Deep neck space infections

1. Deep neck space infections Dr. SheetalRai Assistant Professor Dept of ENT Yenepoya Medical College Mangalore

2. Anatomy of deep neck spaces

3. Neck is divided into 4 compartments by the deep fascia • 2 neurovascular compartments • Visceral compartment • Musculoskeletal compartment • Deep fascia of the neck can be divided into three layers • Investing layer • Pretracheal layer • Prevertebral layer

4. Investing layer of DCF • Attachments • Superior, inferior, anterior & posterior • Spaces: parotid & masticator • Submental space

6. Middle layer or pre-tracheal layer • Encloses viscera, strap muscles, neurovascular structures • Attachments superior: base of skull Inferior: continues with fibrous pericardium • Buccopharyngeal fascia • Surgical importance

8. Carotid sheath • Superior: base of skull • Inferior : merges around arch of aorta & pericardium • CONTENTS • Carotid artery • Vagus nerve • IJV • Cervical sympathetic trunk

9. Deep layer of DCF • Arises from spinous processes & ligamentumnuchae • Splits into 2 layers 1. ALAR superior: base of skull inferior: upper mediastinum T1 – T2 2. PREVERTEBRAL skull base to coccyx Extends as axillary sheath

13. DEEP NECK SPACE INFECTIONS

14. Source of infection • Dental infection • Isolated nodal abscesses • Peritonsillar cellulitis or abscess • Upper aerodigestive trauma • Retropharyngeal lymphadenitis • Pott’s disease • Sialadenitis • Bezold’s abscess • Congenital cysts and fistulae • Subcuteneous or IV drug abuse

15. Microbiology • Mixed microbial flora • α and β hemolytic streptococcus • Staphylococcus • Peptostreptococcus • Bacteroides melanogenica • B.oralis • Veillonella • Actinomyces • Spirochaetes • Ekinella corrodens

16. Clinical manifestations • Pain • Fever • Trismus and limitation of neck movements OTHERS Dysphagia Odynophagia Change in voice Dyspnoea

17. General work up • Careful history • Complete physical examination • Investigations • CBC, Blood Culture • X-rays : Lateral neck X-ray • Non invasive techniques : CT or MRI

18. Specific Deep Neck Infections

19. Ludwig’s Angina • Infection of Submandibular space • Origin in submaxillary space  sublingual space

20. Submandibular space • Divided by mylohyoid into two spaces-submaxillary and sublingual. • Boundaries-sup,inf,lat,floor. • Contents- submandibular gland, Wharton’s duct, lingual & hypoglossal nerve, branch of facial artery and lymphatics

23. Ludwig’s Angina Criteria for Diagnosis • Rapidly progressing cellulitis; no tendency to form abscess • Involvement of submaxillary & sublingual space • Spread along fascial planes • Involvement of muscle & facsia but not submandibular gland & LN

24. Clinical features • Fever • Increasing oral or neck pain & swelling • Neck rigidity • Trismus, odynophagia • Drooling of saliva • Dyspnoea & stridor

25. On examination • Floor of the mouth swollen and inflammed, tense, indurated • Tongue displaced upwards & backwards towards the palatal vault • Woody induration • X-ray : shows soft tissue edema airway encroachment

28. Treatment • Early stage : IV antibiotics, supportive measures, extraction of inciting tooth • Advanced stage : Surgery • Secure Airway : Tracheostomy under LA • Surgical Drainage : Incision – Median horizontal incision 2 ½ breadths below the mandibular margin • Drainage : Multiple drains placed & wound left open.

29. Complications • Airway obstruction • Spread of infection to carotid sheath or retropharyngeal space  mediastinal extension

30. Parapharyngeal abscess

31. Parapharyngeal space • Inverted pyramidal shape • Boundaries base-petrous temporal bone apex- hyoid bone med-BP fascia post-prevertebral fascia lat-med pterygoidmuscle,mandible,deep parotid gland

33. Divided into anterior & post compartment by styloid process and muscles attached • Contents-carotid art, IJV, 9th,10th,11th and 12th C N, sympathetic trunk & upper deep cervical nodes

35. Aetiology: • pharynx: acute & chronic tonsillitis, adenoiditis, peritonsillar abscess • Teeth: infn. from lower last molar tooth • Ear: Bezold’s abscess, petrositis • Other spaces: infn from parotid, Retropharyngeal space, submaxillary space • External trauma: penetrating neck injuries

36. Clinical features Anterior compartment involvement: • Anterior & medial displacement of the tonsil • Trismus • External swelling behind the angle of the jaw Posterior compartment involvement: • Swelling of the palate & lat pharyngeal wall behind the posterior pillar • Paralysis of cranial nerves 9,10,11,12 & cervical sympathetic chain[HORNER’S SYNDROME] • Swelling of the parotid region

37. Common to both compartments: • Fever • Odynophagia • Sore throat • Torticollis • Signs of toxemia

38. Treatment • Early stage:IV antibiotics, fluid replacement, close observation • Late stage:surgical drainage • Approaches:intraoral or extraoral • Extraoral :submandibular incision two & half finger breadths inferior to mandibular margin from ant. limit of submandibular gland to just past the angle of the mandible • Vertical incision at the ant.border of SCM along with transverse for carotid sheath exploration[Mosher]

39. Complications • Airway compromise • IJV thrombosis • Mediastinitis • Carotid artery h’ge

40. Retropharyngeal abscess

41. Retropharyngeal space • Lies b/w pharynx, oesophagus & alar layer of DCF • Boundaries sup-base of skull inf-T2 vertebra ant- B P fascia post- alar layer

42. Aetiology: Abscessed LNs draining ear, nose & throat. Regional trauma: FB ingestion oral endotracheal intubation endoscopic procedures Retropharngeal space

43. Children Irritability, poor appetite, fever Neck rigidity, tenderness, muffled cry, drooling, dyspnoea. Adults Fever, sore throat, odynophagia, neck tenderness. U/L swelling of posterior pharyngeal wall pushing the soft palate forwards. DD: Pott’s abscess. Inv: X ray lat view of neck. CXR: Mediastinal involvement Clinical features

44. Management • Initial : IV antibiotics/ Fluid replacement. • Surgical: Incision & Drainage per oral (Rose’s position) • Inferior extension: Anterior cervical approach or DEAN approach. • Incision along SCM from hyoid to cricoid. • Complications: Haemorrhage, aspiration, Danger space infection

45. Peritonsillar abscess

46. Peritonsillar space • Between capsule of the tonsil and superior constrictor muscle. • Importance –spread of infection to para pharyngeal space, carotid sheath and mediastinum. • posterior spread to retropharyngeal space.

47. Peritonsillar abscess • Aetiology : Follows acute tonsillitis • Bacteriology: Mixed growth • Clinical Features : young adults, Unilateral • General symptoms : Fever, chills, malaise • Local: Severe throat pain , odynophagia, drooling of saliva, hot patato voice, foul breath, ipsilateral ear ache, trismus

48. On examination: • tonsil pillars and soft palate, congested & swollen • Uvula oedematous, pushed to opposite side • Bulging of soft palate & anterior pillar above the tonsil • Tender enlarged JD nodes Torticollis

49. Treatment • Hospitalisation • Aspiration of pus with a wide bore needle • Analgesics & IV antibiotics • Incision & Drainage • Quinsy forceps is used • Incision made at the point of maximum bulge or at the point where two imaginary lines meet – one drawn along the base of the uvula and the other drawn vertically along the anterior pillar.(shown in asterix in the picture above) • Interval tonsillectomy

50. Complications: • Respiratory obstruction • Parapharyngeal abscess • IJV thrombosis • Carotid artery H’ge • Septicemia, pneumonitis