1. The document discusses various deep neck spaces and infections that can arise within them, including Ludwig's angina (submandibular space infection), retropharyngeal abscess, and parapharyngeal abscess. 2. These deep neck space infections commonly arise from dental infections or tonsillitis and can spread rapidly, potentially causing airway obstruction. 3. Management involves intravenous antibiotics, incision and drainage of abscesses, and tracheostomy if needed to secure the airway. Proper identification of the involved neck space guides surgical drainage approach.

1. Deep neck space infection
Dr ramesh parajuli, MS
Chitwan Medical College, Bharatpur-10,
Chitwan, Nepal

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. (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

5. 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

8. 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

9. Subdivisions of submandibular space
1. Sublingual space: above mylohyoid muscle
2. Submaxillary space: below mylohyoid muscle
Contents: Submandibular salivary gland, lymph nodes

10. 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

11. Causative agentsCausative agents
Mixed aerobic & anaerobic infection
 Streptococcus pyogenes
 Streptococcus viridans
 Streptococcus pneumoniae
 Staphylococcus
 Fusobacterium
 Bacteroides
 Peptostreptococcus

12. 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)

13.  Parapharyngeal abscess
 Retropharyngeal abscess
 Acute airway obstruction (within
hours):
due to falling back of tongue
 Aspiration pneumonia
 Septicemia
 Death
ComplicationsComplications

14. 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

15. 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

17. 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

18. Symptoms
 H/o upper respiratory tract infection
 Dysphagia / odynophagia
 Difficulty in breathing
 Neck stiffness/ torticollis

19. Signs
 Febrile, ill-looking, child with drooling
 Tender neck swelling
 Torticollis (twisted neck)
 Bulge on posterior pharyngeal wall
Torticollis

20. Widened pre-vertebral soft tissue
shadow

21. Air-fluid level & gas shadow

22. Tuberculosis of cervical spine with
retropharyngeal abscess

23. Complications
1. Airway obstruction:
2. Spread of abscess to other neck spaces
3. Spontaneous rupture of abscess
4. Septicemia
5. Death

24. 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

25. 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

27. 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

28. 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

29. 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

30. Clinical features
1. Fever, sore throat, odynophagia, torticollis
2. Tonsils pushed medially
3. Trismus
4. Neck swelling behind angle of mandible

31. 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

32. 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)

33. 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

34. Complications of quinsy
1. Parapharyngeal abscess
2. Retropharyngeal abscess
3. Laryngitis & laryngeal edema
4. Lung abscess
5. Internal jugular vein thrombosis
6. Septicemia

35. 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

36. Incision & drainage site

37.  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

38. 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

39.  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

40. Thank youThank you