Ludwig's angina is a rapidly progressing cellulitis of the submandibular space that can cause airway compromise. It is usually caused by dental or periodontal infections and treated with IV antibiotics and incision and drainage. Parapharyngeal abscesses are usually caused by infections from the pharynx, teeth, or ears and can spread to nearby structures. Acute retropharyngeal abscesses commonly affect young children and are treated with IV antibiotics and drainage, while chronic abscesses are often tuberculous and require long term antibiotics. All three infections require prompt treatment to prevent complications including airway obstruction.

1. Deep neck space infections
Dr. Krishna Koirala
2020.02.10

2. Questions
• Define Ludwig’s angina. Write down the clinical features and
treatment of Ludwig’s angina.
• What is the etiology of parapharyngeal abscess? Write down
the clinical features, investigations and treatment of
parapharyngeal abscess.
• Write down the clinical features, investigation and treatment
of acute/ chronic retropharyngeal abscess.

3. Ludwig’s Angina
• Rapidly progressing polymicrobial cellulitis of the
submandibular space that can result in life
threatening airway compromise
• Angina - Strangling
• Mortality
– Before the advent of antibiotics : 50%
– Nowadays : 8–10%
– Most common cause of death is respiratory
compromise ( encircling of the upper airway)

5. • Predisposing Factors
– Dental or periodontal infection (80%)
•Poor dental hygiene (carious and abscessed teeth)
•Tooth extraction (lower molars and premolars)
– Others
•Upper respiratory infections, floor-of-mouth trauma,
mandibular fractures, sialoadenitis, peritonsillar
abscess, IV drug abuse
– Comorbid conditions
•Diabetes mellitus , malnutrition, alcoholism,
neutropenia, lupus erythematosus, aplastic anemia,
glomerulonephritis

6. • Causative organisms
– Group A beta-hemolytic streptococcal species
(streptococcus pyogenes)
– Alpha-hemolytic streptococcal species (streptococcus
viridans, streptococcus pneumoniae)
– Staphylococcus aureus
– Fusobacterium , Bacteroides melaninogenicus and oralis
– Peptostreptococcus, Actinomyces ,Neisseria species
– Occasional : Pseudomonas species, Escherichia coli, and
Haemophilus influenzae

7. Clinical Features
• Highest prevalence seen in young adults
• Pain in any involved teeth, with severe tender localized
swelling in the submandibular region
• Drooling (due to dysphagia) , halitosis, trismus , stridor ( from
laryngeal edema and elevation of the posterior tongue against
the palate)
• Fever, chills, tachycardia
• Boardlike firmness of the floor of the mouth and brawny
induration of the suprahyoid soft tissues
• Airway obstruction within hours !!

9. Criteria for diagnosing Ludwig's angina (Grodinsky)
- Rapidly spreading cellulitis with no specific tendency to form
abscess
- Involvement of both submaxillary and sublingual spaces,
usually bilaterally
- Spread by direct extension along facial planes and not
through lymphatics
- Involvement of muscle and fascia but not submandibular
gland or lymph nodes
- Originates in the submaxillary space with progression to
involve the sublingual space and floor of the mouth

10. Investigations
• Routine blood investigations
• Pus culture
• Plain radiographs to assess the
degree of soft tissue swelling
and airway obstruction
• CT - most useful imaging tool

11. Treatment
• Frequent assessment
– To assess the risk of progression and airway
compromise
• Empirical therapy
– High-dose intravenous antibiotics : Cefuroxime
and metronidazole

12. • Incision and drainage : intraoral and external
– Transverse incision across the midline from one
angle of jaw to the other  Muscles of the tongue
opened vertically Myelohyoid muscle sectioned
longitudinally
– Drains placed in all fascial spaces
• Tracheostomy to maintain an airway

14. Retropharyngeal Abscess
• Collection of pus in the retropharyngeal space
• Classification
– Acute
– Chronic

15. Retropharyngeal Abscess contd..
Acute
• Common in children
below 5 yrs
• Causes
– Suppuration of
retropharyngeal lymph
node
– Penetrating FB e.g.
Fish bones
– Post trauma / surgery
Chronic
• Affects any age
• Causes
– Tubercular infection
of retropharyngeal LN
– Caries of cervical
spine
– Post trauma/ surgery

16. Acute retropharyngeal abscess
• Symptoms
– History of upper
respiratory tract infection
– Dysphagia
– Difficulty in breathing,
noisy breathing
– Croupy cough
– Torticollis
• Signs
– Ill looking, febrile, drooling of
saliva
– Hyperextension of the head
– Hot potato (muffled) voice
– Neck swelling and tenderness
– Bulge on posterior pharyngeal
wall - usually unilateral
– Absent laryngeal crepitus
– Positive tracheal rock sign

17. Investigations
• Complete blood count to look for septicemia
• Plain X- Ray soft tissue neck Lateral view
– At the level of C2 : Distance from the anterior border of
the cervical vertebrae to the posterior border of airway :
≤ 7 mm regardless of the patient's age
– At C6 : ≤14 mm in children younger than 15 years and
up to 22 mm in adults

18. • Widened prevertebral soft tissue
shadow more than normal in all
ages or more than 2/3 of
corresponding cervical vertebral
body or presence of air fluid level
signifies retropharyngeal abscess
• CT scan of neck : Plain and
contrast
– Extent of infection/ abscess,
involvement of other spaces

19. Treatment
• Adequate hydration : I.V. fluid supplement
• Systemic antibiotics : Ceftriaxone, metronidazole ,
amikacin
• Incision and Drainage
– Transoral : No anesthesia, supine with head low ,
incision and suction of pus
– Transcervical : Through lateral neck incision
• Tracheostomy

21. Chronic Retropharyngeal abscess
• Clinical Features
• Indolent in comparison to acute form
• Chronic discomfort in throat, dysphagia, bulge
of posterior pharyngeal wall with fluctuant
swelling

22. Forms
• Lateral type :
– Koch's infection of the cervical lymph node
spreading to retropharyngeal nodes and forming
a cold abscess
– Usually seen in children below 5 years of age
– Intraoral swelling classically on the sides which
is fluctuant with minimal signs of inflammation

23. • Central type
– Common etiology: Pott’s tuberculous cervical
spine
– Abscess present between the body of vertebra
and the prevertebral fascia
– Swelling is usually in the midline, spreads to
both sides, causing diffuse bulge of the
posterior pharyngeal wall and is fluctuant with
less signs of inflammation

24. • Investigations
− As in acute retropharyngeal abscess
− ZN stain of the pus after aspiration
• Treatment
− IV antibiotics
− Incision and drainage : Per-oral / external
− Antitubercular chemotherapy
− Neck exploration

25. Complications
• Secondary to mass effect : airway obstruction
• Rupture of the abscess: aspiration, septicemia,
mediastinitis
• Spread of abscess to other neck spaces

26. Parapharyngeal Abscess
• Etiology
– Pharynx : Acute tonsillitis, peritonsillar abscess
– Teeth : Dental infections - lower last molar
– Ear : Bezold’s abscess
– Others : Parotid, retropharyngeal, submandibular
– Penetrating injuries

27. Clinical Features
• Fever, sore throat, odynophagia, torticollis
• Anterior Compartment
– Tonsils pushed medially
– Induration along the angle of the mandible
– Trismus
– External swelling behind the angle of jaw

28. • Posterior compartment
– Bulge of pharynx behind the posterior pillar
– Paralysis of IX, X, XI, XII cranial nerves and
cervical sympathetic chain
– Erode into the carotid artery or cause septic
thrombophlebitis of the internal jugular vein
(Lemierre syndrome)

31. Treatment
• Systemic antibiotics
–Ceftriaxone 1 gm. iv BD
–Amoxyclav 1.2 gm. iv TDS
–Metronidazole 500mg iv TDS
• Incision & drainage
–Intraoral drainage from tonsillar fossa
–External incision from the neck

32. Surgical approaches to Parapharyngeal Space
a) Transoral
– Small benign lesions of the prestyloid space
presenting as an oropharyngeal mass
– Problems -- limited exposure, increased risk of
tumor spillage, possibility of neurovascular injury
b) Cervical with or without mandibulotomy
– A transverse incision at the level of the hyoid bone
with removal or displacement of the
submandibular gland
– Tracheostomy necessary with this approach

33. - Tumors in the lower parapharyngeal space
extending to the neck
c) Cervical - parotid
– Extension of the cervical approach incision
superiorly in front of the ear
– Tumours in the midparapharyngeal space without
extension superiorly into the skull base or
posteriorly around the petrous internal carotid
artery
d) Transparotid
e) Infratemporal fossa