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Chapter 52
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Head and Neck Space Infections
PAROTID ABSCESS
It is suppuration of the parotid space. Deep cervical fascia
splits into two layers, superficial and deep, to enclose the
parotid gland and its associated structures. Parotid space
lies deep to its superficial layer.
Contents of parotid space include parotid gland and
its associated parotid lymph nodes, facial nerve, external
carotid artery and retromandibular vein. Fascial layer is very
thick superficially but very thin on the deep side of the parotid gland where parotid abscess can burst to form a parapharyngeal abscess and thence spread to the mediastinum.
AETIOLOGY
Dehydration, particularly in postsurgical cases and debilitated patients, with stasis of salivary flow is the predisposing cause. Infection from the oral cavity travels via the
Stenson’s duct to invade the parotid gland. Multiple small
abscesses may form in the parenchyma. They may then
coalesce to form a single abscess.
BACTERIOLOGY
Most common organism is Staphylococcus aureus but Streptococci, anaerobic organisms and rarely the Gram- negative
organisms have been cultured.
CLINICAL FEATURES
Usually follows 5–7 days after operation. There is swelling, redness, indurations and tenderness in the parotid
area and at the angle of mandible.
Parotid abscess is usually unilateral, but bilateral abscesses may occur. Fluctuation is difficult to elicit due to
thick capsule. Opening of the Stenson’s duct becomes
congested and may exude pus on pressure over the parotid. Patient is toxic, running high fever and dehydrated.
DIAGNOSIS
Diagnosis of the abscess can be made by ultrasound or
computed tomography scan. More than one loculi of pus
may be seen. Aspiration of abscess can be done for culture
and sensitivity of the causative organisms.
TREATMENT
Correct the dehydration, improve oral hygiene and promote salivary flow. Intravenous antibiotics are instituted.
Surgical drainage under local or general anaesthesia
is carried out by a preauricular incision as employed for
parotidectomy. Skin flap is raised to expose surface of the
gland, and the abscess or abscesses are bluntly opened
working parallel to the branches of the VIIth nerve. Skin
incision is loosely approximated over a drain and allowed
to heal by secondary intention.
LUDWIG’S ANGINA
APPLIED ANATOMY
Submandibular space lies between mucous membrane of
the floor of mouth and tongue on one side and superficial
layer of deep cervical fascia extending between the hyoid
bone and mandible on the other (Figure 52.1). It is divided into two compartments by the mylohyoid muscle:
1. Sublingual compartment (above the mylohyoid).
2. Submaxillary and submental compartment (below the
mylohyoid).
The two compartments are continuous around the
posterior border of mylohyoid muscle.
Ludwig’s angina is infection of submandibular space.
AETIOLOGY
1. dental inFections. They account for 80% of the
cases. Roots of premolars often lie above the attachment
of mylohyoid and cause sublingual space infection while
roots of the molar teeth extend up to or below the mylohyoid line and primarily cause submaxillary space infection (Figure 52.2).
2. submandibular sialadenitis, injuries oF oral
mucosa and Fractures oF the mandible account for
other cases.
BACTERIOLOGY
Mixed infections involving both aerobes and anaerobes are
common. Alpha-haemolytic Streptococci, Staphylococci
and bacteroides groups are common. Rarely Haemophilus
influenzae, Escherichia coli and Pseudomonas are seen.
CLINICAL FEATURES
There is marked difficulty in swallowing (odynophagia)
with varying degrees of trismus.
When infection is localized to the sublingual space,
structures in the floor of mouth are swollen and tongue
seems to be pushed up and back.
When infection spreads to submaxillary space, sub-
mental and submandibular regions become swollen and
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SECTION IV — Diseases of Pharynx
Figure 52.3. Ludwig’s angina in a 7-year-old child.
Figure 52.1. Anatomy of submandibular space.
PERITONSILLAR ABSCESS (QUINSY)
It is a collection of pus in the peritonsillar space which
lies between the capsule of tonsil and the superior constrictor muscle.
Figure 52.2. Roots of molar teeth project below and those of premolars above the attachment of mylohyoid muscle.
tender, and impart woody-hard feel. Usually, there is cellulitis of the tissues rather than frank abscess. Tongue is
progressively pushed upwards and backwards threatening
the airway. Laryngeal oedema may appear (Figure 52.3).
TREATMENT
1. Systemic antibiotics.
2. Incision and drainage of abscess.
(a) Intraoral—if infection is still localized to sublin-
gual space.
(b) External—if infection involves submaxillary space.
A transverse incision extending from one angle of
mandible to the other is made with vertical opening of midline musculature of tongue with a blunt
haemostat. Very often it is serous fluid rather than
frank pus that is encountered.
3. Tracheostomy, if airway is endangered.
COMPLICATIONS
1. Spread of infection to parapharyngeal and retropharyngeal spaces and thence to the mediastinum.
2. Airway obstruction due to laryngeal oedema, or swelling and pushing back of the tongue.
3. Septicaemia.
4. Aspiration pneumonia.
AETIOLOGY
Peritonsillar abscess usually follows acute tonsillitis
though it may arise de novo without previous history
of sore throats. First, one of the tonsillar crypts, usually
the crypta magna, gets infected and sealed off. It forms
an intratonsillar abscess which then bursts through
the tonsillar capsule to set up peritonsillitis and then an
abscess.
Culture of pus from the abscess may reveal pure growth
of Streptococcus pyogenes, S. aureus or anaerobic organisms.
More often the growth is mixed, with both aerobic and
anaerobic organisms.
CLINICAL FEATURES
Peritonsillar abscess mostly affects adults and rarely the
children though acute tonsillitis is more common in children. Usually, it is unilateral though occasionally bilateral
abscesses are recorded. Clinical features are divided into:
1. General. They are due to septicaemia and resemble
any acute infection. They include fever (upto 104 °F),
chills and rigors, general malaise, body aches, head-
ache, nausea and constipation.
2. Local
(a) Severe pain in throat. Usually unilateral.
(b) Odynophagia. It is so marked that the patient can-
not even swallow his own saliva which dribbles
from the angle of his mouth. Patient is usually dehydrated.
(c) Muffled and thick speech, often called “hot potato
voice.”
(d) Foul breath due to sepsis in the oral cavity and
poor hygiene.
(e) Ipsilateral earache. This is referred pain via CN IX
which supplies both the tonsil and the ear.
(f) Trismus due to spasm of pterygoid muscles which
are in close proximity to the superior constrictor.
Figure 52.4. Peritonsillar abscess left side.
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Chapter 52 — Head and Neck Space Infections
Figure 52.5. Peritonsillar abscess. Site of drainage is just lateral to
the junction of vertical line through anterior pillar and horizontal line
through base of uvula.
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EXAMINATION
1. The tonsil, pillars and soft palate on the involved side
are congested and swollen. Tonsil itself may not appear
enlarged as it gets buried in the oedematous pillars
(Figure 52.4).
2. Uvula is swollen and oedematous and pushed to the
opposite side.
3. Bulging of the soft palate and anterior pillar above the
tonsil.
4. Mucopus may be seen covering the tonsillar region.
5. Cervical lymphadenopathy is commonly seen. This
involves jugulodigastric lymph nodes.
6. Torticollis. Patient keeps the neck tilted to the side
of abscess.
INVESTIGATION
Contrast-enhanced CT or MRI shows the abscess and its
extent. Needle aspiration of an abscess provides material
for culture and sensitivity of bacteria.
TREATMENT
1. Hospitalization.
2. Intravenous fluids to combat dehydration.
3. Antibiotics. Suitable antibiotics in large i.v. doses to
cover both aerobic and anaerobic organisms.
4. Analgesics like paracetamol are given for relief of pain
and to lower the temperature. Sometimes, stronger
analgesics like pethidine may be required. Aspirin is
avoided because of the danger of bleeding.
5. Oral hygiene should be maintained by hydrogen peroxide or saline mouth washes.
The above conservative measures may cure peritonsil-
litis. If a frank abscess has formed, incision and drainage
will be required.
• Incision and drainage of abscess. A peritonsillar ab-
scess is opened at the point of maximum bulge above
the upper pole of tonsil or just lateral to the point of
junction of anterior pillar with a line drawn through
the base of uvula (Figure 52.5). With the help of a
guarded knife, a small stab incision is made and then
a sinus forceps inserted to open the abscess. Putting
the sinus forceps the following day may also be necessary to drain any reaccumulation.
• Interval tonsillectomy. Tonsils are removed 4–6 weeks
following an attack of quinsy.
• Abscess or hot tonsillectomy. Some people prefer to
do “hot” tonsillectomy instead of incision and drainage. Abscess tonsillectomy has the risk of rupture of
the abscess during anaesthesia and excessive bleeding
at the time of operation.
COMPLICATIONS
Rare with modern therapy.
1. Parapharyngeal abscess (a peritonsillar abscess is a potential parapharyngeal abscess).
2. Oedema of larynx. Tracheostomy may be required.
3. Septicaemia. Other complications like endocarditis,
nephritis, brain abscess may occur.
4. Pneumonitis or lung abscess. Due to aspiration of pus,
if spontaneous rupture of abscess has taken place.
5. Jugular vein thrombosis.
6. Spontaneous haemorrhage from carotid artery or
jugular vein.
RETROPHARYNGEAL ABSCESS
APPLIED ANATOMY
• Retropharyngeal space. It lies behind the pharynx
between the buccopharyngeal fascia covering pharyngeal constrictor muscles and the prevertebral fascia. It extends from the base of skull to the bifurcation of trachea. The space is divided into two lateral
compartments (spaces of Gillette) by a fibrous raphe
( Figure 52.6). Each lateral space contains retropharyngeal nodes which usually disappear at 3–4 years of
age. Parapharyngeal space communicates with the
retropharyngeal space. Infection of retropharyngeal
space can pass down behind the oesophagus into the
mediastinum.
• Prevertebral space. It lies between the vertebral bodies
posteriorly and the prevertebral fascia anteriorly. It extends from the base to skull of coccyx. Infection of this
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SECTION IV — Diseases of Pharynx
Figure 52.6. Spaces in relation to pharynx where abscesses can form.
space usually comes from the caries of spine. Abscess
of this space produces a midline bulge in contrast to
abscess of retropharyngeal space which causes unilateral bulge.
ACUTE RETROPHARYNGEAL ABSCESS
AETIOLOGY
It is commonly seen in children below 3 years. It is the result of suppuration of retropharyngeal lymph nodes secondary to infection in the adenoids, nasopharynx, posterior nasal sinuses or nasal cavity. In adults, it may result
from penetrating injury of posterior pharyngeal wall or
cervical oesophagus. Rarely, pus from acute mastoiditis
tracks along the undersurface of petrous bone to present
as retropharyngeal abscess.
CLINICAL FEATURES
1. Dysphagia and difficulty in breathing are prominent
symptoms as the abscess obstructs the air and food
passages.
2. Stridor and croupy cough may be present.
3. Torticollis. The neck becomes stiff and the head is kept
extended.
4. Bulge in posterior pharyngeal wall. Usually seen on one
side of the midline.
Radiograph of soft tissue, lateral view of the neck shows
widening of prevertebral shadow and possibly even the
presence of gas (Figure 52.7). A contrast-enhanced CT
shows the extent of the abscess and also if it extends below the hyoid bone. Any associated abscess, for example
of the parapharyngeal space, may also be seen.
TREATMENT
1. incision and drainage oF abscess. This is usu-
ally done without anaesthesia as there is risk of rupture
Figure 52.7. Retropharyngeal abscess. Radiograph of soft tissue,
lateral view neck showing widening of prevertebral space with gas
formation (arrow).
of abscess during intubation. Child is kept supine with
head low. Mouth is opened with a gag. A vertical incision
is given in the most fluctuant area of the abscess. Suction should always be available to prevent aspiration of
pus. If done under GA, care should be taken that the abscess does not rupture during intubation with aspiration
of pus. The pharynx is always packed. Aspiration for an
abscess can be done before incision to break the pressure
in the abscess and gush of pus.
Chapter 52 — Head and Neck Space Infections
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2. systemic antibiotics. Suitable antibiotics are given.
3. tracheostomy. A large abscess may cause mechani-
cal obstruction to the airway or lead to laryngeal oedema.
Tracheostomy becomes mandatory in these cases.
CHRONIC RETROPHARYNGEAL ABSCESS
(PREVERTEBRAL ABSCESS)
AETIOLOGY
It is tubercular in nature and is the result of (i) caries of
cervical spine or (ii) tuberculous infection of retropharyngeal lymph nodes secondary to tuberculosis of deep cervical nodes. The former presents centrally behind the
prevertebral fascia while the latter is limited to one side
of midline as in true retropharyngeal abscess behind the
buccopharyngeal fascia.
CLINICAL FEATURES
Patient may complain of discomfort in throat. Dysphagia, though present, is not marked. Posterior pharyngeal
wall shows a fluctuant swelling centrally or on one side of
midline (Figure 52.8). Neck may show tuberculous lymph
nodes. In cases with caries of cervical spine, X-rays are
diagnostic.
APPLIED ANATOMY
Parapharyngeal space is pyramidal in shape with its base
at the base of skull and its apex at the hyoid bone.
RELATIONS (FIGURES 52.6, 52.7 AND 52.9)
• Medial. Buccopharyngeal fascia covering the constric-
tor muscles.
• Posterior. Prevertebral fascia covering prevertebral
muscles and transverse processes of cervical vertebrae.
• Lateral. Medial pterygoid muscle, mandible and deep
surface of parotid gland.
Styloid process and the muscles attached to it divide
the parapharyngeal space into anterior and posterior
compartments. Anterior compartment is related to tonsillar fossa medially and medial pterygoid muscle laterally.
Posterior compartment is related to posterior part of lateral pharyngeal wall medially and parotid gland laterally.
Through the posterior compartment pass the carotid artery, jugular vein, IXth, Xth, XIth, XIIth cranial nerves
and sympathetic trunk.
It also contains upper deep cervical nodes.
Parapharyngeal space communicates with other spac-
es, viz. retropharyngeal, submandibular, parotid, carotid
and visceral (Table 52.1).
TREATMENT
1. Incision and drainage of abscess. It can be done through
a vertical incision along the anterior border of sternomastoid (for low abscess) or along its posterior border
(for high abscess).
2. Full course of antitubercular therapy should be given in
cases of tubercular abscess.
PARAPHARYNGEAL ABSCESS
(Syn. Abscess of pharyngomaxillary or lateral pharyngeal
space.)
AETIOLOGY
Infection of parapharyngeal space can occur from:
1. Pharynx. Acute and chronic infections of tonsil and
adenoid, bursting of peritonsillar abscess.
2. Teeth. Dental infection usually comes from the lower
last molar tooth.
3. Ear. Bezold abscess and petrositis.
4. Other spaces. Infections of parotid, retropharyngeal
and submaxillary spaces.
5. External trauma. Penetrating injuries of neck, injection of local anaesthetic for tonsillectomy or mandibular nerve block.
Figure 52.8. (A) A prevertebral abscess (tubercular) as seen in the oropharynx. (B) An X-ray of the same.
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Figure 52.9. Spaces of head and neck seen in coronal section. Mucosa (1), pharyngobasilar fascia (2), buccopharyngeal fascia (3), superior constrictor muscle (4), superficial layer of deep cervical fascia enclosing submandibular gland (5), parotid gland (6), masseter muscle (7), temporalis
muscle (8) and medial pterygoid muscle (9).
SECTION IV — Diseases of Pharynx
TABLE 52.1 IMPORTANT SPACES OF THE HEAD AND NECK AND THEIR SOURCE OF INFECTION
Space Extent Location Source of infection
Parotid space Within two layers of superficial
layer of deep cervical fascia
Submandibular space
(submaxillary plus sublingual)
Peritonsillar space Between superior constrictor
Retropharyngeal space Base of skull to tracheal
Danger space Base of skull to diaphragm Between prevertebral fascia and
Prevertebral space Base of skull to coccyx Between vertebrae on one side
Parapharyngeal space (Lateral
pharyngeal space or pharyngomaxillary space)
Masticator space Base of skull to lower border of
• Sublingual space. Oral mucosa
to mylohyoid muscle
• Submaxillary space. Mylohyoid
muscle to superficial layer of
deep cervical fascia extending
from mandible to hyoid bone
and fibrous capsule on the
lateral aspect of tonsil
bifurcation (T4)
Base of skull to hyoid bone and
submandibular gland
mandible
Parotid area Infection of oral cavity via
Stenson’s duct
Below the tongue
Submental and submandibular
triangles
Lateral to tonsil Infection of tonsillar crypt
Between alar fascia and the
buccopharyngeal fascia
covering constrictor muscles
alar fascia
and prevertebral muscles and
the prevertebral fascia on the
other
Buccopharyngeal fascia covering
lateral aspect of pharynx
medially, and fascia covering
pterygoid muscles, mandible
and parotid gland laterally
Between superficial layer of
deep cervical fascia and the
muscles of mastication—
masseter, medial and lateral
pterygoids insertion of
temporalis muscle and the
mandible and the deep layer
of deep cervical fascia
• Sublingualsialadenitis,tooth
infection
• Submandibulargland
sialadenitis
• Molartoothinfection
• Extensionofinfectionfrom
parapharyngeal space, parotid
or masticator space
• Oesophagealperforation
• Suppurationof
retropharyngeal nodes
Infected by rupture of
retropharyngeal abscess
• Tuberculosisofspine
• Penetratingtrauma
• Peritonsillarabscess
• Parotidabscess
• Submandibulargland
infection
• Masticatorspaceabscess
Infection of second and third
molar
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CLINICAL FEATURES
Clinical features depend on the compartment involved.
Anterior compartment infections produce a triad of
symptoms: (i) prolapse of tonsil and tonsillar fossa,
(ii) trismus (due to spasm of medial pterygoid muscle)
and (iii) external swelling behind the angle of jaw. There
is marked odynophagia associated with it.
Posterior compartment involvement produces (i) bulge
of pharynx behind the posterior pillar, (ii) paralysis of CN
IX, X, XI, and XII and sympathetic chain, and (iii) swelling of parotid region. There is minimal trismus or tonsillar prolapse.
Fever, odynophagia, sore throat, torticollis (due to
spasm of prevertebral muscles) and signs of toxaemia are
common to both compartments.
DIAGNOSIS
Contrast-enhanced CT scan neck will reveal the extent
of a lesion. Magnetic resonance arteriography is useful if
thrombosis of the internal jugular vein or aneurysm of
the internal carotid artery is suspected.
COMPLICATIONS
1. Acute oedema of larynx with respiratory obstruction.
2. Thrombophlebitis of jugular vein with septicaemia.
3. Spread of infection to retropharyngeal space.
4. Spread of infection to mediastinum along the carotid
space.
5. Mycotic aneurysm of carotid artery from weakening of
its wall by purulent material. It may involve common
carotid or internal carotid artery.
6. Carotid blow out with massive haemorrhage.
MASTICATOR SPACE
It lies between two layers of deep cervical fascia; the superficial (lateral) layer covers the masseter and temporal
muscles while deep layer covers the medial and lateral
pterygoids muscles medially. It consists of three spaces:
(i) masseteric space, (ii) temporal space and (iii) pterygomandibular space (Figure 52.10).
Contents include:
• masseter muscle,
• medial and lateral pterygoid muscles,
• temporalis muscle tendon attached to coronoid
process,
• ramus and posterior part of mandible,
• maxillary artery and its inferior alveolar branch and
• inferior alveolar nerve.
It communicates with the parotid and parapharyngeal
spaces.
Dental infections, particularly of the second and third
molar teeth, are the most common source of abscess formation. To drain the abscess, this space can be approached
through an incision just lateral to the retromolar trigone
and bluntly reaching the masseteric space and pterygomandibular spaces. Temporal space(s) can be drained
by a horizontal incision above the zygomatic arch.
TREATMENT
1. Systemic antibiotics. Intravenous antibiotics may
become necessary to combat infection. Antibiotics
should be able to affect both aerobic and anaerobic organisms. Antibiotics selected for treatment
are amoxicillin–clavulanic acid, imipenem or meropenem along with clindamycin or metronidazole.
Gentamicin is useful for Gram-negative bacteria. The
sensitivity of an antibiotic should determine the selection of antibiotic.
2. Drainage of abscess. This is usually done under
general anaesthesia. If the trismus is marked, preoperative tracheostomy becomes mandatory. Abscess is
drained by a horizontal incision, made 2–3 cm below
the angle of mandible. Blunt dissection along the inner surface of medial pterygoid muscle towards styloid
process is carried out and abscess evacuated. A drain is
inserted. Transoral drainage should never be done due
to danger of injury to great vessels which pass through
this space.
Figure 52.10. Masticator space. It consists of three spaces: masseteric, pterygomandibular and temporal.
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Chapter 53
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Tumours of Oropharynx
BENIGN TUMOURS
They are far less common compared to malignant tumours. The common ones are described here.
PAPILLOMA
It is usually pedunculated, arises from the tonsil, soft
palate or faucial pillars. Often asymptomatic, it may be
discovered accidentally by the patient or the physician.
When large, it causes local irritation in the throat. Treatment is surgical excision.
HAEMANGIOMA
It can occur on the palate, tonsil, posterior and lateral
pharyngeal wall. It may be of capillary or cavernous type.
Capillary haemangioma or asymptomatic cavernous
haemangioma may be left alone. It is treated only if it
is increasing in size or giving symptoms of bleeding and
dysphagia. Treatment is diathermy coagulation or injection of sclerosing agents. Cryotherapy or laser coagulation is very effective.
PLEOMORPHIC ADENOMA
It is mostly seen submucosally on the hard or soft palate.
It is potentially malignant and should be excised totally.
MUCOUS CYST
It is usually seen in the vallecula. It is yellow in appearance and may be pedunculated or sessile. When large, it
causes foreign body sensation in the throat. Treatment is
surgical excision, if pedunculated; or incision and drainage with removal of its cyst wall.
Lipoma, fibroma and neuroma are other rare benign
tumours.
2. Exophytic
3. Ulcerative
4. Infiltrative
The first two types are seen in the palatine arch; they
are rarely associated with metastasis. Ulcerative and infiltrative types often involve the base of tongue and tonsil.
They have poor prognosis and deeply invade the adjoining structures and have marked tendency for regional metastasis.
Histologically, the tumours may be:
1. Squamous cell carcinoma. Shows various grades of dif-
ferentiation (well, moderately or poorly differentiated)
and is the most common variety.
2. Lymphoepithelioma. A poorly differentiated variant of
the above, with admixture of lymphocytes, which do
not show any features of malignancy. This is often
seen in tonsil, base of tongue and vallecula.
3. Adenocarcinoma. It arises from minor salivary glands. It
is mostly seen on the palate and fauces.
4. Lymphomas. Both Hodgkin and non-Hodgkin lympho-
mas arise from the tonsil and base of tongue. They are
seen in the young adults and sometimes in the chil-
dren. Enlarged cervical nodes may coexist.
tnm classiFication. It is similar to the one used in can-
cer of the oral cavity. (see Table 53.2).
treatment. Treatment of oropharyngeal cancer depends
upon the site and extent of disease, patient’s general condition, philosophy and experience of the treating surgeon
and facilities available at a particular centre. The various
options are:
1. Surgery alone
2. Radiation alone
3. Combination of surgery and radiotherapy
4. Chemotherapy alone or as an adjunct to surgery or
radiotherapy
5. Palliative therapy.
MALIGNANT TUMOURS
The common sites of malignancy in the oropharynx are:
(Table 53.1)
1. Posterior one-third (or base) of tongue.
2. Tonsil and tonsillar fossa.
3. Faucial palatine arch, i.e. soft palate and anterior pillar.
4. Posterior and lateral pharyngeal wall.
Gross appearances of the tumour can be divided into
four types:
1. Superficially spreading
A. CARCINOMA OF POSTERIOR ONE-THIRD
OR BASE OF TONGUE
This is commonly seen in India (Figures 53.1 and 53.2).
The lesion remains asymptomatic for a long time and
patient presents when metastases in cervical nodes make
their appearance. Earlier symptoms of sore throat, feeling
of lump in the throat and slight discomfort on swallowing are often ignored or attributed to lingual tonsils. Late
features are referred pain in the ear, dysphagia, bleeding
from the mouth and change in the quality of speech (hot
potato voice).
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