By Khushi BS

Moderator: Dr. Lavanya M

Deep neck space infections

• Submandibular Space

• Peritonsillar Space

• Parotid Space

• Retropharyngeal Space

• Parapaharyngeal space

• Danger space

• Prevertebral space

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Dr. ASHLY ALEXANDER 3
 Etiopathogenesis
At risk: – Dental infection (major source)
• Immunocompromised – Salivary gland infections
• Diabetes – URTI
• IV drug abusers
– Peritonsillar abscess
• Infants
– trauma
– Retropharyngeal lymphadenitis
– Pott’s disease
– Foreign body, instrumentation
– Spread from other areas
– Congenital cysts and fistulas
– Intravenous drug abuse
– Unknown causes-20%

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Microbiology

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 Submandibular space infection (Ludwig’s angina)

• Rapidly spreading infection of the

sublingual space initially and later the
submaxillary space.

• Cellulitis of submandibular space (LN not

involved)

• Main etiology- dental caries Etiology-

– Anterior teeth and first molars –
infection of sublingual space
– Second and third molars –
infection of submaxillary space
• Alpha haemolytic streptococci,
Staphylococci, bacteroids groups
are common.
• infection following trauma of the
tongue, floor of mouth
• Lingual tonsillitis
• Infection following dental
extraction

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 Ludwig’s angina
CLINICAL FEATURES:

20-50yrs individuals are commonly affected.

• Fever, malaise
• Painful neck swelling in the region below the mandible.
• Dysphagia, difficulty in opening mouth
• Signs-

1. Signs of sepsis: fever, rapid pulse and toxic appearance,

2. Rapidly increasing cellulitis with induration,
3. erythema below the mandible
4. Trismus
5. Brawny edema at the floor of the mouth and tongue pushing the
tongue posteriorly.
6. Drooling of saliva
7. Dyspnea and stridor
Diagnosis
It is based mainly on classical clinical presentation
Dental X-rays to assess dental status
CT scan 7
Ludwig’s angina

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 Ludwig’s angina
TREATMENT
• IVantibiotics, extraction of Complications:-
the diseased tooth.
• Incision and drainage Airway obstruction
Horizontal incision with wide spread of infection to parap
exposure
Incision from one angle of the retropharyngeal spaces.
mandible to the other
Fluid is allowed to drain. Aspiration pneumonia
Drainage tube or antibiotic soaked
ribbon gauge is placed. septicemia
Tracheotomy if airway is
endangered.

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 Parapharyngeal abscess
• Causes
– Acute/chronic tonsillitis
– Peritonsillar abscess
– Dental infection
– From other spaces
– External trauma

• Clinical features

– Anterior compartment(leads to
abscess)
• Prolapse of tonsil
• Trismus
•External swelling behind
angle of jaw
• Odynophagia, fever
– Posterior compartment
• Bulge of pharynx behind posterior
pillar
• cranial nerve9, 10,11,12. paralysis
• Swelling of parotid region
• Odynophagia, fever 10
Dr. ASHLY ALEXANDER 11
Dr. ASHLY ALEXANDER 12
• Treatment
– IV antibiotics

• External approach
(Incision given externally- 2-3cm
below the lower border of mandible)

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Complications:
• Rates of About 16%
• Carotid sheath involvement
causing Internal jugular vein
thrombosis, Carotid artery
thrombosis.
• Internal carotid artery pseudo aneurysm
(carotid artery rupture)
• Mediastinitis

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 Acute Retropharyngeal Abscess
• Pediatrics
– Cause—suppurative process in lymph nodes
• Nose, adenoids, nasopharynx, sinuses
• Adults
– Cause—trauma, instrumentation, extension from
adjoining deep neck space

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Features
fever
Dysphagia, difficulty in breathing
Stridor and croupy cough may be present
Torticollis
Unilateral bulge in posterior pharyngeal wall.

• Lateral neck plain film

– Normal: 7mm at
C-2, 14mm at C-6 for
kids, 22mm at C-6 for
adults
– Loss of cervical lordosis
– prevertebral soft tissue
shadow widening.
– Air shadow in
prevertebral space
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 Retropharyngeal Abscess(acute)
• Treatment
– IV antibiotics and fluid
replacement
– Surgical drainage
• Intraoral
• External –
tracheostomy +
anterior cervical
approach
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 Chronic Retropharyngeal abscess
(prevertebral abscess)
• This is due to Tuberculosis of the cervical spine.
• This may initially involve the prevertbral space
alone and later the danger space and
retropharyngeal spaces.

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Symptoms
• The throat symptoms are not severe
compared to acute retropharyngeal abscess.
• Insidious onset
Systemic features of TB +/ - (chronic cough,
evening rise in temperature, night sweats, loss
of appetite and loss of weight)
Painless lump in the throat
Dysphagia
Cervical pain may radiate to the upper limbs
with or without sensory / motor neurological
deficits.
Signs
Median bulge on the posterior pharyngeal wall
No signs of acute inflammation
Signs of cervical spine or lymph node
tuberculosis and neurological radiculopathies
may be present.

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 Chronic Retropharyngeal
abscess
Diagnosis Treatment
• Clinical examination • Antitubercular drugs

• Blood Examination

• Sputum for AFB

• X-Ray cervical spine

• X-Ray Chest

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 Retropharyngeal abscess
Complications:- meningitis
Haemorrhage
  laryngeal spasm 
septicemia  
Metastatic
abscess
Jugular vein thrombosis
Rupture with aspirationpneumonia 
 Pericardial tamponade     
  Mediastinitis
  Spead in to other spaces

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 Peritonsillar abscess (quinsy)
• Cause
-Local complication of tonsillar infection
-Infection→crypta magna→peritonsillar space
More common in adults due to atrophied crypta manga.

• Symptoms
– Fever with chills and rigor
– Odynophagia
– “Hot Potato” voice
– Halitosis
– Head tilted towards affected site

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Dr. ASHLY ALEXANDER 26
 Peritonsillar abscess (quinsy)
Signs
• Anxious facies and stiffly held head,↑ pulse &↑ temp

• Trismus

• Unilateral swelling over palate & ant pillar

• Uvula pushed to opposite site

• Tonsil displaced medially and downward

• Palate angry red, immobile, thick mucous

• JDLN enlarged & tender

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 Peritonsillar abscess (quinsy)
Treatment :

• Hospitalization
• Correction of dehydration
• Systemic parentral broad spectrum
antibiotics
• Aspiration of pus done
• Incision and drainage

If pus present:I&D and supportive treatment

After 6weeks tonsillectomy (intermittent

tonsillectomy)to prevent recurrence

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 Peritonsillar abscess (quinsy)

Complications :
•Parapharyngeal abscess.

•Oedema of larynx

•Septicemia

•IJV thrombosis

•Pneumonitis or lung abscess

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 Parotid space infections
This space lies in-between the enveloping layers of deep
cervical fascia covering the parotid gland

Route: via stensons duct

Predisposing factors- dehydration (oral),poor orodental

hygiene, DM, Immunocompromised.

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Clinical features
• usually follow 5-7 day after surgery.
• marked swelling of jaw
• Pain and induration over parotid gland
• Congested stenson’s duct.
• No fluctuation d/to thick capsule.

Treatment
correct dehydration
improve oral hygine IV
antibiotics
I&D: just in front of pinna (vertical)
Hiltons method

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 Complications
• Internal Jugular Vein Thrombophlebitis
(Lemierre’s syndrome)

– Fusobacterium necrophorum
– High fever with chills and rigor
– Swelling and pain along SCM
– Bacteremia, septic embolization, dural sinus
thrombosis
– IV drug abusers
– Treatment
• IV antibiotics
• Anticoagulation - controversial
• Ligation and excision

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 Complications

• Mediastinitis
– Mortality of 40%
– Increasing dyspnea, chest pain
– CXR - widened mediastinum
– Treatment
• EARLY RECOGNITION AND INTERVENTION
• Aggressive IV antibiotic therapy
• Surgical drainage
– Transcervical approach
– Chest tube / thoracotomy

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 Complications

• Cranial nerve deficits

• Necrotising cervical fasciitis
• Osteomyelitis
• Grisel syndrome ( inflammatory
torticollis causing cervical vertebral
subluxation )

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References

1. Textbook of ear, nose, throat and head and neck

surgery by P. Hazarika
2. Dhingra’s diseases of ear, nose and throat
3. Cumming’s otolaryngology, head and neck surgery
book
4. https://www.ccjm.org/content/86/9/577
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