Deep Space Neck Infections

Question 1

Deep Space Neck Infections

Characteristics

Answer 1

Infections of the floor of the mouth and posterior pharynx.

• Can spread along fascial planes of the neck
• Rapidly progressive
• Most commonly arise from oral/dental focus
• Usually caused by polymicrobial mouth flora
• Must be dx and tx promptly

Question 2

Clinically Important

Sites

Answer 2

• Submandibular space
• Parapharyngeal or lateral pharyngeal space
• Retropharyngeal space

Question 3

Submandibular Space

Answer 3

• Floor of the mouth
• Lies within the submental and submandibular triangles
• Subdivided by mylohyoid muscle into:
  
  • Sublingual space
  • Submylohyoid space

Question 4

Ludwig’s Angina

Definition

Answer 4

Primary infection in floor of mouth or tongue.

• Source of infection usually dental
  
  • Most commonly related to 2nd or 3rd mandibular molar teeth
• Brawny, bilateral woody swelling of submandibular tissue
• Inflammation and purulent discharge in floor of mouth pushes tongue upward ⇒ potential airway compromise

Question 5

Ludwig’s Angina

Clinical Presentation

Answer 5

• Fever, chills, malaise
• Mouth or dental pain
• Protruding, enlarged tongue
• Neck pain and stiffness
• Drooling
• Dysphagia
• Trismus
• Inspiratory stridor

Question 6

Ludwig’s Angina

Physical Exam

Answer 6

• Febrile
• Protruding, enlarged tongue
• Tender, bilateral “woody” swelling in submandibular area
• Mouth often held open d/t tongue swelling
• Floor of mouth erythematous, indurated, and TTP
• Pts may lead forward to maximize opening of airway

Question 7

Lateral Pharyngeal Space

Answer 7

“Parapharyngeal space”

• Located in the lateral aspect of the neck
• Divided by styloid process into:
  
  • Anterior compartment
  • Posterior compoartment
    
    • Contains vital neurovascular structures
      
      • Carotid artery
      • Internal jugular vein
      • Cranial nerves IX-XII
• Infections in this space is usually unilateral

Question 8

Lateral Pharyngeal Space

Anterior Compartment Infections

Answer 8

• Predisposing conditions:
  
  • Dental infection
  • URI / Pharyngitis
  • Peritonsillar abscess
  • Otitis media with mastoiditis
• Clinical manifestations:
  
  • Unilateral trismus
  • Induration and swelling below mandibular angle
  • Medial bulging of pharynglea wall
  • Fever, rigors, and systemic toxicity

Question 9

Lateral Pharyngeal Space

Posterior Compartment Infections

Answer 9

• Can result in compromise of neurovascuar structures
  
  • Carotid artery
  • Internal jugular vein
  • Cranial nerves IX-XII
  • Sympathetic cervical trunk
• Clinical manifestations:
  
  • Can see absence of localizing signs or sx
  • IJV: Suppurative jugular thrombophlebitis
    
    • When caused by Fusobacterium spp. ⇒ Lemierre’s Syndrome
      
      • Can lead to sepsis and septic emboli
  • Carotid artery: arteritis ⇒ aneurysm ⇒ rupture
  • Cranial nerve palsies

Question 10

Retropharyngeal Space

Answer 10

Long space posterior to the pharynx which tracts down into chest cavity.

Question 11

Retropharyngeal Space Infections

Answer 11

• Origin:
  
  • Odontogenic
  • Penetrating trauma (chicken or fish bone)
  • Peritonsillar abscess
• Clinical manifestations:
  
  • Fever
  • Sore throat
  • Dysphagia
  • Stiff neck
  • Dyspnea
  • In children: refusal to eat, hold neck stiff

Question 12

Peritonsillar Abscess

Answer 12

Complication of tonsillitis

• Clinical manifestations:
  
  • Fever
  • Sore throat
  • Dysphagia
  • Drooling
  • Muffled voice
• Physical exam:
  
  • Swelling of tonsils and soft palate

Question 13

Deep Space Neck Infection

Complications

Answer 13

• Sepsis
• Airway obstruction
• Pleuropulmonary infection
• Osteomyelitis

Question 14

Deep Space Neck Infection

Diagnosis

Answer 14

• Clinical ⇒ based on history and physical exam
• Radiology ⇒ plain film, CT of neck

Question 15

Deep Space Neck Infection

Treatment

Answer 15

• Airway management
• IV antibiotics
• Surgical drainage ⇒ required in most cases
• Possible hyperbaric oxygen