Seminar in Otorhinolaryngology

Deep neck space infections

M. J. Porter and C. A. van Hasselt

Abstract
Deep neck space infections occur within the potential compartments of the neck between the fascial layers. The commonest causes are acute tonsillitis, foreign bodies or dental disease. The patients usually complain of pain and swelling of the neck and, unless treated, the condition can rapidly deteriorate to cause asphyxiation. The treatment is initially by high dose intravenous antibiotics, usually penicillin and metronidazole. If the airway is in danger, a tracheostomy should be performed. When the infection progresses to abscess formation, then external surgical drainage will be required. Keywords: Abscess; Neck space

Introduction
Infections of the deep spaces of the head and neck are uncommon in the modern antibiotic era. However, they appear to be encountered frequently in the Far East.1 The main factors responsible for this are the generally poor level of dental hygiene and the frequent ingestion of foreign bodies, especially fish bones.2 These infections still pose a serious threat to life so that prompt diagnosis and appropriate treatment are necessary.

1. The investing layer of deep fascia is attached to the mandible above, to the hyoid bone and inferiorly to the clavicle. It splits to enclose the sternomastoid and trapezius muscles. It also gives a covering to the submandibular gland. 2. The middle or visceral layer of fascia encircles the pharynx, larynx, thyroid and oesophagus. The carotid sheath, which surrounds the carotid arteries, internal jugular vein and vagus nerve, is derived from the visceral layer. 3. The prevertebral layer of deep fascia lies on the surface of the prevertebral muscles and attaches to the spinous processes of the cervical vertebrae. The major potential spaces lie between these fascial layers as follows: a. The parapharyngeal space (also known as lateral pharyngeal or pharyngomaxillary space) is a large potential space which has the shape of an inverted pyramid and lies lateral to the visceral fascia from the base of skull down to the level of the hyoid. It is limited inferiorly by the attachment of the fascia covering the submandibular gland to the digastric and stylohyoid muscles. It contains the carotid sheath, lymphatic and cranial nerves IX, X, XI and XII.4 b. The retropharyngeal space lies between the visceral fascial layer and the prevertebral fascial layer. This potential space extends from the skull base down into the posterior mediastinum.

Anatomy
There are many potential 'spaces' in the head and neck and the subject can be made unnecessarily complicated by their enumeration. It is important to realize that most of these spaces communicate with the parapharyngeal space which should be regarded as the key to understanding the anatomy and pathology of these infections.3 The neck contains superficial and deep fascial layers. The superficial fascia envelopes the platysma muscle. The deep fascia is divided into three layers (Fig. I).
Division of Otorhinolaryngology, Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Sha Tin, Hong Kong M.J. Porter, MA, FRCS C. A. van Hasselt, FCS (SA) M Med (Otol) Correspondence to: Dr C. A. van Hasselt

Porter & van Hasselt: Deep neck space infections

Prevertebral Fascia Carotid Sheath Jugular Vein Vagus Nerve Hypoglossal Nerve Carotid Artery Parotid Gland Mandible Visceral Fascia Tonsil Tongue 1 Retropharyngeal Space 2 Parapharyngeal Space Fig. 1. Anatomical cross section of the neck at the level of the tonsil.

c. The submandibular space is bounded by the floor of the mouth and the superficial fascial layer passing from the mandible to the hyoid. It is divided into a sublingual space (above) and submaxillary space (below) by the mylohyoid muscle. Other potential spaces described include the superficial and deep temporal spaces, the parotid space, the masseter and buccal spaces, the canine space and the pterygomandibular space.5 It should be remembered that paratonsillar abscesses (Quinsies) are still sometimes encountered after an episode of acute tonsillitis. These abscesses lie between the visceral layer of fascia and the tonsil and may coexist with an abscess in any of the deep neck spaces.

disease, dental caries or apical abscess. Two important clinical points should be made: 1. The dental condition responsible may not be symptomatic. 2. Infection may start spreading immediately after dental treatment aimed at removing a focus of disease, e.g. extraction.8 In Hong Kong, the accidental ingestion of fish and animal bones is a common occurrence. These may lacerate or lodge in the pharynx or oesophagus. Attempts at removal may also result in lacerations and further damage. A breach in the mucosa offers access for organisms and consequent spread of infection. Such a patient would experience pain after swallowing the bone, find that the pain eased after 24 hours, but then re-emerged as cellulitis and abscess formation became established. Other causes of deep neck space infections4, 9, 10 include: salivary gland calculus or sialectasis oral trauma endotracheal intubation rigid oesophagoscopy congenital cysts.

Aetiology
In the pre-antibiotic era, tonsillitis or pharyngolaryngitis were the usual causes of deep neck space infections.6 Although these are still a cause, other conditions are now responsible for at least half of the cases seen in Hong Kong. Dental pathology is a common aetiology7 and may take the form of gum

J Hong Kong Med Assoc Vol. 44, No. 1, March 1992

Complications
Spontaneous rupture of the abscess can occur through the skin surface or alternatively into the mouth or pharynx. This may cause aspiration of pus and fatal chest infection.12 An abscess and the surrounding oedema behaves as a space occupying lesion which can rapidly lead to airway obstruction and asphyxiation. This is especially true of infections of the submandibular space. Here, because of the firm attachment of the superficial layer of fascia to the mandible and hyoid, the tongue is pushed backwards into the airway. Intubation under these circumstances is difficult and hazardous because of the distorted anatomy. Indeed, on attempting intubation in the young child with a retropharyngeal abscess, there is a danger of rupturing the abscess and aspiration of the pus. The jugular vein may become thrombosed and send off septic emboli which in turn may result in bacterial endocarditis, glomerulonephritis, septic arthritis or lung abscess.13 The wall of the carotid artery may necrose leading to fatal haemorrhage. Should intraoral bleeding from the internal carotid artery occur, ligation of the common carotid artery is recommended.14 Spread of infection from the neck into the chest can occur either along the carotid sheath into the superior mediastinum or via the prevertebral space into the posterior mediastinum. This can result in the serious complications of mediastinitis and empyema.15, 16

Investigations
Routine haematology shows a raised white cell count and erythrocyte sedimentation rate (ESR). The biochemical profile is usually normal. Blood cultures should be sent to identify the organisms and their antibiotic sensitivity. A lateral neck x-ray is useful in the diagnosis of a retropharyngeal'space infection as judged by the expansion of the prevertebral soft tissue shadow (Fig. 2). In both the normal adult and child, the distance from the body of C2 to the pharynx is between 2 and 7 mm (average 3.5). At C6 the distance is between 5 and 14 mm (average 7.9) for children and between 9 and 22 mm (average 14) for adults.17 (It must be noted that in children the figure is dependent on the position of the neck, being greater when the neck is flexed). Other features seen on plain films are air in the soft tissues and loss of the normal cervical lordosis. Both computed tomography and ultrasound may demonstrate an abscess cavity (Fig. 3). The diagnostic features are those of a low density mass with air visible in the centre, an enhancing rim and surrounding oedema.18, 19 Total reliance on these investigations is dangerous and the authors have experience of both false positive and false negative scans.

Microbiology
As techniques for anaerobic culture have improved, it has become apparent that most infections are predominantly anaerobic or mixed, a pure aerobic culture being uncommon. The oral flora or the organisms commonly responsible for acute tonsillitis are usually cultured. We have noted a high incidence of Streptococcus milleri in the infections encountered at the Prince of Wales Hospital. Other organisms often found are the anaerobic Streptococci or Peptostreptococci, Bacteroides melaginensis and Fusobacterium. The aerobic organism is most commonly a Streptococcus. B. fragilis and Staphylococcus aureus are noticeably absent from culture.11

Presentation
It will be apparent from the above that there are many possible antecedents to a deep neck space infection. The patient may give a history of a recent episode of acute tonsillitis or upper respiratory tract infection. An episode of difficulty swallowing a bone may be recalled. A history of dental pain or recent dental surgery can be important. The features specific to the infection, however, include pain in the mouth, throat or neck, fever, neck stiffness and trismus (due to irritation of the pterygoids). There is usually a visible swelling around the angle of the jaw although this may not be apparent in a purely retropharyngeal space infection. Neurological defects can occur due to involvement of the cranial nerves IX, X, XI and XII within the parapharyngeal space and a Horner's syndrome may be present. The progression of the infective process causes difficulty with swallowing and airway obstruction, a sign which indicates impending disaster. If the condition spreads to the mediastinum, then increasing dyspnoea and chest pain become evident.14 In children, the diagnosis of a purely retropharyngeal abscess can be difficult to confirm as the symptoms are non-specific.

Treatment
Antibiotics should be administered intravenously when there is clinical evidence of spreading infection in the neck, bearing in mind the likely sensitivity of the responsible organisms until a specimen has been cultured. As a first line of treatment, penicillin in doses up to 20 megaunits a day should be administered together with metronidazole. In cases of penicillin allergy, clindamycin is a good alternative. The aminglycosides are not normally indicated. Resistance of B. melaninogensis is uncommon but reported in up

Fig, 3.

ity (arrow) in the prevertebr

swelling in the neck. A persistent temperature, leucocytosis and tachycardia would suggest abscess formation. The patient should also be followed with serial lateral neck x-ravs, ultrasound and CT scans. Failure to respond to antibiotics alone is an indication for drainage. If the history is of a swelling progressing over several days, then it is likely that pus will have formed. The finding of pus on needle aspiration or definite radiological evidence of abscess lo.rmaf.ion are both indications far immediate drainage. Some cases have been successfully treated by CT-guided needle aspiration alone.20, 21
Fig, 2, Lateral x-ray of neck showing widening of the prevertebral soft tissues, a gas shadow (upper arrow) and a foreign body (lower arrow).

Surgical approaches
Unilateral submandibular space infections and parapharyngeal space infections are approached as Cor submandibular gland excision (Fig. 4, 1), continuing by blunt dissection in front of the carotid sheath. This route leads all the way up to the skull base," Retropharyngeal space infections may require different approaches depending upon the clinical circumstances. In infants, it is usually due to suppurative lymphadenitis and peroral incision is ideal. In earlier times, it used to be recommended that this be performed in the head down position without anaesthesia for fear of rupturing the abscess with subsequent aspiration of pus. With the availability of modern paediatric anaesthesia, initial intubation is preferable.23 In the adult, the retropharyngeal space is best approached via an incision anterior to the middle third of sternomastoid muscle, retracting the carotid sheath posteriorly (Fig. 4, 2). If the abscess is high in the neck, it can be approached behind the sternomastoid, retracting the carotid sheath anteriorly.24 if the infection is thought to be due to tuberculosis of the cervical spine, aspiration rather than external drainage of the pus is required.

to 20% of isolates in the United States.19 This should be remembered if the infection fails to resolve as expected. Definitive therapy will be determined by the antibiotic sensitivity of organisms cultured from material obtained from aspiration or surgical drainage. In cases where respiratory obstruction threatens, securing an airway becomes the priority. Intubation requires the expertise of a skilled anaesthetist and may not always be successful. A tracheostomy, being the only alternative, may equally be difficult and hazardous to perform. The need for surgical drainage requires careful clinical judgement. Many infections are seen at the stage of cellulitis before an abscess cavity and frank pus have formed and it may be difficult to decide how long to continue with conservative management or when to abandon it in favour of surgery. If the history is short and the patient well, then at least 24 hours of antibiotic therapy should be administered before surgical drainage is considered. The patient's general clinical condition and. airway require close monitoring. The clinical features to be observed are the degree of pain, dysphagia and the amount of

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2. 3. 4. 5.

6. 7. 8. 9. 10. 11. Fig. 4. Diagram to illustrate the incisions used to drain neck abscesses. 12. 13. 14. 15. 16. 17. 18. 19.

An infection of the submandibular space is often bilateral and requires a midline horizontal incision (Fig. 4, 3). Ludwig's angina is a necrotising cellulitis in this compartment, in which abscess formation can occur but is unusual. Intravenous antibiotics are the first line of treatment. The condition can progress to respiratory obstruction in as little as 12 hours and tracheostomy is indicated if there is any doubt about the safety of the airway. If the infection fails to respond or pus can be demonstrated, then the space should be explored surgically. In Patterson's series of 20 cases, seven needed airway support of which four required a tracheostomy. Of the nine cases explored, pus was present in fewer than half.8 Masseter spaces are drained into the mouth and temporal spaces from above the zygoma (Fig. 4, 4). In conclusion, deep neck space infections constitute an emergency which requires prompt admission to hospital, immediate parenteral antibiotics and vigilant clinical attention. Progression may be rapid resulting in extension of the infection to the chest or airway obstruction. Surgical drainage is often required to prevent the occurrence of these life-threatening complications.

20.

21. 22. 23.

References
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24.

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