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- 1. “Deep Neck Space Infections” Dr.Ashly Alexander ENT RSO - 2nd Year GMC Bhopal
- 2. • Anatomy ofthe Cervical Fascia • Anatomy of the Deep Neck Spaces • Deep Neck Space Infections 2 Dr. ASHLY ALEXANDER
- 3. Cervical Fascia • SuperficialFascia • Deep Fascia – Superficial(investing) – Middle(pretracheal) – Deep(prevertebral) 3 Dr. ASHLY ALEXANDER
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- 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 6 Dr. ASHLY ALEXANDER
- 7. Deep Cervical Fascia 1)Superficial layer 2) Middle layer 3) Deep layer 7 Dr. ASHLY ALEXANDER
- 8. Superficial Layer ofthe 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… 8 Dr. ASHLY ALEXANDER
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- 10. Superficial Layer ofthe Deep Cervical Fascia (Enveloping,Investing,Anterior layer) • Envelopes – SCM – Trapezius – Submandibular – Parotid • Forms floor of submandibular space • Create superficial sternal space (of Burn) 10 Dr. ASHLY ALEXANDER
- 11. Middle Layer ofthe 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…11 Dr. ASHLY ALEXANDER
- 12. Middle Layer ofthe 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 12 Dr. ASHLY ALEXANDER
- 13. Deep Layer ofDeep 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 13 Dr. ASHLY ALEXANDER
- 14. Deep Neck Spaces •Described in relation to the hyoid – Entire length of the neck – Suprahyoid – Infrahyoid 14 Dr. ASHLY ALEXANDER
- 15. Space Involving EntireLength Of Neck • Superficial space • Retropharyngeal Space • Danger Space • Prevertebral Space • Carotid Sheath Space 15 Dr. ASHLY ALEXANDER
- 16. Superficial Space • EntireLength 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 16 Dr. ASHLY ALEXANDER
- 17. Retropharyngeal Space • Entirelength 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 17 Dr. ASHLY ALEXANDER
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- 20. Danger Space Entire lengthof 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 20 Dr. ASHLY ALEXANDER
- 21. Prevertebral Space Entire lengthof 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 21 Dr. ASHLY ALEXANDER
- 22. Visceral Vascular Space (CarotidSheath 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. 22 Dr. ASHLY ALEXANDER
- 23. Space Limit ToAbove The Hyoid Bone • Submandibular Space • Parapharyngeal Space • Peritonsillar Space • Parotid Space • Masticator & Temporal Space 23 Dr. 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 24 Dr. ASHLY ALEXANDER
- 25. Submandibular Space • 2compartments – Sublingual space • Areolar tissue • Hypoglossal and lingual nerves • Sublingual gland • Wharton’s duct – Submaxillary space • Anterior bellies of digastric • Submandibular gland 25 Dr. ASHLY ALEXANDER
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- 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 27 Dr. ASHLY ALEXANDER
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- 30. Parapharyngeal Space Divided into2 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 30 Dr. ASHLY ALEXANDER
- 31. Peritonsillar Space • Suprahyoid •Medial—capsule of palatine tonsil • Lateral—superior pharyngeal constrictor 31 Dr. ASHLY ALEXANDER
- 32. Parotid Space • Suprahyoid •Superficial layer of deep fascia • Dense septa from capsule into gland • Direct communication to parapharyngeal space 32 Dr. ASHLY ALEXANDER
- 33. Masticator and TemporalSpaces • 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… 33 Dr. ASHLY ALEXANDER
- 34. Masticator and TemporalSpaces • 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 34 Dr. 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 35 Dr. ASHLY ALEXANDER
- 36. Deep Neck SpaceInfections • Etiology/ pathogenesis of Infection • Microbiology • Clinical manifestations • Some specific infections • Complications 36 Dr. ASHLY ALEXANDER
- 37. Etiopathogenesis • Deep neckspace 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 37 Dr. 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 38 Dr. 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 39 Dr. ASHLY ALEXANDER
- 40. Ludwig’s angina • Describedby 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 40 Dr. ASHLY ALEXANDER
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- 42. Ludwig’s angina • Criteriafor 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 42 Dr. 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 43 Dr. 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 44 Dr. ASHLY ALEXANDER
- 45. Ludwig’s angina 45 Dr. ASHLYALEXANDER
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- 47. Ludwig's angina Axial CTsection through the tongue demonstrates diffuse enlargement of the tongue associated with low attenuation areas consistent with phlegmon. 47 Dr. ASHLY ALEXANDER
- 48. Ludwig’s angina TREATMENT • Earlystage- 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 48 Dr. ASHLY ALEXANDER
- 49. Ludwig’s angina Complications:- Airway obstruction spreadof infection to PFS and RFS and mediastinum. Aspiration pneumonia Lung abscess Fluid and electrolyte imbalance Tongue necrosis septicemia 49 Dr. 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 50 Dr. ASHLY ALEXANDER
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- 53. • Treatment – IVantibiotics – Correct dehydration – Analgesics – Surgery • External approach (access along the carotid sheath) –Transverse submandibular incision – Mosher’s T-shaped incision 53 Dr. ASHLY ALEXANDER
- 54. Complications: • Rates ofAbout 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 54 Dr. 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 55 Dr. ASHLY ALEXANDER
- 56. Retropharyngeal Abscess 56 Dr. ASHLYALEXANDER
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- 58. Retropharyngeal Abscess • Pediatrics –Cause—suppurative process in lymph nodes • Nose, adenoids, nasopharynx, sinuses • Adults – Cause—trauma, instrumentation, extension from adjoining deep neck space 58 Dr. ASHLY ALEXANDER
- 59. Retropharyngeal Abscess • Lateralneck 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 59 Dr. ASHLY ALEXANDER
- 60. Retropharyngeal abscess, CT+Cshows a large retropharyngeal fluid collection (arrows) with peripheral rimlike enhancement 60 Dr. ASHLY ALEXANDER
- 61. Retropharyngeal Abscess • Treatment –IV antibiotics and fluid replacement – Surgical drainage • Intraoral • External – tracheostomy + anterior cervical approach 61 Dr. ASHLY ALEXANDER
- 62. Chronic Retropharyngeal abscess • Commonin 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 62 Dr. ASHLY ALEXANDER
- 63. Tuberculosis of cervical Spinewith retropharyngeal abscess 63 Dr. ASHLY ALEXANDER
- 64. Chronic Retropharyngeal abscess Diagnosis • Clinicalexamination • 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 64 Dr. ASHLY ALEXANDER
- 65. •Acute Retropharyngeal •ChronicRetropharyngeal 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 65 Dr. ASHLY ALEXANDER
- 66. Retropharyngeal abscess Complications:- meningitis haemorrhage laryngealspasm septicemia Metastatic abscess Jugular vein thrombosis Rupture with aspiration pneumonia Pericardial tamponade Mediastinitis Acute hemiplegia of childhood Spead in to other spaces 66 Dr. 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 67 Dr. ASHLY ALEXANDER
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- 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 70 Dr. 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 71 Dr. 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 72 Dr. ASHLY ALEXANDER
- 73. Peritonsillar abscess (quinsy) Complications: •Mediastinitis •Necrotizing fasciitis. •Oedema of larynx •Septicemia •IJV thrombosis •Pneumonitis or lung abscess 73 Dr. ASHLY ALEXANDER
- 74. Parotid space infections Contents:-parotidgland 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. 74 Dr. ASHLY ALEXANDER
- 75. Clinical features • usuallyfollow 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 75 Dr. ASHLY ALEXANDER
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- 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 77 Dr. ASHLY ALEXANDER
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- 79. Complications • Internal JugularVein 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 79 Dr. ASHLY ALEXANDER
- 80. Complications • Mediastinitis – Mortalityof 40% – Increasing dyspnea, chest pain – CXR - widened mediastinum – Treatment • EARLY RECOGNITION AND INTERVENTION • Aggressive IV antibiotic therapy • Surgical drainage – Transcervical approach – Chest tube / thoracotomy 80 Dr. ASHLY ALEXANDER
- 81. Complications • Cranial nervedeficits • Necrotising cervical fasciitis • Osteomyelitis • Grisel syndrome ( inflammatory torticollis causing cervical vertebral subluxation ) 81 Dr. ASHLY ALEXANDER
- 82. Special considerations • Airwayprotection – Observation – Intubation • Direct laryngoscopy: risk of rupture and aspiration • Flexible fiberoptic – Tracheostomy • Safest • Abscess may overlie trachea • Distorted anatomy and tissue planes 82 Dr. ASHLY ALEXANDER
- 83. Special considerations • Image-guidedAspiration – Patient selection • Smaller abscesses, limited extension, uniloculated – Advantages • Early specimen collection • Reduced expense • Avoidance of neck scar 83 Dr. ASHLY ALEXANDER
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