Opening of retropharyngeal and retroesophageal phlegmons
Retropharyngeal abscesses and phlegmons most commonly result from suppuration of the retropharyngeal lymph nodes.
For young children with an abscess, the transoral approach is preferred. The child is secured in the assistant's arms, with the torso tilted forward. After inserting a mouth gag and depressing the tongue with a spatula, anesthesia of the posterior pharyngeal wall is performed (lubricated with a cocaine solution). The incision is made longitudinally along the posterior wall. A scalpel is used with its blade wrapped in adhesive plaster so that only 1 cm of the cutting edge remains open. Immediately after opening the abscess, the patient's head must be quickly tilted forward—this is a critically important action to prevent pus from flowing into the larynx. In the postoperative period, frequent gargling with antibiotics is indicated to prevent premature wound closure.
Opening of a retropharyngeal phlegmon from the neck is performed in the supine position with a bolster under the shoulder blades. An incision 6–8 cm long is made downwards from the angle of the mandible along the posterior border of the sternocleidomastoid muscle (m. sternocleidomastoideus). The muscle sheath is opened along a grooved probe, after which the muscle itself and the neurovascular bundle are retracted anteriorly. Penetration into the loose connective tissue of the retropharyngeal space is performed exclusively using blunt instruments, completing the operation by placing a drainage tube with a gauze tampon.
Access to a retroesophageal phlegmon requires turning the patient's head to the right (with a bolster under the shoulder blades). The incision is made from the jugular notch to the thyroid cartilage along the anterior border of the left m. sternocleidomastoideus. The muscle, together with the internal jugular vein and common carotid artery, is retracted laterally, and the thyroid gland is retracted medially. The abscess near the posterior wall of the esophagus is opened bluntly. For drainage, a rubber tube with a tampon or glove rubber is used.
Surgeries for neurovascular bundle phlegmon
Purulent infection of the fascial sheath of the neurovascular bundle is extremely dangerous: pus can spread upwards (into the cranial cavity) or downwards (into the anterior mediastinum), and can also provoke purulent thrombophlebitis of the internal jugular vein. The main surgical principle here is the widest possible surgical access.
Depending on the level of sheath involvement, different incisions are used:
- de Quervain incision — for the lower neck. Tissues are incised along the anterior border of m. sternocleidomastoideus from the mastoid process to the clavicle, then the incision is continued horizontally (outwards and backwards) parallel to the clavicle. The muscle is transected along a probe 2–3 cm above the clavicle. The external jugular vein is ligated between two ligatures and transected. The musculocutaneous flap is reflected outwards. If thrombosis of the internal jugular vein (v. jugularis interna) is detected, it is ligated with two ligatures outside the thrombosed area (above and below) and transected.
- Küttner incision — for the upper section. The incision line runs along the anterior border of the muscle, and from the mastoid process continues at an angle (transversely, downwards and backwards). M. sternocleidomastoideus is transected 1.0–1.5 cm below the mastoid process. The formed flap is pulled downwards and outwards. During this manipulation, it is important to remember that the accessory nerve (n. accessorius) approaches the upper part of the muscle and must not be damaged.
Following interventions on the internal jugular vein and opening of the sheath, a loose gauze tampon or a strip of glove rubber is necessarily inserted into the loose connective tissue surrounding the vessels.
Opening of pre-visceral space phlegmon
The pre-visceral space can become infected as a result of larynx and trachea injuries, acute infectious thyroiditis, or lymphadenitis. The surgeon's primary task is to prevent the descent of pus into the anterior mediastinum.
The operation is performed via a transverse incision between the right and left m. sternocleidomastoideus. As dissection proceeds deeper into the second fascia, the median and anterior jugular veins are isolated and transected between ligatures. Next, the second and third fascias of the neck are incised along with the long muscles located anterior to the trachea.
A critically important point is the level of surgical access. The transverse incision must be made 4–5 cm above the jugular notch. This is justified by the neck topography: a lower incision can lead to infection of the suprasternal interaponeurotic space (spatium interaponeuroticum suprasternale). The cavity of the purulent infiltrate is widely opened, leaving rubber drainage tubes wrapped in gauze tampons inside it.
Briefly: answers to topical questions
Which neck fascias are incised during the opening of a pre-visceral phlegmon?
During the opening of a pre-visceral phlegmon, the second and third fascias of the neck are incised.
Surgical access involves a transverse incision of the skin, subcutaneous tissue, platysma (platysma), and superficial fascia. In the deep layers, the following is performed:
- Second fascia of the neck — incised with isolation and ligation of the median and anterior jugular veins.
- Third fascia of the neck — incised together with the second fascia and the long muscles lying anterior to the trachea to widely expose the purulent infiltrate.
What anatomical structures form the neurovascular bundle of the neck?
The neurovascular bundle of the neck consists of major vessels and a nerve surrounded by a common fascial sheath.
According to its anatomical structure, the bundle includes the following formations:
- Common carotid artery (a. carotis communis)
- Internal jugular vein (v. jugularis interna)
- Vagus nerve (n. vagus)
These structures are enclosed within the neurovascular bundle sheath (vagina carotica), which is formed by the parietal layer of the middle (fourth) cervical fascia.
What are the walls of the retropharyngeal space?
The retropharyngeal space (spatium retropharyngeum) has anterior and posterior walls and is also divided into two halves.
The boundaries of the space are represented by the following structures:
- Anterior wall — the posterior wall of the pharynx, which is covered by the visceral layer of the middle (4th) cervical fascia.
- Posterior wall — the prevertebral (5th) fascia.
- Median wall — a connective tissue septum that divides the retropharyngeal space down the middle into right and left halves.
Where does the accessory nerve (n. accessorius) run in relation to the sternocleidomastoid muscle?
The accessory nerve (n. accessorius) approaches the sternocleidomastoid muscle in its upper part and emerges from beneath its posterior border.
Topographically, the nerve is located as follows:
- It approaches the muscle in its upper part, so when opening phlegmons in the upper neck, it is not injured.
- It emerges from beneath the posterior border of the muscle at the border of its upper and middle thirds.
- It is exposed when the sternocleidomastoid muscle is strongly retracted laterally.
What are the possible pathways of infection spread in deep neck phlegmons?
Infection in deep neck phlegmons spreads along fascial spaces, fascial sheaths, and vascular beds.
The main pathways for the spread of purulent collections:
- Into the anterior mediastinum — a descending pathway along the pretracheal loose connective tissue (pre-visceral space).
- Into the posterior mediastinum — along the retrovisceral space and along the spine beneath the prevertebral (5th) fascia.
- Into the mediastinum and to the skull base — downwards and upwards along the neurovascular bundle sheath of the neck (vagina carotica).
- Into the axilla — through the lateral triangle of the neck along the course of the suprascapular neurovascular bundle.
What are the boundaries of the suprasternal interaponeurotic space (spatium interaponeuroticum suprasternale)?
The suprasternal interaponeurotic space (spatium interaponeuroticum suprasternale) is located above the manubrium sterni.
Boundaries of the space:
- Anteriorly — 2nd cervical fascia.
- Posteriorly — 3rd cervical fascia.
In the lower section, 3 cm above the jugular notch, the fascia splits into two layers: the anterior layer attaches to the outer surface of the jugular notch, while the posterior layer attaches to the inner surface of the jugular notch. This space communicates with Gruber's blind pouch (saccus caecus retrosternocleidomastoideus), located behind the lower part of the sternocleidomastoid muscle.
What are the symptoms and complications of internal jugular vein thrombosis?
The provided sources do not describe the clinical symptoms of internal jugular vein thrombosis, but they detail its severe complications.
The main complications of suppurative thrombophlebitis include:
- Generalization of infection — occurs due to the presence of microbial colonies in the venous wall and thrombotic masses.
- Metastatic abscesses — the formation of secondary foci of infection in internal organs.
- Sepsis (sepsis) — a systemic life-threatening complication developing as a result of the generalization of the infectious process.
To memorize the surgical approaches to the vascular bundle: Küttner — Upwards (upper neck, incision from the mastoid process); de Quervain — Downwards (lower neck, T-shaped incision near the clavicle).
Class and exam questions
Why is the scalpel blade wrapped with adhesive tape when opening a retropharyngeal abscess?
This is done to leave only 1 cm of the cutting edge exposed. This measure prevents accidental deep injury to the pharyngeal structures, especially if the child makes a sudden movement.
What should be done if internal jugular vein thrombosis is detected during surgery?
The affected internal jugular vein must be isolated, ligated with two ligatures beyond the thrombus (above and below it), and then divided between them.
Why should an incision not be made directly over the jugular notch of the sternum in pretracheal phlegmon?
The incision is made 4–5 cm above the notch to avoid accidentally opening and infecting the suprasternal interaponeurotic space, which could exacerbate the spread of pus.
In which direction is the muscle retracted during the approach to retropharyngeal phlegmon?
The sternocleidomastoid muscle, along with its fascial sheath and vessels, is retracted laterally, while the thyroid gland is displaced medially.
What else to study on this topic
- Topographic anatomy and fascial spaces of the neck
- Fasciae of the neck and pathways of purulent infection spread
- Surgical anatomy of the sternocleidomastoid muscle
- Topography of the accessory nerve in the upper third of the neck
- Acute purulent mediastinitis as a complication of neck phlegmons
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