Neck phlegmon and purulent mediastinitis

Etiology and routes of infection spread

Inflammation of the loose connective tissue of the neck is most commonly provoked by staphylococci, streptococci, enterobacteria, and non-spore-forming anaerobes. The primary source is carious teeth, tonsillitis, and stomatitis. Putrid odontogenic infection is particularly dangerous: it possesses pronounced lytic properties, rapidly melts tissues, and forms extensive extensions across fascial spaces. Other causes may include penetrating wounds, pathology of the larynx and trachea, as well as osteomyelitis of the cervical vertebrae.

Infection from the neck can descend further and cause purulent mediastinitis, which is inflammation of the mediastinal fat. This occurs by contact (for example, in Ludwig's angina or retropharyngeal abscesses). Mediastinitis also develops due to esophageal trauma (foreign bodies, chemical burns, failure of esophagogastric anastomotic sutures), extension of pus from lung tissue, suppuration of posttraumatic hematomas, or via hematogenous spread in septico-pyemia.

Clinical presentation of neck phlegmons

In the initial stages, a dense, slightly mobile, and mildly nodular infiltrate is palpated in the projection of the lymph nodes (submandibular, submental, or along the sternocleidomastoid muscle). If the abscess is located deep beneath the muscles, the skin remains normal in color for a long time, and edema is absent.

Characteristic clinical signs:

• Odynophagia — sharp pain during swallowing and chewing.
• Hypersalivation — profuse drooling.
• Trismus — spasm of the masticatory muscles.
• Spasmodic torticollis — forced head tilt and rotation toward the affected side to reduce muscle pressure on the inflammatory focus.

A particularly severe form is Ludwig's angina (deep phlegmon of the floor of the mouth). It begins acutely, with diffuse edema and pronounced intoxication. When the carotid sheath of the neck is affected, pus can rapidly descend along the vessels into the subclavian and axillary fossae.

Symptoms and diagnosis of purulent mediastinitis

The disease starts acutely: with severe chills and hectic fever with high daily fluctuations. Patients assume a forced sitting or semi-sitting position with the head tilted forward to ease breathing and reduce pain.

• Anterior mediastinitis: pain is localized behind the sternum, intensifies with percussion and backward head extension. Edema of the neck and chest is observed. Percussion reveals widening of the dullness zone over the sternum.
• Posterior mediastinitis: pain radiates to the interscapular region, back, and epigastrium. Paraspinal edema appears, indicating impaired venous outflow.

In severe cases (especially with esophageal rupture), dyspnea, cyanosis, and putrid halitosis occur. Cardiovascular disorders develop: pulse exceeding 120 beats per minute, drop in blood pressure, increase in central venous pressure, and engorgement of the head and upper extremity veins. The appearance of subcutaneous emphysema on the neck is an extremely formidable sign. X-rays (revealing gas in the mediastinum or contrast extravasation) and esophagoscopy are used to confirm the diagnosis.

Principles of surgical treatment

Conservative antibiotic therapy is effective only in the initial stage of serous inflammation. When abscess formation or a putrid process occurs, emergency surgery is indicated.

Any opening of a neck phlegmon concludes with wound drainage. Tampons perform two crucial functions: they stop capillary bleeding deep within the wound and prevent the cavity from closing before necrotic tissues are sloughed off. The choice of incision depends on the location: for example, a longitudinal incision according to Küttner or a de Quervain approach along the posterior edge of the sternocleidomastoid muscle.

To treat mediastinitis, mediastinotomy (drainage of the mediastinum) is performed. The most frequent approach is cervical mediastinotomy (via an incision above the sternum). For posterior mediastinal lesions, a posterior extraperitoneal or transabdominal inferior mediastinotomy with diaphragmatic incision is used. During neck surgeries, it is important for the surgeon not to damage critical anatomical structures such as the recurrent laryngeal nerve (n. laryngeus recurrens), the deep cervical vein, or the omohyoid muscle (m. omohyoideus). Surgical intervention must be supplemented by robust intensive care.

Class and exam questions

What else to study on this topic

• Topography of incisions for opening neck phlegmons (approaches by Küttner, de Quervain, and in Bezold's abscess)
• Technique for performing cervical and transabdominal inferior mediastinotomy
• Features of surgical access to periesophageal phlegmon and protection of the recurrent laryngeal nerve
• Radiological and endoscopic diagnosis of esophageal ruptures
• Principles of intensive care and correction of vital functions in purulent mediastinitis

Other topics from the section "CHAPTER 11. SURGICAL INFECTION (PURULENT-INFLAMMATORY DISEASES)"

Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.