Agung D. Permana,dr.,M.Kes.

,SpTHT-KL
Deep Neck Space Infection
Introduction
DEEP NECK SPACE INFECTIONS

Life threatening
delay in diagnosis/inadequate/inappropriate treatment
complications mortality rates : 40%
head and neck surgeon :
cervical fascias & potential spaces understand the
treatment & potential complications
antibiotics decreased the incidence and mortality


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
Sternocleidomastoid
Trapezius
Deep Cervical Fascia
Investing layer of deep cervical fascia
Prevertebral fascia
Pretracheal fascia
(visceral part)
Carotid sheath
Buccopharyngeal fascia
Alar fascia
Pretracheal fascia
(muscular part)
T
E
Cervical Fascia
Pathophysiology

Deep neck space infections can arise from a multitude of causes.
Whatever the initiating event, development of a deep neck space
infection proceeds by one of several paths, as follows:


Spread of infection can be from the oral cavity, face, or superficial
neck to the deep neck space via the lymphatic system.
Lymphadenopathy may lead to suppuration and finally focal
abscess formation.
Infection can spread among the deep neck spaces by the paths of
communication between spaces.
Direct infection may occur by penetrating trauma.

Sign And Symptoms


Mass effect of inflamed tissue or abscess cavity
on surrounding structures
Direct involvement of surrounding structures
with the infectious process

Presentation
Obtain a detailed history from patients in whom deep neck space
infection is suspected. Eliciting a history of the following is
important:


Pain
Recent dental procedures
Upper respiratory tract infections (URTIs)
Neck or oral cavity trauma
Respiratory difficulties
Dysphagia
Immunosuppression or immunocompromised status
Rate of onset
Duration of symptoms

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

Pediatrics
"Cause > suppurative process in lymph nodes
#Nose, adenoids, nasopharynx, sinuses!

Adults
Cause > trauma, instrumentation, extension
adjoining deep neck space
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
Manifestations
Midline abcess
Cold abcess posterior pharynx
Slow spread of suppuration of this area
Treatment
Needle aspiration w/ subsequent antituberculosis th/
Stabilization of spine
Source
Vertebral bodies
Penetrating injuries
Tuberculosis of the 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


Manifestations
Pitting edema over SCM
Torticollis

Treatment
External drainage
I.V. antibiotics
Possible ligation of IJV

Complications
Septic shock
Carotid artery erotions
Endocarditis
Cavernous sinus
thrombosis

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
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

Submandibular Space Infection
Sublingual space
Sublingual gland
Hypoglossal nerve
Whartons ducts
Submaxillary space
Central compartement
Submental compartement
Submaxillary compartement
subdivided by anterior bellies of
digastric m.
Contents
Submandibular gland
Lymph nodes
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

Ludwigs Angina

Ludwigs angina

Masticator Space Infection
Source
Molar teeth

Manifestations
1. Extreme trismus
2. 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 Trismus
Treatment
External drainage
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
Microbiology


Preantibiotic eraS.aureus
Currentlyaerobic Strep species and non-strep
anaerobes
Gram-negatives uncommon
Almost always polymicrobial
Remember resistance !!!
Imaging

Lateral neck plain film
"Screening exammainly for retropharyngeal and
pretracheal spaces
"Normal: 7mm at C-2, 14mm at C-6 for kids,
22mm at C-6 for adults

Imaging
Imaging

High-resolution Ultrasound
"Advantages
Avoids radiation
Portable

"Disadvantages
Not widely accepted
Operator dependent
Inferior anatomic detail
"Uses
Following infection during therapy
Image guided aspiration
Imaging

Contrast enhanced CT
"Advantages
Quick, easy
Widely available
Familiarity
Superior anatomic detail
Differentiate abscess and cellulitis

"Disadvantages
Ionizing radiation
Allergenic contrast agent
Soft tissue detail
Artifact
Imaging
MRI
"Advantages
No radiation
Safer contrast agent
Better soft tissue detail
Imaging in multiple planes
No artifact by dental fillings

"Disadvantages
Increased cost
Increased exam time
Dependent on patient cooperation
Availability
Treatment

Airway protection

Antibiotic therapy

Surgical drainage

Airway protection
"Observation

"Intubation
Direct laryngoscopy: possible risk of rupture and
aspiration
Flexible fiberoptic

"Tracheostomy
Ideally = planned, awake, local anesthesia
Abscess may overlie trachea
Distorted anatomy and tissue planes
Treatment

Antibiotic Therapy
"Polymicrobial infections
Aerobic Strep, anaerobes
Ampicillin/sulbactam with metronidazole
"Beta-Lactam resistance in 17-47% of isolates

"Alternatives
Third generation cephalosporins
clindamycin

"Culture and sensitivity
Treatment

Surgical Drainage
Transoral
Preoperative CT where are the great vessels? CT
Cruciate mucosal incision, blunt spreading through superior
pharyngeal constrictor

External drainage

Surgical Drainage
"External
EXPOSURE, EXPOSURE!!!

approach
Submandibular incision
Submental incision
T-incision
Complication
Airway obstruction
Ruptured abscess
Internal Jugular Vein Thrombosis
Carotid artery Rupture
Mediastinitis

history
Physical examination
Secure airway
Culture, IV antibiotic
CT scan
Small abcess
Needle aspiration
for culture and drainage
Impending complication ?
No abcess Large abcess
Watch and wait
24-48 hours
Clinical improvement ?
Continue antibiotic,
Needle aspirations
Surgical incision
And drainage
No
Yes
Yes
No

Pharingomaxillary Space Infection
Treatment
External drainage
Tracheotomy
Complications
Septic thrombosis of IJV
Carotid artery erosions
Cranial nerve involvement
Mediastinitis

Peritonsillar Space Infection
Treatment
Peroral drainage
tonsilectomy

Complications
Spread into pharyngomaxilary
space through posterior
pharyngeal wall

Retropharyngeal Space Infection
Treatment
1. Fasting
2. I.V. antibiotics
3. Tracheotomy
4. Emergent surgical drainage
- intraoral drainage
- external drainage
Complications
1. Rupture of abcess w/
aspiration & pneumonia
2. Mediastinitis
3. Airway obstruction
PMS
Masticator
Submandibular
Peritonsillar
VVS
Danger
Mediastinum Anterior Visceral
Temporal
Parotid
Prevertebral
Retropharingeal
Pharingomaxillary Space Infection