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Neck Space Infections

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  1. Neck Space Infections Dr. Vishal Sharma

  2. Fascial layers of neck A. Superficial cervical fascia: encloses platysma B. Deep cervical fascia 1. Superficial or Investing layer 2. Middle layer 3. Deep layer a. Muscular division a. Alar fascia b. Visceral division b. Pre-vertebral fascia

  3. Deep Cervical Fascia Investing layer: Encloses trapezius & SCM; parotid, submandibular gland & carotid sheath Visceral layer:Surrounds strap muscles, pharynx, larynx, esophagus, trachea, thyroid Deep layer: Covers deep neck muscles, cervical plexus, phrenic nerve & brachial plexus. Cervical sympathetic chain lies superficial to this fascia.

  4. Classification of neck spaces

  5. A. Involves entire neckB. Spaces above hyoid 1. Superficial neck space 1. Submental 2. Deep neck spaces 2. Submandibular a. Carotid sheath a. Sublingual b. Retro-pharyngeal b. Submaxillary c. Danger space 3. Masticator d. Pre-vertebral 4. Parotid C. Below Hyoid 5. Parapharyngeal 1. Pre-tracheal space6. Peri-tonsillar

  6. Masticator spaces Formed around muscles of mastication (masseter, pterygoids, insertion of temporalis) & covered by investing layer of deep cervical fascia

  7. Classification of neck space infections

  8. A. Involves entire neckB. Supra-hyoid abscess 1. Superficial space Sub-mental  Necrotizing fascitis Masticator 2. Deep space abscess Parotid  Carotid sheath  Ludwig’s angina  Retro-pharyngeal  Para-pharyngeal  Danger space  Peri-tonsillar (quinsy)  Pre-vertebralC. Infra-hyoid abscess  Pre-tracheal

  9. Necrotizing fasciitis

  10. Rare infection of superficial neck space causing necrosis of fascia + subcutaneous tissue, initially sparing skin & muscle • Term coined in 1952 by Wilson • Etiology:Dental infections, skin trauma, quinsy & parapharyngeal abscess • Bacteriology:β-hemolytic streptococcus, Staphylococcus aureus, anaerobes

  11. Clinical Presentation • Outer zone of erythema, intermediate zone of tender ecchymosis & central zone of vesiculation + black necrosis + ulceration • Fascial necrosis extends beyond skin necrosis • Skin anesthesia (damage of cutaneous nerves) • Soft tissue crepitus due to gas formation • Hypocalcemia, hyponatremia & dehydration

  12. Necrotizing fasciitis of chest

  13. CT scan showing gas formation

  14. Treatment • Early correction of fluid & electrolyte imbalance • I.V. Ampicillin + Gentamicin + Clindamycin • Immediate radical debridement of necrotic tissue (in presence of subcutaneous air, progressive infection despite 48 hours of medical therapy, obvious fluctuation or skin necrosis) • Skin grafting after debridement

  15. Wound debridement

  16. Skin grafting

  17. Healed wound

  18. Poor prognostic factors:Diabetes mellitus, atherosclerosis, chronic renal failure, obesity, immuno-suppression, malnutrition • Complications:necrosis of chest wall fascia, mediastinitis, pleural effusion, pericardial effusion, empyema, airway obstruction, arterial erosion, jugular vein thrombophlebitis, septic shock, lung abscess, carotid artery thrombosis

  19. Ludwig’s Angina

  20. Rapidly progressing poly-microbial cellulitis of sublingual & submaxillary spaces with potentially life-threatening airway compromise

  21. Submandibular space Boundaries:Anterior & lateral:mandible Medial: anterior belly of digastric Posterior:submandibular gland Inferior: level of hyoid bone Subdivisions: 1. Sublingual space: above mylohyoid muscle 2. Submaxillary space:below mylohyoid muscle Contents:Submandibular salivary gland, lymph nodes

  22. Etiology of Ludwig’s angina

  23. A. Lower dental or periodontal infection (80%): 1. Poor dental hygiene (caries & abscess) 2. Tooth extraction (lower molars & premolars) Roots of premolars & 1st molar lie above mylohyoid  sublingual space infection Roots of 2nd & 3rd molars lie below mylohyoid  submaxillary space infection B. Others (20%):submandibular sialadenitis, floor of mouth trauma, mandibular fractures

  24. Causative organisms Mixed aerobic & anaerobic infection • Streptococcus pyogenes • Streptococcus viridans • Streptococcus pneumoniae • Staphylococcus • Fusobacterium • Bacteroides • Peptostreptococcus

  25. Clinical Features • Toothache, fever, odynophagia, drooling • Floor of mouth swelling + tongue elevation in sublingual space infection • Brawny / woody tender swelling below chin in submaxillary space infection • Trismus • Stridor: falling back of tongue, laryngeal edema • Initial cellulitis  delayed pus formation

  26. Elevation of tongue

  27. Submandibular swelling

  28. Submandibular swelling

  29. X-ray soft tissue neck lateral assess degree of soft tissue swelling & airway obstruction

  30. C.T. scan

  31. Treatment of Ludwig’s angina

  32. 1. I.V. antibiotics:Cefuroxime / Ceftriaxone + Metronidazole / Clindamycin 2. Airway:endotracheal intubation / tracheostomy 3. Incision & drainage of serous fluid / pus a. Intra-oral:for sublingual space infection b. Extra-oral:for submaxillary space infection Transverse incision from one angle of mandible to opposite angle of mandible 4. IV fluid for adequate hydration 5. Periodic assessment for disease progression & airway compromise

  33. Incision drainage + Tracheostomy

  34. Incision drainage + Tracheostomy

  35. Complications • Parapharyngeal abscess • Retropharyngeal abscess • Acute airway obstruction (within hours): due to pushing back of tongue, laryngeal edema • Aspiration pneumonia • Septicemia • Death

  36. Retropharyngeal abscess

  37. Retropharyngeal Space Superior: Base of skull Inferior:Mediastinum (till tracheal bifurcation) Anterior: Buccopharyngeal fascia Posterior:Alar fascia Lateral: Parapharyngeal spaces Divided into two lateral compartments (space of Gillette) by midline fibrous raphe

  38. Retropharyngeal abscess Collection of pus in retropharyngeal space Classification: 1. Acute 2. Chronic Acute abscess is common in children below 3-5 yrs as retropharyngeal nodes of Rouviere regress later

  39. Acute Retropharyngeal Abscess

  40. Etiology • Suppuration of retropharyngeal lymph node of Rouviere from upper respiratory tract infection • Penetrating injury of posterior pharyngeal wall (e.g.. fish bone, vertebral fracture) • Following endoscopic trauma to pharynx • Acute mastoitis: pus tracking under petrous bone