1. INFECTIONS OF THE DEEP
SPACES OF THE NECK

2. DEEP NECK SPACES AND INFECTIONS
Anatomy of the Cervical Fascia
Anatomy of the Deep Neck Spaces
Deep Neck Space Infections

3. CERVICAL FASCIA Superficial fascia Deep fascia Superficial layer
Middle layer
Deep layer
…This division… must be considered arbitrary and created by man rather
than nature in order to convert an anatomical thought into a verbal picture…
Levitt, 1968

4. DEEP CERVICAL FASCIA Superficial layer of the deep cervical fascia
“the enveloping layer”
Muscles
Sternocleidomastoid
Trapezius
Glands
Submandibular
Parotid
Spaces
Subvaginal space
Suprasternal space of Burns

5. DEEP CERVICAL FASCIA Middle layer of the deep cervical fascia
Muscular Division
Infrahyoid Strap Muscles
Visceral Division
Pharynx, Larynx,
Esophagus, Trachea,
Thyroid
Buccopharyngeal Fascia

6. DEEP CERVICAL FASCIA Deep Layer of Deep Cervical Fascia Alar Layer
Posterior to visceral layer
of middle fascia
Anterior to prevertebral layer
Prevertebral Layer
Vertebral bodies
Deep muscles of the neck

7. SPECIAL FASCIAL SHEATH
Carotid Sheath
Formed by all three layers of deep fascia
Contains carotid artery, internal jugular vein, and vagus nerve
Runs from the skull through the lateral pharyngeal space into the chest

8. DEEP NECK SPACES Described in relation to the hyoid
Entire length of the neck
1. Retropharyngeal Space
2. Danger Space
3. Prevertebral Space
4. Visceral Vascular Space
Suprahyoid
5. Submandibular Space
6. Lateral Pharyngeal Space
7. Masticator/Temporal Space
8. Parotid Space
9. Peritonsillar Space
Infrahyoid
10. Anterior Visceral Space
Levitt, 1968

9. DEEP NECK SPACES Entire Length of Neck: 1. Prevertebral Space
Anterior border is prevertebral
fascia, posterior border is vertebral
bodies and deep neck muscles.
Extends along entire length
of vertebral column.
Conteins very compact tissue

10. DEEP NECK SPACES Entire Length of Neck: 2. Danger Space
Anterior border is alar layer
of deep fascia, posterior border
is prevertebral layer.
Extends from skull through
posterior mediastinum to
diaphragm.
Conteins very loose
areolar tissue offering
little resistance to the spread
of infection to the mediastinum

11. DEEP NECK SPACES Entire Length of Neck: 3. Retropharyngeal Space
Posterior to pharynx
and esophagus, anterior
to alar layer of deep fascia
Extends from skull base
to T1-T2
Two chains of nodes on
either side of the midline

12. DEEP NECK SPACES Infrahyoid 3. Anterior Visceral Space
Middle layer of deep fascia
Contains thyroid,
trachea, esophagus
Extends from thyroid
cartilage into superior
mediastinum

13. DEEP NECK SPACES Suprahyoid: 4. Lateral Pharyngeal Space
Superior: skull base
Inferior: hyoid
Prestyloid
Contains fat, connective
tissue, nodes
Poststyloid
Carotid sheath
Cranial nerves IX, X, XII

14. DEEP NECK SPACES Suprahyoid: 5. Submandibular Space
Anterior/Lateral: mandible
Superior: oral mucosa
Inferior: superficial layer of deep fascia
Posterior/Inferior: hyoid
Supramylohyoid portion
Sublingual gland
Hypoglossal and lingual
nerves
Portion of Submandibular gland
Inframylohyoid portion
Submandibular gland
Wharton’s duct
Anterior bellies of digastrics

15. DEEP NECK SPACES Suprahyoid: 6. Masticator and Temporal Spaces
Bounded by the
superficial layer of deep
cervical fascia
Contains masseter, pterygoids,
temporalis, ramus and
posterior portions of the body
of mandible, inferior alveolar
vessels and nerves

16. DEEP NECK SPACES Suprahyoid: 7. Parotid Space Superficial layer
of deep fascia
Dense septa from
capsule into gland
Relationship
to parapharyngeal space

17. DEEP NECK SPACES

18. DEEP NECK SPACES

19. DEEP NECK SPACES

20. DEEP NECK SPACES

21. DEEP NECK SPACES

22. DEEP NECK SPACES

23. Network of patterns of infectious extension
DEEP NECK SPACES
Network of patterns of infectious extension
Submandibular
Masticator
Temporal
Peritonsillar
Lateral
Pharyngeal
Parotid
Vascular
Retropharyngeal
Danger
Prevertebral
Anterior Visceral
Mediastinum

24. CAUSES OF DEEP NECK INFECTIONS (ENT Department, Treviso Regional Hospital)
151 cases ( )

25. AGE DISTRIBUTION (ENT Department, Treviso Regional Hospital)
151 cases ( )

26. CLINICAL PRESENTATION (ENT Department, Treviso Regional Hospital)
151 cases ( )

27. DISTRIBUTION OF CASES (ENT Department, Treviso Regional Hospital)

28. DEEP NECK SPACE INFECTIONS
Origin and clinical presentation of infection
Retropharyngeal Infections
Pediatrics
Suppurative process in retropharyngeal nodes from nose, adenoids, nasopharynx or sinuses infections
Fever, irritability, lymphadenopathy, torticollis, poor oral intake, sore throat, drooling
Adults
Trauma Instrumentation; extension from adjoining deep neck space
Pain, dysphagia, anorexia, snoring, nasal obstruction, nasal regurgitation.
Dyspnea and respiratory distress
Unilateral posterior pharyngeal swelling (the buccopharyngeal fascia is adherent to the alar fascia in the medline)

29. DEEP NECK SPACE INFECTIONS
Retropharyngeal Infections
Adult
Child

30. DEEP NECK SPACE INFECTIONS
Clinical Presentation and Origin of infection
Danger Space Infections
Presentation and exam nearly identical to retropharyngeal
space infection but the infection spreads rapidly through
the loose areolar tissue within this space to the posterior
mediastinum
Extension from retropharyngeal, prevertebral or lateral
pharyngeal space

31. DEEP NECK SPACE INFECTIONS
Clinical Presentation and Origin of infection
Prevertebral Space Infections
Back, shoulder, neck pain made worse by deglutition
Dysphagia or dyspnea
Bulding mass in the midline of the pharynx
Extension from retropharyngeal and danger spaces,
Pott’s abscess, iatrogenic trauma, osteomyelitis

32. DEEP NECK SPACE INFECTIONS
Prevertebral Space Infections

33. DEEP NECK SPACE INFECTIONS
Clinical Presentation and Origin of infection
Anterior Visceral Space
Dysphagia, odynophagia, hoarseness, dyspnea
Edema of hypopharynx
Anterior neck edema with subcutaneous emphysema
Extension from retropharyngeal, perforation of anterior
esophageal wall, foreign body, external trauma,
extension of infection in thyroid

34. DEEP NECK SPACE INFECTIONS
Anterior Visceral Space

35. DEEP NECK SPACE INFECTIONS
Clinical Presentation and Origin of infection
Visceral Vascular Space Infections
Induration and tenderness deep to the SCM
Torticollis toward opposite side
Septicemia, spiking fevers
Intravenous drug abuse,
extension from other deep neck spaces

36. DEEP NECK SPACE INFECTIONS
Visceral Vascular Space Infections:
Lemierre Syndrome

37. DEEP NECK SPACE INFECTIONS
Clinical Presentation and Origin of infection
Submandibular Space Infections
Pain, drooling, dysphagia, neck stiffness
Anterior neck swelling, floor of mouth edema
70% have odontogenic origin
First molar: supramylohyoid space
Second and third molars: inframylohyoid space
Sialadenitis, lymphadenitis
Lacerations of the floor of mouth, mandible fractures
Tonsillar disease
Ludwig’s angina

38. DEEP NECK SPACE INFECTIONS
Particular Clinical Presentation
Ludwig’s angina (Morbus Strangolatorius)
Grodinsky’s criteria (1939):
1. A cellulitis, not an abscess of submandibular space
2. The cellulitis involves all the sublingual and bilateral submaxillary
spaces
3. The cellulitis produces a serosanguineous putrid infiltration
but very little or no frank pus
4. Fascia, muscle, connective tissue involvement, sparing glands
5. The cellulitis is spread by continuity and not by lymphatics

39. DEEP NECK SPACE INFECTIONS
Clinical Presentation
Ludwig’s angina
“Woody” hardness with well defined border.
Comparative slight inflammation of throat and absence of infection in regional lymph nodes
“Hot potato” voice, drooling, tachypnea, dyspnea, stridor
Complications:
1. Spread along the styloglossus muscle back into the parapharyngeal space retropharyngeal space superior mediastinum
2. Tongue displacement posteriorly and superiorly against the palate with respiratory embarrassment (Morbus strangolatorius)

40. DEEP NECK SPACE INFECTIONS
Ludwig’s angina

41. DENTALSCAN

42. DENTALSCAN

43. DEEP NECK SPACE INFECTIONS
Clinical Presentation and Origin of infection
Lateral Pharyngeal Space Infections
Sore throat, dysphagia, odynophagia, otalgia, trismus
Medial bulge of lateral pharyngeal wall
Infection of pharynx, tonsil, adenoids, teeth,
parotid, mastoid (Bezold’s abscess), suppurative lymphadenitis,
extension from other deep neck spaces

44. DEEP NECK SPACE INFECTIONS
Lateral Pharyngeal Space Infections

45. DEEP NECK SPACE INFECTIONS
Clinical Presentation and Origin of infection
Parotid Space infections
Pain, swelling of the angle of jaw, medial bulge
of posterior lateral pharyngeal wall,
Parotitis, sialolithiasis, Sjogren’s syndrome

46. DEEP NECK SPACE INFECTIONS
Parotid Space infections

47. BACTERIOLOGY Most abscesses contained mixed bacterial flora
Aerobes: Streptococci a-hemolytic (Strept. viridans)
Staphylococci, Neisseria, Klebsiella, Haemophilus
(Decresed role of b-hemolytic Streptococci)
Anaerobes: Bacteroides, Peptostreptococcus
Anaerobes are understimated (>35%)
widespread antibiotic use prior to collection of cultures
poor sample collection techniques
fragility of anaerobes
Anaerobes product b-lactamase

48. BATTERIOLOGY Gold Standard: Empirical Treatment
To initiate antibiotic treatment
after appropiate cultures are obtained
Empirical Treatment

49. (+/- cefuroxime 0.75-1.5gr tid)
BATTERIOLOGY
Empirical Treatment
First-line
Clindamycin mg tid
(+/- cefuroxime gr tid) or
Penicillin G
24 million units/day +
Metronidazole 1gr bid
Alternatives
AMX/CL 1.5-3gr qid or
PIP/TZ 2.25gr qid gr tid

50. through intact skin or mucosal surface cleaned with antiseptic
BATTERIOLOGY
Culture
Needle Aspiration
through intact skin or mucosal surface cleaned with antiseptic
Blood culture bottle
for aerobes
Blood culture bottle
for anaerobes
Sterile container for
Gram and
Ziehl-Nielsen Stain

51. BATTERIOLOGY Two to Three Blood Culture Blood culture bottle
for aerobes
Blood culture bottle
for anaerobes

52. DEEP NECK SPACE INFECTIONS
Diagnostic Studies
Radiographs of the chest
Lateral soft tissue radiographs
Ultrasonography
Contrast Enhanced CT
MRI

53. DEEP NECK SPACE INFECTIONS
Diagnostic Studies
Contrast Enhanced Computer Tomography
Intravenous contrast may help identify an abscess as a “rim-enhancing lesion” with a low-density center.
A gas-fluid level or gas bubbles are also diagnostic of an abscess
Intravenous contrast also helps delineate vascular structures (e.g. trombosis of the jugular vein)

54. DEEP NECK SPACE INFECTIONS

55. History + Physical examination
MANAGEMENT
History + Physical examination
Culture, IV antibiotics, Airway control, Chest RX
cellulitis CT
large abscess
small abscess
W&W
24-48h
needle aspiration
for culture e drainage
improvement?
complications? No
Yes
surgical incision
and drainage
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