Deep neck space infections

Deep neck space infections

1. Deep neck space
infections
Dr. Krishna
Koirala
28-09-2015

2. Ludwig’s Angina
•Rapidly progressing polymicrobial
cellulitis of the submandibular
space that can result in life
threatening airway compromise
•Wilhelm Frederick von Ludwig
(1936)
•Angina - Strangling

3. •Mortality
Before the advent of antibiotics
: 50%
 Nowadays : 8–10%
Most common cause of death
is respiratory compromise
( encircling of the upper airway)

5. •Predisposing Factors
–Dental or periodontal infection (80%)
•Poor dental hygiene (carious and
abscessed teeth)
•Tooth extraction (lower molars and
premolars)
–Others
•Upper respiratory infections , floor-of-
mouth trauma , mandibular fractures ,
sialoadenitis, peritonsillar abscess , IV
drug abuse
–Comorbid conditions
•Diabetes mellitus , malnutrition,
alcoholism, neutropenia, lupus
erythematosus, aplastic anemia,
glomerulonephritis

6. •Causative organisms
–Group A beta-hemolytic streptococcal
species (streptococcus pyogenes)
–Alpha-hemolytic streptococcal species
(streptococcus viridans, streptococcus
pneumoniae)
–Staphylococcus aureus
–Fusobacterium , Bacteroides
(melaninogenicus and oralis)
–Peptostreptococcus, Actinomyces ,Neisseria
species
–Occasional : Pseudomonas species,
Escherichia coli, and Haemophilus influenzae

7. Clinical Features
•Young adults - highest prevalence
•Pain in any involved teeth, with severe tender
localized submental and sublingual induration
•Boardlike firmness of the floor of the mouth
and brawny induration of the suprahyoid soft
tissues
•Drooling , trismus , dysphagia, stridor ( from
laryngeal edema and elevation of the posterior
tongue against the palate)
•Fever, chills, tachycardia
•Airway obstruction within hours !!

9. Criteria for diagnosing Ludwig's angina
(Grodinsky)
-Rapidly spreading cellulitis with no specific
tendency to form abscess
-Involvement of both submaxillary and sublingual
spaces, usually bilaterally
-Spread by direct extension along facial planes
and not through lymphatics
-Involvement of muscle and fascia but not
submandibular gland or lymph nodes
-Originates in the submaxillary space with
progression to involve the sublingual space and
floor of the mouth

10. Investigations
Routine blood investigations
Pus culture
Plain radiographs
To assess the degree of
soft tissue swelling and
airway obstruction
CT - most useful imaging tool

11. Treatment
•Frequent assessment
–To assess the risk of progression and
airway compromise
•Empirical therapy
–High-dose intravenous antibiotics : 
Cefuroxime and metronidazole

12. •Incision and drainage : intraoral and
external
–Transverse incision across the midline
from one angle of jaw to the other 
Muscles of the tongue opened
vertically Myelohyoid muscle
sectioned longitudinally
–Drains placed in all fascial spaces
•Tracheostomy - to maintain an airway

14. Retropharyngeal
Abscess
•Collection of pus in the retropharyngeal
space
•Classification
–Acute
–Chronic

15. Acute retropharyngeal
Abscess
•Common in children below 5 yrs
•Predisposing factors
–Suppuration of retropharyngeal
lymph node of Rouviere
–Penetrating FB eg. Fish bones
–Post surgical

16. Clinical Features
Symptoms
–History of upper respiratory
tract infection
–Dysphagia
–Difficulty in breathing, noisy
breathing
–Croupy cough
–Torticollis

17. Signs
•Ill looking, febrile, drooling of saliva
•Hyperextension of the head
•Hot potato (muffled )voice
•Neck swelling and tenderness
•Bulge on posterior pharyngeal wall -
usually unilateral
•Tracheal rock sign : pain while gently
moving the larynx and trachea from side to
side

18. Investigations
Complete blood count
Plain X- Ray soft tissue neck Lateral view

At the level of C2 : Distance from the
anterior border of the cervical
vertebrae to the posterior border of the
airway : ≤ 7 mm , regardless of the
patient's age
At C6 : ≤14 mm in children younger
than 15 years
and up to 22 mm in adults

19. Widened prevertebral soft tissue
shadow more than normal in all
ages or >2/3 of corresponding
cervical vertebral body signifies
retropharyngeal abscess
CT scan of neck : Plain and
contrast
Extent of abscess, involvement of
other spaces

20. Complications
•Secondary to mass effect
•Rupture of the abscess
•Spread of infection

21. Endoscopic finding
of retropharyngeal
abscess

22. Treatment
•Adequate hydration : I.V. Fluids
•Systemic antibiotics :
Ceftriaxone/metronidazole
•Incision and Drainage
–Transoral : No anesthesia, supine with
head low , incision and suction of pus
–Transcervical : Through lateral neck
incision
•Tracheostomy

24. Chronic Retropharyngeal abscess
•Causes
–Caries of cervical spine
–Tubercular infection of retropharyngeal
LN
–Post traumatic
•Clinical Features
–Chronic discomfort in throat
–Dysphagia
–Bulge of posterior pharyngeal wall with
fluctuant swelling

25. Forms
a) Lateral type : Koch's infection of the
cervical lymph node spreading to
retropharyngeal nodes and forming a
cold abscess
•Seen in children below 5 years of age
•Swelling seen intra orally is classically
on the sides and not in the midline (as
there is a central raphe)
•Swelling is fluctuant and with minimal
signs of inflammation

26. b) Central type :
Pott’s tuberculous cervical spine
Abscess present between the body of
vertebra and the prevertebral fascia
Begins in the midline and spreads to
both sides
On oral examination there is a swelling
in the midline in the posterior
pharyngeal wall, which is fluctuant with
less signs of inflammation

27. •Investigations
•As in acute retropharyngeal abscess
•ZN stain of the pus after aspiration
•Treatment
•IV antibiotics
•Incision and drainage : Per-oral /
external
•Antitubercular chemotherapy
•Neck exploration

28. •Complications
–Airway obstruction
–Spread of abscess to other
neck spaces
–Septicemia
–Death

29. Parapharyngeal Abscess
Etiology
•Pharynx : Acute tonsillitis,
peritonsillar abscess
•Teeth: Dental infections - lower last
molar
•Ear : Bezold’s abscess
•Others: Parotid, retropharyngeal,
submandibular
•Penetrating injuries

30. Clinical Features
•Fever, sore throat, odynophagia,
torticollis
•Anterior Compartment
–Tonsils pushed medially
–Induration along the angle of the
mandible
–Trismus
–External swelling behind the
angle of jaw

31. •Posterior compartment
–Bulge of pharynx behind the
posterior pillar
–Paralysis of IX, X, XI, XII cranial
nerves and cervical sympathetic
chain
–Erode into the carotid artery or
cause septic thrombophlebitis of
the internal jugular vein (Lemierre
syndrome)

35. Treatment
•Systemic antibiotics
–Ceftriaxone 1 gm. iv BD
–Amoxyclav 1.2 gm. iv TDS
–Metronidazole 500mg iv TDS
•Incision & drainage
–Intraoral drainage from tonsillar
fossa
–External incision from the neck

36. Surgical approaches to
Parapharyngeal Space
a) Transoral
–Small benign lesions of the prestyloid
space presenting as an oropharyngeal
mass
–Problems -- limited exposure, increased
risk of tumor spillage, possibility of
neurovascular injury
b) Cervical with or without mandibulotomy
–A transverse incision at the level of the
hyoid bone with removal or
displacement of the submandibular
gland
–Tracheostomy necessary with this
approach

37. - Tumors in the lower parapharyngeal
space extending to the neck
c) Cervical - parotid
–Extension of the cervical approach
incision superiorly in front of the ear
–Tumours in the midparapharyngeal space
without extension superiorly into the
skull base or posteriorly around the
petrous internal carotid artery
d) Transparotid
e) Infratemporal fossa