Deep Neck Space Infections

The neck is divided in to separate compartments, these are further divided by layers of fascia

These deep neck space compartments act as spaces for the spread of infection and tumours

Deep neck spaces carry a risk of mortality of 1-2%

Layers of cervical fascia

Cervical fascia can be divided into superficial and deep fascia.

• The superficial fascia consists of the dermis, subcutaneous tissue and platysma.

• The deep fascia is further subdivided into superficial, middle and deep layers.

• Superficial/investing layer of deep fascia covers the parotid glands as well as muscles deep to the platysma

• Middle (Pre-tracheal) fascia – encloses visceral organs (thyroid/parathyroid/larynx/trachea)

• Deep (prevertebral layer) – Covers vertebral column and prevertebral muscles

Clinical features

• Odynophagia (pain on swallowing)

• Dysphagia (difficulty swallowing)

• Restricted neck movements

• Trismus

• Voice change

• Respiratory distress/Stridor

• Neck swellings

• Fevers/septic

• Raised inflammatory markers on bloods

Flexible nasendoscopy findings (Airway compromise? Parapharyngeal swelling? Posterior pharyngeal wall swelling?)

Management

• ABC

• Involve seniors early (ENT/ITU)

• Secure airway if needed

• High flow oxygen

• FNE if stable enough

• Bloods (including cultures)

• IV Abx (Follow trust guidelines)

• IV Dexamethasone (7.6mg)

• PRN adrenaline nebs if needed

• Imaging (CT neck + chest with contrast) – D/W Senior

• Surgical drainage

Parapharyngeal Infections

Upside down pyramid

• Base: Skull Base

• Apex: Hyoid

• Lateral: Ramus of mandible, medial pterygoid, deep lobe of parotid

• Medial: Bucco-pharyngeal fascia

 Causes:

• Progression of tonsillitis/quinsy (most common)

• Dental abscess

• Extension from nearby spaces (peritonsillar, submandibular, retropharyngeal, parotitis)

• Trauma

• FNE may show a unilateral swelling of the pharyngeal wall (See the presentation for examples)

Complications:

• Neurological (CN 9-12 palsies?)

• Septic internal jugular vein thrombosis

• Horner’s syndrome

• Airway compromise

• Carotid artery erosion

• Extension to other spaces (mediastinum)

Retropharyngeal infections

• More common in younger patients (96% occur before 6 years of age)

Common causes:

• Preceding URTI (tonsillitis/sinusitis/quinsy)

• Trauma (More common cause in adults

• Extension from other spaces (e.g: parapharyngeal)

Diagnosis and treatment as above

FNE may show swelling of the posterior pharyngeal wall (See the presentation for examples)

Submandibular Infections (Ludwig’s angina)

Subdivisions:

• Sublingual space – Above mylohyoid

• Submaxillary space – Below mylohyoid

What is it?

• Rapidly spreading cellulitis of the floor of the mouth (submandibular space)

• Life-threatening airway risk (URGENT)

Causes?

• Dental infection (80%)

• Injury to the floor of the mouth

• Submandibular sialadenitis

Clinical features?

• Raised hard floor of the mouth

• Elevated oedematous tongue

• “Double tongue sign”

• Airway compromise

• Trismus

• Drooling

Peritonsillar Collection (Quinsy)

• Abscess formation between the capsule of the tonsil and the pharyngeal muscles

• Usually a consequence of acute tonsillitis

Complications:

• Parapharyngeal abscess

• Retropharyngeal abscess

• Internal jugular vein thrombosis

• Septicaemia

Tom Ringrose

Diagram of deep neck spaces