1. DEEP NECK
INFECTION

2. Anatomy of cervical fascia
1) Superficial cervical fascia
2) Deep cervical fascia

3. Superficial Cervical Fascia
Encircle H&N and attached to clavicle and zygomatic arch
Contain plastysma m. and external jugular v.
Marginal mandibular br. of facial n. lies just deep to superficial cervical fascia

4. Deep Cervical Fascial
Superficial layer
Middle layer
Deep layer

5. Superficial layer (Enveloping,Investing,Anterior layer)
From ligamentum nuchae, completely enclose the neck
Encircle trapezius m. , sternocleidomastiod m.
Encircle submandibular gl., parotid gl.,masticater muscle
Create superficial sternal space (of Burn)

6. Middle layer (Cervical layer,Pretracheal layer)
Encircle strap m. (muscular division)
Encircle esophagus trachea,thyroid gl., pharynx (visceral division)
Buccopharyngeal fascia ( part of visceral division that cover constrictor m. and buccinator m.)

7. Deep layer (Carpet fascia)
Cover vertebral body and paraspinous m.
Devided into
1. Alar division
from base of skull to T2 level
2.Prevertebral division
from base of skull to diaphram

8. Carotid sheath Extend from skull base to clavicle
Made up of 3 layer of deep cervical fascia
Contain carotid a., internal jugular v., vagus n. and sympathetic chain
Avenues for spread of infection from neck to mediastinum

9. Deep Neck Space Anatomy
Space Involving Entire Length Of Neck
Space Limited To Above The Hyoid Bone
Space limited To Below The Hyoid Bone

10. Space Involving Entire Length Of Neck
Retropharyngeal Space
Danger Space (Prevertebral Space)
Paravertebral Space
Carotid Sheath Space

11. Retropharyngeal Space
Between visceral division of middle layer and alar division of deep layer
Extend from skull base to T2 level
Midline raphae
More commom in children due to presence of retropharyngeal node

12. Danger Space
Between alar division and prevetebral division of deep layer (locate posterior to retropharyngeal space)
Extend from skull base to diaphram
No midline raphae
Infection spread from neck to posterior mediastinum easily

13. Paravertebral Space
Between prevertebral division of deep layer and vertebral bodies
Extend from skull base to coccyx
Infection in this space is rare and spread slowly due to compact connective tissue

14. Carotid sheath Space Made up from all deep cervical fascia
Infection from any deep fascia can spread to this space (lincoln High way)

15. Space Limit To Above The Hyoid Bone
Parapharyngeal Space
Submandibular Space
Masticator Space
Temporal Space
Parotid Space

16. Parapharyngeal Space (Lateral phryngeal Space) (Pharyngomaxillaly Space)
Boundary
Superiorly : Skull base
Inferiorly : Hyoid bone
Laterally : Medial pterygoid m.
Medially :Buccopharyngeal fascia
Anteriorly : Submandibular space
Posteromedialy : Prevertebral fascia and retrophryngeal space

17. Submandibular Space Divided into 2 spaces by mylohyoid m.
Sublingual space (above mylohyoid m.)
Submaxillaly space (below mylohyiod m.)
These 2 spaces can communicate each other by mylohyoid cleft

18. Masticator Space
Between masticator m. and superficial layer of deep cervical fascia
(Masticator m. = massestor m.,medial and lateral pterygoid m. and temporalis muscle)
Locate anterior and lateral to parapharyngeal space

19. Parotid Space
Between parotid gl. and superficial layer of deep cervical fascia
Infection can spread easily to parapharyngeal space due to incompleted encircle at upper inner surface of parotid gl.

20. Space Limit To Below The Hyoid Bone
Anterior Viseral Space (Pretracheal Space)
Between trachea, esophagus and middle layer of deep cervical fascia
Extend from hyoid bone to superior mediastinum

21. Etiology Of Deep neck Space
Dental infection
Tonsillar and peritonsillar infection
Trauma of upper aerodigestive tract
Retropharyngeal lymphadenitis
Pott’s disease
Sialadenitis
Bezold’s abscess
Infection of congenital cyst and fistula
Intravenous drug abuse

22. SPECIFIC DEEP NECK INFECTION

23. PARAPHARYNGEAL SPACE INFECTION
Most common cause :
Peritonsillar infection
Typical finding
1.Trismus
2. Angle mandible swelling
3. Medial displacement of lateral pharyngeal wall
Others : fever, limit neck motion,neurologic deficit (C.N 9,10,12,Horner’s syndrom)

24. PARAPHARYNGEAL SPACE INFECTION
Treatment
Evaluate and maintain airway & fluid hydration
Parenteral antibiotic high dose hrs.
If not improve, consider surgical drainage

25. PARAPHARYNGEAL SPACE INFECTION
Surgical drainage
Intraoral approch
(for peritonillar abscess only)
2. External approach
-transverse submandibular incision
-T. shape incision (Mosher)

26. SUBMANDIBULAR SPACE INFECTION
Most common cause : Dental caries
Anterior teeth & first molar : infection enter sublingual space
Second & third molar
: infection enter submaxillary space

27. SUBMANDIBULAR SPACE INFECTION
Organisms
- Mixed of aerobes(alpha hemolytic strep, staph) and anaerobes make synnergistic effect of endotoxins
- Consider gram – in immunocompromize host

28. SUBMANDIBULAR SPACE INFECTION
Clinical feature
(True Lugwig’s angina)
Start unilateral and progress bilaterally
Induration of submandibular region and floor of mouth
( severe cellulitis)
Tongue trusted posteriorly and superiorly (cause airway obstruction)
Drolling, odynophagia, trismus, fever
No purulence(due to no time to developed)

29. SUBMANDIBULAR SPACE INFECTION
Treatment
Early stage
(unilat,mild swelling and edema)
-IV antibiotic, extration of infected tooth
Advance stage
(bilateral swelling, dysphagia with drolling)
-early airway intervention
-surgical drainage (submandibular incision)

30. RETROPHARYNGEAL SPACE INFECTION PREVERTEBRAL SPACE INFECTION
Most commmon cause
In children
-retropharyngeal lymphadenitis from nose,PNS,ET)
In adult
-regional truma and endoscopic procedure

31. RETROPHARYNGEAL SPACE INFECTION PREVERTEBRAL SPACE INFECTION
Clinical feature
In children
irritability,neck rigidity, fever,drolling,muffle cry, airway compromise
In adult
fever, sore throat, odynophagia, neck tenderness, dysnea

32. RETROPHARYNGEAL SPACE INFECTION PREVERTEBRAL SPACE INFECTION
Clinical feature
Retropharyngeal space abscess form abscess lateral to midline
Prevertebral space abscess
form abscess in midline
Mediastinitis S&S Dysnea,chest pain, tachycardia, fever,wideded mediastinum

33. RETROPHARYNGEAL SPACE INFECTION PREVERTEBRAL SPACE INFECTION
Investigation
Lateral neck film
- C2 > 7 mm. both children and adult
- C7 > 14 mm. in children
> 22 mm. in adult.
Chest film
- detection of mediastinitis

34. RETROPHARYNGEAL SPACE INFECTION PREVERTEBRAL SPACE INFECTION
Treatment
Surgical drainage
Intraoral drainage
-Lesion confined in larynx esp.child
External drainage (Dean)
-Lesion beyond pharyngeal level
-Airway compromise
-Involve other deep neck spaces

35. PARAVERTEBRAL SPACE INFECTION
Most common cause Penetrating trauma (F.B, endoscope)
TB spine
Infection spread slowly and more localize due to compact CNT.
Clinical feature
-Same as others posterior space abscess
-Vertebral osteomyelitis and spinal instability

36. MASTICATOR SPACE INFECTION
Most common cause Dental carices
Clinical feature
Extream trismus with minimum facial swelling
Massesteric space
(lateral compartment) :
edema at ramus of mandible
- Ptrygomandibular space (medial compartment):
edema at retromolar trigone

37. MASTICATOR SPACE INFECTION
Treatment
1. Intraoral drainage (medial compartment)
- along inner margin of mandibular ramus to the retromolar trigone
External approch (lateral compartment)
- submandibular incision
- preauricular incision or Gilles incision for temporal space abscess

38. PAROTID SPACE INFECTION
Most common cause : Bacterial retrograde from oral cavity
Clinical feature
high fever, weakness, mark swelling and tenderness of parotid gland,fluctuation,pus at stensen’s duct

39. PAROTID SPACE INFECTION
Treatment
IV ATB
Surgical drainage indicated for
-fluctuation
-medical failure after hr. or progression
of disease

40. COMPICATION OF DEEP NECK INFECTION
Internal jugular vein thrombosis
Cavernous sinus thrombosis
Neurologic deficit
Osteomyelitis of the mandible
Osteomyelitis of the spine
Mediastinitis
Pulmonary edema
Pericarditis
Aspiration
Sepsis