Deep neck space infections

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