DEEP NECK SPACE

INFECTIONS
By Dr. Sandeep
Anatomy of cervical fascia
Cervical fascia

1) Superficial cervical fascia

2) Deep cervical fascia



Superficial Cervical Fascia
Continuous sheath of fibrofatty subcutaneous
tissue
attachments: zygomatic process to thorax
and axilla
Contents: platysma & muscle of facial
expression
Between superficial and deep layers:
fat,sensory nerves, EJ, AJ, superficial
lymphatics

Marginal mandibular br. of facial n. lies just
deep to superficial cervical fascia
Deep Cervical Fascial
1) Superficial layer

2) Middle layer

3) Deep layer
Superficial layer
(Enveloping,Investing,Anterior layer)
Arises from ligamentum nuchae &
the spinous process; completely
enclose the neck
Splits at mandible and covers the
masseter laterally & the medial
surface of medial pterygoid
encloses trapazius, SCM,
omohyoid, parotid and
submandibular gland
Forms floor of submandibular
space
Also forms stylomandibular
ligament

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.)
Deep layer
(prevertebral fascia/carpet fascia)
Cover vertebral body and
paraspinous m.
Forms floor of the post.
Triangle of neck
Devided into
1. Alar division
from base of skull to T2 level
2.Prevertebral division
from base of skull to
diaphram
Extend laterally as axillary
sheath

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
Sheath is overlapped by
the ant. Border of SCM
Space Involving Entire Length Of
Neck
1. Retropharyngeal Space
2. Danger Space
(Prevertebral Space)
3. Paravertebral Space
4. Carotid Sheath Space
Retropharyngeal Space
Between visceral
division of middle layer
and alar division of deep
layer
Extend from skull base
to T2 level
Midline raphae divide it
into two compartments
Each lateral space
contain retropharyngeal
nodes

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
Contains loose areolar
tissue
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
Carotid sheath Space
Made up from all
deep cervical fascia
Infection from any
deep fascia can
spread to this space
(lincoln High way)
Travels through
pharygomaxillary
space

Space Limit To Above The Hyoid Bone
1. Parapharyngeal Space
2. Submandibular Space
3. Masticator Space
4. Temporal Space
5. Parotid Space
Parapharyngeal Spac
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

Pharyngomaxillary space
Prestyloid
Muscular compartment
Medialtonsillar fossa
Lateralmedial pterygoid
Contains fat, connective
tissue, nodes
Poststyloid
Neurovascular compartment
Carotid sheath
Cranial nerves IX, X, XI, XII
Sympathetic chain
Stylopharyngeal aponeurosis
of Zuckerkandel and Testut
Alar, buccopharyngeal and
stylomuscular fascia.
Prevents infectious spread
from anterior to posterior.
Pharyngomaxillary Space
Communicates
with several deep
neck spaces.
Parotid
Masticator
Peritonsillar
Submandibular
Retropharyngeal
Submandibular Space

Divided into 2 spaces by
mylohyoid m.
1. Sublingual space (above
mylohyoid m.)
2. Submaxillaly space (below
mylohyiod m.)

These 2 spaces can
communicate each other
by mylohyoid cleft
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
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.
Contains
External carotid artery
Posterior facial vein
Facial nerve
Lymph nodes
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
Contains delphin nodes

Etiology
Before the widespread use of antibiotics,
70% of deep neck space infections were
caused by spread from tonsillar and
pharyngeal infections. Today, tonsillitis
remains the most common etiology of
deep neck space infections in children,
whereas odontogenic origin is the most
common etiology in adults.
Causes of deep neck infections include
the follwing
Tonsillar and pharyngeal infections
Dental infections or abscesses
Oral surgical procedures
Salivary gland infection or obstruction
Trauma to the oral cavity and pharynx (e.g.,
gun shot wounds, pharynx injury caused by
esophageal lacerations from ingestion of fish
bones or other sharp objects)
Causes.
Instrumentation, particularly from
esophagoscopy or bronchoscopy
Foreign body aspiration
Cervical lymphadenitis
Thyroiditis
Mastoiditis with petrous apicitis and Bezold
abscess
Intravenous drug abuse
Necrosis and suppuration of a malignant
cervical lymph node or mass
As many as 20-50% of deep neck infections
have no identifiable source.
Other important considerations include patients
who are immunosuppressed because of
human immunodeficiency virus (HIV) infection,
chemotherapy, or immunosuppressant drugs
for transplantation. These patients may have
increased frequency of deep neck infections
and atypical organisms, and they may have
more frequent complications.
The signs and symptoms of a deep neck
abscess develop because of the following
Mass effect of inflamed tissue or abscess cavity
on surrounding structures
Direct involvement of surrounding structures with
the infectious process
The microbiology of deep neck infections
usually reveals mixed aerobic and anaerobic
organisms, often with a predominance of oral
flora. Both gram-positive and gram-negative
organisms may be cultured.
Pathogens
Likely dependent on portal of entry and space involved
Aerobic: Strep-predom viridans and B-hemolytic
streptococci, staph, diphtheroid, Neisseria, Klebsiella,
Haemophilus
Anaerobic: Bacteroides, Peptostreptococcus, Eikenella
(often clinda resistant), FUsobacterium, B fragilis
SPECIFIC DEEP NECK
INFECTION

PARAPHARYNGEAL SPACE
INFECTION
Most common cause :
Peritonsillar infection
Typical finding
1.Trismus
2. Angle mandible
swelling
3. prolapse of tonsil &
tonsillar fossa
4. marked
odynophagia

Others : fever, limit neck
motion,neurologic
deficit (C.N 9,10,12
paralysis)
Parapharyngeal space abscess
Potential complications


Laryngeal edema

Spread of infection to retropharyngeal space

Horner's syndrome

Cranial nerve palsies

Suppurative jugular thrombophlebitis (lemierre syndrome)

Carotid artery erosion
Lemierres Syndrome
Septic thrombophlebitis of internal jugular vein

Septic emboli lung / liver abscesses / septic
arthritis

Fusobacterium necrophorum
PARAPHARYNGEAL SPACE INFECTION
Treatment
1. Evaluate and maintain airway & fluid hydration
2. Parenteral antibiotic high dose 24-48 hrs.
3. If not improve, consider surgical drainage

Pharyngomaxillary/Parapharyngeal
/
Lateral pharyngeal space
Never approach
intraorally
Traditionally: Mosher
incision
Horizontal neck incision
follow carotid sheath
into space finger
dissect below
submandibular gland,
along posterior belly of
digastric deep to mastoid
tip toward styloid
PARAPHARYNGEAL SPACE INFECTION
Surgical drainage
Peritonsillar Space
Suprahyoid

Medialcapsule of
palatine tonsil
Lateralsuperior
pharyngeal constrictor
Superioranterior tonsil
pillar
Inferiorposterior tonsil
pillar
Infection leads to quinsy.
Needle aspiration, I&D, quincy tonsillectomy all
equally effective initial management with 10-
15% recurrrence rate.
SUBMANDIBULAR SPACE
INFECTION
Most common cause :
Dental caries
Anterior teeth & first molar
: infection enter sublingual
space
Second & third molar
: infection enter
submaxillary space
SUBMANDIBULAR SPACE INFECTION
Organisms
- Mixed of aerobes(alpha hemolytic strep,
staph) and anaerobes make synnergistic effect
of endotoxins
- Consider gram in immunocompromize host
SUBMANDIBULAR SPACE INFECTION
Clinical feature
(True Lugwigs angina)
Start unilateral and progress
bilaterally
Induration of submandibular
region and floor of mouth
( severe cellulitis)
Tongue pushed posteriorly and
superiorly (cause airway
obstruction)
Drolling, odynophagia, trismus,
fever
No purulence(due to no time to
developed)


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

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


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

RETROPHARYNGEAL SPACE INFECTION
PREVERTEBRAL SPACE INFECTION
Investigation
1. Lateral neck film
- C2 > 7 mm. both
children and adult
- C6 > 14 mm. in children
> 22 mm. in adult.
2. Chest film
- detection of mediastinitis
RETROPHARYNGEAL SPACE INFECTION
PREVERTEBRAL SPACE INFECTION
Treatment
Surgical drainage
1. Intraoral drainage
-for acute retropharyngeal
abcess in children
2. External drainage (Dean)
-Lesion beyond pharyngeal
level
-Airway compromise
-Involve other deep neck
spaces
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
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
MASTICATOR SPACE INFECTION
Treatment
1. Intraoral drainage (medial compartment)
- along inner margin of mandibular ramus
to the retromolar trigone
2. External approch (lateral compartment)
- submandibular incision
- preauricular incision or Gilles incision for
temporal space abscess
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 stensens duct

PAROTID SPACE INFECTION
Treatment
IV ATB
Surgical drainage indicated for
-fluctuation
-medical failure after 24-48 hr. or progression
of disease

COMPICATION OF DEEP NECK INFECTION
1. Internal jugular vein thrombosis
2. Cavernous sinus thrombosis
3. Neurologic deficit
4. Osteomyelitis of the mandible
5. Osteomyelitis of the spine
6. Mediastinitis
7. Pulmonary edema
8. Pericarditis
9. Aspiration
10. Sepsis
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