Deep Neck Space Infection

Dr Sinta Sari R, M.Kes,Sp THT-KL

School of Medicine Padjajaran University

Departmen of Otolaryngology HNS
Hasan Sadikin General Hospital
Bandung
2007

Introduction
DEEP NECK SPACE INFECTIONS
antibiotics decreased the incidence and mortality
deep neck space infections remain life threatening
delay in diagnosis/inadequate/inappropriate treatment
complications (mediastinitis) mortality rates : 40%
head and neck surgeon :
cervical fascias & potential spaces understand the
treatment & potential complications

Anatomy Of The Cervical Fascia

Superficial cervical fascia
Deep cervical fascia
1. Superficial layer
2. Middle layer
- Muscular division
- Visceral division

3. Deep layer
- Prevertebral division
- Alar division

Cervical Fascia

Retropharyngeal Space Infection

Source

Nose
Sinuses
Adenoids
Nasopharynx

Manifestations

Acute URTI in infants & children

Dysphagia & odynophagia
Drooling & difficult to expell excretions
Cervical rigidity
Muffled voice
Dyspnea
Unilateral bulging of posterior pharyngeal wall
Sepsis

Retropharyngeal Space Infection

Retropharyngeal Space Infection

Treatment
1.
2.
3.
4.

Fasting
I.V. antibiotics
Tracheotomy
Emergent surgical drainage
- intraoral drainage
- external drainage

Complications
1.
2.
3.

Rupture of abcess w/
aspiration & pneumonia
Mediastinitis
Airway obstruction

Danger Space Infection

Source

Retropharyngeal space
Prevetebral space
Parapharyngeal space

Manifestations

Same as primary space infection

Severe sepsis

Treatment
Same as for primary space infection

Complications
Potential for rapid spread through the loose areolar tissue
Inferior spread to the posterior mediastinum to the level of diafragma

Prevertebral Space Infection

Source
Vertebral bodies
Penetrating injuries
Tuberculosis of the spine

Manifestations
Midline abcess
Cold abcess posterior pharynx
Slow spread of suppuration of this area

Treatment

Needle aspiration w/ subsequent antituberculosis th/

Stabilization of spine

Complications
Spine instability progression of vetebral process

Visceral Vascular Space Infection

potential space within the carotid sheath

infections remain relatively localized compact
space contains little areolar connective tissue
lymphatics contained within this space receive
secondary drainage from most of the lymphatics
of the head and neck
Lincoln Highway of The Neck (Mosher) all
three layers of the DCF contribute to the carotid
sheath

Visceral Vascular Space Infection

Source

Parapharyngeal space
Submandibular space
Visceral space

Treatment

External drainage
I.V. antibiotics
Possible ligation of IJV

Complications

Manifestations

Pitting edema over SCM

Torticollis

Septic shock
Carotid artery erotions
Endocarditis
Cavernous sinus
thrombosis

Pharingomaxillary Space Infection

Pharingomaxillary Space Infection

Prestyloid Compartement [anterior-muscular]

Fat
Lymph nodes
Internal maxilarry artery
Inferior alveolar, lingual,auriculotemporal nerves

Poststyloid Compartement [posterior-neurovascular]

Carotid artery
Internal jugular vein
Symphatetic chain
IX, X, XI, XII nerves

Pharingomaxillary Space Infection

Source

Tonsil
Pharynx
Teeth
Temporal bone (petrous)
Parotis gland
Lymph nodes of nose &
nasopharynx

Manifestations

Medial displacement of lateral

pharyngeal wall and tonsils
Trismus
Parotid edema
Retromandibular neck fullness
Dysphagia

Pharingomaxillary Space Infection

Treatment

External drainage
Tracheotomy

Complications

Septic thrombosis of IJV

Carotid artery erosions
Cranial nerve involvement
Mediastinitis

Pharingomaxillary Space Infection

Submandibular

Peritonsillar

VVS

Masticator

Temporal

PMS

Parotid

Retropharingeal

Danger
Prevertebral

Anterior Visceral

Mediastinum

Submandibular Space Infection

Submaxillary space
Central compartement
Submental compartement
Submaxillary compartement
subdivided by anterior bellies of
digastric m.
Contents
Submandibular gland
Lymph nodes

Sublingual space

Sublingual gland
Hypoglossal nerve
Whartons ducts

Submandibular Space Infection

Source

Teeth
Salivary glands
Pharynx & tonsils
Sinuses

Manifestations

Dysphagia
Odynophagia

Treatment

Underlying pathology
External drainage if it progress
- sublingual
- submandibula

Complications
Ludwigs Angina

Masticator Space Infection

Source
Molar teeth

Manifestations
1.
2.

Extreme trismus
Edema & tenderness over
the posterior ramus of
mandible

Treatment
External drainage

Temporal Space Infection

Temporalis m. :
- superficial compartments

- deep compartments

Manifestation
Pain in this area

Treatment
External drainage

Trismus

Peritonsillar Space Infection

Source
Tonsils & pharynx

Manifestations

Dysphagia/odynophagia
Drooling and hot potato voice
Muffleed voice
Reffered otalgia
Trismus
Displaced tonsil toward midline
Deviated uvula

PERITONSILLAR ABSCESS

Peritonsillar Space Infection

Treatment

Peroral drainage
tonsilectomy

Complications
Spread into pharyngomaxilary
space through posterior
pharyngeal wall

Anterior Visceral Space

Contents

Pharynx
Esophagus
Larynx
Trachea
Thyroid gland

Source

Tonsils
Esophageal injury
Blunt trauma w/ mucosal tear
Acute thyroiditis
Chest infection

Anterior Visceral Space

Manifestations

Dysphagia/odynophagia
Hoarseness
Dyspnea
Emphysema

Treatment

Complications

Serious infection
Laryngeal edema
Mediastinal emphysema
Bronchopneumonia
Sepsis

Fasting
I.V. hydration
Antibiotics
Tracheotomy
Surgical drainage

history
Physical examination
Secure airway
Culture, IV antibiotic
CT scan
No abcess

Large abcess

Small abcess
Needle aspiration

Watch and wait

for culture and drainage

24-48 hours

No
Impending complication ?

Clinical improvement ?

Yes

No

Continue antibiotic,
Needle aspirations

Yes
Surgical incision
And drainage