Neck Spaces Anatomy & Infections

Dr. Utkal Mishra

ANATOMY

Cervical Fascia Superficial Cervical

Fascia

Deep Cervical Fascia› Superficial Investing

Layer

› Middle Visceral Layer

› Deep Layer Prevertebral Layer

Alar Layer

Superficial Cervical Fascia

Extends from head & neck to thorax & shoulder.

Contains voluntary muscles of facial expression & platysma.

Superficial Investing Layer

Attachement – Superiorly – Nuchal RidgeInferiorly - Clavicle

It Invests - › Muscles

Sternocleidomastoid Trapezius

› Glands Submandibular Parotid

› Spaces Posterior Triangle Suprasternal space of Burns Parotid Space

Middle Visceral Layer Attached from hyoid & skull

base above to sternum below. Modified to form

› Bucopharyngeal fascia postr. To pharynx

› Pretracheal Fascia› Prethyroid Fascia

2 Divisions – › Muscular Division

Strap Muscles

› Visceral Division Thyroid, Trachea, Pharynx,

Larynx, Esophagus

Deep Layer

2 Layers› Alar Fascia

Lies between middle visceral layer and prevertebral layer

› Pre-vertebral Fascia Vertebral bodies Deep muscles of the

neck

Carotid Sheath

Carotid Sheath› Formed by all three

layers of deep fascia.

› Contains carotid artery, internal jugular vein, and vagus nerve

Deep Neck Spaces Retropharyngeal Space Parapharyngeal Space Danger Space

Retropharyngeal Space Lies behind pharynx between

Buccopharyngeal Fascia & Alar Fascia.

Extends from Base of skull to Bifurcation of trachea.

Space is divided by a median raphe into 2 lateral spaces called SPACE OF GILLETE.

Content – Lymph Nodes, Areolar tissue, Fat

Acute Retropharyngeal Abscess

Commonly seen in children below 3yrs. Cause – IN CHILDREN - Suppuration of

retropharyngeal nodes secondary to infection of adenoids. IN ADULTS – Penetrating Injury by FB or Rigid esophagoscopy.Organism – Streptococci/Staphylococci

Clinical Features – 1. Dysphagia 2. Difficulty Breathing 3. Stridor , Croupy cough 4. Torticollis 5. Bulge in PPW

Treatment –1. Transoral I & D. without GA2. I.V. Antibiotics3. Tracheostomy

Chronic Retropharyngeal Abscess Commonly seen in adults Cause – 1. Caries Spine

2. TB of retropharyngeal nodes

Clinical Features – 1. Discomfort in throat2. Neck rigidity3. Bulge in PPWDiagnosis – X RAY- widening of RP space > 3/4th of vertebral body.

Treatment –1. I & D through a oblique incision along antr. Border of SCM2. Antitubercular Therapy

Para-pharyngeal Space Pyramidal in shape with its

base at the base of skull & its apex at the hyoid bone.

Medial- Buccopharyngeal fascia.

Posteriorly – Prevertebral fascia Lateral – Medial pterygoid Divided into 2 compartments

by Styloid process 1. Anterior/ Prestyloid2. Posterior/ Poststyloid

Para pharyngeal Abscess Cause - 1. Peritonsillar abscess

2. Tonsillitis, Adenoiditis3. Dental caries- Lower last molar4. Bezold Abscess5. Penetrating injuries of neck

Clinical Features –1. Anterior Compartment – Triad of - 1. Prolapse of Tonsil , 2. Trismus due to Med. Pterygoid spasm 3. External swelling behind angle of jaw2. Posterior Compartment –1. Bulge behind postr. Pillar2. Paralysis of IX, X, XI, XII cranial N.3. Swelling of Parotid region

Treatment – 1. IV Antibiotics2. I & D of abscess by a horz. Incision made 2-3 cm below the angle of mandible

Danger Space› Anterior border is alar layer

of deep fascia› Posterior border is pre-

vertebral layer› Extends from skull base to

posterior mediastinum &diaphragm.

› It is so named because it contains loose areolar tissue and offers little resistance to the spread of infection.

Submandibular Space Divided into 2 compartments

by Mylohyoid m.› Sublingual Space

Areolar tissue Hypoglossal and lingual nerves Sublingual gland Wharton’s duct

› Submaxillary Space Anterior bellies of digastrics Submandibular gland (These two subdivisions freely

communicate around the posterior border of the mylohyoid. )

Ludwig’s Angina Infection of Submandibular Space. It is usually a cellulitis not abscess so don’t

expect pus. Aetiology –

1. Dental Infection – premolar, molar2. Submandibular Sialoadenitis3. Fracture Mandible

Clinical Feature –1. Odyniophagia , Trismus2. Tongue pushed up & back3. Swelling of submandibular region

with tenderness & woody hard feel.

4. Laryngeal edema may appear. Treatment -

1. I & D intraoral if sublingual, External transverse incision if submandibular.

2. IV antibiotics

Peritonsillar Abscess (QUINSY) Collection of pus in peritonsillar space between

capsule of tonsil & superior constrictor. Aetiology – Complication of Tonsillitis Organism – Mixed Clinical Feature – Commonly Adult Commonly Unilateral Symptoms - Fever with Chills, Odynophagia ,

Trismus, Hot potato voice , Foul breath, Ipsilateral ear pain

Signs – Tonsillar pillar swollenUvula pushed to opposite sideCervical lymphadenopathyTorticollis

Treatment –

1. I & D2. IV antibiotics3. H2O2 Gargle

4. Interval Tonsillectomy after 6wks

Parotid Abscess Infection of Parotid space between superficial &

deep layer of deep cervical fascia. Aetiology –

1. Dehydration – Post surgical cases after 5-7 d

2. Infections of oral cavity via stenson’s duct

Clinical Feature –1. Parotid area swollen ,tender,

indurated2. No fluctuation3. Congestion of Stenson’s duct opening

with pus exuding on pressure4. Fever with chills & rigor

Diagnosis – USG / CT- SCAN Treatment -

1. I & D With Lazy S incision & skin flap raise

2. IV antibiotics3. IV Fluid

MCQ

Trismus in parapharyngeal abscess is due to spasm of which muscle

Investigation of choice for parapharyngeal abscess ?

What is LINCOLN’S HIGHWAY in neck ?