Deep Neck

Infections
Huseyin Altun, MD
 Cervical fascia

Anatomy of • 1) Superficial cervical fascia

Cervical Fascia • 2) Deep cervical fascia

 This fascia serves to envelope
the muscles, nerves, vessels
and viscera of the neck,
thereby forming planes and
potential spaces that serve to
divide the neck into functional
units.
Cervical Fascia
It functions to both direct and
limit the spread of disease
processes in the neck.
 • Encircle H&N and attached to clavicle and
zygomatic arch
Superficial • Contain plastysma m. and external jugular
v.
Cervical Fascia • Marginal mandibular br. of facial n. lies just
deep to superficial cervical fascia
 1) Superficial layer

Deep Servical 2) Middle layer

Fascia
3) Deep layer
Superficial Layer(Investing Layer)
• From ligamentum nuchae, completely enclose the neck
• Muscels
• SCM
• Trapezius
• Glands
• Submandibular gland
• Parotid gland
• Spaces:
• Posterior triangle
• Suprasytrenal space
Superficial Layer
• It originates from the spinous processes of the vertebral column and
spreads circumferentially around the neck.
• It also covers the anterior bellies of the digastrics and the mylohyoid,
thereby forming the floor of the submandibular space
• It forms the space of the posterior triangle on either side of the neck
and the suprasternal space of Burns in the midline.
Middle layer
(Cervical layer,Pretracheal layer)
• Muscular division. Encircle infrahyoid strap muscles
(St.Hyoid, St. Thyroid, Th.Hyoid, Omohy.)
• Visceral division. Encircle pharynx, larynx, esophagus, trachea, and
thyroid gland.
• Buccopharyngeal fascia ( part of visceral division that cover
constrictor m. and buccinator m.)
• The visceral division passes inferiorly into the upper mediastinum
where it is continuous with the fibrous pericardium and covers the
thoracic trachea and esophagus.
Deep Layer
• The deep layer of the deep cervical fascia originates from the spinous
processes of the cervical vertebra and the ligamentum nuchae.
• At the transverse processes of the cervical vertebra, it divides into an
anterior alar layer and a posterior prevertebral layer
• The alar fascia extends from the base of the skull to the second
thoracic vertebra
• The prevertebral fascia lies just anterior to the vertebral bodies and
extends the entire length of the vertebral column.
Deep layer
(Carpet fascia)
• Cover vertebral body and paraspinous m.
• Devided into
1. Alar division
from base of skull to T2 level
• Post. Visceral layer of middle fascia
• Ant. To prevertebral layer

2.Prevertebral division
from base of skull to diaphram
• Vertebral bodies
• Deep muscles of the neck
Carotid sheath

• The carotid sheath is a fascial layer that is associated with but is

anatomically separate from the previously described layers
• It continues from the skull base through the neck along the anterior
surface of the prevertebral fascia, and enters the chest behind the
clavicle
• Made up of 3 layer of deep cervical fascia
• Contain carotid a., internal jugular v., vagus n.
• Avenues for spread of infection from neck to mediastinum
Deep Neck Spaces
• Described in relation to the hyoid

• Entire length of the neck

• Suprahyoid
• Infrahyoid
Deep Neck Spaces
-Entire length of Neck
• Superficial space
• Surround platysma
• Contains areolar tissue, nodes nerves and vessels
• Subplatysmal flaps
• Involved with cellulitis and superficial abscess
• Treat with I&D along langer’s lines + Abx
Entire Length Of Neck
1. Retropharyngeal Space
2. Danger Space (Prevertebral Space)
3. Paravertebral Space
4. Carotid Sheath Space
Deep Neck Spaces
Entire length of Neck
Retropharyngeal space

• Between visceral division of middle layer and alar division of deep

layer
• Post. To pharynx and esophagus
• Extend from skull base to T2 level
• Midline raphae
• More commom in children due to presence of retropharyngeal node
Deep Neck Spaces
Entire length of the Neck
Danger Space

• Ant. Border is alar layer of deep fascia

• Post. Border is prevertebral layer
• Extend from skull base to diaphram
• No midline raphae
• Infection spread from neck to posterior mediastinum easily
Deep Neck Spaces
Entire length of the Neck
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
Deep Neck Spaces
Entire length of the Neck
Carotid Sheath Space

• Made up from all deep cervical fascia

• Infection from any deep fascia can spread to this space (lincoln High
way)
Deep Neck Spaces
Suprahyoid Spaces
1. Parapharyngeal Space
2. Submandibular Space
3. Masticator Space
4. Temporal Space
5. Parotid Space
Deep Neck Spaces
Suprahyoid spaces
Parapharyngeal Space
(Lateral pharyngeal Space)

Boundary
• Superiorly : Skull base
• Inferiorly : Hyoid bone
• Laterally : Medial pterygoid m.
• Medially :Buccopharyngeal fascia
• Anteriorly : Submandibular space
• Posteromedialy : Prevertebral fascia and
retrophryngeal space
Deep Neck Spaces
Suprahyoid Spaces
Deep Neck Spaces
Suprahyoid spaces
Submandibular Space

Divided into 2 spaces by mylohyoid m.

1. Sublingual space (above mylohyoid m.)
2. Submaxillary space (below mylohyiod m.)

• These 2 spaces can communicate each other by mylohyoid cleft

Deep Neck Spaces
Suprahyoid spaces
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
Deep Neck Spaces
Suprahyoid spaces
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.
Infrahyoid Spaces
Anterior Viseral Space (Pretracheal Space)
• Between trachea, esophagus and middle layer of deep cervical fascia
• Extend from hyoid bone to superior mediastinum
Etiology Of Deep neck Space
1. Dental infection
2. Tonsillar and peritonsillar infection
3. Trauma of upper aerodigestive tract
4. Retropharyngeal lymphadenitis
5. Pott’s disease
6. Sialadenitis
7. Bezold’s abscess
8. Infection of congenital cyst and fistula
9. Intravenous drug abuse
SPECIFIC DEEP NECK INFECTION
 • Most common cause :
Peritonsillar infection
• Typical finding
1.Trismus
PARAPHARYNG 2. Angle mandible swelling
EAL SPACE 3. Medial displacement of lateral
INFECTION pharyngeal wall

Others : fever, limit neck motion,neurologic

deficit (C.N 9,10,12,Horner’s syndrom)
PARAPHARYNG
EAL SPACE
INFECTION
 Treatment

1. Evaluate and maintain airway & fluid

Pharapahryngeal hydration
Space Infection 2. Parenteral antibiotic high dose 24-48 hrs.
3. If not improve, consider surgical drainage
 Surgical drainage
1. Intraoral approch
(for peritonillar abscess only)
Pharapharyngeal 2. External approach
Space Infection
-transverse submandibular incision
-T. shape incision (Mosher)
 Intraoral Approach

Pharapharyngeal
Space Infection
 • Most common cause :
Dental caries
SUBMANDIBUL • Anterior teeth & first molar ;
AR SPACE infection enter sublingual space
INFECTION • Second & third molar
infection enter submaxillary space
 Clinical feature
(True Lugwig’s angina)
• Start unilateral and progress bilaterally
• Induration of submandibular region and floor of
SUBMANDIBUL mouth
AR SPACE ( severe cellulitis)
INFECTION • Tongue trusted posteriorly and superiorly (cause
airway obstruction)
• Drolling, odynophagia, trismus, fever
• No purulence(due to no time to developed)
 Treatment
• Early stage
(unilat,mild swelling and edema)
SUBMANDIBUL -IV antibiotic, extration of infected tooth
AR SPACE • Advance stage
INFECTION (bilateral swelling, dysphagia with drolling)
-early airway intervention
-surgical drainage (submandibular incision)
 Most commmon cause
• In children
RETROPHARYNGEAL -retropharyngeal lymphadenitis from
SPACE INFECTION nose,PNS,ET)
(PREVERTEBRAL SPACE • In adult
INFECTION) -regional trauma and endoscopic procedure
 Clinical feature
RETROPHARYNG • In children
EAL SPACE irritability,neck rigidity, fever,drolling,muffle
INFECTION cry, airway compromise
• In adult
PREVERTEBRAL fever, sore throat, odynophagia, neck
SPACE tenderness, dysnea
INFECTION
 Clinical feature
RETROPHARYNG • Retropharyngeal space abscess form abscess
lateral to midline
EAL SPACE
INFECTION • Prevertebral space abscess
form abscess in midline
PREVERTEBRAL • Mediastinitis S&S Dyspnea,chest pain,
SPACE tachycardia, fever, wideded mediastinum
INFECTION
RETROPHARYNG
EAL SPACE
INFECTION

PREVERTEBRAL
SPACE
INFECTION
 Investigation
1. Lateral neck film
- C2 > 7 mm. both children and adult
- C7 > 14 mm. in children
RETROPHARYNG > 22 mm. in adult.
EAL SPACE 2. Chest film
INFECTION - detection of mediastinitis

PREVERTEBRAL
SPACE
INFECTION
 Treatment
Surgical drainage
RETROPHARYNG
1. Intraoral drainage
EAL SPACE
INFECTION -Lesion confined in larynx esp.child
2. External drainage (Dean)
PREVERTEBRAL -Lesion beyond pharyngeal level
SPACE -Airway compromise
INFECTION
-Involve other deep neck spaces
 • Most common cause Penetrating trauma
(F.B, endoscope)
TB spine
• Infection spread slowly and more localize due
PARAVERTEBRAL to compact CNT.
SPACE Clinical feature
INFECTION -Same as others posterior space abscess
-Vertebral osteomyelitis and spinal instability
 Clinical feature
PARAVERTEBRAL -Same as others posterior space abscess
SPACE
INFECTION -Vertebral osteomyelitis and spinal instability
MASTICATOR Most common cause

SPACE • Dental carices

INFECTION
 Clinical feature

• Extream trismus with minimum facial

MASTICATOR swelling
- Massesteric space
SPACE (lateral compartment) :
INFECTION edema at ramus of mandible
- Ptrygomandibular space (medial
compartment):
edema at retromolar trigone
 Treatment
1. Intraoral drainage (medial compartment)

MASTICATOR - along inner margin of mandibular ramus

to the retromolar trigone
SPACE 2. External approch (lateral compartment)

INFECTION - submandibular incision

- preauricular incision or Gilles incision
for temporal space abscess
PAROTID SPACE Most common cause :
Bacterial retrograde from oral cavity
INFECTION
 Clinical feature

PAROTID SPACE • high fever, weakness, mark

swelling and tenderness of
INFECTION parotid gland,fluctuation,pus at
stensen’s duct
 Treatment
• IV ATB

PAROTID SPACE • Surgical drainage indicated for

-fluctuation

INFECTION -medical failure after 24-48 hr. or

progression
of disease
 Internal jugular vein thrombosis

Cavernous sinus thrombosis

Neurologic deficit

Osteomyelitis of the mandible

COMPLICATIONS Osteomyelitis of the spine

OF DEEP NECK Mediastinitis

INFECTION Pulmonary edema

Pericarditis

Aspiration

Sepsis