DEEP NECK INFECTIONS
Dr Imtiaz M Qazi
Introduction
“Pus in the neck calls for the surgeon’s best
judgement, his best skill and often for all of
his courage”
…… Mosher
Problems
 Complex Anatomy: precise localization



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difficult
Deep Location: difficult to palpate,
impossible to visualize
Access: intervening neurovascular & soft
tissue structures at risk
Proximity: vital structures
Communication: spread to adjacent space,
large area of neck
Deep Neck Spaces And Infections
• Anatomy of the Cervical Fascia
• Anatomy of the Deep Neck Spaces
• Deep Neck Space Infections
Cervical Fascia
 Superficial Cervical Fascia
 Deep Cervical Fascia
 Encircle H&N and attached
to clavicle and zygomatic
arch
 Contain plastysma m. and
external jugular v.
 Marginal mandibular br. of
Facial n. lies just deep
to superficial cervical fascia
Deep Cervical fascia
 Superficial Layer
 Middle Layer
 Deep Layer
Superficial Layer DCF
Investing/ Enveloping layer
Muscles
 Sternocleidomastoid
 Trapezius
Glands
 Submandibular
 Parotid
Space
 Suprasternal space of Burns
Middle Layer DCF
Muscular Division

Infrahyoid Strap Muscles
Visceral Division

Pharynx, Larynx,

Esophagus, Trachea,

Thyroid
Buccopharyngeal Fascia
Deep Layer DCF
Alar Layer

Posterior to visceral layer
of middle fascia

Anterior to prevertebra
layer
Prevertebral Layer

Vertebral bodies

Deep muscles of the neck
Carotid Sheath
 Formed by all three layers of deep fascia
 Contains carotid artery, internal jugular vein,
and vagus nerve
 “Lincoln’s Highway”
Deep Neck Spaces And Infections
• Anatomy of the Cervical Fascia
• Anatomy of the Deep Neck Spaces
• Deep Neck Space Infections
Deep Neck Spaces
Described in relation to the hyoid
A. Entire length of the neck
C.
B. Suprahyoid
1. Retropharyngeal Space
5. Submandibular Space
2. Danger Space
6. ParaPharyngeal Space
3. Prevertebral Space
7. Masticator/Temporal Space
4. Visceral Vascular (Carotid) Space
8. Parotid Space
Infrahyoid
10. Anterior Visceral Space
9. Peritonsillar Space
Deep Neck Spaces
Entire Length of Neck:
1. Prevertebral Space
Anterior border is prevertebral
fascia, posterior border is vertebral
bodies and deep neck muscles.
Extends along entire length
of vertebral column from skull base to
coccyx
Contains very compact tissue
Spread is therefore slow
Deep Neck Spaces
Entire Length of Neck:
2. Danger Space
Anterior border is alar layer
of deep fascia, posterior border
is prevertebral layer.
Extends from skull through
posterior mediastinum to
diaphragm.
Contains very loose
areolar tissue offering
little resistance to the spread
of infection to the mediastinum
Deep Neck Spaces
Entire Length of Neck:
3. Retropharyngeal
Space
Posterior to pharynx
and esophagus, between visceral div
of middle layer and alar div of deep
layer
Extends from skull base to T1-T2
Midline raphe
Two chains of nodes on either side of the
midline
Deep Neck Spaces
Infrahyoid
3. Anterior Visceral
Space
Middle layer of deep fascia
Contains thyroid,
trachea, esophagus
Extends from thyroid
cartilage into superior
mediastinum
Deep Neck Spaces
Suprahyoid:
4. Para Pharyngeal Space
Superior: skull base
Inferior: hyoid
Prestyloid
IMA
Inf Alveolar N
Auriculotemporal N
Connective tissue, fat & nodes
Poststyloid
Carotid sheath
Cranial nerves IX, X, XII
Sympathetic chain
Deep Neck Spaces
Suprahyoid:
5. Submandibular Space
Anterior/Lateral: mandible
Superior: oral mucosa
Inferior: superficial layer of deep fascia
Posterior/Inferior: hyoid
Supramylohyoid portion
Sublingual gland
Hypoglossal and lingual
nerves
Portion of Submandibular gland
Inframylohyoid portion
Submandibular gland
Wharton’s duct
Anterior bellies of digastrics
Deep Neck Spaces
Suprahyoid:
6. Masticator and
Temporal Spaces
Bounded by the
superficial layer of deep
cervical fascia
Contains masseter, pterygoids,
temporalis, ramus and
posterior portions of the body
of mandible, inferior alveolar
vessels and nerves
Deep Neck Spaces
Suprahyoid:
7. Parotid Space
Superficial layer
of deep fascia
Dense septa from
capsule into gland
Relationship
to parapharyngeal space
Deep Neck Spaces
Deep Neck Spaces
NETWORK OF PATTERNS OF INFECTIOUS
EXTENSION
Submandibular
Masticator
Temporal
Peritonsillar
Lateral
Pharyngeal
Parotid
Vascular
Danger
Retropharyngeal
Prevertebral
Mediastinum
Anterior Visceral
Deep Neck Spaces And Infections
• Anatomy of the Cervical Fascia
• Anatomy of the Deep Neck Spaces
• Deep Neck Space Infections
Deep Neck Space Infections
 Before antibiotics - 70% by tonsillar and
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pharyngeal sources
Most common cause in adults:
Odontogenic, IVDA
Most common cause in paeds:
Tonsillar, URTI
Others: salivary gland, trauma, FB,
instrumentation, local or superficial source
22% without cause
1. Tom MB, Rice DH: Presentation and management of neck abscesses: a retrospective analysis, Laryngoscope 98:877, 1988
Etiology
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Tonsillar and pharyngeal infection
Dental infection
Oral surgical procedures
Trauma of upper aerodigestive tract
Cervical lymphadenitis
Retropharyngeal lymphadenitis
Pott’s disease
Sialadenitis
Bezold’s abscess
Infection of congenital cyst and fistula
Intravenous drug abuse
Necrosis/suppuration of a malignant cervical LN/mass
Bacteriology
1. Most abscesses contain mixed bacterial flora
Aerobes:
Streptococci β-hemolytic (Strep pyogehes),
Strept. Viridans, Strep pneumoniae
Staphylococci, Neisseria, Klebsiella, Haemophilus
(Decresed role of b-hemolytic Streptococci)
Anaerobes:
Less common:
Bacteroides, Peptostreptococcus , fusobacterium
Pseudomonas, E.coli & H. infuenzae
2. Anaerobes are understimated (>35%)
widespread antibiotic use prior to collection of cultures
poor sample collection techniques
fragility of anaerobes
3. Anaerobes produce b-lactamase
Signs and Symptoms
 Fever, elevated WBC count, & tenderness
 Asymmetry of neck & asstd neck mass/LN
 Medial displacement of tonsil or lateral
pharyngeal wall
 Trismus
 Torticollis
 Fluctuation usually not palpable
 Neural deficit: Horner’s Synd, Hoarseness
 Spiking fever: IJV Thrombosis, Septic embolus
 Airway obstruction
Treatment
 Airway protection
 Antibiotic therapy
 Surgical drainage
Treatment
 Empirical Treatment
First-line
Alternatives
Clindamycin 600-900mg tid
(+/- cefuroxime 0.75-1.5gr tid)
AMX/CL 1.5-3gr qid
or
or
Penicillin G
PIP/TZ 2.25gr qid - 4.5 gr tid
24 million units/day
+
Metronidazole 1gr bid
Treatment
Imaging
 Lateral neck plain film
 Screening exam—mainly
for retropharyngeal and
pretracheal spaces
 Normal: 7mm at C-2,
14mm at C-6 for kids,
22mm at C-6 for adults
 Technique dependent
 Extension
 Inspiration
 Nagy, et al
 Sensitivity 83%,
compared to CT 100%
Imaging
 Ultrasound (USG)
 Advantages
 Avoids radiation
 Portable
 Disadvantages
 Not widely accepted
 Operator dependent
 Inferior anatomic detail
 Uses
 Following infection during therapy
 Image guided aspiration
Imaging
 Contrast enhanced CT
 Advantages
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Quick, easy
Widely available
Familiarity
Superior anatomic detail
Differentiate abscess and
cellulitis
 Disadvantages
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Ionizing radiation
Allergenic contrast agent
Soft tissue detail
Artifact
Imaging
 MRI
 Advantages
 No radiation
 Safer contrast agent
 Better soft tissue detail
 Imaging in multiple planes
 No artifact by dental fillings
 Disadvantages
 Increased cost
 Increased exam time
 Dependent on patient
cooperation
 Availability
Munoz, et al: MRI vs. CT
Management
History + Physical examination
Culture, IV antibiotics, Airway control, Chest RX
cellulitis
CT
small abscess
needle aspiration
for culture & drainage
W&W
24-48h
complications?
improvement?
Yes
Continue AB
No
surgical incision
and drainage
large abscess
Complications
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Airway obstruction
Internal jugular vein thrombosis
Cavernous sinus thrombosis
Neurologic deficit – Horner’s, hoarseness
Erosion of carotid artery
Osteomyelitis of the mandible
Osteomyelitis of the spine
Mediastinitis
Pulmonary edema
Pericarditis
Aspiration
Sepsis
Para Pharyngeal Abscess
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Most common cause :
Peritonsillar infection
Typical finding
1.Trismus
2.Angle mandible swelling
3. Medial displacement of lateral
pharyngeal wall
Others : fever, limit neck motion,
neurologic deficit (C.N
9,10,12,Horner’s syndrome)
Para Pharyngeal Abscess
Treatment
1. Evaluate and maintain airway & fluid hydration
2. Parenteral antibiotic high dose 24-48 hrs.
3. If not improve, consider surgical drainage
Surgical drainage
1. Intraoral approch
(for peritonillar abscess only)
2. External approach
-transverse submandibular incision
-T. shape incision (Mosher)
Retro Pharyngeal Abscess
Clinical feature
 In children
irritability, neck rigidity, fever,
drooling, muffled cry, airway
compromise
 In adult
fever, sore throat, odynophagia,
neck tenderness, dyspnoea
Retropharyngeal Abscess
Investigation
1.
2.
Lateral neck film
- C2 > 7 mm. both children and adult
- C7 > 14 mm. in children
> 22 mm. in adult.
Chest film
- detection of mediastinitis
Retropharyngeal Abscess
Treatment
Surgical drainage
1. Intraoral drainage
-Lesion confined in RP space esp.child
2. External drainage (Dean)
-Lesion beyond pharyngeal level
-Airway compromise
-Involve other deep neck spaces
Quinsy
 Peritonsillar Space
 Fever, malaise
 Dysphagia, odynophagia
 “Hot-potato” voice,
trismus, bulging of
superior tonsil pole and
soft palate, deviation of
uvula
 Cause—extension from
tonsillitis
Parotid Space Infection
 Most common cause : Bacterial
retrograde from oral cavity
Clinical feature
 high fever, weakness, mark
swelling and tenderness of
parotid gland, fluctuation,pus
at stensen’s duct
Ludwig’s Angina
Ludwig’s angina is characterized by rapidly spreading cellulitis / infection of
the sublingual and submaxillary spaces with associated swelling of the
submental region, tongue and floor of the mouth, secondary to dental
infection.
Ludwig’s Angina
Grodinsky’s criteria (1939):
1. A cellulitis, not an abscess of submandibular space
2. The cellulitis involves all the sublingual and bilateral
submaxillary spaces
3. The cellulitis produces a serosanguineous putrid
infiltration but very little or no frank pus
4. Fascia, muscle, connective tissue involvement, sparing
glands
5. The cellulitis is spread by continuity and not by
lymphatics
Ludwig’s Angina