Approach to Deep Space Neck Infections

Surface Anatomy of the Neck

 The SCM muscle divides the neck into 2 anatomical triangles

 Recognise that these triangles are artificial and have not been chosen for clinical and
embryological reasons and as a result, pathology does not often respect or follow
their boundaries
 Anterior triangle – Submandibular triangle + Carotid triangle + Inferior carotid triangle
 Posterior triangle – Occipital triangle + Subclavian triangle

Deep Neck Anatomy

 The neck is divided into anatomical compartments by strong fascia which is arranged
in layers and tends to align neck structures in bundles
 The outermost layer that surrounds the neck is the investing fascia
 There are 2 main compartments of the neck, which are separated by the
prevertebral fascia.
 The posterior skeletal compartment contains the cervical spine and its musculature
 The anterior visceral compartment contains all other structures and organs. This
contains bundles of structures, each of which is enclosed by a fascial envelope.
o Pretracheal fascia: Encloses the thyroid glands and binds it to the trachea
which is why when the larynx and trachea move with swallowing, the thyroid
gland also ascends and descends
o The investing fascia, pretracheal fascia, prevertebral fascia are the
superficial, middle and deep layers of the deep cervical fascia which can be
thought of as a series of cylindrical compartments that extend longitudinally
from the base of the skull to the mediastinum
o All 3 layers of the deep cervical fascia contribute to the carotid sheath which
forms a neurovascular compartment
o Carotid sheath: Fascial bundle that encloses the carotid, internal jugular
vein and vagus nerve
 Between all of the fascial bundles are potential spaces known collectively as the deep
neck spaces. Infections of the neck can spread along these spaces to form deep-
seated abscesses.
 The most important spaces are the parapharyngeal, retropharyngeal and
submandibular spaces.
o The submandibular space lies within the submental and submandibular
triangles between the mucosa of the floor of the mouth and the superficial
layer of the deep cervical fascia. It is subdivided by the mylohyoid muscle into
the sublingual space and the submylohyoid space. The 2 divisions
communicate posteriorly around the mylohyoid muscle. It is this space that is
primarily involved in Ludwig’s angina. Infection within the sublingual space
results in gross swelling of the tongue that can result in acute airway
obstruction. Infection of the submylohyoid space may spread posteriorly
along the styloglossus muscle into the parapharyngeal space and continue to
spread into the loose areolar tissue of the retropharyngeal space and then
further inferiorly into the superior mediastinum.
o The parapharyngeal space is shaped like an inverted cone, with its base at
the skull and its apex at the hyoid bone. The anterior compartment contains
no vital structures but the posterior compartment contains CN9 to CN12
superiorly and CN10 more inferiorly, the carotid sheath and the cervical
sympathetic trunk
o The retropharyngeal space is bound anteriorly by the constrictor muscles of
the neck and posterioly by the alar layer of the deep cervical fascia.
o The danger space is posterior to the retropharyngeal space. It extends from
the base of the skull and descends freely through the entire posterior
mediastinum to the level of the diaphragm (T1 to T2).
Etiology of Deep Space Neck Infections

 Most DSNIs contain mixed flora

 Aerobic organisms include Streptococcus and Staphylococcus. Aerobic orgnanisms
tend to be associated with IV drug abuse.
 Infections of dental origin tend to involve anaerobes, especially Bacteroides.
 Today, the most common origin of DSNIs is odontogenic.
 In addition, salivary gland infections are a common source and spread to involve
the submaxillary space.
 IV drug abusers are particularly prone to DSNIs of the vascular region as they may
inject this area.
 In the paediatric population, acute tonsilitis can lead to infection of the peritonsillar
space.

Diagnosis of Deep Space Neck infections

 Fever, neck and pain swelling are the most common presenting symptoms
 Other findings may include trismus, dysphagia and dental abnormalities
 If a DSNI is suspected, a CT should be ordered to difrerentiate cellulitis from an
abscess and to delineate which structures are invovled

Specific Deep Space Neck Infections

 Peritonsillar abscess (quinsy)

Definition - A suppurative complication of acute tonsilitis with extension into the

peritonsillar space
- Begins as a cellulitis and progresses to an abscess formation, most
commonly near the superior pole of the tonsil
S/Sx - High fever, odynophagia, unilateral sore throat, otalgia
- Muffled voice, trismus, unilateral deviation of the uvula towards the
unaffected side and soft palate fullness or edema
Etiology - Often polymicrobial
- The predominant bacterial species are Streptococcus pyogenes (Grp
A Strep) and oral anaerobes

 Parotid space infections

Definition - Acute suppurative parotitis is typically seen in the elderly, debilitated

and/or dehydrated patients who may be diabetic or taking
anticholinergic medications that decrease salivary flow
S/Sx - Sudden onset of unilateral induration and erythema that extends
from the cheek to the angle of the jaw
- The parotid gland becomes swollen and extremely tender
- Purulent discharge may be expressed by gentle compression around
the orifice of the parotid duct i.e. Stensen’s duct
Etiology - Often polymicrobial
- Staph. aureus is the most frequently isolated pathogen, but
anaerobes are also common

 Ludwig’s angina

Definition - Bilateral infection of submandibular space that begins in the floor of

the mouth, most commonly related to the 2nd or 3rd mandibular molar
teeth
S/Sx - An aggressive rapidly spreading woody or brawny cellulitis without
lymphadenopathy
Etiology - Typically a polymicrobial infection involving flora of the oral cavity
 Pretracheal space infections

Definition - Commonly arise as a consequence of perforation of the anterior

esophageal wall, or through contiguous extension from a
retropharyngeal space infection, or as a consequence of prolonged
tracheostomy
S/Sx - Severe dyspnea, hoarseness as 1st complaint
- Difficulty swallowing
Etiology

 Prevertebral space infections

 Retropharyngeal and danger spac infections