Neck space infections

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Transcript Neck space infections

Neck Space Infections

Dr. Vishal Sharma

Fascial layers of neck

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

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.

Classification of neck spaces

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

Masticator spaces

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

Classification of neck space infections

A. Involves entire neck 1. Superficial space

Necrotizing fascitis 2. Deep space abscess

Carotid sheath


Danger space

Pre-vertebral B. Supra-hyoid abscess




Ludwig’s angina


Peri-tonsillar (quinsy) C. Infra-hyoid abscess


Necrotizing fasciitis

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

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

Necrotizing fasciitis of chest

CT scan showing gas formation


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

Wound debridement

Skin grafting

Healed wound

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

Ludwig’s Angina

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

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

Etiology of Ludwig’s angina

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

Causative organisms

Mixed aerobic & anaerobic infection

Streptococcus pyogenes

Streptococcus viridans

Streptococcus pneumoniae





Clinical Features

Toothache, fever, odynophagia, drooling

Floor of mouth swelling + tongue elevation in sublingual space infection

Brawny / woody tender swelling below chin in submaxillary space infection


Stridor: falling back of tongue, laryngeal edema

Initial cellulitis

delayed pus formation

Elevation of tongue

Submandibular swelling

Submandibular swelling

X-ray soft tissue neck lateral

assess degree of soft tissue swelling & airway obstruction

C.T. scan

Treatment of Ludwig’s angina

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

Incision drainage + Tracheostomy

Incision drainage + Tracheostomy


Parapharyngeal abscess

Retropharyngeal abscess

Acute airway obstruction (within hours): due to pushing back of tongue, laryngeal edema

Aspiration pneumonia



Retropharyngeal abscess

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

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

Acute Retropharyngeal Abscess


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


H/o upper respiratory tract infection

Dysphagia / odynophagia

Difficulty in breathing

Croupy cough

Hot potato voice

Neck stiffness


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

Posterior pharyngeal wall swelling on left side

Endoscopic view of posterior pharyngeal wall bulge

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

High retropharyngeal abscess

Air-fluid level & gas shadow

CT scan axial cuts


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

Chronic Retropharyngeal Abscess


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

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

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

Tuberculosis of cervical spine with chronic retropharyngeal abscess


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 9 - 12 months


1. Airway obstruction:

mechanical obstruction

laryngeal edema 2. Spread of abscess to other neck spaces 3. Spontaneous rupture of abscess 4. Septicemia 5. Death

Parapharyngeal abscess

Parapharyngeal space

Base & superior limit:

Skull Base


Lesser cornu of hyoid


Mandible ramus, Medial Pterygoid, Parotid


Bucco-pharyngeal fascia, superior constrictor


Pterygo-mandibular raphe


Pre-vertebral fascia


Deep cervical fascia lateral to mandible angle


 Deep lobe of parotid  Internal maxillary artery  Inferior alveolar nerve  Lingual nerve  Auriculo-temporal nerve  Lymph nodes



 Internal carotid artery  Internal jugular vein  Last 4 cranial nerves  Sympathetic chain  Glomus system  Lymph nodes


Styloid process, its 3 muscles + 2 ligaments


Pharynx: acute tonsillitis, peritonsillar abscess

Teeth: dental infection (esp. lower last molar)

Ear: Bezold’s abscess

Spread from other neck abscess: parotid, retropharyngeal, submandibular

Penetrating neck injuries

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

CT scan neck: axial cuts


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

Peritonsillar abscess (Quinsy)

Etio-pathogenesis Pus present between tonsillar capsule & superior constrictor muscle Pathology: aerobic + anaerobic organisms 1. Acute tonsillitis

blockage of crypts

intra tonsillar abscess


quinsy 2. Abscess of Weber's salivary gland in supra tonsillar fossa


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

Peri-tonsillitis & Quinsy


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

Needle aspiration


Incision line & quinsy forceps

Alternate incision site at maximum bulge

Abscess drainage

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.

Surgical treatment

1. Interval tonsillectomy

after 4 – 6 wk.

2. Hot tonsillectomy or abscess tonsillectomy is avoided as it leads to:

more bleeding


Complications of quinsy

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

Parotid abscess

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


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

Causes of parotid dehydration 1. Post-operative patient (surgical mumps) 2. Medications that decrease salivary flow:


Tricyclic antidepressants




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)


C.B.P.: Leukocytosis

Needle aspiration with 18 G needle


C.T. scan


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

Parotid anatomy


1. IV fluid for dehydration 2. IV Ampicillin + Gentamicin + Metronidazole 3. Incision drainage: a.

Blair’s incision made b. Multiple incisions made through fascia, parallel to facial nerve branches c. Blunt dissection to evacuate pus. Drains placed.

Thank You