for undergraduates

1. Deep neck space infection
Dr ramesh parajuli, MS
Chitwan Medical College, Bharatpur-10,
Chitwan, Nepal

2. Fascial layers of the neck
 Fascia is an investing fibrous tissue related to muscles &
major neck structures.
A. Superficial cervical fascia:
B. Deep cervical fascia:
1. Superficial or investing layer
2. Middle layer or visceral fascia
3. Deep layer or pre-vertebral fascia

3. (I)Superficial cervical fascia: encloses platysma
(II) Deep cervical fascia
(i)Investing layer: Encloses strap muscles, SCM, trapezius
Parotid &submandibular glands, carotid sheath
(ii)Middle or Visceral layer: encircles esophagus, trachea,
thyroid
(iii)Deep or pre-vertebral layer: Covers deep neck muscles i.e.
prevertebral muscles

5. Deep neck spaces
 Potential neck spaces
 Contain loose areolar tissue
 Spread of tumor and infection
 Submental space
 Submandibular space
 Parotid
 Peritonsillar
 Parapharyngeal
 Retropharyngeal
 Pretracheal space
 Prevertebral space

8. Ludwig’s angina:
 Rapidly progressing cellulitis of submandibular space
(i.e. sublingual & submaxillary space)
 Mixed flora (poly-microbial)
 May result into life-threatening airway obstruction

9. Subdivisions of submandibular space
1. Sublingual space: above mylohyoid muscle
2. Submaxillary space: below mylohyoid muscle
Contents: Submandibular salivary gland, lymph nodes

10. Etiology:
1. Dental infection: 80% cases
Tooth (lower molars & premolars)
Roots of premolars lie above mylohyoid ⇒ sublingual space
infection
Roots of molars lie below mylohyoid ⇒ submaxillary space
infection
2. Injury to floor of mouth
3. Submandibular sialadenitis

11. Causative agentsCausative agents
Mixed aerobic & anaerobic infection
 Streptococcus pyogenes
 Streptococcus viridans
 Streptococcus pneumoniae
 Staphylococcus
 Fusobacterium
 Bacteroides
 Peptostreptococcus

12. Clinical featuresClinical features
 Toothache, fever, odynophagia, drooling of saliva
 Floor of mouth swelling + tongue elevation
 submental swelling: Brawny induration
 Trismus
 Stridor: falling back of tongue causing upper airway obstn
 Initially cellulitis (no frank pus) ⇒ pus formation (only
at late stage)

13.  Parapharyngeal abscess
 Retropharyngeal abscess
 Acute airway obstruction (within
hours):
due to falling back of tongue
 Aspiration pneumonia
 Septicemia
 Death
ComplicationsComplications

14. Management:
1. I.V. antibiotics: Ceftriaxone + Metronidazole / Clindamycin
2. IV fluid for adequate hydration
3. Monitor vital signs regularly eg. assessment for disease
progression & airway compromise
4. Airway obstruction: Intubation / tracheostomy
5. Incision & drainage
Transverse incision from one angle of mandible to opposite angle
of mandible

15. Retropharyngeal space
It lies behind the pharynx
Superior: Base of skull
Inferior: Mediastinum (till tracheal bifurcation)
Anterior: Buccopharyngeal fascia
Posterior: pre-vertebral fascia
Contains lymph nodes (of Rouviere) which usually
disappear at 3-4 years of age

17. Retropharyngeal abscess
 Collection of pus in retropharyngeal space
 In children: Suppuration of retropharyngeal lymph
node of Rouviere from URTI
 In adults:
 Tubercular infection of retropharyngeal lymph
nodes/cervical spinepresents as posterior
pharyngeal wall swelling

18. Symptoms
 H/o upper respiratory tract infection
 Dysphagia / odynophagia
 Difficulty in breathing
 Neck stiffness/ torticollis

19. Signs
 Febrile, ill-looking, child with drooling
 Tender neck swelling
 Torticollis (twisted neck)
 Bulge on posterior pharyngeal wall
Torticollis

20. Widened pre-vertebral soft tissue
shadow

21. Air-fluid level & gas shadow

22. Tuberculosis of cervical spine with
retropharyngeal abscess

23. Complications
1. Airway obstruction:
2. Spread of abscess to other neck spaces
3. Spontaneous rupture of abscess
4. Septicemia
5. Death

24. Treatment
1. Broad spectrum intravenous antibiotics:
Ceftriaxone + Metronidazole
2. Incision & drainage: without anesthesia, supine with head
hanging down from the table, I & D at most bulging part
of posterior pharyngeal wall bulge, two powerful suctions
to suck out pus thus preventing aspiration
General anesthesia(GA) is contraindicated for fear of
rupture of abscess during intubationaspiration
3. Anti-tubercular therapy

25. Parapharyngeal space
Base & superior limit: Skull Base
Apex: hyoid
Lateral: Ramus of mandible, Medial Pterygoid
deep lobe of parotid
Medial: Bucco-pharyngeal fascia
Anterior: Pterygo-mandibular raphe
Posterior: Pre-vertebral fascia

27. Styloid process divides into two
compartments:-
Prestyloid
◦ Deep lobe of parotid
◦ Contains fat, connective
tissue, nodes
Poststyloid
◦ Neurovascular compartment
◦ Carotid sheath (ICA,IJV)
◦ Cranial nerves (IX, X, XI, XII)
◦ Sympathetic chain

28. Contents of parapharyngeal space
Pre-styloid
• Deep lobe of parotid
•Lymph nodes
•Fat
•Connective tissue
Post-styloid
• Internal carotid artery
• Internal jugular vein
• Cranial nerves(IX,X,XI,XII)
• Sympathetic chain
• Lymph nodes
•Styloid process divides into two spaces

29. 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

30. Clinical features
1. Fever, sore throat, odynophagia, torticollis
2. Tonsils pushed medially
3. Trismus
4. Neck swelling behind angle of mandible

31. Management
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

32. Peritonsillar abscess (quinsy)
 Pus present in the peritonsillar space i.e. between tonsillar
capsule & superior pharyngeal constrictor muscle
 Causative agents: aerobic + anaerobic organisms
 Infection of Weber's gland (Minor salivary gland in supra
tonsillar fossa) → quinsy
 Following acute tonsilitis (Less commonly)

33. Clinical features
Symptoms: odynophagia, fever, halitosis & muffled voice
Signs:
1.Unilateral tonsil enlarged (infection in paratonsillar
spacepseudohypertrophy), pushed medially
2. Congested tonsil,tonsillar pillars, soft palate
3. Jugulo-digastric lymph node tender, enlarged
4. Trismus

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

35. Management
Diagnosis: Peritonsillitis vs Peritonsillar
abscess
Needle aspiration → reveals pus i.e. quinsy
1. Broad spectum IV antibiotics:Ceftriaxone +Metronidazole
2. I.V. fluids & analgesics
3. Antiseptic mouth gargle
4. Repeated needle aspiration
5. Incision and drainage

36. Incision & drainage site

37.  Incision and drainage of quinsy:
1. I & D with quinsy forceps
2. I & D with No.11 surgical blade
3. Repeated pus aspiration with wide bore needle

38. Parotid abscess
 Debilitated & dehydrated pts (decreased salivary
flow)
 Causative organism: Staph. aureus, Streptococci,
Haemophilus & other organisms
 Ascending bacterial infection from oral cavity through
the duct to the gland
 Predisposing conditions: DM, Immunocompromised,
poor oro-dental hygeine

39.  Painful parotid region swelling
 Trismus
 Parotid massage expresses pus
from parotid duct opening
 Rx: Broad spectrum antibiotics
(Inj. Ampicillin plus cloxacillin, and
clindamycin)
 I & D: Modified Blair’s incision

40. Thank youThank you