Introduction
The potential for a seemingly benign entity like an infected tooth, tonsil, or skin lesion to cause life-threatening illness is due to the complex relationship between the spaces of the neck. Deep neck infection (DNI) may result from any of the above and can extend into the mediastinum and beyond when these spaces are involved. Aggressive bacterial species, inadequate host defenses, and access to medical care all contribute to the development of deep neck infections and make management difficult. Understanding the relationship of the potential spaces of the neck to each other, as well as the most common pathogens, is key to successful treatment of this problem.
Key Operative Learning Points
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Knowledge of the anatomy and relationships between the deep neck spaces is necessary to adequately drain the neck during incision and drainage (I&D).
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Failure to drain pockets of infection will prolong recovery or lead to complications.
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Deep neck abscesses are often fulminating and can lead to rapid changes in status by causing airway obstruction, vascular compromise, or sepsis and need to be treated in an urgent manner.
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Tracheostomy is often required for safe airway management.
Preoperative Period
Patients with DNI typically have localized pain and swelling, fever, and an elevated white blood cell counts. All patients undergo a computed tomography (CT) scan to assess the extent of disease, unless airway compromise dictates otherwise. If an aspirate is available for Gram stain analysis, this is helpful in identifying pathogens before empiric antibiotics are administered. Otherwise, intravenous antibiotics should be administered and chosen on the presumed site of origin. Oropharyngeal abscess requires coverage of beta-lactamase producing streptococcal and staphylococcal organisms; oral infections require coverage of anaerobic bacteria. Use of antibiotics with coverage of anaerobes and beta-lactamase–producing microbes provides good broad-spectrum coverage for most cases.
History
- 1.
History of present illness
- a.
Duration of symptoms
- b.
Odynophagia or dysphagia
- c.
Dental history—periodontal disease, fractured teeth, periapical abscess, carious teeth
- d.
Preceding upper respiratory tract infection or trauma
- a.
- 2.
Past medical history
- a.
Diabetes mellitus
- b.
Other forms of immunocompromised states—HIV, iatrogenic (chemotherapy)
- a.
- 3.
Medications
- a.
Antibiotics
- b.
Anticoagulants
- a.
Physical Examination
- 1.
Airway
- a.
Flexible fiberoptic laryngoscopy to assess for pa-tency
- b.
Presence of swelling of the posterior pharyngeal wall
- a.
- 2.
Neck
- a.
Extent and location of edema
- b.
Presence of fluctuance, tenderness, erythema
- a.
- 3.
Oral cavity
- a.
Gingival swelling and erythema, purulent discharge near carious teeth
- b.
Edema of the floor of the mouth with retrodisplacement of the tongue
- a.
- 4.
Oropharynx
- a.
Bulging of the soft palate/tonsil
- b.
Trismus
- a.
Imaging
CT
- 1.
Preferred for rapid procurement of images (over MRI)
- 2.
Contraindicated if the airway is unstable
- 3.
Recommend use of contrast
- 4.
Standard 3-mm cuts
Indications
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Abscess with airway compromise
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Sepsis
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Smaller abscess with lack of response to IV antibiotics
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Lack of resolution that will require revision surgery
Contraindications
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Hemodynamic instability
Preoperative preparation
- 1.
Evaluate imaging to determine the extent of the abscess
- 2.
Culture–If the patient is stable, obtain an aspirate at the bedside to initiate Gram stain and culture studies.
- 3.
Antibiotics–Empiric administration of intravenous antibiotics that provide aerobic and anaerobic coverage
- 4.
Manage any airway compromise
Operative Period
Anesthesia
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Management of impending airway collapse in the patient with a deep neck abscess takes precedence over all other considerations.
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Tracheotomy is achieved with the patient awake with the anesthesiologist prepared to administer general anesthesia once the airway is secured.
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Sedation is contraindicated as it may lead to further collapse of the airway.
Positioning
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The patient is placed in the supine position with a shoulder roll used to gently extend the neck.
Perioperative Antibiotic Prophylaxis
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Antibiotics that provide coverage of aerobes and anaerobes are administered intravenously perioperatively.
Monitoring
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Paralytic agents should not be used in order to avoid injury to the cranial nerves.
Instruments and Equipment to Have Available
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Head and neck instrument set
Key Anatomic Landmarks
Management of deep neck space infections mandates a thorough understanding of the anatomy of deep neck spaces, etiology of the abscess, and knowledge of the pathogens involved.
Anatomy
Anatomic structures and fascial layers delineate the spaces of the neck. Fascial layers envelope muscles, bone, and viscera in the neck and are coalescent in some areas, dehiscent in others. Where multiple layers come together, it is very unlikely that infection will spread beyond as in the inferior limit of the retropharyngeal space. In regions where the fascia is thin, deep neck abscesses are able to spread to neighboring spaces if left untreated.
There are two layers of cervical fascia: superficial and deep. The superficial layer lies superficial to the platysma and extends from the upper chest to the zygoma. DNI only involves the spaces formed by the three layers of deep cervical fascia—superficial, middle, and deep—which create a potential “highway” from the neck, allowing infection to spread as far as the sacral spine.
The superficial layer of deep cervical fascia encircles the neck like a drum. It lies on the submandibular gland (and the marginal mandibular division of the facial nerve runs within it) and sternocleidomastoid (SCM), omohyoid, and trapezius muscles. The superior or “investing” fascia attaches inferiorly to the sternum, clavicle, and first rib, superiorly to the mandible, mastoid, and occipital bone. The lateral portion of the carotid sheath and the stylomandibular ligament are formed by this layer. The submandibular and sublingual spaces lie deep to this fascial layer, which is bordered by the digastric muscle inferiorly, mandible laterally, hyoglossus muscle medially, and sublingual gland superiorly. The masticator space is bounded medially and laterally by the superficial layer as it splits above the jaw and extends up to the skull base and zygomatic arch.
Infections of the sublingual space are most often odontogenic, with the first molar being the usual source. The patient presents with edema of the floor of the mouth, dysarthria, pain, and fever. Transoral drainage is helpful, but dental consultation is paramount in avoiding recurrent infection. If the swelling is due to a periapical abscess, the latter must be drained. Infection of the second molar leads to swelling of the submandibular space, as this tooth lies posterior to the insertion of the mylohyoid muscle ( Fig. 76.1 ). An abscess of the submandibular space should be drained via a transcutaneous route. Ludwig’s angina is an infection of both spaces that often manifests as significant retro-displacement of the tongue, edema of the floor of the mouth, and impending airway collapse ( Fig. 76.2 ). Management often requires awake tracheostomy because intubation is not feasible due to the edema and the position of the tongue. Incision and drainage is done through an incision in the neck and often yields a thin, watery discharge. Wounds are drained and left open; both surgical drains and the tracheostomy are removed once the edema has subsided and the infection has resolved.
