited to anterior part of neck
• Extends from hyoid bone to the thorax where it
blends with fibrous paricardium
– Superior border
• Anterior – hyoid and thyroid cartilage
• Posterior – skull base
– Inferior border – continuous with fibrous pericardium in
the upper mediastinum.
– Contineous posteriorly and superiorly with the
Buccopharyngeal fascia
– Laterally it blends with carotid sheaths

10. Middle Layer of the Deep Cervical
Fascia
– Envelopes
• Thyroid
• Trachea
• Esophagus
• Pharynx
• Larynx
 Muscular division
– Superior border – hyoid and thyroid cartilage
– Inferior border – sternum, clavicle and scapula
– Envelopes infrahyoid strap muscles

11. Deep Layer of Deep Cervical Fascia
• Arises from spinous processes and ligamentum nuchae.
• Splits into two layers at the transverse processes:
 Prevertebral layer
– Front of the prevertebral muscles
– Forms floor of the posterior triangle of neck
– Posterior boarder of Retropharyngeal space
• Superiorly– skull base
• Inferiorly– coccyx
• Envelopes vertebral bodies and deep muscles of the neck.
• Extends laterally as the axillary sheath.
 Alar layer
• Superiorly – skull base
• Inferiorly – upper mediastinum at T1-T2 ( fuses with
middle layer )
The alar layer is only present in anterior midline between
vertebral transverse process

13. Carotid Sheath
• Lincoln’s highway
• Formed by all three layers of deep fascia
• Anatomically separate from all layers.
• Travels through Pharyngomaxillary
space.
• Extends from skull base to thorax.
• Contains
– Common and Internal carotid artery
– internal jugular vein
– vagus nerve
– Deep Cervical Lymph node(Level II,III,IV)
– Carotid sinus nerve
– Sympathetic nerve fibers

14. Classification of neck spaces

15. DEEP NECK SPACES
• Entire the lenth of neck
– Superficial space
– Retropharyngeal
– Danger
– Prevertebral
– Carotid sheath space
– Peripharyngeal(Pharyngomaxillary or
Parapharyngeal)
• Suprahyoid
• Submandibular
• Parotid
• Peritonsillar
• Temporal
• Masticator
• Infrahyoid
• Anterior visceral
• Suprasternal space of burn
• Supra clavicular

16. Retropharyngeal Space
• Entire length of neck
• Extends from base of skull to bifurcation of
trachea
 Anterior border:: pharynx and esophagus
(buccopharyngeal fascia)
 Posterior border - Alar layer of deep fascia
 Superiorly- skull base
 Inferiorly– posterior mediastinum
• Midline raphe 2 space of gillette
• Contains retropharyngeal nodes (glands of
henle/Rouviere) which disappears by 5
years of age

17. Retropharyngeal Space
• Entire length of neck.
1. Anterior border:: pharynx and esophagus
(buccopharyngeal fascia)
2. Posterior border - Alar layer of deep fascia
• Superiorly- skull base
• Inferiorly– superior mediastinum
– Combines with buccopharyngeal fascia at
level of T1-T2
• Midline raphe connects superior constrictor to
the alar layer of deep cervical fascia : divides
into 2 space of gillette
• Contains retropharyngeal nodes (glands of
henle) which disappears by 5 years of age

18. Retropharyngeal Space
• Possible Source of infection
– Adenoids
– Nasopharynx
– Nassal cavity
– Penetrating injury of post pharyngeal wall, cervical oesophagus
– Extention of infection from parapharyngeal space, parotid space
– Rarely from mastoid

19. Acute Retropharyngeal abscess
• Collection of pus in retropharyngeal space
Common: < 5 years
• Bacteriology:
– S.Viridians(41%),S.aureus(26%)
– K.pneumoniae,E.coli,salmonella
Cause:
• Suppuration of RP LN: URTI, infection of
PNS and nasopharynx
• Trauma to PPW or cervical esophagus:
penetrating injury, foreign body,
• Instrumentation
• Spread from adjacent space

20. Clinical feature:
Children:
Irritability, poor oral intake, drooling, sore
throat, Odynophagia, torticollis, cervical
lymphadenopathy, Resp obs , fever
Adult:
anorexia, snoring, neck pain, Odynophagia,
dyspnoea, fever,
O/E
• Bulge on PPW: usually one side of midline
• Cervical Lymphadenopathy
• Very large abscess can be palpated
Investigation:
X-ray soft tissue neck lateral view
• Increase prevertebral soft tissue shadow:
initially
• Abscess with fluid level: late
Normal prevertebral soft
tissue thickness
7mm at C-2
14mm at C-6: Children
22mm at C-6 ; Adults

21. Posterior pharyngeal wall swelling on left side

22. X ray STN Air-fluid level CT scan

23. Treatment
• Antibiotic followed by
• I & D
– Indication:
 Embarrassment to respiration or deglutition
 Fluctuation present
 Presence of complication
– Anaesthesia GA
– Supine position with head lowered sufficently to prevent
inhalation of blood or pus.
– Intraoral: when abscess localized to upper part
– External cervical incision: when large abscess
extend low down to neck

24. Chronic Retropharyngeal abscess
• Collection of abscess in prevertebral space
• Common in adults
• Tubercular / caries of cervical spine
• Clinical feature
– Discomfort in throat
– Dysphagia present but not marked
– Low grade fever, weight loss
– Neck nodes
Investigation:
• X-ray cervical spine
• Pus examination
Treatment
• ATT
• I & D through external approach

25. Danger Space
• Entire length of neck
• Anterior border – Alar layer of deep
fascia
• Posterior border - prevertebral layer
• Extends from skull base to diaphragm
• So called - infection in this space can
extend inferiorly up to mediastinum to
level of diaphragm
• Contains
– loose areolar tissue.
• Possible source of infection
– Infected by rupture of retro pharyngeal
abscess,prevertebral or parapharyngeal
• Clinical feature is identical to
retropharyngeal space infection

27. Prevertebral Space
• Entire length of neck
• Anterior border - prevertebral fascia
• Posterior border - vertebral bodies, anterior
longitudinal ligament and deep neck
muscles
• Lateral border – transverse processes
• Extends along entire length of vertebral
column, till coccyx
• Possible source of infection
– Pott’s abscess
– Trauma
– Extention from retropharyngeal or danger space

28. • Clinical feature:
– Back, shoulder, neck pain made worse by deglutition
– Dysphagia or dyspnea

29. Visceral Vascular Space
• Linclon highway
• Entire length of neck
• Space within Carotid Sheath
Extend: skull base to mediastinum
• Contain
– Common and Internal carotid artery
– internal jugular vein
– vagus nerve
– Deep Cervical Lymph node(Level II,III,IV)
– Carotid sinus nerve
– Sympathetic nerve fibers

30. Visceral Vascular Space
• Possible source of infection
– intravenous drug abuse
– extension from other deep neck spaces
• Clinical feature:
– Induration and tenderness over SCM
– Torticollis toward opposite side
– Spiking fevers
– sepsis

31. Parapharyngeal space
• Aka: pharyngomaxillary, pterygomandibular,
pterygopharyngeal space
• Superior
– Skull base
• Inferior
– Hyoid
• Anterior
– Narrows and extend to ptyergomandibular raphe
• Posterior
– Prevertebral fascia/carotid sheath
• Medial
– Buccopharyngeal fascia
• Lateral
– Superficial layer of deep fascia covering medial
pterygoid muscle, mandible and deep surface of
parotid

32. Parapharyngeal space
Styloid process divides
• Anterior compartment and posterior
compartment
• Anterior compartment is related to tonsilar
fossa medially and pterygoid muscles
laterally
• posterior compartment is related posterior
part of lateral pharyngeal wall medially
and parotid laterally
• Anterior compartment (Prestyloid)
– Muscular compartment
– Contains fat, connective tissue, nodes
• Posterior compartment (Poststyloid)
– Neurovascular compartment
– Carotid sheath
– Cranial nerves IX, X, XI, XII
– Sympathetic chain

33. Parapharyngeal space
• Possible source of infection
– Peritonsillar abscess
– Parotid abscess
– Submandibular gland infection
– Masticator space abscess

34. Parapharyngeal abscess
Etiology
• 60%: Tonsillectomy/tonsillitis:
• 30%: Infection/extraction of lower 3rd
molar
• 10%:
Infection of petrous apex
Infection of mastoid tip
Spread from other space
External trauma: penetrating injury
neck, LA for tonsillectomy,

35. Parapharyngeal abscess
• Clinical feature
– Fever
– Odynophagia
– sorethroat
– torticollis and sign of toxemia
• Prestyioid compartment
– Pseudoenlargement of tonsil
– Trismus
– External swelling behind angle of jaw
• Post styloid compartment
– Bulge behind post pillar
– Involvement of IX, X, XI, XII and sympathetic chain
– Minimal trismus
– Swelling of parotid region

36. Parapharyngeal abscess
• Investivation:CT Scan
• Treatment:
• Medical
• Systemic antibiotic
• Surgical
– Incision and Drainage
• Anaesthesia- GA
• Position – supine with head lowered sufficiently to prevent the
inhalation of blood or pus
• Incision- Horizontal incision 2 cm below angle of mandible

37. Submandibular Space
• Suprahyoid
• Superior – oral mucosa of floor of mouth
• Inferior - superficial layer of deep fascia
; hyoid to mandible
• Medially–inferior border of mandible
• laterally – anterior and posterior belly of
bellies of digastric muscles
Subdivisions:
1. Sublingual space: above mylohyoid muscle
2. Submaxillary space: below mylohyoid
muscle(Sub mylohoid space)

38. Submandibular Space
– Sublingual space
– Content
• Areolar tissue
• Hypoglossal and lingual nerves
• Sublingual gland
• Wharton’s duct
– Submylohoid space
• Anterior bellies of digastrics
– Submental compartment
– Submaxillary compartments
• Content
– Submandibular glan
– Lymphnode(Level IB)

40. Submandibular Space
• Possible source of infection
– Sublingual sialodenitis
– Tooth infection
– Submandibular gland sialodenitis
– Molar tooth infection

41. LUDWIG’S ANGINA
Rapidly spreading cellulitis of floor of
mouth and submandibular space
Etiology
• Dental: lower premolar and molar
• Tonsillar infection
• Soft tissue infection
• Submandibular sialadenitis
• Injuries to oral mucosa
Organism:
• Mixed organism: aerobes and
anaerobes

42. LUDWIG’S ANGINA
Clinical feature:
– Pain
– Fever
– drooling of saliva
– Trismus
– Resp obs
– Swelling of floor of mouth (infection of sublingual
space)
– Swollen, tender, woody hard submandibular area:
(infection in submaxillary space)
• Diagnosis –C/f and USG

43. LUDWIG’S ANGINA
Treatment
• IV Antibiotic
• I & D
Intraoral: infection is localized to sublingual space
External: Horizontal extending from one angle of
mandible to another through superficial fascia
Mylohyoid muscle

44. Parotid Space
• Suprahyoid
• Space created by Superficial
layer of deep fascia as it splits to
surround mandible and parotid
– Fascia is thin/deficient on
superomedial surface of gland
facilitating direct
communication to
Parapharyngeal space
– Parotid sheath limits swelling
so it causes severe pain when
infected

45. Parotid Space
• Contains
– External carotid artery
– Parotid gland`
– Posterior facial vein
– Facial nerve
– Lymph nodes
– Retromandibular vein
• Possible source of infection
– Oral cavity
– Fore head
– Lateral part of eye lid
– Temporal region
– Lateral surface of auricle
– Anterior wall of EAC-fissure of santorini

47. Parotid space infection
Etiology:
• Odontogenic
• Dehydration: post surgical,stasis of salivary flow
• Infection of oral cavity via stensen duct
• Spread from masseteric space
Clinical feature
• Swelling, redness, indurations in parotid area/ angle of
mandible
• Systemic s/s more prominent; toxic, high fever,
dehydration
• Stensen duct opening: congested, pus may come by
pressing over parotid
• Less Fluctuating: thick capsule
• No Trismus

49. Parotid space infection
• Investigation
– USG/ CT
• Diagnosis-
– C/f, USG and CT scan
• Treatment
• Medical
– Correct dehydration
– Improve oral hygiene
– Antibiotic
• Surgical
– I and D

50. • Anaesthesia GA
• Position –Supine with neck slightly extended
and head turned away from surgeon
• Incision- Blair’s incision
– along skin crease approx 2 finger below the
mandible and well forwards.
– Paralllel to ramus of mandible onto SMC where it
incline upward upto the mastoid process
– At mastoid process it curves forwards to point at
which the lobe of ear join the face
– It than follow the preauricular area upwards
almost to the top of pinna.

51. Peritonsillar Space
• Suprahyoid
• Medially—capsule of palatine
tonsil
• Laterally—superior pharyngeal
constrictor
• Superiorly—superior pole tonsil
• Inferiorly—inferior pole tonsil
• Content :
Loose areolar tissue
Minor salivary glands
Possible source of infection
– Infection of tonsillar crypt

52. Peritonsillar abscess (Quinsy)
Collection of pus in Peritonsillar space
Cause:
• Following acute tonsillitis
• Infection of minor salivary gland
• Molar teeth
• de novo
Organism
• Strept pyogenes, staph aureus,
anaerobic organism
• More often mixed both aerobes and
anaerobes
• Age: adult> child
• Unilateral / bilateral also recorded

53. Peritonsillar abscess (Quinsy)
Clinical feature:
• General: Fever, chills with rigor , Malaise,
body ache
• Local
– Sore throat( unilateral)
– Odynophagia, drooling of saliva
– Halitosis
– Referred otalgia and Trismus
Examination
– Tonsil, pillar, soft palate: congested & swollen
– Tonsil buried in edematous pillar
– Bulging of soft palate and pillar
– Mucopus covering tonsillar region
– Cervical Lymphadenopathy and Torticollis

54. Peritonsillar abscess (Quinsy)
• Treatment
• Diagnosis
– C/f and Aspitration
• Medical
– Rehydration
– Antibiotic: aerobes and anaerobes
– Analgesic
– Oral hygiene
• Surgical
– I & D
– Anaesthesia- without

55. Masticator and Temporal Spaces
• Suprahyoid
• Formed by superficial layer of deep
cervical fascia
• Masticator space
– Base of skull to lower border of
mandible
– Antero-lateral to
pharyngomaxillary space.
– Contains
• Masseter
• Pterygoids
• Body and ramus of the mandible
• Inferior alveolar nerves and vessels
• Tendon of the temporalis muscle
• Possible source of infection:
– Infection of 3rd molar

56. • Temporal space
– Continuous with masticator space.
– Lateral border – temporalis fascia
– Medial border – periosteum of
temporal bone
– Superficial and deep spaces divided
by temporalis muscle
• Clinical feature
– Pain
– trismus
– Swelling along ramus of mandible

57. Anterior Visceral Space
• Infrahyoid
• aka – Pretracheal space
• Enclosed by visceral division of middle layer
of deep fascia
• Contains
– thyroid
– Surrounds trachea
• Superior border –
– Thyroid cartilage and hyoid
• Inferior border
– Anterior superior mediastinum down to the arch
of the aorta.
• Posterior border
– Anterior wall of esophagus

58. Anterior Visceral Space
• Possible source of infection
– foreign body
– instrumentation
– extension of infection in thyroid
• Clinical feature:
– Hoarseness
– Dyspnea
– dysphagia
– Odynophagia
– Erythema,
– edema of hypopharynx may extend to include glottis and supraglottis
– Anterior neck edema
– pain, crepitus

59. Complications
• Airway obstruction
– Endotracheal intubation
– Tracheostomy
• Ruptured abscess
– Pneumonia
– Lung Absces
• Internal Jugular Vein Thrombosis
– Lemierre’s syndrome
– swelling and pain along SCM
– Bacteremia
– septic embolization,
– dural sinus thrombosis
– IV drug abusers
– Treatment-IV antibiotic therapy,Anticoagulation?

60. Complications
• Carotid Artery Rupture
– Sentinel bleeds from ear, nose, mouth
– Majority from internal carotid
– less from external carotid
– fewest from common carotid
– Treatment-Ligation
• Descending necrotizing mediastinitis
– Mediastinal infection in which pathology
originates in fascial spaces of head and neck
and extends down.
– Retropharyngeal and Danger Space – 71%
– Visceral vascular – 20%
– Anterior visceral – 7-8%
– Increasing dyspnea, chest pain
– CXR = widened mediastinum

61. Complications
• Treatment
IV antibiotics
• Surgery-
• Cervical drainage
– Cervical abscesses
– Superior mediastinal abscesses above T4 (tracheal
bifurcation)
• Transthoracic drainage
 Abscesses below T4

62. Inter-communication between neck spaces
Parapharyngeal space communicates with
– Parotid space
– Masticator space
– Peritonsillar space
– Submandibular space
– Retropharyngeal space
• Anterior Visceral Space Communicates with
– Retropharyngeal space below
• Temporal space Communicates with
– Masticator space.