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Ear,Nose and Throat Associates
Johnson City ,Tennessee
 Infections
are one of the most
commonly occurring head and neck
pathologies
 Spread of infection can be predicted
by anatomic boundaries
 Mortality from head and neck
infections has decreased
significantly since the advent of
antibiotics, but resistant organisms
are spreading into the community
 Before
antibiotics, 70% deep neck infections
were caused by tonsillar and pharyngeal
sources. More recently,
 Most common cause in adults:
odontogenic, IVDA
 Most common cause in peds:
tonsillar, URI
 Others: salivary gland, trauma, FB,
instrumentation, local or superficial source
 22% without cause (1)
1. Tom MB, Rice DH: Presentation and management of neck abscesses: a retrospective analysis, Laryngoscope 98:877, 1988
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Odontogenic
Tonsillitis
IV drug injection
Trauma
Foreign body
Sialoadenitis
Parotitis
Osteomyelitis
Epiglottitis
URI
Iatrogenic
Congenital anomalies
Idiopathic
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Most common symptoms
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Most common symptoms (exluding peritonsillar abscesses)
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Sore throat (72%)
Odynophagia (63%)
Neck swelling (70%)
Neck Pain (63%)
Pediatric
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Fever
Decreased PO
Odynophagia
Malaise
Torticollis
Neck pain
Otalgia
HA
Trismus
Neck swelling
Vocal quality change
Worsening of snoring, sleep apnea
Superficial cervical fascia
Deep cervical fascia
superficial, middle, and deep layers.
The superficial (investing) layer of the deep cervical fascia invests
the sternocleidomastoid, trapezius, strap muscles, parotid and
submandibular
The middle (visceral) layer surrounds the thyroid gland,
esophagus and trachea.
The deep layer of the deep cervical fascia splits into prevertebral
and alar layers. The prevertebral layer lies immediately adjacent
to the vertebral bodies .
All contribute to the carotid sheath so that infection of any layer
may spread directly to involve the great vessels of the neck, which
have direct communication to the chest.
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MRI
• Pros
 MRI superior to CT in initial
assessment
 More precise identification
of space involvement
(multiplanar)
 Better detection of
underlying lesion
 Less dental artifact
 Better for floor of mouth
 No radiation
 Non iodine contrast
• Cons
 Cost
 Pt cooperation
 Slower (19 to 35 minutes)
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CT with contrast
• Pros
 Widely available
 Faster (5-15 minutes)
 Abscess vs cellulitis
 Less expensive
• Cons
 Contrast
 Radiation
 Uniplanar
 Dental artifacts
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Regular cavity wall with
ring enhancement (RE)
• Sensitivity - 89%
• Specificity - 0%
Irregular wall
(scalloped)
• Sensitivity - 64%
• Specificity - 82%
• PPV - 94%
 An
imaging modality that is gaining
popularity. It is safer than CT scan, since
it is portable and does not use radiation.
Ultrasound is also less traumatic to
children, requiring less frequent use of
sedation.
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Described in relation to the hyoid.
• Entire length of neck
 Superficial space
 Retropharyngeal
 Danger
 Prevertebral
 Vascular visceral
• Suprahyoid
 Submandibular
 Pharyngomaxillary (Parapharyngeal)
 Parotid
 Peritonsillar
 Temporal
 Masticator
• Infrahyoid
 Anterior visceral
Carotid artery rupture has a 20-40% mortality rate.
Jugular vein thrombosis had a mortality rate of 60% prior
to the use of antibiotics. Identifying this complication is
essential. Osteomyelitis and vertebral erosion can
cause subluxation and subsequent spinal cord injury.
In older children and adults, the disease spreads
directly into the fascial planes and is a more deadly
Mediastinitis has a 40-50% mortality rate secondary to
sepsis. Acute necrotizing mediastinitis and purulent
pericarditis with tamponade also can be fatal.
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The most common sources of life-threatening soft tissue
infections of the head and neck are the dentition and
tonsils.
Most infections are polymicrobial and the responsible
bacteria are often normal flora (Bacteroides, Peptostreptococcus,
Actimomyces, Fusobacterium etc). that become virulent and
invasive when normal barriers are broken (ie.
tonsillitis, dental abscess, trauma).
Obligate anaerobes frequently outnumber the
anaerobes.
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Deep space infections can be secondary to
instrumentation of the upper respiratory tract.
• Laryngoscopy
• Endoscopy
• Feeding tube insertion
• Endotracheal intubation
• Head and neck surgery
• Dental procedures
• Injections
 Spaces
involving
entire length of neck:
1. Retropharyngeal
2. Danger
3. Prevertebral
4. Visceral vascular
 Suprahyoid
spaces:
1.
Pharyngomaxillary/
Lateral pharyngeal
2. Submandibular
3. Parotid
4. Masticator
5. Peritonsillar
6. Buccal
 Infrahyoid spaces:
1. Anterior visceral
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This space (also called the lateral pharyngeal space or
pharyngomaxillary space) occupies a critical area in the neck, as
it communicates with all other fascial spaces. It sits as an inverted
cone with its base at the base of skull and apex at the hyoid bone.
It can be divided into anterior (prestyloid) and posterior
(retrostyloid) compartments by the styloid process. The anterior
compartment contains only fat, lymph nodes and muscle. The
posterior compartment contains the carotid and internal jugular
vessels, as well as cranial nerves IX through XII.
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Connects to the majority
of other fascial spaces
Sources: parotid,
masticator,
submandibular,
peritonsillar,
tonsils/pharynx,
odontogenic, LN from
nose and throat,
mastoiditis (Bezold
abscess)
 Laterally
parotid gland,parotid fascia,
medial pterygoid,mandible
 Medially
pharynx separated by
sup.cons
 Posteriorly communicates with
retropharyngeal space
 Superiorly base of skull,
 Inferiorly
sub mandibular gland fascia
 It
can spread from
Tonsillitis ,post tonsillectomy 60%
Dental infections lower last
molars 35 %
Trauma
 Communication with
peritonsillar,retropharyngeal or
submandibular space
 Tonsillitis
 Peritonsillar
abscess
 Dental infections
 Mastoiditis rarely via petrous
apex,digastric muscle sheath
 Pharyngeal F.B
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Pain throat,difficult swallowing
Trismus , spasm of pterygoids
Pyrexia,malaise,
Painful external swelling in neck at the posterior part of
middle third of sternomastoid
Swelling in retromolar region
Tonsil pushed medially
Last cranial nerves palsies
Parotid pushed laterally
 CT
scanning is the imaging modality of
choice and is helpful in confirming which
compartments are involved.
 Systemic
antibiotic
 In complicated cases such as septic
jugular vein thrombosis, several weeks of
intravenous antibiotics may be required.
 Incision and drainage
 Vertical incision at the ant.border of scm
 tracheostomy
 Acute
laryngeal edema
 Septecimia
and ijv thrombophelibitis
 Mediastinitis
 Spread
to other spaces of neck
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The peritonsillar space consists of
loose connective tissue between
the capsule of the palatine tonsil
and the superior constrictor
muscle. The anterior and
posterior tonsillar pillars
contribute to its anterior and
posterior borders, respectively.
The posterior tongue forms the
inferior boundary. Peritonsillar
infections may readily spread
to the parapharyngeal space.
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Boundaries: anterior and posterior pillars, palatine
tonsil, superior constrictor muscle
Indications for Quincy tonsillectomy?
No clear cut indications. Treatment is still controversial.
Needle aspiration, I&D, quincy tonsillectomy all equally
effective initial management with 10-15% recurrrence
rate. (1)
Again, 10-15% recurrence after needle aspiration
and/or I&D; greatest risk in patients <40 with history of
recurrent tonsillitis (2)
1. Johnson RF, Stewart MG, Wright CC. An evidence-based review of the treatment of peritonsillar abscess. Otolaryngol Head Neck Surg. 2003
Mar;128(3):332-43.
2. Herzon FS. Peritonsillar abscess: incidence, current management practices, and a proposal for treatment guidelines. Laryngoscope 1995;105
[suppl 74]:1-7.
 The
submandibular space extends from
the hyoid bone to the mucosa of the floor
of the mouth. It is bound anteriorly and
laterally by the mandible and inferiorly
by the superficial layer of the deep
cervical fascia.
 The mylohyoid muscle acts as a sling
across the mandible and divides the
submandibular space into sublingual and
submylohyoid spaces.
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The infection of this space was described by Ludwig in 1836.
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He described a gangrenous infection of the neck with woody
cellulitis without suppuration and insidious asphyxiation
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Cellulitis involving fascial spaces between muscles and other
structures of the posterior floor of the mouth that can compromise
the airway.
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Most patients are young, healthy adults with an
odontogenic infection. Usually present with mouth pain,
dysphagia, drooling and stiff neck. In the case of
Ludwigs angina, massive tongue and floor of mouth
edema can rapidly lead to posterior and superior
displacement of the tongue as well as anterior
displacement out the mouth. The patient often
maintains the neck in an extended position and may
have a muffled or "hot potato" voice. The neck shows a
characteristic erythematous woody swelling but
fluctuance is usually absent.
Sublingual space
Submaxillary space
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The most common cause of death in Ludwigs angina is
asphyxia. Airway control is the first priority of
treatment, followed by intravenous antibiotics and
timely surgical drainage.
Tracheotomy is still the most widely used method of
airway control but some authors feel the risk of
aspiration pneumonia Cricothyroidotomy is usually not
a good option with in patients with massive neck
edema.
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Closely monitor patients with airway compromise and
do not allow these patients to leave the acute care area.
Sedation and paralytics can relax airway muscles,
leading to complete obstruction.
Endotracheal intubation is dangerous unless
performed under direct visualization. consider
fiberoptic intubation or a surgical airway (eg,
cricothyroidotomy, tracheotomy
• Broad-spectrum coverage is indicated. Clindamycin is first-
line treatment,initiated alone or in combination with
cefoxitin or a beta-lactamase–resistant penicillin, such as
ticarcillin/clavulanate, piperacillin/tazobactam, or
ampicillin/sulbactam.
• Patients with cellulitis can be treated with parenteral
antibiotics alone. Closely observe these patients for
development of an abscess.
 Spaces
involving
entire length of neck:
1. Retropharyngeal
2. Danger
3. Prevertebral
4. Visceral vascular
 Suprahyoid
spaces:
1.
Pharyngomaxillary/
Lateral pharyngeal
2. Submandibular
3. Parotid
4. Masticator
5. Peritonsillar
6. Buccal
 Infrahyoid spaces:
1. Anterior visceral
 Lies
between prevertebral and
buccopharyngeal fascia
 Extending from skull base to tracheal
bifurcation
 Continous below with sup.mediastinum
and laterally with parapharyngeal space
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Most commonly seen in
peds due to drainage
source
Peds: preceding URI, fever,
dysphagia, odynophagia,
nuchal rigidity, asymmetric
bulging of post pharyngeal
wall due to midline raphe
Adults: pain, dysphagia,
cervical motion limitation,
noisy breathing
Can extend to:
mediastinum, danger
space, parapharyngeal
space
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Acute
in infants
more than 50%
due to lymphadinitis secondary
to URTI
high grade temp
sore throat
head extension and neck stiffness
respiratory & feeding problems
 Croupy
cough
 Muffled voice
 Cervical lymphadenopathy
 Smooth swelling on one side of
post.ph.wall with airway impairement
 May obstruct post.nares
 May push the palate down
 Infant spine short and larynx high
 predisposing
infections pharyngitis, tonsillitis, otitis,
adenitis, sinusitis, and nasal, salivary, and dental infections.
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from contiguous spaces, such as the parapharyngeal space
(eg, abscesses), submandibular space (eg, Ludwig angina), or
prevertebral space (eg, osteomyelitis, diskitis).
secondary to penetrating trauma.
• Running and falling down after putting something in their
mouths (eg, toy, stick, popsicle, lollipop, toothbrush) is not
unusual in children. Because parents may be unaware of
these predisposing events
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Almost exclusively a pediatric diagnosis.
Most incidents occur in children aged 6 months to 6
years, with a mean age of 3-4 years. Other deep neck
abscesses (eg, parapharyngeal, peritonsillar) are
observed more frequently in adults and older children.
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Most patients are febrile. Some appear toxic and irritable.
Cervical lymphadenopathy, usually unilateral, most common
decreased or painful range of motion of their necks or jaws.
A neck mass or tenderness may be appreciated.
may present with a muffled "hot potato" voice (ie, dysphonia) or
with a voice that sounds like a duck quack (ie, cri du canard).
may be able to appreciate a mass in the posterior pharyngeal
wall.
• As many as 30% of patients have this mass
• This is not midline,.
• "Tracheal rock sign" elicits pain
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Patients in respiratory distress or those who present with stridor or
drooling have potential airway compromise.
• These patients prefer to lie supine with their necks extended,
maximizing their airway patency..
Address vascular complications in the physical examination.
• Jugular vein thrombophlebitis may manifest as tender induration at
the anterior sternocleidomastoid border, vocal cord paralysis, or
sepsis of an unknown source.
• Carotid artery rupture can be heralded by sentinel bleeding from
the ear, nose, or mouth.
 Likely
to be due to tuberculous infection
of the cervical spine
 Slow onset
 Pharyngeal discomfort,some dysphagia
 Cervical spine radiography
 Look for associated infections
A
lateral soft tissue neck x-ray is helpful .
• An abscess occupies the soft tissue space, which
can be observed between the radiolucent
airway (ie, pharynx, trachea) and the spine.
• Widening of these soft tissues is pathologic until
proven otherwise.
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Lateral soft tissue XR (extension, inspiration) abnormal
findings:
1. C2-post pharyngeal soft tissue >7mm
2. C6–adults >22mm, peds >14mm
3. STS of post pharyngeal region >50% width of vertebral
body
 is
currently the imaging modality of
choice..
• can be used to determine the presence of an
abscess and help distinguish it from cellulitis (an
abscess has a central area of lucency). also can
assist in determining the location of the abscess,
extent of abscess spread, and presence of any
complications.
• CT scan can be more than 90% sensitive.
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are secondary to mass effect,
rupture of the abscess, or
spread of infection.
Rupture of the abscess can cause aspiration of pus, resulting in
asphyxiation or pneumonia.. Spread of the infection to the
mediastinum can result in mediastinitis, purulent pericarditis ,etc.
Spread of the infection laterally can involve the carotid sheath and
cause jugular vein thrombosis or carotid artery rupture. Posterior
spread of infection can result in osteomyelitis and erosion of the
spinal column, causing subluxation and spinal injury. It can evolve
into necrotizing fasciitis, sepsis, and death
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Incision and drainage
Limitation of GA
Infant wrapped and held upright
Abscess incised with a gaurded knife
Sinus forceps plunged into it and open
Copious flow of pus
Baby face turned down to allow escape
Immediate relief
Antibiotics
 Incision
and drainage over the
post.border of scm vertical incision
 Abscess is sought for by dissection
between the carotid sheath and the
prevertebral muscles and is drained from
the neck
 Tracheostomy
 Anti TB regimes
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Visceral layer-mid
RETROPHARYNGEA
L SPACE (T2)
Alar division-deep
DANGER SPACE
(diaphragm)
Prevertebral division
PREVERTEBRAL
SPACE (coccyx)
Vertebrae
Potential Space, dangerous for rapid inferior
spread of infection to the posterior
mediastinum through its loose areolar tissue
 Boundaries
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Superior: skull base
Inferior: diaphragm
Anterior: alar fascia, retropharyngeal space
Posterior: prevertebral fascia
Lateral: transverse processes of vertebrae
Contains: sympathetic trunk
 Routes of entry: retropharyngeal,
parapharyngeal, or prevertebral spaces
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Potential space
 Boundaries
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•
•
•
•
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Superior: clivus of the skull base
Inferior: coccyx
Anterior: prevertebral fascia
Posterior: vertebral bodies
Lateral: transverse processes
Contains: paraspinous, prevertebral, and
scalene muscles, vertebral artery and vein,
brachial plexus, and phrenic nerve
 Routes of entry: infection of the vertebral
bodies and penetrating injuries
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Bacteriology
Aerobic
G (+)
n
%
G (-)
n
%
Total
645
87.40
Total
137
18.56
Strep sp.
229
31.03
Klebsiella sp.
90
Staph sp.
112
15.18
Neisseria sp.
B-hemolytic Strep
80
10.84
Strep viridans
71
Staph aureus
Anaerobic
n
%
Total
201
27.24
12.20
Peptostreptococcus
43
5.83
20
2.71
Bacteroides sp.
50
6.78
Acinebacter sp.
7
0.95
Unidentified
46
6.23
9.62
Enterobacter sp.
7
0.95
Bacteroides melaninogenicus
13
1.76
57
7.72
Proteus sp.
4
0.54
Propionibacterium
9
1.22
Coagulase neg. Staph sp.
55
7.45
E coli
3
0.41
Provotella sp.
7
0.95
Strep pneum
13
1.76
Citrobacter sp
2
0.27
Fusobacterium
7
0.95
Enterococcus
10
1.36
M. Catarrhalis
2
0.27
Bacteroidies fragilis
6
0.81
Mycobacterium tub.*
10
1.36
Pseudomonas sp.
1
0.14
Eubacterium
6
0.81
Micrococcus
8
1.08
H. Parainfluenza
1
0.14
Peptococcus
6
0.81
Diptheroids
7
0.95
H influenzae
1
0.14
Veillonella parvula
5
0.68
Bacillus sp.
6
0.81
Salmonella sp.
1
0.14
Clostridium sp.
4
0.54
Actinomycosis israelii
3
0.41
Lactobacillus
4
0.54
Bifidobacterium sp.
3
0.41
Polymicrobial
181
24.53
Sterile
71
9.62
Modified and combined data from 738 patients (1, 2, 3, 4, 5, 6, 7).
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Initial therapy
• Cover Gram positive cocci and
anaerobes
• If pt is diabetic, should consider covering
gram negatives empirically.
• Unasyn, Clindamycin, 2nd generation
cephalosporin.
• PCN, gentamicin and flagyl - developing
nations.
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IV abx alone (based on retro and
parapharyngeal infections)
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•
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Patient stability and nature of lesion.
Cellulitis/phlegmon by CT.
Abscesses in clinically stable patient.
If no clinical improvement in 24 - 48 hours
proceed to surgical intervention.
• Aspiration can help determine the presence of an abscess
and help distinguish it from cellulitis. It can be diagnostic
and therapeutic.
• An intraoral route usually is indicated, except when an
abscess is isolated lateral to the carotid sheath. In this case,
an external approach can be used. CT scan or ultrasound
can help guide the aspiration. With an abscess involving
multiple spaces, perform needle aspiration with an open
external approach.

External drainage
• Landmarks
 Tip of greater horn of hyoid
 Cricoid cartilage
 Styloid process
 SCM

Transoral drainage
• Parapharyngeal,
retropharyngeal abscesses
• Great vessels lateral to
abscess
• Tonsillectomy for exposure

Needle aspiration
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Airway obstruction
• Trach 10 – 20%
• Ludwig’s angina - 75%
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Mediastinitis – 2.7%
UGI bleeding
Sepsis
Pneumonia
IJV thrombosis
Skin defect
Vocal cord palsy
Pleural effusion
Hemorrhage
• 20 - 80% mortality

Multiple space involvement
 HPV
associated >50%CA of oropharynx
in U.S. and Western Europe
 Larynx may be less common site
 Affect younger pts.w/oHx tobacco/etoh
use
 Most are tonsil and base of tongue
 Most associated with early LN mets
 Better prognosis /response to therapy
than HPV neg. tumors
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Older pts
Systemic dz
• Immunodeficient pts
 HIV
 Myelodysplasia
• Cirrhosis
• DM
 Most common systemic
 Mbio – Klebsiella pneum. (56%)
 33% with complications
 Higher mortality rate
 Prolonged hospital stay
 20 days vs. 10 days