OUTLINE

I. Etiology
II. Microbiology
III. Common Fascial Space Infections
IV. Clinical Evaluation
V. Laboratory Evaluation
VI. Treatment
VII. Selected Complications
VIII. Reference

OBJECTIVES

REFERENCE

 Marieb, E. & Hoehn, K. (2011). Essentials of Human Anatomy

and Physiology (9th ed.). Pearson Education Inc.

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II. Masticator Space

1. Masticator Space
 Temporal Space
 Masseteric Space
 Pterygoid Space
 Created by the splitting of the superficial cervical fascia
Figure X. Masticator Spaces. Green area: Superficial
around the masseter and the internal pterygoid muscle
temporal space. Blue area: Masseteric space. Red area: Deep
 It also contained the ramus of the mandible, the temporalis
temporal space. Brown area: pterygomandibular area
muscle, fat and loose connective tissue
 Usually, one infection can spread to the other.
 Infections of the masticator space are still related to dental
infections can be from trauma or surgery.
 REMEMBER: Trismus is manifested in masticator space
infections

2. Peritonsillar Space
 Diagnosis is clinical
 Result of spread of infection from the tonsils or minor
salivary glands of Weber
 Abscess forms deep to the tonsillar capsule between the:
o Tonsil
o Superior constrictor muscle
o Palatopharyngeus muscle

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Figure X. Peritonsillar space
 The anterior and posterior limits of this space is formed by
the anterior and posterior pillar.
o Anterior pillar: Palatoglossus
o Posterior pillar: Palatopharyngeus
3. Parapharyngeal Space
 Secondary to infection in the tonsils or dental apparatus
 Base is at the skull base and apex at the hyoid bone
 Produces trismus; difficult to distinguish from peritonsillar
abscess
 Accompanied by brawny induration of the neck with
limitation of cervical motion
 Initial symptoms include trismus, pain, dysphagia and stiff
neck
 Describes the potential deep cervical space anterior to the
carotid sheath medial to the pterygoid musculature and
lateral to the pharyngeal wall and tonsil
 Difference from peritonsillar space infection: Stiff neck
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Figure X. Parapharyngeal Space Infection. Similar to
peritonsillar space infection. Very hyperemic and very tense.
Uvula deviated to the other side.
4. Retropharyngeal Space
 Rhinosinusitis is often considered as the initiating event
 Pain, dysphagia, dysarthria and stiff neck
 Potential space posterior to the pharyngeal wall and
anterior to the alar component of the prevertebral
fascia
 Extends from skull base to the mid thorax
 If there is fullness in the posterior pharyngeal wall, there is
a high suspicion that it is retropharyngeal abscess.
 Characterized by anterior displacement of the posterior
pharyngeal wall, dysphagia, and hot potato voice
 Extends from skull base to midthorax
 If not treated properly, it can cause mediastinitis or
meningismus
5. Danger Space
 Extends from the skull base to the level of the diaphragm
 Anteriorly by the alar portion of the deep layer of deep
cervical fascia and posteriorly by the prevertebral
portion of deep layer of deep cervical fascia
 Spread of infection coming from the retropharyngeal
space, parapharyngeal space and the prevertebral space
 Notable structure in this space is the cervical sympathetic
trunk.
6. Prevertebral Space
 Almost solely from osteomyelitis of the spine
 Potential space that lies anterior to the spinal column, and
is formed by the alar fascia anteriorly and prevertebral
fascia posteriorly
 Extends from skull base to the sacrum inferiorly
 Conduit of infection from the neck to the abdomen
Figure X. Retropharyngeal, Danger and Prevertebral
space. Yellow area: Retropharyngeal space. Red area: Danger
Space. White area: prevertebral space
III. Clinical Evaluation
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A. History
 Symptoms are determined by both the generalized
inflammatory process and localizing symptoms at the site
of infection
o Inflammatory signs: Rubor, calor, dolor, pain, fever,
swelling and redness
o Localizing symptoms: Dysphagia, odynophagia, “hot
potato” voice, drooling, hoarseness, dyspnea, trismus,
ear pain
 Information about the onset and duration of symptoms
should be elicited
 Recent events such as that preceded worsening
symptoms should be identified in order to formulate a
differential of likely microorganisms and common
pathways of spread
o Dental work
o Upper airway surgery or intubation
o IV drug use
o Sinusitis, pharyngitis, otitis
o Blunt or penetrating soft tissue trauma
 Medical history should be reviewed to account for
antibiotic allergies and immunodeficiency status
o History of human immunodeficiency virus (HIV),
hepatitis, diabetes, collagen vascular diseases,
hematologic malignancy, and recent chemotherapy or
steroid use are at increased risk of atypical pathogens
and rapidly progressive disease that may not display
an acute inflammatory response
B. Physical Examination
 Complete head and neck physical examination is required
in all patients with potential DNI
o Palpation of the head and neck
 Identify localizing tenderness or fluctuance and
crepitus caused by airway trauma or gas-
producing organisms
o Otoscopic evaluation of the ear and nasal passages
 Can rapidly reveal edema, purulence, drainage,
and tenderness, and it can rule out obstructing
foreign bodies
o Examination of oral cavity and oropharynx is
facilitated by the use of a headlamp, which will free up
the hands for bimanual examination
 Difficulty with mouth opening indicates that
inflammation has already spread to the
parapharyngeal, pterygoid, or masseteric spaces
 An odontogenic source of infection should be
considered in the presence of alveolar swelling
and decayed, loose, tender, or broken teeth
 The floor of the mouth should be assessed for
visible edema, which may cause posterior
deflection of the oral tongue
 Stensen and Wharton ducts should be assessed
for purulent discharge and should be palpated for
obstructing stones
o Complete oral cavity examination
o Visualization of the oropharynx
 Assess for asymmetric lateral or posterior wall
swelling and/or deviation of the uvula
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 Unilateral pharyngeal wall swelling in the
absence of associated inflammatory symptoms,
such as fever and mucosal erythema, should
raise the possibility of parapharyngeal tumors,
which should not be biopsied or incised without
further evaluation
 Unilaterally enlarged, irregular, or ulcerated
tonsil, especially in the setting of prolonged
exposure to tobacco and alcohol, may indicate
the presence of a tonsillar malignancy
o Complete cranial nerve examination is recommended
 Infections of the upper dentition, paranasal
sinuses, facial soft tissues, and parotid place the
orbits at increased risk because of retrograde
flow through the facial and ophthalmic veins
 Edematous eyelids must be manually separated
to assess the underlying globe
 Reduced mobility of the globe and/or an absent
papillary light reflex indicates orbital inflammation
or abscess, which will require urgent attention to
save the eye
o Flexible fiberoptic evaluation of the upper airway in an
awake patient is indicated in most cases of suspected
DNI, especially if the patient has hoarseness,
dyspnea, stridor, and/or dysphagia or odynophagia
without an obvious cause on oropharyngeal
examination
 A normal pulse oximetry reading does not
eliminate the need for direct airway evaluation,
because the oxygen saturation is a poor proxy for
airway status, because it typically does not fall
until the airway is completely occluded
 Patent, midline, nonedematous airway should be
documented before transport for radiographic
evaluation in order to prevent an airway
emergency while the patient is supine in the
radiology suite
 Direct evaluation of the airway will identify
patients who may be difficult to intubate by
standard technique, should surgery be required
C. Laboratory Evaluation
 Blood tests
o Initial complete blood count typically demonstrates
leukocytosis in cases of DNI
o Lack of a leukocytic response may indicate viral
illness, immunodeficiency, or a condition such as
tumor, which can be confused with DNI
o IV steroids should not be withheld out of concern that
steroid-related leukocytosis will make it difficult to
monitor treatment response
 Electrolyte panel
o A basic electrolyte panel should be obtained to
assess glucose level, bodily hydration, and renal
function in the event that general anesthesia becomes
necessary during treatment
 Patient may be dehydrated due to dysphagia
 Imaging studies
o Plain film radiography
 Radiographic imaging plays a critical role in the
evaluation of suspected DNI
 Plain film technology is inexpensive, rapid, widely
available, and provides excellent information in
select circumstances
 In cases of suspected dental origin
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 Plain film radiography or a panoramic view of
the jaw can help to identify dental sources of
infection or salivary stones (>5 mm)
 Translucencies at the apex of the dental root
are a common finding with dental related
abscess
 In cases of suspected retropharyngeal abscess
or supraglottitis
 Lateral neck films are useful for a quick
evaluation of the upper aerodigestive tract
 Presence of an air-fluid level or a thickening
of the prevertebral tissue at C2 of more
than 5 mm in a child or more than 7 mm in
an adult indicate retropharyngeal infection
 Thickening of the epiglottis, commonly
known as the thumbprint sign, or thickening
of the arytenoids indicates likely supraglottitis
with urgent need for direct airway evaluation
in a controlled setting with tracheotomy
capabilities
 Chest radiography is indicated in cases of
dyspnea, tachycardia, and/or cough to rule out
aspiration and/or mediastinitis
o CT Scan
 CT scans of the head and neck remain the
standard radiographic technique for the
evaluation of DNI
 CT scans with IV contrast provide excellent
visualization of most bony and soft tissue
structures of the head and neck
 IV contrast allows visualization of the great
neck vessels and enhancement of areas of
inflammation
 Use of IV contrast is contraindicated in most
patients with iodine or contrast dye allergy
and in patients with compromised renal
function
 CT scans are valuable in determining whether the
infection is contained within the lymph nodes, or if
it has spread beyond that and into the fascial
planes of the head and neck
 CT cannot reliably differentiate between the
generalized edema of phlegmon versus purulent
abscess, because both often commonly appear
as hypodense collections with peripheral
enhancement
 CT provides the surgeon with valuable
information about which neck spaces require
exploration and drainage at the time of surgery
o MRI
 MRI is not routinely used for suspected DNI
 MRI scanning is time consuming, and it is less
likely to be tolerated by patients in pain or those
having trouble swallowing or maintaining their
airway while supine
 MRI scans may provide additional detail to CT in
infections that involve the intracranial cavity,
parotid, and prevertebral space
 Evaluation of the major vessels of the head and
neck is occasionally indicated if there
 is a suspicion of suppurative thrombi of major
head and neck
 vessels or if infection followed trauma to the neck
 MR angiography with venous flow-through
provides excellent evaluation of thrombi and
pseudoaneurysm, but invasive angiographic
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techniques may be needed for stenting or balloon
occlusion in rare cases of infected
pseudoaneuryms
o Ultrasound
 The noninvasive nature of ultrasound makes it an
attractive imaging modality for pediatric patients,
and the lack of radiation reduces concerns about
potential long-term harm
 Most ultrasonography practitioners are adept at
using ultrasound to perform fine needle
aspiration, which may be helpful to obtain culture
or provide therapeutic drainage
 Ultrasound may be limited in cases of significant
neck edema or phlegmon, and it may be less
sensitive for nonlateral neck spaces (e.g.,
parapharyngeal, retropharyngeal), which may be
beyond the focal range of the technology
 Although the fluid levels of an abscess can be
seen by ultrasound if they are large and
superficial enough, lack of visualization does not
rule out the possibility of abscess because of its
limitations on serial evaluation of multiple cross-
sectional spaces better seen on CT
IV. Treatment
A. Medical Management ()
1. Airway Management
 The initial management of any patient with known or
suspected DNI is securing the airway
 Loss of airway has traditionally been the major source of
mortality from DNI
 Airway complications should be anticipated in all cases of
DNI, especially in those that involve the floor of the
mouth and the parapharyngeal and retropharyngeal
spaces
 Patients with airway compromise should not be
transported out of an intensive care suite for prolonged
radiographic testing until the airway is secure
 First-line airway therapy includes use of an oxygenated
face tent with cool mist humidity, IV steroids, and
epinephrine nebulizers
 If the patient has mild airway symptoms, and the
examination reveals mild edema with less than 50%
obstruction at the glottic or supraglottic level, the patient
will often respond to medical therapy alone while under
direct observation in the emergency suite or intensive care
unit
 Urgent airway intervention is necessary in the event of
greater levels of stridor and dyspnea, which are usually
accompanied by airway obstruction of more than 50%
 An elective tracheotomy may be considered if extubation
is not anticipated within 24 to 48 hours, or if surgical
drainage procedures are likely to result in significant or
prolonged airway edema
 An awake tracheotomy should be planned in cases where
minimal or no airway lumen is visualized
 Increasing peak airway pressures and frothy airway
secretions following successful intubation may indicate the
onset of postobstructive pulmonary edema, which typically
resolves with positive-pressure mechanical ventilation and
judicious use of IV diuretics
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2. Fluid Resuscitation
 Poor fluid intake before presentation is common in cases
where neck infection causes significant dysphagia,
odynophagia, or trismus
 Dehydration is especially common in infections of the
peritonsillar and retropharyngeal spaces, and it may be the
main etiology of sialadenitis-related infections of the
parotid space
 Signs of fluid deficit include tachycardia, dry and pasty
mucous membranes, and decreased skin turgor
 Most patients benefit from timely infusion of 1 to 2 L of
isotonic IV fluids
 Providing adequate fluid resuscitation before surgical
intervention will reduce the severity of anesthesia-related
hypotension
o Patient should be kept on a nothing-by-mouth status
and should be closely monitored for changes in
clinical status and elevation in white blood cell count
o Repeat imaging and/or surgical intervention are
necessary in patients who fail to improve or who
worsen during the observation period
o If significant clinical improvement is noted with IV
antibiotics after 48 to 72 hours, therapy is continued
for 24 hours beyond normalization of symptoms,
followed by a 2-week course of an equivalent oral
antibiotic
o Patients who require surgery usually need 48 to 72
hours of IV antibiotics postoperatively before
discharge home on oral therapy

3. Antibiotic Therapy
 DNI requires timely treatment with IV antibiotics at the time
of diagnosis because of the rapidly progressive nature of
these infections
 Culture is not required before empiric antibiotic therapy
 Broad-spectrum coverage is usually mandatory, because
most cases involve mixed flora of gram-positive cocci and
gram-negative rods with or without anaerobes
 Clindamycin is the initial therapy of choice in children
younger than 2 years die to the increasing rates of MRSA
in the community
 Ampicillin-sulbactam is recommended as a first-line drug
given the up to 20% resistance rate to penicillin G and
clindamycin in DNI
 Penicillin with or without metronidazole and clindamycin in
the penicillin-allergic patient have proven to be effective in
most cases
o Combined therapy of penicillin with metronidazole
provides for broad coverage of both aerobic and
anaerobic bacteria with the elimination of β-lactamase
producing bacteria and with minimal side effects
 Antibiotic coverage may need to be expanded in cases of
otologic or sinus infection or nosocomial infections, in Figure X. First-line antiobiotic alternatives for DNI
which Pseudomonas is common, whereas expanded
anaerobic coverage is often necessary for fulminate B. Surgical Treatment
odontogenic infections
 Fluids obtained from aspiration or incision and drainage 1. Principles of Surgical Management
should be sent for culture and sensitivity because of the  Several guiding principles should be heeded when surgical
increasing rate of resistant organisms in the at-large therapy is considered for DNI.
community o Antibiotic availability in pus-filled spaces is limited by
 Prophylactic antibiotics before dental, oral, and head and poor vascularity
neck procedures may reduce the risk of DNI o Treatment of a fascial space infection depends on
o Prophylaxis should consist of an oral or IV dose of a adequate open incision and dependent drainage
β-lactamase–resistant penicillin or clindamycin given o Fascial spaces are contiguous, and infection can
within 30 minutes of procedures on nonsterile body spread readily from one space to another, so it is
cavities important to open all primary and secondary
o Prophylaxis is mandatory for any patient with a history spaces; once opened, spaces need to have drains
of heart murmur or rheumatic valve disease and in and possibly irrigation catheters placed
those with vascular or joint prosthetic devices o Involved teeth should be extracted, ideally at the
 IV antibiotic therapy without surgical intervention may be time of incision and drainage, to ensure resolution of
sufficient in select circumstances the infection; once a fascial space infection has
o If the patient is clinically stable and otherwise healthy occurred, it is prudent to extract the involved teeth
with abscess cavities less than 2.5 cm in diameter rather than to rely on endodontic treatment
and involving a single neck space, a 48- to 72-hour  Surgical drainage is necessary under certain
trial of empiric IV antibiotic therapy is appropriate circumstances:
o A trial of empiric antibiotics is recommended in almost o When an air-fluid level is present in the neck or when
all stable pediatric cases, because even sizable gasproducing organisms are evident
collections may respond favorably to IV antibiotics o When airway compromise is a threat from abscess or
and steroids alone phlegmon
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o When the patient fails to respond to 48 to 72 hours of o Preauricular parotid incision with neck extension as
empiric IV antibiotic therapy necessary allows access to the parotid and temporal
 The main goals of surgical intervention include: spaces
o Providing a fluid or tissue sample for tissue staining, o Horizontal neck incision in a natural skin crease
culture, and sensitivity testing provides access to the masticator, parapharyngeal,
o Providing therapeutic irrigation of the infected body pterygoid, submandibular, prevertebral,
cavity retropharyngeal, carotid, and lateral neck spaces
o Establishing a stable external drainage pathway to o Horizontal submental incision provides a direct
prevent the reaccumulation of abscess route to the bilateral submandibular spaces and
floor of mouth
2. Needle Aspiration ()
 Needle aspiration without incision will often suffice for
small abscesses contained within the confines of a lymph
node or with acute infections caused by suspected
congenital cysts or fibrotic pseudocysts
 Complete surgical excision should be planned after the
acute inflammation subsides because recurrent infection is
common in head and neck cysts
 Image-guided techniques that use ultrasound or CT scan
are being increasingly used in cases where initial
unguided fine needle aspiration is unsuccessful, or the
mass is nonpalpable
 Image guidance can also allow placement of small pigtail
catheters using a Seldinger technique for drainage and
flushing

3. Transoral Incision and Drainage ()

 The peritonsillar space can be accessed transorally in a
cooperative adult without significant trismus
o Tonsillectomy at a later date is an option for patients
with a history of peritonsillar abscess, recurrent or
chronic tonsillitis, or obstructive symptoms from
tonsillar hypertrophy
o Acute “quinsy” tonsillectomy at the time of
presentation can be considered in cases of recurrent
peritonsillar abscess, recurrent acute tonsillitis, or if a
general anesthetic is needed because of patient
discomfort or poor exposure
 Transoral incision and drainage is also a preferred method
of surgery for select deep neck-space infections
o Neck incision with dependent drainage of the bilateral
floor of the mouth through the mylohyoid muscle is
mandatory in cases of Ludwig angina in order to
reduce the risk of airway obstruction
 The buccal space can be accessed via transoral incision
of the buccal mucosa with blunt dissection parallel to the
facial nerve through the buccinators
 The masticator space can be entered by incision of the
retromolar trigone with blunt dissection through the
masseter
 The retropharyngeal space is often best entered
transorally, especially because many infections in this
space originate from the adenoids and are located in the
high oropharynx or nasopharynx, which is difficult to
access through the neck

4. Transcervical Incision and Drainage ()

 The traditional surgical approach to deep neck-space
infection
 The location of the incision is dictated by the neck spaces
that require exploration
 Deep neck spaces can be accessed by one of three
potential incisions that provide both excellent anatomic
exposure and cosmetic healing:

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Appendix A. Major Deep Neck Spaces and Their Contents

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Appendix B. Common pathways of spread in deep neck infection

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