Opening of neck abscesses and phlegmons

Surgical tactics for superficial abscesses and carbuncles

Superficially localized purulent processes require different approaches depending on their nature.

Superficial abscesses of the anterior neck are opened relatively simply. For this purpose, transverse incisions are used, which should pass precisely through the center of fluctuation (the area of maximum softening and pus accumulation).

Carbuncles of the posterior neck represent a more complex pathology. The purulent-necrotic process in a carbuncle initially develops in the subcutaneous adipose tissue, but is capable of spreading deeply, involving the deep cervical fascia and underlying muscles.

At early stages, conservative treatment is possible:

• X-ray irradiation of the affected area.
• Blockage (infiltration) of tissues around and beneath the carbuncle with a 0.5% procaine solution with added antibiotics.

In severe cases or when inflammation spreads to the deep cervical fascia, surgical treatment is indicated. Its goal is the wide opening of the focus and radical excision of necrotic tissues.

Surgical technique for carbuncle:

1. The patient is placed in a prone position with the head tilted downward.
2. A deep cruciate incision is performed. It must pass through the entire thickness of the carbuncle and reach healthy tissues.
3. The four resulting triangular skin flaps are undermined to the borders of unchanged tissues.
4. Necrotic areas in the center of the carbuncle are carefully trimmed with scissors. If the deep cervical fascia and muscles are involved in the process, they are also excised within healthy borders.
5. After hemostasis (vessel ligation), the wound is loosely packed with gauze sponges.

Opening of phlegmon of the floor of the oral cavity

Phlegmon of the sublingual salivary glands requires immediate establishment of pus drainage. There are two possible approaches:

• From the oral cavity (sublingually): this route often turns out to be difficult or impossible due to developed trismus—pronounced spasm of the masticatory muscles.
• From the neck (through the submental triangle): this is the preferred method, as it provides much better outflow of exudate.

Stages of opening from the neck: The patient lies on their back, a bolster is placed under the shoulder blades, and the head is maximally extended.

1. A longitudinal skin incision is made from the chin to the hyoid bone. The skin, subcutaneous adipose tissue, platysma (platysma), and superficial fascia are incised layer by layer.
2. The incision is made strictly in the longitudinal direction, guided by the space between the anterior bellies of the digastric muscles (m. digastricus).
3. A grooved probe is introduced into the wound. The second cervical fascia and the mylohyoid raphe (raphe mylohyoidea) are incised along it.
4. By blunt dissection, the surgeon penetrates through the thickness of the genioglossus muscle, passing between the geniohyoid muscles. Progression proceeds in a fan-like manner directly into the loose tissue of the sublingual region.
5. Strips cut from surgical gloves are placed in the wound for drainage.

Important complication: the inflammatory process can spread along the excretory duct of the submandibular salivary gland directly into the anatomical bed of the gland itself.

Surgical approach in submandibular phlegmon

The main task of the surgeon in submandibular space phlegmon is not only to remove pus, but also to prevent its infiltration into the vital parapharyngeal space. The patient's position on the operating table is identical to that in phlegmon of the floor of the mouth (supine, with a bolster under the shoulder blades and extended head).

Course of the surgical procedure:

1. An incision 5–6 cm long is made. It is localized 2–3 cm below the edge of the mandible, strictly parallel to it and anterior to the angle of the mandible.
2. Superficial structures are incised layer by layer: skin, subcutaneous tissue, platysma, and the superficial fascia of the neck.
3. The marginal branch of the mandibular nerve (r. marginalis mandibuli) and the facial vein passing here are carefully retracted upward with a blunt hook to avoid their damage.
4. The capsule of the gland (formed by the second cervical fascia) is incised. The facial vein is isolated within the capsule, secured with two ligatures, and transected, after which accumulated pus is evacuated.
5. A rubber tube with a gauze tampon is placed in the wound for adequate drainage.

If the salivary gland itself is involved in the purulent inflammation (parenchymal infiltration), the surgeon must transect its excretory duct between ligatures and completely remove the affected gland. If the patient is diagnosed with bilateral submandibular phlegmon, the operations are not combined—the opening is performed strictly separately on each side.

Briefly: answers to topical questions

Class and exam questions

What else to study on this topic

• Topography of cervical fasciae and interfascial spaces
• Anatomy of the parapharyngeal space and pathways of pus spread
• Structure and boundaries of the submental and submandibular triangles
• Topography of facial nerve branches and facial vessels in the neck region
• Pathogenesis of trismus development in purulent-inflammatory diseases of the maxillofacial region

Other topics in the «Neck Surgery» section

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