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
Retro-pharyngeal
Danger space
Pre-vertebral B. Supra-hyoid abscess
Sub-mental
Masticator
Parotid
Ludwig’s angina
Para-pharyngeal
Peri-tonsillar (quinsy) C. Infra-hyoid abscess
Pre-tracheal
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
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
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
Staphylococcus
Fusobacterium
Bacteroides
Peptostreptococcus
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
Trismus
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
Complications
Parapharyngeal abscess
Retropharyngeal abscess
Acute airway obstruction (within hours): due to pushing back of tongue, laryngeal edema
Aspiration pneumonia
Septicemia
Death
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
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
Symptoms
H/o upper respiratory tract infection
Dysphagia / odynophagia
Difficulty in breathing
Croupy cough
Hot potato voice
Neck stiffness
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
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
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
Chronic Retropharyngeal Abscess
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
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
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 9 - 12 months
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
Parapharyngeal abscess
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
Pre-styloid
Deep lobe of parotid Internal maxillary artery Inferior alveolar nerve Lingual nerve Auriculo-temporal nerve Lymph nodes
Contents
Post-styloid
Internal carotid artery Internal jugular vein Last 4 cranial nerves Sympathetic chain Glomus system Lymph nodes
Styloid:
Styloid process, its 3 muscles + 2 ligaments
Etiology
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
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
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
peritonsillitis
quinsy 2. Abscess of Weber's salivary gland in supra tonsillar fossa
quinsy
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
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
Needle aspiration
Incision
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
septicemia
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
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
Causes of parotid dehydration 1. Post-operative patient (surgical mumps) 2. Medications that decrease salivary flow:
Antihistamines
Tricyclic antidepressants
Barbiturates
Diuretics
Parasympathomimetics
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)
Investigation
C.B.P.: Leukocytosis
Needle aspiration with 18 G needle
Ultrasonography
C.T. scan
M.R.I.
C.T. scan & M.R.I.
Parotid anatomy
Treatment
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.