an upto date regarding deep neck space infections

1. DEEP NECK SPACE
INFECTIONS
DR. NAIM MANHAS
E.N.T. SURGEON
KING ABDUL AZIZ HOSPITAL

2. Neck
Divided in several
compartments
By fascias
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3. Peritonsillar
space
Submandibular
space
Parapharyngeal
space
Retropharyngeal
space
Parotid space
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4. Importance of fascial compartments
 Understanding inter-fascial
spaces for pathogenesis , clinical
manifestation and potential
results of spread of infections
involving these spaces
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5. One space /multispace
involvement
30%
63%
Single space
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6. MICROBIOLOGY
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
aerobes anaerobes
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7.  Anaeorbic bacteria are major constiuents of
normal human flora.
 Anaerobic bacteria contains a number of
virulence factors, including toxins, are often
associated with tissue necrosis and abscess
formation.
 Usually involves all anatomic sites including
cerebral, dental,peritonsilliar, lung ,
intraabdominal, tubo-ovarian prostatic and
cutaneous abscesses.
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8. Incidence of anaerobes
50
200
290
560
21994 1998 2001 2004
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9.  Presence of Gas in the tissue is another clue
to the presence of anaerobic bacteria, but it is
not considered diagnostic as sometimes we
do get aerobic bacteria producing gas.
 The putrid odor of discharge of infections or
discharge is present.
 Detected by palpation, radiography or
scanning techinques.
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10. 10Dr. Naim Manhas

11. Immunocompromised state
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12. Presentation
 Unusual presentation :-
 Wide spread use of antibiotics
 Profond immunosupression
 Cellullitis
 Necrotizing cellulitis
 Associated with
thrombophelibitis (Lemierre’s )
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13. The widespread
use of
antibiotcs and
/or profound
immunosppress
ion , the classic
signs of
erythema,
edma,
flauctuance
may be absent
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14. IMAGING
Without contrast With contrast
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15. Imaging
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16. IMAGING
Abscess versus phelgmon
Necrotizing fascitis with
abscess
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17. plain x-ray
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18. 18Dr. Naim Manhas

19. Aspiration versus I/D
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
asp i/d
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20. RECOMMENDATIONS
 Aspiration :-
 1. depends upon the site
 2. no clear differentiation
between cellulitis and abscess
 3. diagnostic confirmation
 Premature incision into an area of cellulitis
may actually worsen the situation by
breaking down the natural defenses (barriers)
, thus hastening spread of infection
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21. PERITONSILLAR ABSCESS
peritonsillar cellulitis :-
Inflammatory reaction of the
tissue between the capsule of
the palatine tonsil and the
pharyngeal muscles.
Peritonsillar abscess :-
Collection of abscess between
the capsule of the tonsil and the
pharyngeal muscles.
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22. Submandibular Space
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23. Submandibular abscess/ludwigs angina
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24. Dr. Naim Manhas 24

25. Dr. Naim Manhas 25

26. Importance of
penetrating
the mylohyoid
muscle for
complete
drainage of
the abscess in
the sublingual
space
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27. parapharyngeal space
Parapharyngeal
space infections
are potentially
life threatening if
not treated in
time.
Presence of
important
structures in para
pharyngeal space
.
Source of
infection from
dental abscess,
peritonsillar
abscess.
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28. parapharyngeal abscess
Ct scan showing abscess Para pharyngeal abscess
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29. Complications
Extensive
parapaharyngeal
abscess with neck
cellulitis .
Involvement of
carotid sheath. And
juglar
thrombophelibitis.
“LEMIERRE’S
syndrome
(fusobacterium
necrophorum)
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30. Retropharyngeal space
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31. RETROPHARYNGEAL ABSCESS
Retropharyngeal
abscesses are among the
most serious of deep neck
infections.
Infection can extend
directly to anterior or
posterior regions of
mediastinum.
Common in infants and
children .
In adults due to impacted
foreign body or due to
“potts disease.
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32. RETROPHARYNGEAL ABSCESS
Ct scan showing
extension of
retropharyngeal
abscess in upper
mediastium
Can cause acute
necrotizing
mediastinitis
Mortality becomes
high 25% in adults.
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33. Antimicrobial agents
 Oral or odontogenic source
 Amoxicillin-clavulanic acid (beta lactamase
inhibitor) 1.2 G I/V every 8-12 hours
 Metroniadiazole 500mg I/V every 6-8 hours
 OR
 Clindamycin 600mg I/V every 6-8 hours
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34. Rhinogenic or otogenic source
 Ceftriaxone 1 G I/V every 24 hours
 Metroniadazole 500mg I/V every 6-8 hours
 OR
 Ceprofloxacin 400mg I/V every 12 hours
 Clindamycin 600mg I/V every 6-8 hours
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35. Immunocompromised patients
 Cefepime 2G I/V every 12 hours
 Metroniadazole 500mg I/V every 6-8 hours
 OR
 Imipenem 500mg I/V every 6 hours
 OR
 Meropenem 1G I/V every 8 hours
 (carbapenem group of antibiotics )
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36. Objectives of Management
 aspiration
 Adequate drainage
 Incisional
 Antimicrobial therapy
 Supportive care
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37. ???
Branchial cyst After drainage (cavity)
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38. NECROTIZING FASCITIS
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39. NECROTIZING SOFT TISSUE INFECTIONS
 necrotizing forms of cellulitis , faciitis and
myositis.
 Characterized by fulminanat tissue
destruction,systemic signs of toxcity and high
mortality.
 Early recognition is critical, rapid progression
to extensive destruction leading to systemic
toxicity .
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40. Clinical presentation
Within 3-5 days after
onset, skin breaksdown
with bullae formation.
Thrombosis of small
blood vessels with pain
sensation is decreased
due to destruction of
superficial nerves.
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41. NECROTIZING SOFT TISSUE INFECTIONS
 Type 1.
 Usually in immunocompromised patients
 Polymicrobial infection:- usually anaerobic
species
 Bacteriodes, clostridum or
peptostreptococcus in addition to anaerobic
streptococcus.
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42. NECROTIZING SOFT TISSUE INFECTIONS
 Type 2.
 Mainly due to Group A Streptococcus (GAS)
 Either alone or in combination with either
species most commonly S.aureus
 Can occur among healthy individuals in any
age group
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43. Predisposing factors:-
 H/o skin injury
 Laceration
 Burn
 Blunt trauma
 Recent surgery
 Injection drug use
 In case above factors are absent then
pathogenesis of infection likely consists of
hematogenous translocation of GAS from throat
(aymptomatic or symptomatic Pharyngitis)
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44. MANAGEMENT:-
Aggressive
surgical
exploration.
Debriment of
necrotic tissue.
Antimicrobial
agents.
Hemodynamic
support
100.0%
25%
Without
debrim
ent
1
9
8
7
6
5
4
3
2
1
0
With debriment
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45. NECROTIZING SOFT TISSUE INFECTIONS
Aggressive debriment of all
Necrotic tissue until healthy,
viable (bleeding) tissue is
reached.
Reevaluated after 24 hours
and if necrotic tissue is
present needs agreessive
debriment again.
Once the wound is healthy
then reconstruction is done.
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46. ANTIBIOTIC THERAPY
Acceptable regimes:-
“carbapenem” group
Imipenem 500mg I/V every 6 hours
OR
Meropenem 1G I/V every8 hours
Clindamycin 600-900 mg I/V every 8 hours
Vancomycin 15-20mg/Kg /I/V every 8-12 hours
OR
Linezolid 600 mg I/V every 12 hours.
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