Deep neck space
infections
fascial compartments of the neck
Superficial cervical fascia
Deep cervical fascia
superficial, middle, and deep layers.
The superficial (investing) layer of the deep cervical
fascia invests the sternocleidomastoid, trapezius, strap
muscles, parotid and submandibular
The middle (visceral) layer surrounds the thyroid gland,
esophagus and trachea.
The deep layer of the deep cervical fascia splits into
prevertebral and alar layers. The prevertebral layer lies
immediately adjacent to the vertebral bodies .
All contribute to the carotid sheath so that infection of any
layer may spread directly to involve the great vessels of
the neck, which have direct communication to the chest.
catastrophy
Carotid artery rupture has a 20-40% mortality
rate.
Jugular vein thrombosis had a mortality rate of
60% prior to the use of antibiotics. Identifying
this complication is essential. Osteomyelitis and
vertebral erosion can cause subluxation and
subsequent spinal cord injury. In older children
and adults, the disease spreads directly into the
fascial planes and is a more deadly
Mediastinitis has a 40-50% mortality rate
secondary to sepsis. Acute necrotizing
mediastinitis and purulent pericarditis with
tamponade also can be fatal.
Anatomic Considerations
 The most common sources of life-threatening
soft tissue infections of the head and neck are
the dentition and tonsils.
 Most infections are polymicrobial and the
responsible bacteria are often normal flora
(Bacteroides, Peptostreptococcus, Actimomyces, Fusobacterium etc).
that become virulent and invasive when normal
barriers are broken (ie. tonsillitis, dental
abscess, trauma).
 Obligate anaerobes frequently outnumber the
anaerobes.
iatrogenic
 Deep space infections can be secondary to
instrumentation of the upper respiratory tract.
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Laryngoscopy
Endoscopy
Feeding tube insertion
Endotracheal intubation
Head and neck surgery
Dental procedures
Injections
parapharyngeal space
 This space (also called the lateral pharyngeal space or
pharyngomaxillary space) occupies a critical area in the
neck, as it communicates with all other fascial spaces. It
sits as an inverted cone with its base at the base of skull
and apex at the hyoid bone.
 It can be divided into anterior (prestyloid) and posterior
(retrostyloid) compartments by the styloid process. The
anterior compartment contains only fat, lymph nodes and
muscle. The posterior compartment contains the carotid
and internal jugular vessels, as well as cranial nerves IX
through XII.
Parapharyngeal space
 Laterally
 Medially
parotid gland,parotid fascia,
medial pterygoid,mandible
pharynx separated by
sup.cons
 Posteriorly communicates with
retropharyngeal space
 Superiorly base of skull,
 Inferiorly
sub mandibular gland fascia
Parapharyngeal space
infection/abscess
 It can spread from
Tonsillitis ,post tonsillectomy
60%
Dental infections lower last
molars 35 %
Trauma
 Communication with
peritonsillar,retropharyngeal or
submandibular space
causes
 Tonsillitis
 Peritonsillar abscess
 Dental infections
 Mastoiditis rarely via petrous
apex,digastric muscle sheath
 Pharyngeal F.B
Clinical features
 Pain throat,difficult swallowing
 Trismus , spasm of pterygoids
 Pyrexia,malaise,
 Painful external swelling in neck at the posterior
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part of middle third of sternomastoid
Swelling in retromolar region
Tonsil pushed medially
Last cranial nerves palsies
Parotid pushed laterally
 CT scanning is the imaging modality of choice
and is helpful in confirming which compartments
are involved.
Treatment
 Systemic antibiotic
 In complicated cases such as septic
jugular vein thrombosis, several weeks
of intravenous antibiotics may be
required.
 Incision and drainage
 Vertical incision at the ant.border of scm
 tracheostomy
Complications
 Acute laryngeal oedema
 Septecimia and ijv thrombophelibitis
 Mediastinitis
 Spread to other spaces of neck
Retropharyngeal space
 Lies between prevertebral and
buccopharyngeal fascia
 Extending from skull base to tracheal
bifurcation
 Continous below with sup.mediastinum
and laterally with parapharyngeal space
Retropharyngeal space
infection/abscess
 Acute
in infants
more than 50%
due to lymphadinitis
secondary
to URTI
high grade temp
sore throat
head extension and neck stiffness
respiratory & feeding problems
Retropharyngeal space
infection/abscess
 Croupy cough
 Muffled voice
 Cervical lymphadenopathy
 Smooth swelling on one side of
post.ph.wall with airway impairement
 May obstruct post.nares
 May push the palate down
 Infant spine short and larynx high
Causes:
 predisposing infections pharyngitis, tonsillitis,
otitis, adenitis, sinusitis, and nasal, salivary, and dental
infections.
 from contiguous spaces, such as the
parapharyngeal space (eg, abscesses), submandibular
space (eg, Ludwig angina), or prevertebral space (eg,
osteomyelitis, diskitis).
 secondary to penetrating trauma.
 Running and falling down after putting something in
their mouths (eg, toy, stick, popsicle, lollipop,
toothbrush) is not unusual in children. Because
parents may be unaware of these predisposing
events
Age
 Almost exclusively a pediatric diagnosis.
 Most incidents occur in children aged 6 months
to 6 years, with a mean age of 3-4 years. Other
deep neck abscesses (eg, parapharyngeal,
peritonsillar) are observed more frequently in
adults and older children.
Physical
 Most patients are febrile. Some appear toxic and irritable.
 Cervical lymphadenopathy, usually unilateral, most
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common
decreased or painful range of motion of their necks or
jaws.
A neck mass or tenderness may be appreciated.
may present with a muffled "hot potato" voice (ie,
dysphonia) or with a voice that sounds like a duck quack
(ie, cri du canard).
may be able to appreciate a mass in the posterior
pharyngeal wall.
 As many as 30% of patients have this mass
 This is not midline,.
 "Tracheal rock sign" elicits pain
Physical
 Patients in respiratory distress or those who present with
stridor or drooling have potential airway compromise.
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These patients prefer to lie supine with their necks
extended, maximizing their airway patency..
 Address vascular complications in the physical
examination.
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Jugular vein thrombophlebitis may manifest as tender
induration at the anterior sternocleidomastoid border,
vocal cord paralysis, or sepsis of an unknown source.
Carotid artery rupture can be heralded by sentinel
bleeding from the ear, nose, or mouth.
In Adults
 Likely to be due to tuberculous infection
of the cervical spine
 Slow onset
 Pharyngeal discomfort,some dysphagia
 Cervical spine radiography
 Look for associated infections
Imaging Studies
 A lateral soft tissue neck x-ray is helpful .
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An abscess occupies the soft tissue space,
which can be observed between the
radiolucent airway (ie, pharynx, trachea)
and the spine.
Widening of these soft tissues is pathologic
until proven otherwise.
Ultrasound
 An imaging modality that is gaining
popularity. It is safer than CT scan, since
it is portable and does not use radiation.
Ultrasound is also less traumatic to
children, requiring less frequent use of
sedation.
CT scanning
 is currently the imaging modality of
choice..
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can be used to determine the presence of
an abscess and help distinguish it from
cellulitis (an abscess has a central area of
lucency). also can assist in determining the
location of the abscess, extent of abscess
spread, and presence of any
complications.
CT scan can be more than 90% sensitive.
MRI
 produces superior images , used when
the abscess has spread to the CNS.
 this requires a period of time when the
patient is in an unmonitored setting.
Children usually require sedation for this
test, which is also dangerous in any
patient with a potentially unstable airway.
Needle aspiration of a
suspected abscess
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Aspiration can help determine the presence of an
abscess and help distinguish it from cellulitis. It can
be diagnostic and therapeutic.
An intraoral route usually is indicated, except when
an abscess is isolated lateral to the carotid sheath.
In this case, an external approach can be used. CT
scan or ultrasound can help guide the aspiration.
With an abscess involving multiple spaces, perform
needle aspiration with an open external approach.
Complications of retropharyngeal abscesses
 are secondary to mass effect,
 rupture of the abscess, or
 spread of infection.
 Rupture of the abscess can cause aspiration of pus,
resulting in asphyxiation or pneumonia.. Spread of the
infection to the mediastinum can result in mediastinitis,
purulent pericarditis ,etc. Spread of the infection laterally
can involve the carotid sheath and cause jugular vein
thrombosis or carotid artery rupture. Posterior spread of
infection can result in osteomyelitis and erosion of the
spinal column, causing subluxation and spinal injury. It
can evolve into necrotizing fasciitis, sepsis, and death
Treatment
 Incision and drainage
 Limitation of GA
 Infant wrapped and held upright
 Abscess incised with a gaurded knife
 Sinus forceps plunged into it and open
 Copious flow of pus
 Baby face turned down to allow escape
 Immediate relief
 Antibiotics
Treatment
 Incision and drainage over the
post.border of scm vertical incision
 Abscess is sought for by dissection
between the carotid sheath and the
prevertebral muscles and is drained from
the neck
 Tracheostomy
 Anti TB regimes
Submandibular Space
 The submandibular space extends from
the hyoid bone to the mucosa of the floor
of the mouth. It is bound anteriorly and
laterally by the mandible and inferiorly by
the superficial layer of the deep cervical
fascia.
 The mylohyoid muscle acts as a sling
across the mandible and divides the
submandibular space into sublingual and
submylohyoid spaces.
Ludwig angina
 The infection of this space was described by Ludwig in
1836.
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He described a gangrenous infection of the neck with
woody cellulitis without suppuration and insidious
asphyxiation
 Cellulitis involving fascial spaces between muscles and
other structures of the posterior floor of the mouth that
can compromise the airway.
Clinical presentation
 Most patients are young, healthy adults with an
odontogenic infection. Usually present with
mouth pain, dysphagia, drooling and stiff neck.
In the case of Ludwigs angina, massive tongue
and floor of mouth edema can rapidly lead to
posterior and superior displacement of the
tongue as well as anterior displacement out the
mouth. The patient often maintains the neck in
an extended position and may have a muffled
or "hot potato" voice. The neck shows a
characteristic erythematous woody swelling but
fluctuance is usually absent.
Asphyxia
 The most common cause of death in Ludwigs
angina is asphyxia. Airway control is the first
priority of treatment, followed by intravenous
antibiotics and timely surgical drainage.
 Tracheotomy is still the most widely used
method of airway control but some authors feel
the risk of aspiration pneumonia
Cricothyroidotomy is usually not a good option
with in patients with massive neck edema.
Treatment
 Closely monitor patients with airway
compromise and do not allow these patients to
leave the acute care area.
 Sedation and paralytics can relax airway
muscles, leading to complete obstruction.
 Endotracheal intubation is dangerous unless
performed under direct visualization. consider
fiberoptic intubation or a surgical airway (eg,
cricothyroidotomy, tracheotomy
Antibiotic therapy
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Broad-spectrum coverage is indicated. Clindamycin
is first-line treatment,initiated alone or in
combination with cefoxitin or a beta-lactamase–
resistant penicillin, such as ticarcillin/clavulanate,
piperacillin/tazobactam, or ampicillin/sulbactam.
Patients with cellulitis can be treated with
parenteral antibiotics alone. Closely observe these
patients for development of an abscess.
Surgical Care:
 Surgical airway control may be
necessary in patients whose airways are
difficult to visualize or are obstructed
completely. Depending on the age of the
patient and the experience of the
physician, perform needle
cricothyroidostomy or cricothyroidotomy
only if the child cannot be transported to
the operating room safely or quickly.
Alternatively perform a tracheotomy.
Pharyngeal Pouches
Acquired
protrusion of mucosa through the
muscle layers of the wall of an organ
Congenital
covered by all the muscle layers of the
e.g Meckels diverticulum
Pharyngeal pouch
three inherent areas of
weakness
 inferior border of the cricopharyngea with the superior
oblique fibers of the esophagus. This is referred to as
Laimer's triangle.
 A second inherent weak point is between the oblique and
the transverse fibers of the cricopharyngeus muscle: this
is referred to as the Killian-Jamieson area, where lateral
or Killian-Jamieson diverticula can form.
 Then, finally, the most significant area is the Killian's
triangle, which is formed by the inferior-most fibers of the
inferior constrictor muscle with the superior border of the
cricopharyngea, and this is thought to be where the
Zenker's diverticulum develops.
theories
 One of the primary theories is
pharyngoesophageal incoordination , an
incoordination between the opening of the
cricopharyngeus and the peristaltic contractions
propagating the bolus through the hypopharynx.
 Another theory of the development of Zenker's
is that of cricopharyngeal spasm, and that
likely in response to stimulation by reflux - the
cricopharyngeus muscle simply spasms down.
Zenker's diverticulum
 1877 .the German pathologist, Zenker, described that
traction diverticulum is formed due to external traction on
the wall of the digestive tract resulting in the pouch
formation, whereas the pulsion diverticulum is formed
because of an imbalance of intraluminal force combined
with the strength of the digestive tract wall. Foregut
diverticula can also be classified based on their anatomic
location, one of which is the midesophageal diverticulum,
another described as the epiphrenic diverticulum. There
are small transitory diverticula which appear throughout
the swallowing cycle and then disappear; and then, of
course, the hypopharyngeal diverticulum or Zenker's
diverticulum.
Zenker's
 It is typically in the seventh and eighth
decades. It is predominantly in males .
Now the incidence varies depending on
the region that you are in. In the United
Kingdom, which has the highest
incidence, it is about 2:100,000 people
per year.
Clinical features
 Commonest symptoms are dysphagia,
regurgitation and cough
 Recurrent aspiration can result in
pulmonary complications
 A carcinoma can develop within the
pouch
 Clinical signs are often absent
 A cervical lump may be present that
gurgles on palpation
Zenker's present with
 dysphagia, between 80% and 90%.
 regurgitation of undigested food.
 The combination of regurgitation of undigested
food with cervical borborygmi is almost
pathognomonic of Zenker's diverticulum.
 30 to 40% will present with aspiration and a
chronic cough,
 and up to 15% of these total patients will
actually have episodes of aspiration pneumonia
diagnostic evaluation
 consists of primarily the barium swallow,
which shows, as in our patient, a
posterior pharyngeal diverticulum with
pooling of contrast. The swallow can
also offer other clues.
Treatment
Depends on size of pouch and
age of patient
Options include:
 Diverticulectomy
 Dohlman's
procedure
Diverticulectomy
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Fascia at anterior border of sternomastoid is divided
Pouch is identified anterior to prevertebral fascia
Pouch is then excised an defect closed
Cricopharyngeal myotomy is performed to prevent recurrence
Patient should be feed via a nasogastric tube for a week
postoperatively
 Complications include:
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Recurrent laryngeal nerve palsy
Cervical emphysema
Mediastinitis
Cutaneous fistula
endoscopic diverticulectomy
 reintroduced in 1960 by Dohlman with no
more mortality and only a 7% recurrence
rate.
 In 1993, Collard introduced the next
major breakthrough in using the
endoscopic GIA staple-assisted
diverticulectomy.
 Other methods that have been used are
KTP lasers, CO 2 lasers, and flexible
endoscopy with electrocautery.
Dohlman's procedure
 Is an endoscopic procedure
 A double-lipped oesophagoscope is used
 Wall between the diverticulum and oesophageal
wall is exposed
 Hypopharyngeal bar divided with diathermy or
laser
 Minimally invasive techniques allow:
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Shorter duration of anaesthesia
More rapid resumption of oral intake
Shorter hospital stay
Quicker recovery
thanks