Deep Neck Space Infection

55 Deep Neck Space Infection


55.1 Sites


• Retropharynx


• Parapharyngeal


• Anterior deep neck


55.2 Anatomy


• Fascial layers:


figure Fascial compartments are potential spaces between fascial planes


figure Superficial and deep layers


figure Deep,* divided into:


– Superficial: investing


– Middle: visceral


– Deep: prevertebral, alar


• Spaces


figure See Table 55.1


* All 3 contribute to carotid sheath


55.3 Retropharyngeal Abscess (Fig. 55.1)


• 2nd most common neck abscess in children (peritonsillar abscess/quinsy most common)


• Retropharyngeal lymph nodes atrophy with age


• Aetiology:


figure Suppurative adenoiditis


figure Trauma


figure Vertebral osteomyelitis


• Presentation:


figure Pyrexia*


figure Neck pain*


figure Airway obstruction


figure Drooling


figure Torticollis


figure Age of presentation is typically 6 months to 6 years (mean 3–5 years)


• Management:


figure Airway is the priority


figure Transoral aspiration/drainage if abscess medial to great vessels unless other neck spaces involved


figure Specimen pus urgent Gram stain and culture and sensitivity and abscess wall


figure Intravenous antibiotics (discuss with microbiology common regimes include: clindamycin/piperacillin or penicillin/gentamicin + metronidazole) ± steroids


* Most common


55.4 Anterior Deep Neck


• Ludwig angina; floor of mouth cellulitis


• Anatomy



figure

Fig. 55.1 Retropharyngeal abscess.



figure

figure Submandibular space extends from hyoid to mandible divided by mylohyoid muscle


figure Sublingual space superior to muscle


figure Submaxillary space inferior


• Features


figure Mouth pain


figure Drooling


figure Dysphagia


figure Neck pain


figure Swelling in floor of mouth


figure Superior tongue displacement


• Aetiology


figure 80% dental—typically lower 3rd molar


figure 20% soft tissue/tonsil infection


• Management


figure Airway is priority consider HDU for observation


figure Timely surgical intervention with appropriate IV ABx


figure Surgical drainage


– Sublingual space only—intra-oral


– Submaxillary space—external


55.5 Parapharyngeal Abscess


• Anatomy


figure Parapharyngeal space 2 compartments: pre- (anterior) and post-styloid


figure Communicates anterior with submaxillary space via buccopharyngeal gap created by styloglossus


figure Communicates posteriorly with the retropharyngeal and danger spaces


• Presentation


figure Airway obstruction—stridor/stertor


figure Pain


figure Dysphagia/dysphonia


figure Trismus (20%)


figure Snoring/OSA


figure Neck swelling/fullness/increasing erythema


• Aetiology


figure Tonsillitis (particularly immunocompromised) (Fig. 55.2)


figure Dental


figure IV drug abusers


figure Epiglottitis


figure Parotitis


figure Foreign body


figure Branchial cleft cysts (if recur)


figure Extension from petrous apex/mastoid tip (Citelli abscess)


• Treatment


figure Ensure airway stable, may need tracheostomy


figure May require ICU admission


figure Preop CT scan for surgical planning (if airway stable), and cardiothoracic referral if mediastinum involved


figure Incision guided by imaging and clinical examination


figure Urgent microbiology inc. Gram stain and culture


figure Multiple neck spaces may need opening, finger dissection useful at breaking down loculations and entering planes



figure
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Jul 4, 2016 | Posted by in OTOLARYNGOLOGY | Comments Off on Deep Neck Space Infection

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