1. Deep Neck spaces and Infection
Dr.Samir M. Bawazir
Consultant Pediatric ORL.H&NS

2. Deep Neck Spaces and Infection
Anatomy of the Cervical Fascia
Anatomy of the Deep Neck Spaces
Deep Neck Space Infections

3. Cervical Fascia Superficial Layer Deep Layer * Superficial * Middle

5. Cervical Fascia Superfecial Layer * Platysma * Muscels of facial
expression

6. Cervical Fascia Superficial Layer of the Deep Cervical Fascia
* Muscels: - SCM
- Trapezius
* Glands: - SMG
- Parotid
* Spaces: - Posterior
Triangle
- Suprasternal
space

7. Meddle Layer of the Deep Cervical Fascia * Muscular Division
- Infrahyoid Strap Muscles
(St.Hy, St.Th, Th.Hy, Omohy.)
* Visceral Division
- Pharynx, Larynx,
Esophagus,Trachea, Thyroid
- Buccopharyngeal fascia

8. Cervical Fascia Deep Layer of Deep Cervical Fascia * Alar Layer:
- Post. visceral layer of
middle fascia.
- Ant. to prevertibral
layer
* Prevertibral Layer:
- Vertebral bodies
- Deep muscles of the
neck

9. Cervical Fascia Carotid Sheath: * Formed by all 3 layers of
deep fascia
* Contains carotid A., int.
jugular V. and vagus N.
(highway to the brain neck
and chest)

10. Deep Neck Spaces Described in relation to the hyoid
* Entire length of the neck.
* Suprahyoid.
* Infrahyoid

11. Deep Neck Spaces Entire length of Neck: * Superficial Space
- Surround platysma
- Contains areolar tissue, nodes
nerves and vessels.
- Subplatysmal Flaps.
- Involved with cellulitis and
superficial abscesses
- Treat with I&D along Langer’s lines + Abx

12. Deep Neck Spaces Retropharyngeal space - Entire Length of Neck
- Post. To pharynx and
esophagus
- Ant. To alar layer of deep
fascia
- Extend from skull
base to T1-T2

13. Deep Neck Spaces Danger Space - Entire Length of Neck
- Ant. Border is alar layer of deep
fascia.
- Post. Border is prevertebral
layer.
- Extend from skull base to
diaphragm.

14. Deep Neck Spaces - Suprahyoid Submandibular Space
- Ant./ Lat.- mandible
- Sup.- mucosa
- Inf. – superficial layer
of deep fascia
- Post./ Inf.- hyoid

15. Deep Neck Spaces Submandibular Space
- Sublingual space (under the tongue) content Areolar tissue, Hypoglossal and lingual N., Sublingual gland and Wharton’s duct.
- Submylohyoid (submaxillary) Space Ant. Bellies of digastric Submandibular gland

16. Deep Neck Spaces Parapharyngeal Space - Suprahyoid
- Superior- skull base
- Inferior- hyoid
- Anterior ptyergomandibular
raphe.
- Posterior- prevertebral fascia
- Medial- buccopharyngeal
fascia.
- Lateral- superficial layer of
deep fascia.

17. Parapharyngeal Space

18. Deep Neck Spaces - Prestyloid Parapharyngeal Space
+ Medial- tonsillar fossa
+ Lateral- medial
pterygoid
+ Contains fat, connective
tissue, nodes
- Post styloid
+ Carotid sheath
+ Cranial N. IX, X, XII

19. - Suprahyoid Peritonsillar space - Medial- capsule of
the palatine tonsil
- Lat.- sup. Phary.
Constrictor
- Sup.- ant. Tonsil
pillar
- Inf.- post. Tonsil

20. Deep Neck Space Infections
Presentation / Origin of infection
Microbiology
Imaging
Treatment
Complications

21. Presentation/Origin Retropharyngeal Abscess
50% in pt months of age
96% before 6 years of age
In children – fever, irritability, lymphadenopathy, torticollis, poor oral intake, sore throat, drooling.
In adults-- pain, dysphagia, anorexia, snoring, nasal obstruction, nasal regurgitation.
Dyspnea and respiratory distress
O/E: Lateral posterior oropharyngeal bulge.

22. Origin
Pediatrics
Caused by infectious process in the LN from Nose, Adenoid, NP, Sinuses
Adult
Caused by trauma, instrumentation extension from adjoining deep infection

23. Presentation/Origin Danger Space
Presentation and exam – identical to Ret-Ph.
space infection
Cause – extension from Retropharyngeal,
prevertebral Or parapharyngeal space

24. Presentation/Origin Submandibular Space
Pain , drooling, dysphagia, neck stiffness
Anterior neck swelling, floor of mouth edema
Causes % have odontogenic origin
First molar and anterior
Second and third molar
Sialadenitis, lymphadenitis,
laceration of the floor of
mouth, mandible fractures

25. Presentation/Origin Ludwig’s angina - Cellulitis – not abscess
- limited to SM space
- Foul serosanguinous fluid,
no frank purulence
- Fascia, muscle, connective tissue
involvement, sparing glands
- Direct spread rather than
lymphatic spread
- Tender, firm anterior neck edema without fluctuance
- Hot potato voice
- Tachypnea, dyspnea, stridor

26. Ludwig’s angina a

27. Presentation/Origin Parapharyngeal Space Fever, chills, malaise
Pain, dysphagia, trismus
Medial bulge of lateral ph. Wall
Cause- infection of pharynx,
tonsil, adenoids, dentition,
parotid, mastoid,
suppurative lymphadenitis,
extension from other DNSI

28. Presentation/Origin Peritonsillar Space Fever, malaise
Dysphagia, odenophagia
Hot potato voice, trismus,
bulging of superior tonsil
pole and soft palate,
deviation of uvula
Cause- extension from
tonsillitis

29. Presentation/Origin Anterior Visceral Space
Hoarseness, dyspnea, dysphagia, odynophagia
Erythema, edema of hypopharynx, may extend to include glottis and supraglottis
Anterior neck edema, pain, erythema, crepitus
Cause- FB., instrumentation, extension of infection in thyroid

30. Microbiology Preantibiotic era—S.aureus
Currently—aerobic Strep species and non- strep anaerobes
Gram-negatives uncommon
Almost always polymicrobial
Remember resistance

31. Imaging Lateral neck plain film
Screening exam—mainly for retropharyngeal and pretracheal spaces
Normal: for kids7mm at C-2, 14mm at C-6, for adults
22mm at C-6
Technique dependent
Sensitivity 83%,
compared to CT 100%
(Nagy, et al)

32. Imaging Ultrasound Advantages - Avoids radiation - Portable
- consistency
Disadvantages
- Not widely accepted
- Operator dependent
- Inferior anatomic detail
Uses
- Following infection during therapy
- Image guided aspiration

33. Imaging Contrast enhanced CT Advantages Disadvantages - Quick, easy
- Widely available
- Superior anatomic detail
- Differentiate abscess and
cellulitis
Disadvantages
- Ionizing radiation
- Allergenic contrast agent
- Artifact

34. 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

35. Treatment
Airway protection
Antibiotic therapy
Surgical drainage

36. Treatment 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

37. Treatment LUDWIG’S ANGINA Admission Close observation
May need intubation vs trach.

38. Treatment Antibiotic Therapy Cellulitis Improvement in 24-48 hours
Abscess?
* 50-90% respond to IV-Abx

39. 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

40. Treatment Surgical Drainage Transoral
- Preoperative CT- where are the great vessels?
- Cruciate mucosal incision, blunt spreading
through superior pharyngeal constrictor
- Nagy, et al: retro-, parapharyngeal or
combo in kids, 22/23 successfully treated
with intraoralincision and drainage
External

41. Treatment Surgical Drainage External * EXPOSURE, EXPOSURE, EXPOSURE
* Levitt: anterior vs.
posterior approach
* Submandibular incision
* Submental incision
* T-incision

42. Treatment Image-guided Aspiration Patient selection
- Smaller abscesses, limited extension,
uniloculated
- Early specimen collection, reduced expense,
avoidance of neck scar
Yeow, et al: Ultrasound guided aspiration
8/10 patients successfully treated with needle
aspiration
5/5 patients successful treated with catheter
insertion

43. Complications Airway obstruction - Endotracheal intubation
- Tracheotomy
Ruptured abscess
- Pneumonia
- Lung Abscess

44. Complications
Internal Jugular Vein Thrombosis - F/C, prostration, swelling and pain along SCM - Bacteremia, septic embolization, dural sinus thrombosis - IV drug abusers - Treatment + IV antibiotic therapy + Anticoagulation? + Ligation and excision

45. Complications - Sentinel bleeds from ear, nose, mouth
Carotid Artery Rupture
- Mortality of 20-40%
- Sentinel bleeds from ear, nose, mouth
- Majority from internal carotid, less from
external carotid, and fewest from common
carotid
- Treatment
+ Proximal and distal control
+ Ligation
+ Patching or grafting?

46. 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 vs. thoracotomy

47. Conclosion Cervical fascia- superficial & deep
Multiple neck spaces- supra and infra hyoid
Retropharyngeal, paraph, submandibular and peritonsilar spaces are important.
Ludwig’s angina can cause airway obst.
Airway protection first action
Contrasted CT diagnostic
Rx-IV Abx
I&D or aspiration may be neede