PPT

1. Head and Neck Space Infections
Dr. SRIKANTH REDDY. B
MBBS MS ENT
ASSISSTANT PROFESSOR
TRR MEDICAL COLLEGE

3. PAROTID ABSCESS
• It is suppuration of the parotid space.
• Deep cervical fascia splits into two layers, superficial
and deep, to enclose the parotid gland and its
associated structures.
• Parotid space lies deep to its superficial layer.
• Contents of parotid space include parotid gland and its
associated parotid lymph nodes, facial nerve, external
carotid artery and retromandibular vein.
• Fascial layer is very thick superficially but very thin on
the deep side of the parotid gland where parotid
abscess can burst to form a parapharyngeal abscess
and thence spread to the mediastinum.

4. AETIOLOGY
• Dehydration, particularly in postsurgical cases
and debilitated patients, with stasis of salivary
flow is the predisposing cause.
• Infection from the oral cavity travels via the
• Stenson’s duct to invade the parotid gland.
• Multiple small abscesses may form in the
parenchyma.
• They may then coalesce to form a single
abscess.

5. BACTERIOLOGY
• Most common organism is Staphylococcus
aureus but Streptococci, anaerobic organisms
and rarely the Gram-negative organisms have
been cultured

6. CLINICAL FEATURES
• Usually follows 5–7 days after operation.
• There is swelling, redness, indurations and tenderness
in the parotid area and at the angle of mandible.
• Parotid abscess is usually unilateral, but bilateral
abscesses may occur.
• Fluctuation is difficult to elicit due to thick capsule.
• Opening of the Stenson’s duct becomes congested and
may exude pus on pressure over the parotid.
• Patient is toxic, running high fever and dehydrated.

7. DIAGNOSIS
• Diagnosis of the abscess can be made by
ultrasound or computed tomography scan.
• More than one loculi of pus be seen.
• Aspiration of abscess can be done for culture
and sensitivity of the causative organisms.

8. TREATMENT
• Correct the dehydration, improve oral hygiene and promote
salivary flow.
• Intravenous antibiotics are instituted.
• Surgical drainage under local or general anaesthesia is
carried out by a preauricular incision as employed for
parotidectomy.
• Skin flap is raised to expose surface of the gland, and the
abscess or abscesses are bluntly opened working parallel to
the branches of the VIIth nerve.
• Skin incision is loosely approximated over a drain and
allowed to heal by secondary intention.

9. LUDWIG’S ANGINA
• Submandibular space lies between mucous membrane of the floor
of mouth and tongue on one side and superficial layer of deep
cervical fascia extending between the hyoid bone and mandible on
the other.
• It is divided into two compartments by the mylohyoid muscle:
1. Sublingual compartment (above the mylohyoid).
2. Submaxillary and submental compartment (below the
mylohyoid).
• The two compartments are continuous around the posterior border
of mylohyoid muscle.
• Ludwig’s angina is infection of submandibular space.

10. APPLIED ANATOMY

11. AETIOLOGY
1. Dental Infections.
• They account for 80% of the cases.
• Roots of premolars often lie above the attachment of
mylohyoid and cause sublingual space infection while
roots of the molar teeth extend up to or below the
mylohyoid line and primarily cause submaxillary space
infection (Figure 52.2).
2. Submandibular Sialadenitis, Injuries of Oral
• Mucosa and Fractures of the Mandible account for
other cases.

13. BACTERIOLOGY
• Mixed infections involving both aerobes and
anaerobes are common.
• Alpha-haemolytic Streptococci, Staphylococci
and bacteroides groups are common.
• Rarely Haemophilus influenzae, Escherichia
coli and Pseudomonas are seen

14. CLINICAL FEATURES
• There is marked difficulty in swallowing (odynophagia) with varying
degrees of trismus.
• When infection is localized to the sublingual space, structures in the
floor of mouth are swollen and tongue seems to be pushed up and
back.
• When infection spreads to submaxillary space,submental and
submandibular regions become swollen and tender, and impart
woody-hard feel.
• Usually, there is cellulitis of the tissues rather than frank abscess.
• Tongue is progressively pushed upwards and backwards threatening
the airway.
• Laryngeal oedema may appear (Figure 52.3).

16. TREATMENT
1. Systemic antibiotics.
2. Incision and drainage of abscess.
(a) Intraoral—if infection is still localized to sublingual
space.
(b) External—if infection involves submaxillary space.
• A transverse incision extending from one angle of
mandible to the other is made with vertical opening
of midline musculature of tongue with a blunt haemostat.
• Very often it is serous fluid rather than frank pus that is
encountered.
3. Tracheostomy, if airway is endangered.

17. COMPLICATIONS
1. Spread of infection to parapharyngeal and
retropharyngeal spaces and thence to the
mediastinum.
2. Airway obstruction due to laryngeal oedema,
or swelling and pushing back of the tongue.
3. Septicaemia.
4. Aspiration pneumonia.

18. PERITONSILLAR ABSCESS (QUINSY)
• It is a collection of pus in the peritonsillar
space which lies between the capsule of tonsil
and the superior constrictor muscle

19. AETIOLOGY
• Peritonsillar abscess usually follows acute tonsillitis though it may
arise de novo without previous history of sore throats.
• First, one of the tonsillar crypts, usually the crypta magna, gets
infected and sealed off.
• It forms an intratonsillar abscess which then bursts through
the tonsillar capsule to set up peritonsillitis and then an abscess.
• Culture of pus from the abscess may reveal pure growth
of Streptococcus pyogenes, S. aureus or anaerobic organisms.
• More often the growth is mixed, with both aerobic and
anaerobic organisms.

20. CLINICAL FEATURES
• Peritonsillar abscess mostly affects adults and
rarely the children though acute tonsillitis is
more common in children.
• Usually, it is unilateral though occasionally
bilateral abscesses are recorded.
• Clinical features are divided into:
1) GENERAL
2) LOCAL

21. 1. General
• They are due to septicaemia and resemble
any acute infection.
• They include fever (upto 104 °F), chills and
rigors, general malaise, body aches, headache,
nausea and constipation.

22. 2. Local
(a) Severe pain in throat. Usually unilateral.
(b) Odynophagia. It is so marked that the patient cannot
even swallow his own saliva which dribbles from the angle of his
mouth.
• Patient is usually dehydrated.
(c) Muffled and thick speech, often called “hot potato voice.”
(d) Foul breath due to sepsis in the oral cavity and poor hygiene.
(e) Ipsilateral earache. This is referred pain via CN IX which supplies
both the tonsil and the ear.
(f) Trismus due to spasm of pterygoid muscles which are in close
proximity to the superior constrictor.

23. EXAMINATION
1. The tonsil, pillars and soft palate on the involved side are congested and
swollen.
Tonsil itself may not appear enlarged as it gets buried in the oedematous pillars
(Figure 52.4).
2. Uvula is swollen and oedematous and pushed to the opposite side.
3. Bulging of the soft palate and anterior pillar above the tonsil.
4. Mucopus may be seen covering the tonsillar region.
5. Cervical lymphadenopathy is commonly seen.
• This involves jugulodigastric lymph nodes.
6. Torticollis. Patient keeps the neck tilted to the side of abscess.

25. INVESTIGATION
• Contrast-enhanced CT or MRI shows the
abscess and its extent.
• Needle aspiration of an abscess provides
material for culture and sensitivity of bacteria.

26. TREATMENT
1. Hospitalization.
2. Intravenous fluids to combat dehydration.
3. Antibiotics. Suitable antibiotics in large i.v. doses to
cover both aerobic and anaerobic organisms.
4. Analgesics like paracetamol are given for relief of pain
and to lower the temperature. Sometimes, stronger
analgesics like pethidine may be required.
• Aspirin is avoided because of the danger of bleeding.
5. Oral hygiene should be maintained by hydrogen peroxide
or saline mouth washes.

27. RETROPHARYNGEAL ABSCESS
APPLIED ANATOMY
Retropharyngeal space.
• It lies behind the pharynx between the buccopharyngeal fascia covering pharyngeal constrictor
muscles and the prevertebral fascia.
• It extends from the base of skull to the bifurcation of trachea.
•
• The space is divided into two lateral compartments (spaces of Gillette) by a fibrous raphe (Figure
52.6).
• Each lateral space contains retropharyngeal nodes which usually disappear at 3–4 years of age.
• Parapharyngeal space communicates with the retropharyngeal space.
• Infection of retropharyngeal space can pass down behind the oesophagus into the mediastinum.

28. Retropharyngeal space.

29. APPLIED ANATOMY
Prevertebral space.
• It lies between the vertebral bodies posteriorly
and the prevertebral fascia anteriorly.
• It extends from the base to skull of coccyx.
• Infection of this space usually comes from the
caries of spine.
• Abscess of this space produces a midline bulge in
contrast to abscess of retropharyngeal space
which causes unilateral bulge.

30. ACUTE RETROPHARYNGEAL ABSCESS
AETIOLOGY
• It is commonly seen in children below 3 years.
• It is the result of suppuration of retropharyngeal lymph nodes
secondary to infection in the adenoids, nasopharynx, posterior
nasal sinuses or nasal cavity.
• In adults, it may result from penetrating injury of posterior
pharyngeal wall or cervical oesophagus.
• Rarely, pus from acute mastoiditis tracks along the undersurface of
petrous bone to present as retropharyngeal abscess.

31. CLINICAL FEATURES
1. Dysphagia and difficulty in breathing are
prominent symptoms as the abscess obstructs
the air and food passages.
2. Stridor and croupy cough may be present.
3. Torticollis. The neck becomes stiff and the head
is kept extended.
4. Bulge in posterior pharyngeal wall. Usually
seen on one side of the midline.

32. DIAGNOSIS
• Radiograph of soft tissue,
lateral view of the neck shows
widening of prevertebral
shadow and possibly even the
presence of gas .
• A contrast-enhanced CT
• shows the extent of the
abscess and also if it extends
below the hyoid bone.
• Any associated abscess, for
example of the
parapharyngeal space, may
also be seen.

33. TREATMENT
1. Incision and Drainage of Abscess.
• This is usually done without anaesthesia as there is risk of rupture of abscess during
intubation.
• Child is kept supine with head low.
• Mouth is opened with a gag.
• A vertical incision is given in the most fluctuant area of the abscess.
• Suction should always be available to prevent aspiration of pus.
• If done under GA, care should be taken that the abscess does not rupture during
intubation with aspiration of pus.
• The pharynx is always packed.
• Aspiration for an abscess can be done before incision to break the pressure in the abscess
and gush of pus.
2. Systemic Antibiotics. Suitable antibiotics are given.
3. Tracheostomy.
• A large abscess may cause mechanical obstruction to the airway or lead to laryngeal oedema.
• Tracheostomy becomes mandatory in these cases.

34. CHRONIC RETROPHARYNGEAL ABSCESS
(PREVERTEBRAL ABSCESS)
AETIOLOGY
• It is tubercular in nature and is the result of:
(i) caries of cervical spine or
(ii) tuberculous infection of retropharyngeal lymph
nodes secondary to tuberculosis of deep cervical
nodes.
• The former presents centrally behind the prevertebral
fascia while the latter is limited to one side of midline
as in true retropharyngeal abscess behind the
buccopharyngeal fascia.

35. CLINICAL FEATURES
• Patient may complain of discomfort in throat.
• Dysphagia, though present, is not marked.
• Posterior pharyngeal wall shows a fluctuant
swelling centrally or on one side of midline .
• Neck may show tuberculous lymph nodes.
• In cases with caries of cervical spine, X-rays are
diagnostic.

36. PREVERTEBRAL ABSCESS

37. TREATMENT
1. Incision and drainage of abscess.
• It can be done through a vertical incision along the :
Anterior border of sternomastoid (for low abscess)
or
Posterior border (for high abscess).
2. Full course of antitubercular therapy should be
given in cases of tubercular abscess.

38. PARAPHARYNGEAL ABSCESS
Syn.
• Abscess of pharyngomaxillary space or
• Lateral pharyngeal space.
APPLIED ANATOMY
• Parapharyngeal space is pyramidal in shape
with its base at the base of skull and its apex
at the hyoid bone.

39. RELATIONS
Medial.
Buccopharyngeal fascia covering the constrictor
muscles.
Posterior.
Prevertebral fascia covering prevertebral muscles
and transverse processes of cervical vertebrae.
Lateral.
Medial pterygoid muscle, mandible and deep
surface of parotid gland.

40. PARAPHARYNGEAL SPACE

42. PARAPHARYNGEAL SPACE
• Styloid process and the muscles attached to it divide the
parapharyngeal space into anterior and posterior compartments.
• Anterior compartment is related to tonsillar fossa medially and
medial pterygoid muscle laterally.
• Posterior compartment is related to posterior part of lateral
pharyngeal wall medially and parotid gland laterally.
• Through the posterior compartment pass the carotid artery, jugular
vein, IXth, Xth, XIth, XIIth cranial nerves and sympathetic trunk.
• It also contains upper deep cervical nodes.

43. COMMUNICATIONS
• Parapharyngeal space communicates with
other spaces, viz.
• Retropharyngeal,
• Submandibular,
• Parotid,
• Carotid and
• Visceral.

44. AETIOLOGY
• Infection of parapharyngeal space can occur from:
1. Pharynx. Acute and chronic infections of tonsil and
adenoid, bursting of peritonsillar abscess.
2. Teeth. Dental infection usually comes from the lower
last molar tooth.
3. Ear. Bezold abscess and petrositis.
4. Other spaces. Infections of parotid, retropharyngeal
and submaxillary spaces.
5. External trauma. Penetrating injuries of neck, injection
of local anaesthetic for tonsillectomy
or mandibular nerve block.

45. CLINICAL FEATURES
Clinical features depend on the compartment involved.
Anterior compartment infections produce a triad of
symptoms:
(i) prolapse of tonsil and tonsillar fossa,
(ii) trismus (due to spasm of medial pterygoid muscle)
(iii) external swelling behind the angle of jaw.
• There is marked odynophagia associated with it.

46. CLINICAL FEATURES
Posterior compartment involvement produces
(i) bulge of pharynx behind the posterior pillar,
(ii) paralysis of CN IX, X, XI, and XII and sympathetic chain,
(iii) swelling of parotid region.
• There is minimal trismus or tonsillar prolapse.
• Fever, odynophagia, sore throat, torticollis (due to
spasm of prevertebral muscles) and signs of toxaemia
are common to both compartments.

47. DIAGNOSIS
• Contrast-enhanced CT scan neck will reveal
the extent of a lesion.
• Magnetic resonance arteriography is useful if
thrombosis of the internal jugular vein or
aneurysm of the internal carotid artery is
suspected.

48. COMPLICATIONS
1. Acute oedema of larynx with respiratory obstruction.
2. Thrombophlebitis of jugular vein with septicaemia.
3. Spread of infection to retropharyngeal space.
4. Spread of infection to mediastinum along the carotid
space.
5. Mycotic aneurysm of carotid artery from weakening of
its wall by purulent material. It may involve common
carotid or internal carotid artery.
6. Carotid blow out with massive haemorrhage.

49. TREATMENT
1. Systemic antibiotics.
• Intravenous antibiotics may become necessary to combat infection.
• Antibiotics should be able to affect both aerobic and anaerobic
organisms.
• Antibiotics selected for treatment are amoxicillin–clavulanic acid,
imipenem or meropenem along with clindamycin or metronidazole.
• Gentamicin is useful for Gram-negative bacteria.
• The sensitivity of an antibiotic should determine the selection
of antibiotic.

50. TREATMENT
2. Drainage of abscess.
• This is usually done under general anaesthesia.
• If the trismus is marked, preoperative tracheostomy becomes mandatory.
• Abscess is drained by a horizontal incision, made 2–3 cm below the angle of
mandible.
• Blunt dissection along the inner surface of medial pterygoid muscle towards
styloid process is carried out and abscess evacuated.
• A drain is inserted.
• Transoral drainage should never be done due to danger of injury to great vessels
which pass through this space.

51. MASTICATOR SPACE
• It lies between two layers of deep cervical
fascia; the superficial (lateral) layer covers the
masseter and temporal muscles while deep
layer covers the medial and lateral pterygoids
muscles medially.
• It consists of three spaces:
(i) masseteric space,
(ii) temporal space
(iii) pterygomandibular space

53. Contents
• Masseter muscle,
• Medial and lateral pterygoid muscles,
• Temporalis muscle tendon attached to coronoid
process,
• Ramus and posterior part of mandible,
• Maxillary artery and its inferior alveolar branch and
• Inferior alveolar nerve.
• It communicates with the parotid and parapharyngeal
spaces.

54. • Dental infections, particularly of the second and third
molar teeth, are the most common source of abscess
formation.
• To drain the abscess, this space can be approached
through an incision just lateral to the retromolar
trigone and bluntly reaching the masseteric space and
pterygomandibular spaces.
• Temporal space(s) can be drained by a horizontal
incision above the zygomatic arch.