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Neck Space Infections Dr. Vishal Sharma. Fascial layers of neck A. Superficial cervical fascia: encloses platysma B. Deep cervical fascia 1. Superficial.

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Presentation on theme: "Neck Space Infections Dr. Vishal Sharma. Fascial layers of neck A. Superficial cervical fascia: encloses platysma B. Deep cervical fascia 1. Superficial."— Presentation transcript:

1 Neck Space Infections Dr. Vishal Sharma

2 Fascial layers of neck A. Superficial cervical fascia: encloses platysma B. Deep cervical fascia 1. Superficial or Investing layer 2. Middle layer 3. Deep layer a. Muscular division a. Alar fascia b. Visceral division b. Pre-vertebral fascia

3 Deep Cervical Fascia Investing layer: Encloses trapezius & SCM; parotid, submandibular gland & carotid sheath Visceral layer: Surrounds strap muscles, pharynx, larynx, esophagus, trachea, thyroid Deep layer: Covers deep neck muscles, cervical plexus, phrenic nerve & brachial plexus. Cervical sympathetic chain lies superficial to this fascia.

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6 Classification of neck spaces

7 A. Involves entire neck B. Spaces above hyoid 1. Superficial neck space 1. Submental 2. Deep neck spaces 2. Submandibular a. Carotid sheath a. Sublingual b. Retro-pharyngeal b. Submaxillary c. Danger space 3. Masticator d. Pre-vertebral 4. Parotid C. Below Hyoid 5. Parapharyngeal 1. Pre-tracheal space 6. Peri-tonsillar

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12 Masticator spaces Formed around muscles of mastication (masseter, pterygoids, insertion of temporalis) & covered by investing layer of deep cervical fascia

13 Classification of neck space infections

14 A. Involves entire neck B. Supra-hyoid abscess 1. Superficial space Sub-mental Necrotizing fascitis Masticator 2. Deep space abscess Parotid Carotid sheath Ludwigs angina Retro-pharyngeal Para-pharyngeal Danger space Peri-tonsillar (quinsy) Pre-vertebral C. Infra-hyoid abscess Pre-tracheal

15 Necrotizing fasciitis

16 Rare infection of superficial neck space causing necrosis of fascia + subcutaneous tissue, initially sparing skin & muscle Term coined in 1952 by Wilson Etiology: Dental infections, skin trauma, quinsy & parapharyngeal abscess Bacteriology: β-hemolytic streptococcus, Staphylococcus aureus, anaerobes

17 Clinical Presentation Outer zone of erythema, intermediate zone of tender ecchymosis & central zone of vesiculation + black necrosis + ulceration Fascial necrosis extends beyond skin necrosis Skin anesthesia (damage of cutaneous nerves) Soft tissue crepitus due to gas formation Hypocalcemia, hyponatremia & dehydration

18 Necrotizing fasciitis of chest

19 CT scan showing gas formation

20 Treatment Early correction of fluid & electrolyte imbalance I.V. Ampicillin + Gentamicin + Clindamycin Immediate radical debridement of necrotic tissue (in presence of subcutaneous air, progressive infection despite 48 hours of medical therapy, obvious fluctuation or skin necrosis) Skin grafting after debridement

21 Wound debridement

22 Skin grafting

23 Healed wound

24 Poor prognostic factors: Diabetes mellitus, atherosclerosis, chronic renal failure, obesity, immuno-suppression, malnutrition Complications: necrosis of chest wall fascia, mediastinitis, pleural effusion, pericardial effusion, empyema, airway obstruction, arterial erosion, jugular vein thrombophlebitis, septic shock, lung abscess, carotid artery thrombosis

25 Ludwigs Angina

26 Rapidly progressing poly-microbial cellulitis of sublingual & submaxillary spaces with potentially life-threatening airway compromise

27 Submandibular space Boundaries: Anterior & lateral: mandible Medial: anterior belly of digastric Posterior: submandibular gland Inferior: level of hyoid bone Subdivisions: 1. Sublingual space: above mylohyoid muscle 2. Submaxillary space: below mylohyoid muscle Contents: Submandibular salivary gland, lymph nodes

28 Etiology of Ludwigs angina

29 A. Lower dental or periodontal infection (80%): 1. Poor dental hygiene (caries & abscess) 2. Tooth extraction (lower molars & premolars) Roots of premolars & 1 st molar lie above mylohyoid sublingual space infection Roots of 2 nd & 3 rd molars lie below mylohyoid submaxillary space infection B. Others (20%): submandibular sialadenitis, floor of mouth trauma, mandibular fractures

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33 Mixed aerobic & anaerobic infection Streptococcus pyogenes Streptococcus viridans Streptococcus pneumoniae Staphylococcus Fusobacterium Bacteroides Peptostreptococcus Causative organisms

34 Toothache, fever, odynophagia, drooling Floor of mouth swelling + tongue elevation in sublingual space infection Brawny / woody tender swelling below chin in submaxillary space infection Trismus Stridor: falling back of tongue, laryngeal edema Initial cellulitis delayed pus formation Clinical Features

35 Elevation of tongue

36 Submandibular swelling

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38 X-ray soft tissue neck lateral assess degree of soft tissue swelling & airway obstruction

39 C.T. scan

40 Treatment of Ludwigs angina

41 1. I.V. antibiotics: Cefuroxime / Ceftriaxone + Metronidazole / Clindamycin 2. Airway: endotracheal intubation / tracheostomy 3. Incision & drainage of serous fluid / pus a. Intra-oral: for sublingual space infection b. Extra-oral: for submaxillary space infection Transverse incision from one angle of mandible to opposite angle of mandible 4. IV fluid for adequate hydration 5. Periodic assessment for disease progression & airway compromise

42 Incision drainage + Tracheostomy

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44 Parapharyngeal abscess Retropharyngeal abscess Acute airway obstruction (within hours): due to pushing back of tongue, laryngeal edema Aspiration pneumonia Septicemia Death Complications

45 Retropharyngeal abscess

46 Retropharyngeal Space Superior: Base of skull Inferior: Mediastinum (till tracheal bifurcation) Anterior: Buccopharyngeal fascia Posterior: Alar fascia Lateral: Parapharyngeal spaces Divided into two lateral compartments (space of Gillette) by midline fibrous raphe

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48 Retropharyngeal abscess Collection of pus in retropharyngeal space Classification: 1. Acute 2. Chronic Acute abscess is common in children below 3-5 yrs as retropharyngeal nodes of Rouviere regress later

49 Acute Retropharyngeal Abscess

50 Etiology Suppuration of retropharyngeal lymph node of Rouviere from upper respiratory tract infection Penetrating injury of posterior pharyngeal wall (e.g.. fish bone, vertebral fracture) Following endoscopic trauma to pharynx Acute mastoitis: pus tracking under petrous bone

51 Symptoms H/o upper respiratory tract infection Dysphagia / odynophagia Difficulty in breathing Croupy cough Hot potato voice Neck stiffness

52 Signs Febrile, ill-looking, child with drooling Tender neck swelling + fistula Torticollis (twisted neck) on side of abscess followed by hyperextension of neck U/L bulge on posterior pharyngeal wall

53 Posterior pharyngeal wall swelling on left side

54 Endoscopic view of posterior pharyngeal wall bulge

55 X-ray soft tissue neck (lateral) 1. Widened pre-vertebral soft tissue shadow a. > 7 mm at C2 vertebra b. > 14 mm at C6 vertebra below 14 years c. > 22 mm at C6 vertebra above 14 years 2. Presence of air-fluid level & / gas (acute cases) 3. Homogenous pre-vertebral shadow (chronic) 4. Straightening of cervical spine curve due to spasm of pre-vertebral muscles

56 High retropharyngeal abscess

57 Air-fluid level & gas shadow

58 CT scan axial cuts

59 Treatment 1. IV antibiotics: Ceftriaxone + Metronidazole 2. Incision & drainage: No anesthesia (as it may rupture abscess) or very careful endotracheal intubation Supine with head hanging low from table Vertical or horizontal incision on fluctuant area Incision + immediate suction of pus 3. Tracheostomy for airway obstruction

60 Chronic Retropharyngeal Abscess

61 Etiology Caries of cervical spine: presents as central posterior pharyngeal wall swelling Tubercular infection of retropharyngeal lymph nodes from infected deep cervical nodes: presents as lateral posterior pharyngeal wall swelling true retropharyngeal abscess Post traumatic: vertebral fracture Spread from parapharyngeal abscess

62 Clinical Features Chronic mild dysphagia Pain is absent due to cold abscess Bulge of posterior pharyngeal wall with fluctuant swelling (central or lateral) Investigations As in acute retropharyngeal abscess Ziehl Neelsen stain of pus after aspiration

63 X-ray soft tissue neck (lateral): homogenous opacity

64 Tuberculosis of cervical spine with chronic retropharyngeal abscess

65 Treatment 1. I.V. antibiotics: Ceftriaxone + Metronidazole 2. Incision & drainage: Low abscess: along anterior border of sternocleidomastoid muscle High abscess: along posterior border of sternocleidomastoid muscle 3. Anti-tubercular therapy for months

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

67 Parapharyngeal abscess

68 Parapharyngeal space Base & superior limit: Skull Base Apex: Lesser cornu of hyoid Lateral: Mandible ramus, Medial Pterygoid, Parotid Medial: Bucco-pharyngeal fascia, superior constrictor Anterior: Pterygo-mandibular raphe Posterior: Pre-vertebral fascia Inferior: Deep cervical fascia lateral to mandible angle

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71 Contents Pre-styloid Deep lobe of parotid Internal maxillary artery Inferior alveolar nerve Lingual nerve Auriculo-temporal nerve Lymph nodes Styloid: Styloid process, its 3 muscles + 2 ligaments Post-styloid Internal carotid artery Internal jugular vein Last 4 cranial nerves Sympathetic chain Glomus system Lymph nodes

72 Etiology Pharynx: acute tonsillitis, peritonsillar abscess Teeth: dental infection (esp. lower last molar) Ear: Bezolds abscess Spread from other neck abscess: parotid, retropharyngeal, submandibular Penetrating neck injuries

73 Clinical Features 1. Fever, sore throat, odynophagia, torticollis 2. Anterior compartment involvement: a. Tonsils pushed medially b. Trismus c. Neck swelling behind angle of mandible 3. Posterior compartment involvement: a. Medial bulge behind posterior pillar of tonsil b. Paralysis of IX, X, XI, XII & sympathetic chain

74 CT scan neck: axial cuts

75 Treatment 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 / trismus

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77 Peritonsillar abscess (Quinsy)

78 Etio-pathogenesis Pus present between tonsillar capsule & superior constrictor muscle Pathology: aerobic + anaerobic organisms 1. Acute tonsillitis blockage of crypts intra tonsillar abscess peritonsillitis quinsy 2. Abscess of Weber's salivary gland in supra tonsillar fossa quinsy

79 Clinical features Symptoms: Young adult with severe odynophagia, fever, halitosis & muffled voice Signs: 1. Para-tonsil area swollen & congested 2. U/L tonsil ed, pushed medially, congested 3. Jugulo-digastric lymph node tender, enlarged 4. Trismus 5. Torticollis

80 Peri-tonsillitis & Quinsy

81 Management Diagnosis: Needle aspiration reveals pus Medical treatment: 1. Urgent admission, I.V. fluids 2. I.V. Cefotaxime + Metronidazole 3. Antihistamine - decongestant + analgesic 4. Betadine gargle

82 Needle aspiration

83 Incision

84 Incision line & quinsy forceps

85 Alternate incision site at maximum bulge

86 Abscess drainage

87 Incision & drainage Incision made with # 11 blade or Thilenius peritonsillar abscess drainage forceps Nick made above & lateral to junction of 2 imaginary lines. Horizontal along base of uvula, vertical along anterior tonsillar pillar. Incision widened with sinus forceps & pus drained. No anesthesia is required.

88 Surgical treatment 1. Interval tonsillectomy after 4 – 6 wk. 2. Hot tonsillectomy or abscess tonsillectomy is avoided as it leads to: more bleeding septicemia

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

90 Parotid abscess

91 Parotid Space Formed due to splitting of investing layer of deep cervical fascia around parotid salivary gland

92 Etiology Ascent of bacterial infection (Staphylococcus, Haemophillus, Streptococcus) to a dehydrated parotid gland along parotid duct from oral cavity Suppuration of intra-parotid lymph nodes Spread of infection from EAC via cartilaginous fissures of Santorini or bony foramen of Huschke

93 Causes of parotid dehydration 1. Post-operative patient (surgical mumps) 2. Medications that decrease salivary flow: Antihistamines Tricyclic antidepressants Barbiturates Diuretics Parasympathomimetics

94 Parotid abscess Pain + induration over parotid gland Pitting edema of parotid area differentiates parotid abscess from simple parotitis Parotid massage expresses pus from parotid duct into oral cavity (opposite upper 2 nd molar)

95 Investigation C.B.P.: Leukocytosis Needle aspiration with 18 G needle Ultrasonography C.T. scan M.R.I.

96 C.T. scan & M.R.I.

97 Parotid anatomy

98 Treatment 1. IV fluid for dehydration 2. IV Ampicillin + Gentamicin + Metronidazole 3. Incision drainage: a. Blairs incision made b. Multiple incisions made through fascia, parallel to facial nerve branches c. Blunt dissection to evacuate pus. Drains placed.

99 Thank You


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