Deep neck space infections

Dr. Krishna Koirala28-09-2015

Ludwig’s Angina

• Rapidly progressing polymicrobial cellulitis of the submandibular space that can result in life threatening airway compromise

• Wilhelm Frederick von Ludwig (1936)

• Angina - Strangling

•Mortality

Before the advent of antibiotics: 50%

Nowadays : 8–10%

Most common cause of death is respiratory compromise ( encircling of the upper airway)

• Predisposing Factors– Dental or periodontal infection (80%)

• Poor dental hygiene (carious and abscessed teeth)

• Tooth extraction (lower molars and premolars)– Others

• Upper respiratory infections, floor-of-mouth trauma, mandibular fractures, sialoadenitis, peritonsillar abscess, IV drug abuse

– Comorbid conditions • Diabetes mellitus , malnutrition, alcoholism,

neutropenia, lupus erythematosus, aplastic anemia, glomerulonephritis

• Causative organisms

– Group A beta-hemolytic streptococcal species (streptococcus pyogenes)

– Alpha-hemolytic streptococcal species (streptococcus viridans, streptococcus pneumoniae)

– Staphylococcus aureus

– Fusobacterium , Bacteroides (melaninogenicus and oralis)

– Peptostreptococcus, Actinomyces ,Neisseria species

– Occasional : Pseudomonas species, Escherichia coli, and Haemophilus influenzae

Clinical Features• Young adults - highest prevalence

• Pain in any involved teeth, with severe tender localized submental and sublingual induration

• Boardlike firmness of the floor of the mouth and brawny induration of the suprahyoid soft tissues

• Drooling , trismus , dysphagia, stridor ( from laryngeal edema and elevation of the posterior tongue against the palate)

• Fever, chills, tachycardia

• Airway obstruction within hours !!

Criteria for diagnosing Ludwig's angina (Grodinsky)-Rapidly spreading cellulitis with no specific tendency to form abscess

-Involvement of both submaxillary and sublingual spaces, usually bilaterally

-Spread by direct extension along facial planes and not through lymphatics

-Involvement of muscle and fascia but not submandibular gland or lymph nodes

-Originates in the submaxillary space with progression to involve the sublingual space and floor of the mouth

Investigations Routine blood investigations

Pus culture

Plain radiographs

To assess the degree of

soft tissue swelling and

airway obstruction

CT - most useful imaging tool

Treatment

• Frequent assessment

– To assess the risk of progression and airway compromise

• Empirical therapy

– High-dose intravenous antibiotics :  Cefuroxime and metronidazole

• Incision and drainage : intraoral and external

– Transverse incision across the midline from one angle of jaw to the other Muscles of the tongue opened vertically Myelohyoid muscle sectioned longitudinally

– Drains placed in all fascial spaces

• Tracheostomy - to maintain an airway

Retropharyngeal Abscess•Collection of pus in the retropharyngeal space

•Classification

– Acute

– Chronic

Acute retropharyngeal Abscess•Common in children below 5 yrs

•Predisposing factors

– Suppuration of retropharyngeal lymph node of Rouviere

– Penetrating FB eg. Fish bones

– Post surgical

Clinical FeaturesSymptoms

– History of upper respiratory tract infection

– Dysphagia

– Difficulty in breathing, noisy breathing

– Croupy cough

– Torticollis

Signs•Ill looking, febrile, drooling of saliva

•Hyperextension of the head

•Hot potato (muffled )voice

•Neck swelling and tenderness

•Bulge on posterior pharyngeal wall - usually unilateral

•Tracheal rock sign : pain while gently moving the larynx and trachea from side to side

Investigations Complete blood count Plain X- Ray soft tissue neck Lateral view

At the level of C2 : Distance from the anterior border of the cervical vertebrae to the posterior border of the airway : ≤ 7 mm , regardless of the patient's age

At C6 : ≤14 mm in children younger than 15 years and up to 22 mm in adults

Widened prevertebral soft tissue shadow more than normal in all ages or >2/3 of corresponding cervical vertebral body signifies retropharyngeal abscess

CT scan of neck : Plain and contrast Extent of abscess, involvement of

other spaces

Complications

•Secondary to mass effect

•Rupture of the abscess

•Spread of infection

Endoscopic finding of retropharyngeal abscess

Treatment

•Adequate hydration : I.V. Fluids

•Systemic antibiotics : Ceftriaxone/metronidazole

•Incision and Drainage

– Transoral : No anesthesia, supine with head low , incision and suction of pus

– Transcervical : Through lateral neck incision•Tracheostomy

Chronic Retropharyngeal abscess• Causes

– Caries of cervical spine– Tubercular infection of retropharyngeal

LN– Post traumatic

• Clinical Features– Chronic discomfort in throat– Dysphagia– Bulge of posterior pharyngeal wall with

fluctuant swelling

Forms

a) Lateral type : Koch's infection of the cervical lymph node spreading to retropharyngeal nodes and forming a cold abscess

• Seen in children below 5 years of age

• Swelling seen intra orally is classically on the sides and not in the midline (as there is a central raphe)

• Swelling is fluctuant and with minimal signs of inflammation

b) Central type : Pott’s tuberculous cervical spine

Abscess present between the body of vertebra and the prevertebral fascia

Begins in the midline and spreads to both sides

On oral examination there is a swelling in the midline in the posterior pharyngeal wall, which is fluctuant with less signs of inflammation

•Investigations

•As in acute retropharyngeal abscess

•ZN stain of the pus after aspiration

•Treatment•IV antibiotics•Incision and drainage : Per-oral / external•Antitubercular chemotherapy•Neck exploration

•Complications

–Airway obstruction

–Spread of abscess to other neck spaces

–Septicemia

–Death

Parapharyngeal AbscessEtiology

• Pharynx : Acute tonsillitis, peritonsillar abscess

• Teeth : Dental infections - lower last molar

• Ear : Bezold’s abscess

• Others : Parotid, retropharyngeal, submandibular

• Penetrating injuries

Clinical Features

•Fever, sore throat, odynophagia, torticollis

•Anterior Compartment

– Tonsils pushed medially

– Induration along the angle of the mandible

– Trismus

– External swelling behind the angle of jaw

•Posterior compartment

– Bulge of pharynx behind the posterior pillar

– Paralysis of IX, X, XI, XII cranial nerves and cervical sympathetic chain

– Erode into the carotid artery or cause septic thrombophlebitis of the internal jugular vein (Lemierre syndrome)

Treatment• Systemic antibiotics

– Ceftriaxone 1 gm. iv BD– Amoxyclav 1.2 gm. iv TDS– Metronidazole 500mg iv TDS

• Incision & drainage– Intraoral drainage from tonsillar

fossa– External incision from the neck

Surgical approaches to Parapharyngeal Space

a) Transoral– Small benign lesions of the prestyloid space

presenting as an oropharyngeal mass – Problems -- limited exposure, increased risk

of tumor spillage, possibility of neurovascular injury

b) Cervical with or without mandibulotomy– A transverse incision at the level of the

hyoid bone with removal or displacement of the submandibular gland

– Tracheostomy necessary with this approach

- Tumors in the lower parapharyngeal space extending to the neck

c) Cervical - parotid

–Extension of the cervical approach incision superiorly in front of the ear

–Tumours in the midparapharyngeal space without extension superiorly into the skull base or posteriorly around the petrous internal carotid artery

d) Transparotide) Infratemporal fossa