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Deep neck space infections -Dr.Ashly Alexander
- 1. “Deep Neck Space Infections” Dr. Ashly Alexander ENT RSO - 2nd Year GMC Bhopal
- 2. • Anatomy of the Cervical Fascia • Anatomy of the Deep Neck Spaces • Deep Neck Space Infections 2Dr. ASHLY ALEXANDER
- 3. Cervical Fascia • Superficial Fascia • Deep Fascia – Superficial(investing) – Middle(pretracheal) – Deep(prevertebral) 3Dr. ASHLY ALEXANDER
- 6. Superficial fascia (Tela subcuta) • Superior attachment – zygomatic process • Inferior attachment – thorax, axilla. • Similar to subcutaneous tissue • Ensheathes platysma and muscles of facial expression • Marginal mandibular n. lies deep to it 6Dr. ASHLY ALEXANDER
- 7. Deep Cervical Fascia 1) Superficial layer 2) Middle layer 3) Deep layer 7Dr. ASHLY ALEXANDER
- 8. Superficial Layer of the Deep Cervical Fascia (Enveloping,Investing,Anterior layer) • Completely surrounds the neck from skull to chest • Arises from spinous processes, ligamentum nuchae • Superior border – nuchal line, skull base, zygoma, mandible. • Inferior border –scapula, clavicle and manubrium • Splits at mandible and covers the masseter laterally and the medial surface of the medial pterygoid. Contd… 8Dr. ASHLY ALEXANDER
- 10. Superficial Layer of the Deep Cervical Fascia (Enveloping,Investing,Anterior layer) • Envelopes – SCM – Trapezius – Submandibular – Parotid • Forms floor of submandibular space • Create superficial sternal space (of Burn) 10Dr. ASHLY ALEXANDER
- 11. Middle Layer of the Deep Cervical Fascia (Cervical layer,Pretracheal layer) • Visceral Division – Superior border • Anterior – hyoid and thyroid cartilage • Posterior – skull base – Inferior border – continuous with fibrous pericardium in the upper mediastinum. – Buccopharyngeal fascia • Name for portion that covers the pharyngeal constrictors and buccinator. – Envelopes • Thyroid • Trachea • Esophagus • Pharynx • Larynx Contd…11Dr. ASHLY ALEXANDER
- 12. Middle Layer of the Deep Cervical Fascia (Cervical layer,Pretracheal layer) • Muscular Division Superior border – hyoid and thyroid cartilage Inferior border – sternum, clavicle and scapula Envelopes infrahyoid strap muscles 12Dr. ASHLY ALEXANDER
- 13. Deep Layer of Deep Cervical Fascia (Carpet fascia) • Arises from spinous processes and ligamentum nuchae. • Lies deep to the trapezius • Envelopes vertebral bodies and deep muscles of the neck • Splits into two layers at the transverse processes: – Alar layer – Prevertebral layer 13Dr. ASHLY ALEXANDER
- 14. Deep Neck Spaces • Described in relation to the hyoid – Entire length of the neck – Suprahyoid – Infrahyoid 14Dr. ASHLY ALEXANDER
- 15. Space Involving Entire Length Of Neck • Superficial space • Retropharyngeal Space • Danger Space • Prevertebral Space • Carotid Sheath Space 15Dr. ASHLY ALEXANDER
- 16. Superficial Space • Entire Length of Neck: – Surrounds platysma – Contains areolar tissue, nodes, nerves and vessels – Involved in cellulitis and superficial abscesses – Treat with incision along Langer’s lines, drainage and antibiotics 16Dr. ASHLY ALEXANDER
- 17. Retropharyngeal Space • Entire length of neck. • Anterior border - pharynx and esophagus (buccopharyngeal fascia) • Posterior border - alar layer of deep fascia • Superior border - skull base • Inferior border – superior mediastinum T4 • Midline raphe- spaces of Gilette • Contains retropharyngeal nodes-3 in no one median-- nodes of henle two lateral – nodes of rouviere 17Dr. ASHLY ALEXANDER
- 20. Danger Space Entire length of neck • Anterior border - alar layer of deep fascia • Posterior border - prevertebral layer • Extends from skull base to diaphragm • Contains loose areolar tissue. • No midline raphae • Infection spread from neck to posterior mediastinum easily 20Dr. ASHLY ALEXANDER
- 21. Prevertebral Space Entire length of neck • Anterior border - prevertebral fascia • Posterior border - vertebral bodies and deep neck muscles • Lateral border – transverse processes • Extends along entire length of vertebral column • Infection in this space is rare and spread slowly due to compact connective tissue 21Dr. ASHLY ALEXANDER
- 22. Visceral Vascular Space (Carotid Sheath Space) Entire length of neck – Made up from all 3 layers of deep cervical fascia – “Lincoln Highway” – Anatomically separate from all layers – Contains carotid artery, internal jugular vein, and vagus nerve – Infection from any deep fascia can spread to this space – Extends from skull base to thorax. 22Dr. ASHLY ALEXANDER
- 23. Space Limit To Above The Hyoid Bone • Submandibular Space • Parapharyngeal Space • Peritonsillar Space • Parotid Space • Masticator & Temporal Space 23Dr. ASHLY ALEXANDER
- 24. Submandibular Space • Suprahyoid • Superior – oral mucosa • Inferior - superficial layer of deep fascia • Anterior border – mandible • Lateral border - mandible • Posterior - hyoid and base of tongue musculature 24Dr. ASHLY ALEXANDER
- 25. Submandibular Space • 2 compartments – Sublingual space • Areolar tissue • Hypoglossal and lingual nerves • Sublingual gland • Wharton’s duct – Submaxillary space • Anterior bellies of digastric • Submandibular gland 25Dr. ASHLY ALEXANDER
- 27. Parapharyngeal Space • Suprahyoid • Pharyngomaxillary space (lateral pharyngeal, peripharyngeal, pterygopharyngeal, pterygomandibular,pharyngomasticatory) • Boundaries : – Superior—skull base – Inferior—hyoid – Posterior—prevertebral fascia – Medial—buccopharyngeal fascia – Lateral—med pterygoid, mandible, parotid 27Dr. ASHLY ALEXANDER
- 30. Parapharyngeal Space Divided into 2 compartmens by stylohyoid ligament • Prestyloid – Muscular compartment – Medial—tonsillar fossa – Lateral—medial pterygoid – Contains fat, connective tissue, nodes, int maxillary a., inf alveolar n., lingual n., auriculotemporal n. • Poststyloid – Neurovascular compartment – Carotid sheath – Cranial nerves IX, X, XI, XII – Sympathetic chain 30Dr. ASHLY ALEXANDER
- 31. Peritonsillar Space • Suprahyoid • Medial—capsule of palatine tonsil • Lateral—superior pharyngeal constrictor 31Dr. ASHLY ALEXANDER
- 32. Parotid Space • Suprahyoid • Superficial layer of deep fascia • Dense septa from capsule into gland • Direct communication to parapharyngeal space 32Dr. ASHLY ALEXANDER
- 33. Masticator and Temporal Spaces • Suprahyoid • Formed by superficial layer of deep cervical fascia • Masticator space – Antero-lateral to pharyngomaxillary space. – Contains • Masseter • Pterygoids • Body and ramus of the mandible • Inferior alveolar nerves and vessels • Tendon of the temporalis muscle Contd… 33Dr. ASHLY ALEXANDER
- 34. Masticator and Temporal Spaces • Temporal space – Continuous with masticator space. – Lateral border – temporalis fascia – Medial border – periosteum of temporal bone – Divided into superficial and deep spaces by temporalis muscle 34Dr. ASHLY ALEXANDER
- 35. Infrahyoid • Visceral Compartment – Middle layer of deep fascia – Contains thyroid, trachea, esophagus – Extends from thyroid cartilage into superior mediastinum 2 spaces- • Retrovisceral space {Retropharyngeal space} – Extends along whole length of neck • Pretracheal space – Superiorly - attachment of strap muscles to thyroid and hyoid – Inferiorly - up to upper border of arch of aorta 35Dr. ASHLY ALEXANDER
- 36. Deep Neck Space Infections • Etiology/ pathogenesis of Infection • Microbiology • Clinical manifestations • Some specific infections • Complications 36Dr. ASHLY ALEXANDER
- 37. Etiopathogenesis • Deep neck space infeections have been recognised from the time of Galen in 2nd century AD • Preantibiotic era – 70% from infections of pharynx and tonsils • Present situation – Dental infection (major source) – Peritonsillar abscess – Upper aerodigestive tract trauma – Retropharyngeal lymphadenitis – Pott’s disease – Sialadenitis – submandibular, parotid – From temporal bone- Bezold’s abscess, petrous apex infections – Congenital cysts and fistulas – Intravenous drug abuse 37Dr. ASHLY ALEXANDER
- 38. Microbiology • Preantibiotic era – S. aureus • Currently – Aerobes – alpha hemolytic Streptococci, S. aureus – Anaerobes – Fusobacterium, Bacteroides, Peptostreptococcus, Veilonella • Gram-negatives uncommon • Almost always polymicrobial 38Dr. ASHLY ALEXANDER
- 39. Clinical manifestations • Pain – Constant feature – Indication of extension or resolution – Exception – retropharyngeal abscess in children • Fever – Constant feature – Initial spike, followed by elevated temperature – Spiking temperatures- doubt septicemia/septic thrombophlebitis of IJV/mediastinal extension • Swelling • Trismus and limitation of neck movements – depending on site • Progressive dysphagia and odynophagia • Voice change • Dyspnoea • Chest pain 39Dr. ASHLY ALEXANDER
- 40. Ludwig’s angina • Described by William Friedrich von Ludwig, 1836 (“gangrenous induration of the connective tissues of the neck which advances to involve the tissues which cover the small muscles between the larynx and the floor of mouth”) • Cellulitis of submandibular space – Anterior teeth and first molars – infection of sublingual space – Second and third molars – infection of submaxillary space • Causative organism-- haemolytic streptococci 40Dr. ASHLY ALEXANDER
- 42. Ludwig’s angina • Criteria for diagnosis – Rapidly progressive cellulitis, not an abscess – Develops along fascial planes by direct spread, not lymphatic spread – Does not involve submandibular gland or lymph nodes – Involves both sublingual and submaxillary spaces, usually bilateral • Pseudo – ludwig’s angina – Other inflammatory conditions involving floor of mouth – Limited infections involving only sublingual space, submandibular lymph nodes, submandibular gland, submental space, or abscesses involving one or more of these spaces 42Dr. ASHLY ALEXANDER
- 43. Ludwig’s angina ETIOLOGY: • 75-80% dental cause • Extraction of a diseased molar initiates infection • Penetrating injury of the floor of mouth • Mandibular fractures 43Dr. ASHLY ALEXANDER
- 44. Ludwig’s angina CLINICAL FEATURES: • Young man with poor dentition, increasing oral or neck pain and swelling • Increasing edema and induration of perimandibular region and floor of mouth • Thrusting of tongue posteriorly and superiorly • Neck rigidity, trismus, odynophagia, fever • Dyspnoea and stridor 44Dr. ASHLY ALEXANDER
- 45. Ludwig’s angina 45Dr. ASHLY ALEXANDER
- 47. Ludwig's angina Axial CT section through the tongue demonstrates diffuse enlargement of the tongue associated with low attenuation areas consistent with phlegmon. 47Dr. ASHLY ALEXANDER
- 48. Ludwig’s angina TREATMENT • Early stage- IV antibiotics {penicillin + metronidazole}, extraction of the diseased tooth • Late stage- – Airway {tracheostomy } – Surgery • Horizontal incision with wide exposure • Tissues have peculiar “salt pork appearance”, with woody induration, watery edema, and little bleeding • Gross purulence is rare • Multiple drains/wound kept open 48Dr. ASHLY ALEXANDER
- 49. Ludwig’s angina Complications:- Airway obstruction spread of infection to PFS and RFS and mediastinum. Aspiration pneumonia Lung abscess Fluid and electrolyte imbalance Tongue necrosis septicemia 49Dr. ASHLY ALEXANDER
- 50. Parapharyngeal abscess • Causes – Peritonsillar abscess – Dental infection – From other spaces – Trauma • Clinical features – Anterior compartment • Prolapse of tonsil • Trismus • External swelling behind angle of jaw • Odynophagia, fever – Posterior compartment • Bulge of LPW behind posterior pillar • Lower cranial n. paralysis • Horner’s syndrome • Swelling of parotid region • Odynophagia, fever 50Dr. ASHLY ALEXANDER
- 53. • Treatment – IV antibiotics – Correct dehydration – Analgesics – Surgery • External approach (access along the carotid sheath) –Transverse submandibular incision – Mosher’s T-shaped incision 53Dr. ASHLY ALEXANDER
- 54. Complications: • Rates of About 16% • Carotid sheath involvement causing Internal jugular vein thrombosis Carotid artery thrombosis. • Internal carotid artery pseudo aneurysm presenting as Horner's syndrome. • Acute pharyngeal perforation • Mediastinitis; requiring urgent drainage. • Descending necroting fasciitis of neck and mediastinum;requiring widespread debridement. • Upper airway obstruction 54Dr. ASHLY ALEXANDER
- 55. Retropharyngeal Abscess – 50% occur in patients 6-12 months of age – 96% occur before 6 years of age – Children - fever, irritability, lymphadenopathy, torticollis, poor oral intake, sore throat, drooling – Adults - pain, dysphagia, odynophagia, anorexia – Dyspnea and respiratory distress – Lateral posterior pharyngeal wall bulge 55Dr. ASHLY ALEXANDER
- 56. Retropharyngeal Abscess 56Dr. ASHLY ALEXANDER
- 58. Retropharyngeal Abscess • Pediatrics – Cause—suppurative process in lymph nodes • Nose, adenoids, nasopharynx, sinuses • Adults – Cause—trauma, instrumentation, extension from adjoining deep neck space 58Dr. ASHLY ALEXANDER
- 59. Retropharyngeal Abscess • Lateral neck plain film – Normal: 7mm at C-2, 14mm at C-6 for kids, 22mm at C-6 for adults – Loss of cervical lordosis – prevertebral soft tissue shadow more than 50% of width of vertebral body – Air shadow in prevertebral space with or without fluid level 59Dr. ASHLY ALEXANDER
- 60. Retropharyngeal abscess, CT+C shows a large retropharyngeal fluid collection (arrows) with peripheral rimlike enhancement 60Dr. ASHLY ALEXANDER
- 61. Retropharyngeal Abscess • Treatment – IV antibiotics and fluid replacement – Surgical drainage • Intraoral • External – tracheostomy + anterior cervical approach 61Dr. ASHLY ALEXANDER
- 62. Chronic Retropharyngeal abscess • Common in adults • Due to TB of cervical vertebra • Abscess is formed posterior to prevertebral fascia Clinical Features • Initially asymptomatic • Mild discomfort and sore throat • O/E smooth bulging on Post Pharyngeal wall • Without signs of inflammation 62Dr. ASHLY ALEXANDER
- 63. Tuberculosis of cervical Spine with retropharyngeal abscess 63Dr. ASHLY ALEXANDER
- 64. Chronic Retropharyngeal abscess Diagnosis • Clinical examination • Blood Examination • Sputum for AFB • X-Ray cervical spine • X-Ray Chest Treatment • Antitubercular drugs • Aspiration of abscess wide bore needle • Large abscess drainage through external root 64Dr. ASHLY ALEXANDER
- 65. •Acute Retropharyngeal •Chronic Retropharyngeal Age 1-3 yrs Space of Gillette Pyogenic organisms Suppuration of LN Sudden onset Dysphagia Resp distress High fever Swelling one side midline Signs of inflammation I/D Oral route Adults Behind prevertebral fascia Tubercular organisms Cervical carries Slow onset No / mild dysphagia Not common Mild fever Midline swelling No Signs of inflammation Anti TB & aspiration Drainage through external route 65Dr. ASHLY ALEXANDER
- 66. Retropharyngeal abscess Complications:- meningitis haemorrhage laryngeal spasm septicemia Metastatic abscess Jugular vein thrombosis Rupture with aspiration pneumonia Pericardial tamponade Mediastinitis Acute hemiplegia of childhood Spead in to other spaces 66Dr. ASHLY ALEXANDER
- 67. Peritonsillar abscess (quinsy) • Cause -Local complication of tonsillar infection→ Lacunar type -Infection→crypta magna→paratonsillar space -Weber’ glands infection -De novo • Symptoms – Fever with chills and rigor – Odynophagia – “Hot Potato” voice – Halitosis – Head tilted towards affected site 67Dr. ASHLY ALEXANDER
- 70. Peritonsillar abscess (quinsy) Signs • Anxious facies and stiffly held head,↑ pulse &↑ temp • Trismus • Unilateral swelling over palate & ant pillar • Uvula pushed to opposite site • Tonsil displaced medially and downward • Palate angry red, immobile, thick mucous • JDLN enlarged & tender 70Dr. ASHLY ALEXANDER
- 71. Peritonsillar abscess (quinsy) Treatment : • Hospitalization • Correction of dehydration • Systemic parentral broad spectrum antibiotics • Incision and drainage If no pus: parentral antibiotics heavy doses If no response in 24 hrs : I & D If pus present: I&D and supportive treatment After 6weeks tonsillectomy (intermittent tonsillectomy)to prevent recurrence 71Dr. ASHLY ALEXANDER
- 72. • Anesthesia – local • Position –semi sitting • Incision : most prominent part or Halfway between last molar and uvula Stab incision & dilatation by st claire thomson Quinsy scissors and suction of pus Incision and Drainage 72Dr. ASHLY ALEXANDER
- 73. Peritonsillar abscess (quinsy) Complications : •Mediastinitis •Necrotizing fasciitis. •Oedema of larynx •Septicemia •IJV thrombosis •Pneumonitis or lung abscess 73Dr. ASHLY ALEXANDER
- 74. Parotid space infections Contents:-parotid gland VII nerve LN ECA retromandibular vein Etiology:- post surgical cases debilitated and dehydrated pt drugs which decrease salivary flow Infections of oral cavity Severe otitis externa spreading thru fissure of Santorini. 74Dr. ASHLY ALEXANDER
- 75. Clinical features • usually follow 5-7 day after surgery. • marked swelling of jaw • Pain and induration over parotid gland • Congested stenson’s duct. • No fluctuation d/to thick capsule. Treatment correct dehydration improve oral hygine IV antibiotics I&D: Modified Blair’s incision 75Dr. ASHLY ALEXANDER
- 77. Masticator-Temporal Space infection • Cause – Odontogenic – Trauma • Superficial compartment – Extensive facial swelling – Severe trismus – Pain • Deep compartment – Trismus – Pain – Dysphagia and odynophagia – Intraoral swelling in RMT area •Treatment IV antibiotics Surgery Intraoral Along inner margin of mandibular ramus in RMT area External Horizontal incision, 2-3cm beneath angle of mandible 77Dr. ASHLY ALEXANDER
- 79. Complications • Internal Jugular Vein Thrombophlebitis (Lemierre’s syndrome) – Fusobacterium necrophorum – High fever with chills and rigor – Swelling and pain along SCM – Bacteremia, septic embolization, dural sinus thrombosis – IV drug abusers – Treatment • IV antibiotics • Anticoagulation - controversial • Ligation and excision 79Dr. ASHLY ALEXANDER
- 80. Complications • Mediastinitis – Mortality of 40% – Increasing dyspnea, chest pain – CXR - widened mediastinum – Treatment • EARLY RECOGNITION AND INTERVENTION • Aggressive IV antibiotic therapy • Surgical drainage – Transcervical approach – Chest tube / thoracotomy 80Dr. ASHLY ALEXANDER
- 81. Complications • Cranial nerve deficits • Necrotising cervical fasciitis • Osteomyelitis • Grisel syndrome ( inflammatory torticollis causing cervical vertebral subluxation ) 81Dr. ASHLY ALEXANDER
- 82. Special considerations • Airway protection – Observation – Intubation • Direct laryngoscopy: risk of rupture and aspiration • Flexible fiberoptic – Tracheostomy • Safest • Abscess may overlie trachea • Distorted anatomy and tissue planes 82Dr. ASHLY ALEXANDER
- 83. Special considerations • Image-guided Aspiration – Patient selection • Smaller abscesses, limited extension, uniloculated – Advantages • Early specimen collection • Reduced expense • Avoidance of neck scar 83Dr. ASHLY ALEXANDER
Editor's Notes
- These 2 spaces can communicate each other by mylohyoid cleft