Deep Neck Space Infection

Agung D. Permana,dr.,M.Kes.,SpTHT-KL

Introduction
DEEP NECK SPACE INFECTIONS
Life threatening
delay in diagnosis/inadequate/inappropriate
treatment complications mortality rates :
40%
head and neck surgeon :
cervical fascias & potential spaces
understand the treatment & potential
complications
antibiotics decreased the incidence and
mortality

Anatomy Of The Cervical

Fascia
Superficial cervical fascia
Deep cervical fascia
1. Superficial layer
2. Middle layer
- Muscular division
- Visceral division

3. Deep layer
- Prevertebral division
- Alar division

Investing layer of deep cervical fascia

Sternocleidomastoid

Pretracheal fascia
(visceral part)
Carotid sheath

T
E

Pretracheal fascia
(muscular part)

Alar fascia
Buccopharyngeal fascia

Prevertebral fascia

Trapezius

Deep Cervical Fascia

Cervical Fascia

Pathophysiology
Deep neck space infections can arise from a multitude of

causes. Whatever the initiating event, development of a

deep neck space infection proceeds by one of several
paths, as follows:

Spread of infection can be from the oral cavity, face, or

superficial neck to the deep neck space via the

lymphatic system.
Lymphadenopathy may lead to suppuration and finally
focal abscess formation.
Infection can spread among the deep neck spaces by the
paths of communication between spaces.
Direct infection may occur by penetrating trauma.

Sign And Symptoms

Mass effect of inflamed tissue or

abscess cavity on surrounding structures

Direct involvement of surrounding
structures with the infectious process

 Presentation
Obtain a detailed history from patients in whom deep

neck space infection is suspected. Eliciting a history of

the following is important:

Pain
Recent dental procedures
Upper respiratory tract infections (URTIs)
Neck or oral cavity trauma
Respiratory difficulties
Dysphagia
Immunosuppression or immunocompromised status
Rate of onset
Duration of symptoms

Retropharyngeal Space
Infection

Source

Nose
Sinuses
Adenoids
Nasopharynx

Manifestations

Acute URTI in infants & children

Dysphagia & odynophagia
Drooling & difficult to expell excretions
Cervical rigidity
Muffled voice
Dyspnea
Unilateral bulging of posterior pharyngeal wall
Sepsis

Retropharyngeal Space Infection

Pediatrics
"

Cause > suppurative process in lymph nodes

#Nose,

adenoids, nasopharynx, sinuses!

Adults
Cause > trauma, instrumentation, extension

adjoining deep neck space

Danger Space Infection

Source

Retropharyngeal space
Prevetebral space
Parapharyngeal space

Manifestations

Same as primary space infection

Severe sepsis

Treatment
Same as for primary space infection

Complications
Potential for rapid spread through the loose areolar tissue
Inferior spread to the posterior mediastinum to the level of diafragma

Prevertebral Space Infection

Source
Vertebral bodies
Penetrating injuries
Tuberculosis of the spine

Manifestations
Midline abcess
Cold abcess posterior pharynx
Slow spread of suppuration of this area

Treatment

Needle aspiration w/ subsequent antituberculosis th/

Stabilization of spine

Complications
Spine instability progression of vetebral process

Visceral Vascular Space

Infection

potential space within the carotid sheath

infections remain relatively localized

compact space contains little areolar

connective tissue
lymphatics contained within this space receive
secondary drainage from most of the
lymphatics of the head and neck
Lincoln Highway of The Neck (Mosher) all
three layers of the DCF contribute to the
carotid sheath

Visceral Vascular Space

Infection
Source

Treatment

Parapharyngeal space
Submandibular space

External drainage
I.V. antibiotics

Visceral space

Possible ligation of IJV

Complications

Manifestations
Pitting edema over

SCM
Torticollis

Septic shock
Carotid artery erotions
Endocarditis
Cavernous sinus

thrombosis

Pharingomaxillary Space
Infection

Prestyloid Compartement [anterior-muscular]

Fat
Lymph nodes
Internal maxilarry artery
Inferior alveolar, lingual,auriculotemporal nerves

Poststyloid Compartement [posteriorneurovascular]

Carotid artery
Internal jugular vein
Symphatetic chain
IX, X, XI, XII nerves

Pharingomaxillary Space
Infection
Source

Tonsil
Pharynx
Teeth
Temporal bone (petrous)
Parotis gland
Lymph nodes of nose &
nasopharynx

Manifestations

Medial displacement of lateral

pharyngeal wall and tonsils
Trismus
Parotid edema
Retromandibular neck fullness
Dysphagia

Peritonsillar Space Infection

Source
Tonsils & pharynx

Manifestations

Dysphagia/odynophagia
Drooling and hot potato voice
Muffleed voice
Reffered otalgia
Trismus
Displaced tonsil toward midline
Deviated uvula

Submandibular Space
Infection
Submaxillary space
Central compartement
Submental compartement
Submaxillary compartement
subdivided by anterior bellies of
digastric m.
Contents
Submandibular gland
Lymph nodes

Sublingual space

Sublingual gland
Hypoglossal nerve
Whartons ducts

Submandibular Space
Infection
Source

Teeth
Salivary glands
Pharynx & tonsils
Sinuses

Manifestations

Dysphagia
Odynophagia

Treatment

Underlying pathology
External drainage if it progress
- sublingual
- submandibula

Complications
Ludwigs Angina

Ludwigs Angina

Ludwigs angina

Masticator Space Infection

Source
Molar teeth

Manifestations
1.
2.

Extreme trismus
Edema & tenderness
over
the posterior ramus of
mandible

Treatment
External drainage

Temporal Space Infection

Temporalis m. :
- superficial compartments

- deep compartments

Manifestation
Pain in this area

Treatment
External drainage

Trismus

Anterior Visceral Space

Contents

Pharynx
Esophagus
Larynx
Trachea
Thyroid gland

Source

Tonsils
Esophageal injury
Blunt trauma w/ mucosal tear
Acute thyroiditis
Chest infection

Anterior Visceral Space

Microbiology
Preantibiotic eraS.aureus
Currentlyaerobic Strep species and non-

strep anaerobes
Gram-negatives uncommon
Almost always polymicrobial
Remember resistance !!!

Imaging
Lateral neck plain film

Screening exammainly for retropharyngeal and

pretracheal spaces
"Normal: 7mm at C-2, 14mm at C-6 for kids,
"

22mm at C-6 for adults

Imaging

Imaging
High-resolution Ultrasound
"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
Quick, easy
Widely available
Familiarity
Superior anatomic detail
Differentiate abscess and cellulitis
"Disadvantages
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

Treatment
Airway protection
Antibiotic therapy
Surgical drainage

 Airway protection
"Observation

"Intubation

Direct laryngoscopy: possible risk of rupture and

aspiration
Flexible fiberoptic
"Tracheostomy

Ideally = planned, awake, local anesthesia

Abscess may overlie trachea
Distorted anatomy and tissue planes

Treatment
Antibiotic Therapy
"Polymicrobial infections
Aerobic Strep, anaerobes
Ampicillin/sulbactam with metronidazole
"Beta-Lactam resistance in 17-47% of isolates

"Alternatives
Third generation cephalosporins
clindamycin

"Culture and sensitivity

Treatment
Surgical Drainage
Transoral
Preoperative CT where are the great vessels? CT
Cruciate mucosal incision, blunt spreading through

superior pharyngeal constrictor

External drainage

Surgical Drainage
"External
EXPOSURE, EXPOSURE!!!

approach
Submandibular incision
Submental incision
T-incision

Complication
Airway obstruction
Ruptured abscess
Internal Jugular Vein Thrombosis
Carotid artery Rupture
Mediastinitis

history
Physical examination
Secure airway
Culture, IV antibiotic
CT scan
No abcess

Large abcess

Small abcess
Needle aspiration

Watch and wait

for culture and drainage

24-48 hours

No
Impending complication ?

Clinical improvement ?

Yes

No

Continue antibiotic,
Needle aspirations

Yes
Surgical incision
And drainage

Pharingomaxillary Space
Infection
Treatment

External drainage
Tracheotomy

Complications

Septic thrombosis of IJV

Carotid artery erosions
Cranial nerve involvement
Mediastinitis

Peritonsillar Space Infection

Treatment

Peroral drainage
tonsilectomy

Complications
Spread into
pharyngomaxilary space
through posterior
pharyngeal wall

Retropharyngeal Space
Infection
Treatment
1.
2.
3.
4.

Fasting
I.V. antibiotics
Tracheotomy
Emergent surgical
drainage
- intraoral drainage
- external drainage

Complications
1.
2.
3.

Rupture of abcess w/
aspiration & pneumonia
Mediastinitis
Airway obstruction

Pharingomaxillary Space
Infection
Submandibular

Peritonsillar

VVS

Masticator

Temporal

PMS

Parotid

Retropharingeal

Danger
Prevertebral

Anterior Visceral

Mediastinum