DEEP NECK SPACE

INFECTIONS
• Anatomy of the Cervical Fascia

• Anatomy of the Deep Neck Spaces

• Deep Neck Space Infections

• Understanding inter-fascial spaces is important for pathogenesis, clinical manifestation and

potential results of spread of infections involving these spaces.

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 Cervical Fascia
• Superficial Fascia

• Deep Fascia

– Superficial(investing
)
– Middle(pretracheal)
– Deep(prevertebral)

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 Superficial fascia
(Tela subcuta)
• Superior attachment – zygomatic process

• Inferior attachment – thorax, axilla.

• Similar to subcutaneous tissue

• Ensheathes platysma and muscles of facial

expression
• Marginal mandibular n. lies deep to it
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 Deep Cervical Fascia
1) Superficial
layer

2) Middle layer

3) Deep layer

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 Superficial Layer of the Deep Cervical Fascia
(Enveloping,Investing,Anterior layer)
• Completely surrounds the neck from skull to chest

• Arises from spinous processes, ligamentum nuchae

• Superior border – nuchal line, skull base, zygoma,

mandible.
• Inferior border –scapula, clavicle and manubrium

• Splits at mandible and covers the masseter

laterally and the medial surface of the medial
pterygoid. 8
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Superficial Layer of the Deep Cervical
Fascia
(Enveloping,Investing,Anterior layer)
• Envelopes

– Sternocleidomastoid

– Trapezius

– Submandibular

– Parotid

• Forms floor of submandibular space

• Create superficial sternal space (of Burn)

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 Middle Layer of the Deep Cervical Fascia (Cervical
layer,Pretracheal layer)
• Visceral Division
– Superior border
• Anterior – hyoid and thyroid cartilage
• Posterior – skull base
– Inferior border – continuous with fibrous pericardium in
the upper mediastinum.
– Buccopharyngeal fascia
• Name for portion that covers the pharyngeal
constrictors and buccinator.
– Envelopes
• Thyroid -Larynx
• Trachea
• Esophagus
• Pharynx
Middle Layer of the Deep Cervical Fascia (Cervical
layer,Pretracheal layer)

• Muscular Division
Superior border – hyoid and thyroid cartilage

Inferior border – sternum, clavicle and

scapula Envelopes infrahyoid strap muscles

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Deep Layer of Deep Cervical Fascia (Carpet fascia)

• Arises from spinous processes and ligamentum nuchae.

• Lies deep to the trapezius

• Envelopes vertebral bodies and deep muscles of

the neck
• Splits into two layers at the transverse processes:

– Alar layer

– Prevertebral layer
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 Deep Neck Spaces
• Described in relation to the hyoid

– Entire length of the neck

– Suprahyoid

– Infrahyoid

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 Space Involving Entire Length Of Neck
• Superficial space

• Retropharyngeal
Space
• Danger Space

• Prevertebral Space

• Carotid Sheath Space

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 Superficial Space
• Entire Length ofNeck:

– Surrounds platysma

– Contains areolar
tissue, nodes,
nerves and vessels
– Involved in
cellulitis and
superficial
abscesses
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 Retropharyngeal Space
• Entire length of neck.
• Anterior border - pharynx and esophagus
(buccopharyngeal fascia)
• Posterior border - alar layer of deep fascia
• Superior border - skull base
• Inferior border – superior mediastinum T4
• Contains retropharyngeal nodes-3 in no
one median-- nodes of henle
two lateral – nodes of rouviere

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 Danger Space
Entire length of neck
• Anterior border - alar layer of deep
fascia
• Posterior border - prevertebral layer

• Extends from skull base to diaphragm

• Contains loose areolar tissue.

• No midline raphae

• Infection spread from neck to posterior

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mediastinum easily
 Prevertebral Space
Entire length of neck
• Anterior border - prevertebral fascia

• Posterior border - vertebral bodies and deep

neck muscles
• Lateral border – transverse processes

• Extends along entire length of vertebral column

• Infection in this space is rare and spread slowly due

to compact connective tissue 21
 Visceral Vascular Space (Carotid
Sheath Space)
Entire length of neck
– Made up from all 3 layers of deep cervical fascia

– Anatomically separate from all layers

– Contains carotid artery, internal jugular vein, and vagus

nerve
– Infection from any deep fascia can spread to this
space
– Extends from skull base to thorax.
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 Space Limit To Above The Hyoid Bone
• Submandibular Space

• Parapharyngeal Space

• Peritonsillar Space

• Parotid Space

• Masticator & Temporal Space

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 Submandibular Space
• Suprahyoid

• Superior – oral mucosa

• Inferior - superficial layer of deep fascia

• Anterior border – mandible

• Lateral border - mandible

• Posterior - hyoid and base of tongue

musculature

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 Submandibular Space
2 compartments by the mylohyoid
muscle, The two compartments are
continuous around the posterior
border of mylohyoid muscle
– Sublingual space
• Areolar tissue

• Hypoglossal
and lingual
nerves
• Sublingual
gland
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• Wharton’s
duct
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 Parapharyngeal Space
• Suprahyoid

• Pharyngomaxillary space (lateral pharyngeal, peripharyngeal,

pterygopharyngeal,
pterygomandibular,pharyngomasticatory)
• Boundaries :

– Superior—skull base

– Inferior—hyoid

– Posterior—prevertebral fascia

– Medial—buccopharyngeal fascia 27

–
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 Parapharyngeal Space
Divided into 2 compartmens by stylohyoid ligament
• Prestyloid
– Muscular compartment
– Medial—tonsillar fossa
– Lateral—medial pterygoid
– Contains fat, connective tissue, nodes, int
maxillary a., inf alveolar n., lingual n.,
auriculotemporal n.

• Poststyloid
– Neurovascular compartment
– Carotid sheath
– Cranial nerves IX, X, XI, X I I 30

– Sympathetic chain
 Peritonsillar Space

• Suprahyoid

• Medial—capsule of
palatine tonsil
• Lateral—superior
pharyngeal
constrictor 31
 Parotid Space
• Suprahyoid

• Superficial layer of deep fascia

• Dense septa from capsule into gland

• Direct communication to parapharyngeal

space

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 Masticator and Temporal Spaces
• Suprahyoid

• Formed by superficial layer of deep cervical fascia

• Masticator space
– Antero-lateral to pharyngomaxillary space.
– Contains
• Masseter
• Pterygoids
• Body and ramus of the mandible
• Inferior alveolar nerves and vessels
• Tendon of the temporalis muscle

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 Masticator and Temporal Spaces

• Temporal space

– Continuous with masticator space.

– Lateral border – temporalis fascia

– Medial border – periosteum of temporal

bone
– Divided into superficial and deep spaces
by temporalis muscle

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 Infrahyoid
• Visceral Compartment

– Middle layer of deep fascia

– Contains thyroid, trachea, esophagus
– Extends from thyroid cartilage into superior mediastinum
2 spaces-
• Retrovisceral space {Retropharyngeal space}
– Extends along whole length of neck
• Pretracheal space
– Superiorly - attachment of strap muscles
to thyroid and hyoid
– Inferiorly - up to upper border of arch of
aorta 35
 Deep Neck Space Infections
• Etiology/ pathogenesis of Infection

• Microbiology

• Clinical manifestations

• Some specific infections

• Complications
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 Etiopathogenesis
• Deep neck space infeections have been recognised from
the time of Galen in 2nd century AD
• Preantibiotic era – 70% from infections of pharynx
and tonsils
• Present situation
– Dental infection (major source)
– Peritonsillar abscess
– Upper aerodigestive tract trauma
– Retropharyngeal lymphadenitis
– Pott’s disease
– Sialadenitis – submandibular, parotid
– From temporal bone- Bezold’s abscess, petrous apex
infections
– Congenital cysts and fistulas
– Intravenous drug abuse 37
 Microbiology
• Preantibiotic era – S. aureus

• Currently

– Aerobes – alpha hemolytic Streptococci, S. aureus

– Anaerobes – Fusobacterium, Bacteroides,

Peptostreptococcus, Veilonella
• Gram-negatives uncommon

• Almost always polymicrobial

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 Clinical manifestations
• Pain
– Constant feature
– Indication of extension or resolution
– Exception – retropharyngeal abscess in children
• Fever
– Constant feature
– Initial spike, followed by elevated temperature
– Spiking temperatures- doubt septicemia/septic
thrombophlebitis of IJV/mediastinal
extension
• Swelling
• Trismus and limitation of neck movements –
depending
on site
• Progressive dysphagia and odynophagia
•• Voice change
Chest 3
• 9
 Ludwig’s angina
• Described by William Friedrich von Ludwig, 1836
(“gangrenous induration of the connective tissues of the
neck which advances to involve the tissues which cover
the small muscles between the larynx and the floor of
mouth”)
• Cellulitis of submandibular space
– Anterior teeth and first molars – infection of sublingual
space
– Second and third molars – infection of submaxillary
space 40

Causative organism--haemolytic streptococci, Staphylococci

and bacteroides groups are common. Rarely Haemophilus
 Ludwig’s angina
• Criteria for diagnosis
– Rapidly progressive cellulitis, not an abscess

– Develops along fascial planes by direct spread, not

lymphatic spread
– Does not involve submandibular gland or lymph nodes
– Involves both sublingual and submaxillary spaces, usually bilateral

• Pseudo – ludwig’s angina

– Other inflammatory conditions involving floor of mouth
– Limited infections involving only sublingual space, submandibular
lymph nodes, submandibular gland, submental space, or abscesses
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involving one or more of these spaces
 Ludwig’s angina

ETIOLOGY:
• 75-80% dental cause

• Extraction of a diseased molar initiates

infection
• Penetrating injury of the floor of mouth

• Mandibular fractures

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 Ludwig’s angina
CLINICAL FEATURES:
• Increasing oral or neck pain and swelling

• Increasing edema and induration of perimandibular

region and floor of mouth
• Thrusting of tongue posteriorly and superiorly

• Neck rigidity, trismus, odynophagia, fever

• Dyspnoea and stridor

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Ludwig’s
angina

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 Ludwig’s angina
TREATMENT
• Early stage- IV antibiotics {penicillin +
metronidazole}, extraction of the diseased tooth
• Late stage-
– Airway {tracheostomy }

– Surgery
• Horizontal incision with wide exposure
• Tissues have peculiar “salt pork appearance”,
with woody induration, watery edema, and little
bleeding
• Gross purulence is rare
• Multiple drains/wound Dk.e ApHtYL
r S 4
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 Ludwig’s angina
Complications:-

Airway obstruction

spread of infection to PFS and RFS and

mediastinum.

Aspiration pneumonia
Lung abscess

Fluid and electrolyte imbalance

Tongue necrosis 47

septicemia
 Parapharyngeal abscess
• Causes
– Peritonsillar abscess
– Dental infection
– From other spaces
– Trauma

• Clinical features

– Anterior compartment
• Prolapse of tonsil
• Trismus
• External swelling behind
angle of jaw
• Odynophagia,
fever
– Posterior compartment
• Bulge of LPW behind
posterior pillar
• Lower cranial n.
paralysis 48

• Horner’s syndrome
• Swelling of parotid
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• Treatment
– I V antibiotics
– Correct dehydration
– Analgesics
– Surgery

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Complications:
• Rates of About 16%
• Carotid sheath involvement
causing Internal jugular vein
thrombosis Carotid artery
thrombosis.
• Internal carotid artery pseudo aneurysm
presenting as Horner's syndrome.
• Acute pharyngeal perforation
• Mediastinitis; requiring urgent drainage.
• Descending necroting fasciitis of neck and
mediastinum;requiring widespread
debridement.
• Upper airway obstruction 51
 Retropharyngeal Abscess
– 50% occur in patients 6-12 months of age

– 96% occur before 6 years of age

– Children - fever, irritability, lymphadenopathy,

torticollis, poor oral intake, sore throat,
drooling
– Adults - pain, dysphagia, odynophagia, anorexia

– Dyspnea and respiratory distress

– Lateral posterior pharyngeal wall bulge

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Retropharyngeal Abscess

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 Retropharyngeal Abscess
• Pediatrics
– Cause—suppurative process in lymph nodes
• Nose, adenoids, nasopharynx, sinuses
• Adults
– Cause—trauma, instrumentation, extension from
adjoining deep neck space

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Retropharyngeal abscess, CT+C shows a large retropharyngeal
flui collection (arrows) with peripheral rimlike enhancement
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d Dr. ASHLY ALEXANDER

 Retropharyngeal
Abscess
• Treatment
– I V antibiotics and
fluid replacement
– Surgical drainage

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1
 Chronic Retropharyngeal abscess
• Common in adults

• Due to TB of cervical vertebra

• Abscess is formed posterior to prevertebral

fascia

Clinical Features
• Initially asymptomatic

• Mild discomfort and sore throat

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• O/E smooth bulging on Post Pharyngeal wall
Tuberculosis of ce rvical Spine
with retropharyngeal abscess

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 Chronic Retropharyngeal
abscess
Diagnosis
• Clinical examination Treatment

• Blood Examination • Antitubercular drugs

• Sputum for AFB • Aspiration of abscess

• X-Ray wide bore needle

cervical spine
• Large abscess drainage
• X-Ray Chest
through external root
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 •Acute •Chronic
Retropharyngeal Retropharyngeal

 Age
Space1-3 yrs
of Gillette Adults
Behind prevertebral fascia
 Pyogenic organisms Tubercular organisms
 Suppuration of LN Cervical carries
 Sudden onset Slow onset
 Dysphagia No / mild dysphagia
 Resp distress Not common
 High fever Mild fever
 Swelling one side midline Midline swelling
 Signs of inflammation No Signs of inflammation
 I / D Oral route Anti TB & aspiration
Drainage through external
route 62
 Retropharyngeal abscess
Complications:- meningitis
haemorrhage
laryngeal spasm
septicemia
Metastatic
abscess
Jugular vein
thrombosis
Rupture with aspiration
pneumonia Pericardial tamponade
Mediastinitis
Acute hemiplegia of 63

childhood Spead in to other

 Peritonsillar abscess (quinsy)
• Cause
It is a collection of pus in the peritonsillar space which
lies
between the capsule of tonsil and the superior
constrictor
muscle.
-Local complication of tonsillar infection→ Lacunar
type
-Infection→crypta magna→paratonsillar space
-Weber’ glands infection
Symptoms
– Fever with chills and rigor
– Odynophagia
– “Hot Potato” voice
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– Halitosis
– Head tilted towards affected site
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 Peritonsillar abscess (quinsy)
Signs
• Anxious facies and stiffl y held head,↑ pulse &↑
temp
• Trismus

• Unilateral swelling over palate & ant pillar

• Uvula pushed to opposite site

• Tonsil displaced medially and downward

• Palate angry red, immobile, thick mucous
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• JDLN enlarged & tender
 Peritonsillar abscess (quinsy)
Treatment :

• Hospitalization
• Correction of dehydration
• Systemic parentral broad spectrum antibiotics
• Incision and drainage

After 6weeks tonsillectomy (intermittent tonsillectomy)to

prevent recurrence

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 Peritonsillar abscess (quinsy)
Complications :
•Mediastinitis

•Necrotizing fasciitis.

•Oedema of larynx

•Septicemia

•I J V thrombosis

•Pneumonitis or lung
abscess 69
 Parotid space infections
Contents:-parotid gland
V I I nerve
LN
ECA
Retr
om
and
ibul
ar
vein

Etiology:- post
surgical cases 70

debilitated and dehydrated pt

Clinical features
• usually follow 5-7 day after surgery.
• marked swelling of jaw
• Pain and induration over parotid
gland
• Congested stenson’s duct.
• Usually unilateral but bilateral parotid
abcesses can occur.
• No fluctuation d/to thick capsule.
Treatment
correct dehydration improve oral
hygiene and promote salivary flow
I V antibiotics
I&D 71
 DIAGNOSIS
Ultrasound
CT scan
Aspiration of abscess for culture and
sensitivity of causative organisms

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 Masticator-Temporal Space infection
Treatment
I V antibiotic
Surgery
• Cause
– Odontogenic
– Trauma
• Superficial compartment
– Extensive facial swelling
– – Severe trismus
– – Pain
• Deep compartment 73

– Trismus
 Complication
• s
Internal Jugular Vein Thrombophlebitis
(Lemierre’s syndrome)

– Fusobacterium necrophorum
– High fever with chills and rigor
– Swelling and pain along SCM
– Bacteremia, septic embolization, dural sinus
thrombosis
– I V drug abusers
– Treatment
• I V antibiotics
• Anticoagulation - controversial
• Ligation and excision
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 Complication
s
• Mediastinitis
– Mortality of 40%
– Increasing dyspnea, chest pain
– CXR - widened mediastinum
– Treatment
• EARLY RECOGNITION AND INTERVENTION
• Aggressive I V antibiotic therapy
• Surgical drainage

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 Complication
s
• Cranial nerve deficits
• Necrotising cervical fasciitis
• Osteomyelitis
• Grisel syndrome ( inflammatory
torticollis causing cervical
vertebral subluxation )

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THANK YOU

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