Deep Neck Infections

Wattana Sinkijcharoenchai, M.D.

Dept. of Otolaryngology, PSU

Deep Neck Infections

Complex anatomy
Difficult to diagnose and localize the precise location
Proximity to many vital structures

Difficult to access and placing all neurovascular

structures at risk of injury

Communication with each other and

extend to other portions of the body

Classification of Cervical Fascia

Superficial cervical fascia

Deep cervical fascia

Superficial layer (investing layer)
Middle layer (visceral layer)
Deep layer (prevertebral layer)

Superficial Cervical Fascia

Subcutaneous tissue
Superior
epicranium
Inferior
thorax and axilla
Ensheathes platysma
and muscles of facial
expression

Platysma muscle

Superficial space of neck

Entire length of neck

Surrounds platysma
Contains areolar tissue,
nodes, nerves and vessels
Involved with cellulitis and
superficial abscesses
Treat with incision along
Langers lines, drainage and
antibiotics

Superficial cervical abscess

Deep Cervical Fascia

Superficial
Middle
Deep

Superficial layer of
deep cervical fascia

Middle layer of
deep cervical fascia

Deep layer of
deep cervical fascia

Carotid sheath

Formed by all three layers of deep cervical fascia

Deep Neck Spaces

Described in relation to the hyoid

Entire length of neck

Suprahyoid

Peritonsillar
Pharyngomaxillary
(Parapharyngeal)
Submandibular
Masticator
Temporal
Parotid

Anterior visceral (pretracheal)

Retropharyngeal
Danger
Prevertebral
Visceral vascular (carotid sheath)

Infrahyoid

Etiology
Tonsillar and pharyngeal infections
Odontogenic infection
Trauma (accidental/surgical) to the oral cavity
and pharynx
Salivary gland infection/obstruction
Foreign body and removal procedures

Cervical lymphadenitis/necrosis of malignant LN

Etiology
Infection of congenital neck mass
branchial cleft cyst, thyroglossal duct cyst,
laryngopyocele
Thyroiditis
Mastoiditis with Bezold abscess
Contaminated IV drug abuse
Idiopathic

Deep neck infections from

Tonsillar origin

Peritonsillar abscess

Parapharyngeal abscess

Carotid sheath infection

Deep neck infections from

Pharyngeal origin

Retropharyngeal abscess

Prevertebral abscess

Peri-esophageal space abscess

Pretracheal space abscess

Spreading of odontogenic infection

1. Vestibular abscess
2. Buccal or Canine space
abscess
3. Palatal abscess
4. Sublingual space abscess
5. Submaxillary sp. abscess
6. Maxillary sinusitis

Diagnosis
History
Physical
Lab

taking

examination

investigations

Diagnostic

imaging

History taking
Present illness
Dental caries or teeth extraction
Head and neck trauma
Intravenous drug abuse
Risk factors
DM, HIV, steroids, chemotherapy or
other immunocompromised conditions

Present illness

Swelling with pain of the neck

Fever with odynophagia

Symptoms related to the site of infection

dysphagia, trismus, dysphonia, otalgia or dyspnea

Physical examination

Lab investigations
CBC
Blood

with differential

chemistries / Electrolytes

Coagulation
HIV
Blood

studies (PT, PTT)

screening

culture / pus culture

Diagnostic imaging
Plain
Contrast

film

enhanced CT scan

MRI

/ MRA

Ultrasonography

Diagnostic imaging

Lateral soft tissue neck

Screening exam

Differentiate
retropharyngeal abscess
from epiglottitis and FB

Normal:

7mm at C-2
14mm at C-6 for kids
22mm at C-6 for adults

Sensitivity 83%, compared

to CT 100% *

*Nagy M, Backstrom J. Laryngoscope 1999

Imaging
Diagnostic
imaging

Chest X-ray

Pulmonary complications
pneumonia, lung abscess

Mediastinal involvement

CT and MRI

Proper disease delineation in cases with

trismus that may limit the physical examination

Identification of spread between spaces (1)

Early recognition of complications

Identify the original nidus of infection (2-4)

Pus may not be identified during exploration of

up to 25% of cases following CT scans suggestive
of deep space infections (5)
1. Crespo AN, Chone CT, Fonseca AS, et al. Sao Paulo Med J 2004
2. El-Sayed Y, Al Dousary S. J Otolaryngol 1996
3. Holt GR, McManus K, Newman RK, et al. Arch Otolaryngol 1982
4. Lazor JB, Cunningham MJ, Eavey RD, et al. Otolaryngol Head Neck Surg 1994
5. Smith 2ndJL, Hsu JM, Chang J. Am J Otolaryngol 2006

CT
VS MRI
Imaging

CT with contrast

Pros

MRI

Widely available
Faster (5-15 minutes)
Abscess vs cellulitis
Less expensive

Cons

Contrast
Radiation
Uniplanar
Dental artifacts

Pros

MRI superior to CT in initial

assessment
More precise identification of
space involvement
(multiplanar)
Better detection of underlying
lesion
Less dental artifact
Better for floor of mouth
No radiation
Non iodine contrast

Cons

Cost
Pt cooperation
Slower (19 to 35 minutes)

MRI was found to be better than CT in delineating anatomy, recognizing abnormality,

determining extent of infection and identifying the effected spaces in the neck
Munoz A, et al. Journal of Computer Assisted Tomography 2001.

CT scans

MRI

Ultrasound

Portable
No radiation
Dont reveal anatomic
details
Distinguish between
phlegmon and abscess
Follow up infection
Guided aspiration of
abscesses

Gidley PW, et al. Otolaryngology-Head and Neck Surgery 1997.

Management

Airway establishment

Assessment and support of host defenses

Identification of bacteria

Choice of antibiotics

Surgical drainage and decompression

Management
Airway
establishment
Observation
Intubation

Direct

laryngoscope
possible risk of rupture and aspiration
Flexible fiberoptic nasotracheal intubation (1)

Tracheostomy
Awaked

local anesthesia (2)

Distorted anatomy and tissue planes
1.Ovassapian A, Tuncbilek M, Weitzel E, et al. Anesth Analg 2005
2.Yuen H, Loy A, Johari S. Otolaryngol Head Neck Surg 2007

Choice of antibiotics
TYPE OF BACTERIA
Aerobic only
Anaerobic only

Aerobic/anaerobic

%
<5
> 50
90

Choice of
of ATB
antibiotics
Principle
therapy

Commonly originate from an odontogenic or

oropharyngeal infection >> Polymicrobial
Anaerobes

Peptostreptococcus, Bacteroides fragilis, pigmented

Prevotella and Porphyromonas, Fusobacterium, and
Eikenella corrodens

Aerobes

S viridans, Klebsiella pneumoniae, and Staph aureus

Strep pneumoniae, Strep pyogenes, Neisseria and
H influenzae

>60% of deep neck abscesses contain BLPB (1-2)

1. Weed HG, Forest LA. In: Cummings CW. Otolarygology: head and neck surgery, vol3, 2005
2. Brook I. Ann Otol Rhinol Laryngol 2002

Choice of antibiotics for

Immunocompetent patients

Penicillin derivative / beta-lactamase

inhibitor combinations

Ampicillin-Sulbactam is the antibiotic of choice

Penicillin G plus Metronidazole
is an alternative regimen, particularly when suspected for
P. melaninogenicus, B. fragilis, or Fusobacterium spp.

Clindamycin is recommended in
penicillin-allergic patients

Choice of antibiotics for

Immunocompromised patients

Requires broad spectrum antibiotics with

activity against Gram negative rods,
beta-lactamase-producing anaerobes, and

Staph aureus
Extended-spectrum cephalosporins

(Cefotaxime, Ceftizoxime) have excellent

activity against aerobic Gram negative bacilli
and some anaerobes

Choice of antibiotics for

Immunocompromised patients

Alternatively, a Carbapenem (imipenem)

or a Ureidopenicillin / beta-lactamase
inhibitor combination (Ticarcillin-

clavulanate or Piperacillin-tazobactam)

If MRSA is suspected, the addition of

Vancomycin is warranted *

*Weed HG, Forest LA. In: Cummings CW. Otolarygology: head and neck surgery, vol3, 2005

Indications for surgery

Airway compromise
Critical condition and septicemia
Complications
Descending infection
Diabetic mellitus

No improvement within 48 hours of

the initiation of parenteral antibiotics

1.Weed HG, Forest LA. In: Cummings CW. Otolarygology: head and neck surgery, vol3, 2005
2.Yellon RF. In: Bluestone CD. Pediatric otolaryngology, vol2, 2003
3.Boscolo-Rizzo P. Otolaryngol Head Neck Surg 2006
4.Huang T. Head Neck 2003

Surgical approach

Simple intraoral or extraoral I&D

superficial abscesses
External cervical approach
deeper and more complicated infections
Minimally invasive techniques
image-guided needle aspirations and
indwelling catheter placement

Fluid resuscitation before surgery is important

SURGICAL APPROACH

Common deep neck infections

Retropharyngeal space
Peritonsillar space
Parapharyngeal space
Submandibular space

Infection of
Retropharyngeal space

Retropharyngeal space

Anterior
constrictor muscles
and their fascia
Posterior
alar fascia
Extends from the base of
the skull to the T2

Danger space

Anterior
alar fascia
Posterior
prevertebral
fascia
Extends from the
base of the skull
to the diaphragm

Danger space

Prevertebral space

The area between the prevertebral fascia and the

vertebral bodies
Extends from the base of the skull down to the coccyx

Pathogenesis of Infection in
Retropharyngeal space
Two chains of lymph nodes extend along
the retropharyngeal space on either side of
the midline (1)
LNs tend to regress by age 4 years
Most common in children < 6 years old,
with a peak incidence at 3 years of age (2-4)

1. Butler KM, Baker CJ. In: Fegin RD, Cheery JD, ed. Textbook of pediatric infectious diseases 1992
2. Philpott CM, Selvadurai D, Banerjee AR. J Laryngol Otol 2004
3. Craig FW, Schunk JE. Pediatrics 2003
4. Dawes LC, Bova R, Carter P. ANZ J Surg 2002

Pathogenesis of Infection in
Retropharyngeal space
Preceded

by URI: pharyngitis, tonsillitis,

sinusitis, and cervical lymphadenitis.

Other causes: trauma from esophageal

instrumentation (endoscopy, nasogastric tubes,
frequent suctioning, intubation attempts),
foreign bodies, traumatic esophageal rupture,
and spread from contiguous spaces (*)
*Barratt GE, Koopmann Jr CF, Coulthard SW. Laryngoscope 1984

Pathogenesis
of Infection
Retropharyngeal
abscessin
Retropharyngeal space
Offending pathogens frequently include
multiple aerobic and anaerobic organisms
Common isolates include S viridans and
pyogenes, Staph aureus and epidermidis, as well as
Bacteroides, Peptostreptococcus, Fusobacterium,
Haemophilus, and Klebsiella (1-3)

1. Brook I. J Oral Maxillofac Surg 2004

2. Philpott CM, Selvadurai D, Banerjee AR. J Laryngol Otol 2004
3. Liu CH, Lin CD, Cheng YK, et al. Acta Paediatr Taiwan 2004

Clinical manifestations of
Retropharyngeal space infection

Children
Neck pain,
neck swelling
Fever, irritability
Dysphagia, drooling
Dyspnea or noisy
breathing
Stiff neck

Adults
Neck pain
Fever, anorexia
Snoring
Dyspnea

Pleuritic chest pain indicating extension into the mediastinum

Unilateral bulging of the posterior oropharynx

Differential diagnosis

Epiglottitis

Laryngotracheobronchitis

Meningitis

1. Philpott CM, Selvadurai D, Banerjee AR. J Laryngol Otol 2004

2. Craig FW, Schunk JE. Pediatrics 2003
3. Dawes LC, Bova R, Carter P. ANZ J Surg 2002
4. Liu CH, Lin CD, Cheng YK, et al. Acta Paediatr Taiwan 2004

Lateral soft tissue neck

CT scan

Acute epiglottitis

Viral croup

Rx of retropharyngeal space infection

Adequate anaerobic and oral gram-positive coverage is

the mainstay of therapy
Mediastinal extension requires surgical dbridement of
necrotizing infections and drainage of purulent material
in the pleura and pericardium

Surgical drainage of
retropharyngeal abscess

Complications of
Retropharyngeal space infection
Airway
Severe
Descending

occlusion

pneumonia

necrotizing mediastinitis

Mediastinitis

Downward extension of the infection in the spaces

that extend the length of the neck and the anterior
visceral space
Increasing chest pain or dyspnea
CXR or CT scan >> widened mediastinum or
pneumomediastinum
Transthoracic drainage when infection
spread below the carina
Mortality rate 40%

Gidley P, Ghorayeb B, Stiernberg C. Otolaryngol Head Neck Surg 1997

Infection of peritonsillar space

Suppurative complication of acute tonsillitis

Peritonsillar space

Medial
capsule of tonsil
Lateral
superior pharyngeal
constrictor
Superior
anterior tonsil pillar
Inferior
posterior tonsil pillar

Peritonsillar abscess

Signs & symptoms

Fever, sore throat
Odynophagia & drooling
Hot potato voice
Bulging of superior pole
of tonsillar pillar
Deviation of uvula

Infection of peritonsillar space

Group A beta-hemolytic streptococci

(often as part of a mixed flora containing anaerobes)
are most commonly isolated

Occasionally, other beta-hemolytic streptococci,

Haemophilus influenzae, Staphylococcus aureus, or
oral anaerobes alone are cultured

Infection of peritonsillar space

If treatment is started early,

within the first 24 - 48 hours
following the onset of pain
( the stage of cellulitis),
the condition may resolve
by fibrosis without abscess
formation

Frank pus generally forms on about the fifth day

Rx of peritonsillar abscess

Needle drainage should be attempted, the

patient closely monitored and managed with
intravenous antibiotics

Rx of peritonsillar abscess
Ampicillin-Sulbactam (2 g IV q 4 hours)
coverage against oral anaerobes, including
those that produce beta-lactamases, and
is the treatment of choice.
Penicillin G (2-4 MU IV q 4-6 hours) with
Metronidazole (500 mg IV q 6 hours)
active against anaerobic Gram negative bacilli,
is an alternative regimen
Penicillin allergic patients should be treated with
Clindamycin (600 mg IV q 6 hours)

Peritonsillar abscess

Because peritonsillar abscesses often tend to recur,

tonsillectomy should be performed 6 - 8 weeks
following formation of the abscess

However, this approach is not always necessary in

children because a recurrence rate of only 7%,
compared with 16% in adults

E. Rubenstein, A.B. Onderdonk and J. Rahal Jr. J Pediatr 1974

Complications

Airway obstruction, especially with bilateral

disease or when laryngeal edema

Parapharyngeal space involvement

Continued signs of sepsis after drainage of the

peritonsillar space usually indicate concomitant,
undrained parapharyngeal space infection.

Infection of Parapharyngeal space

Peritonsillar abscess is a common cause

Parapharyngeal space

2.5-cm-long inverted cone extending from skull base to hyoid

Parapharyngeal space

Prestyloid

Muscular
compartment
Medial - tonsillar fossa
Lateral - medial pterygoid
fat, connective tissue, nodes

Poststyloid

Neurovascular
compartment
Carotid sheath
Cranial nerves IX, X, XI, XII
Sympathetic chain

Parapharyngeal space

Communicates with
several deep neck spaces

Parotid
Masticator
Peritonsillar
Submandibular
Retropharyngeal

Pathogenesis
Infections

can develop from various

sources throughout the neck including
the pharynx, teeth, tonsils, adenoids,
parotid gland, submandibular space,
retropharyngeal space, masticator space,
and local lymph nodes (1,2)

1. Levitt GW. Laryngoscope 80. 409-435.1970

2. Blomquist IK, Bayer AS. Infect Dis Clin North Am 1988

Clinical manifestations
of PPA: anterior compartment

Classic signs
dysphagia, trismus, and pain
involving the ipsilateral side
of the neck and jaw, with
referral to the ipsilateral ear

Swelling and
induration at the
angle of the
ipsilateral jaw
Lateral pharyngeal wall
distorted medially with
normal overlying mucosa

Clinical manifestations of PPA:

posterior compartment

Lack the intense trismus

Edema may involve the epiglottis and larynx,

yielding marked dyspnea

Swelling of pharyngeal wall behind

palatopharyngeal arch

Parapharyngeal abscess

Rx of PPA: posterior compartment

Often arise from the lymph nodes
Are contained within fibrous tissue
Infections rarely spread into other spaces

Respond well to intravenous antibiotics

without surgery

Rx of PPA: anterior compartment

Polymicrobial and odontogenic in origin
Tend to liquefy the fat in the anterior space
Rapidly forming large amounts of pus
No limiting boundaries
Rapid spread with multiple complications

Best addressed by surgical drainage plus

antibiotic therapy

Surgical drainage of
Parapharyngeal abscess

Complications

Laryngeal edema and obstruction

Ipsilateral Horner's syndrome or CN 9-12 palsies

carotid space involvement (1-4)

Infection of the other spaces

1. Blomquist IK, Bayer AS. Infect Dis Clin North Am 1988

2. Blum DJ, McCaffrey TV. Otolaryngol Head Neck Surg 1983
3. Wills PI, Vernon Jr. , Jr. RP. Laryngoscope 1981
4. Ramsey PG, Weymuller EA. Emerg Med Clin North Am 1985

Carotid (Visceral vascular) space

Extend from skull base

to mediastinum
Travel through
parapharyngeal space
Contains carotid artery,
internal jugular vein,
cervical sympathetic
chain, and CN 9-12

Clinical manifestations of
Carotid space infection
Swelling with tenderness of the neck
Fever with chill
Ipsilateral Horners syndrome or
vocal fold paralysis
Internal jugular vein thrombosis
Carotid artery rupture

Suppurative jugular thrombophlebitis

(Lemierre

Anaerobic

syndrome)

septic thrombus occluding the

internal jugular vein

Fusobacterium necrophorum (1,2)

Swelling

and tenderness at the angle of jaw

and along the SCM, with signs of sepsis
(spiking fever, chills)
1. Chirinos JA, Lichtstein DM, Garcia J, et al. Medicine (Baltimore) 2002
2. Dool H, Soetekouw R, van Zanten M, et al. Eur Arch Otorhinolaryngol 2005

Treatment of Jugular
thrombophlebitis
Prolonged

antibiotics (4 to 6 weeks)
Surgical ligation of the IJV in cases that
do not respond to adequate antibiotics
Anticoagulant for 3 months when
thrombus progression or septic emboli
are present

Carotid artery
aneurysm or rupture
Pulsatile neck mass
Recurrent sentinel hemorrhages (*)
Protracted clinical course (7-14 days)
Hematoma of surrounding neck tissues
Hemodynamic collapse
Early recognition and surgical intervention to
proximal control of common carotid artery

*Knouse MC, Madeira RG, Celani VJ. Mayo Clin Proc 2002

Infection of
submandibular space

Submandibular spaces
2 compartments
Suprahyoid
Sublingual space
Areolar tissue
Hypoglossal and lingual
Superior
nerves oral mucosa
Sublingual
gland
Inferior
- superficial
Whartons duct
layer
of deep fascia
Submaxillary space
Anterior
of
Anterior
bellies
mandible
digastrics
Lateral -Submental
mandible
compartment
Posterior
- hyoid
Submaxillary
compartment

and
tongue
musculature
Submandibular gland

Pathogenesis of
Submandibular space infection

Typically are odontogenic in nature,

other reported etiologies include lacerations
of the mouth floor, mandibular fractures,
foreign bodies (1), mandibular or lingual
malignancies (2), sialadenitis (3), lymphadenitis
(4), and inferior alveolar nerve blocks (5)

1. Meyers BR, Lawson W, Hirschman SZ. Am J Med 1972

2. Fischmann GE, Graham BS. J Oral Maxillofac Surg 1985
3. Tsuji T, Shimono M, Yamane G, et al. J Oral Maxillofac Surg 1984
4. Levitt GW. Laryngoscope 1970
5.Rothwell BR.Emerg Med Clin North Am 1985

Pathogenesis of
Submandibular space infection

Periapical abscesses involving the first molar initially infect the

sublingual space, infections originating from the second
and third molars infect the submylohyoid space
Infections of the submandibular space can spread quickly to involve the
entire submandibular space

Pathogenesis of
Submandibular space infection

Important
communication
between spaces is
created by the penetration of
the styloglossus muscle
Buccopharyngeal gap
allows spread of infection
from the submandibular space
to the parapharyngeal space
and thence to the
retropharyngeal space

Clinical manifestations of
Submandibular space infection

Mouth pain, drooling, and dysphagia

Muffled voice

Fever, chills, and malaise

Normally lack of trismus

If trismus >> spread into the parapharyngeal space

Megran DW, Scheifele DW, Chow AW. Pediatr Infect Dis 1984

Ludwig angina

A rapidly spreading
woody
inflammation of the
submandibular area
lead to progressive
asphyxiation
No lymph node involvement
No signs of
superficial skin
involvement

Ludwig angina

Protruding tongue
The tongue is displaced,
the floor of the mouth is
elevated, erythematous,
and tender to palpation
Occasionally the
inflammation spreads to
involve the epiglottis

Treatment of
Submandibular space infection
Up to two thirds involve anaerobes (1,2)
Recommend: Penicillin G and Metronidazole
Immunocompromised or recently
hospitalized patients coverage:
Gram-negative rods and

Staphylococcus aureus (3,4)

1. Har-El G, Aroesty JH, Shaha A, et al. Oral Surg Oral Med Oral Pathol 1994
2. Huang TT, Tseng FY, Yeh TH, et al. Acta Otolaryngol 2006
3. Chow AW. In: Mandell GL, Bennett JE, Dolin R, ed. Principles and practice of infectious diseases, 2005
4. Chow AW. Clin Infect Dis 1992

Treatment of
Submandibular space infection

In the Asian literature has reported an

increased incidence of infections caused by
Klebsiella pneumoniae in patients
who have diabetes mellitus (1-3)

1. Huang TT, Tseng FY, Yeh TH, et al. Acta Otolaryngol 2006
2. Wang LF, Kuo WR, Tsai SM, et al. Am J Otolaryngol 2003
3. Lin HT, Tsai CS, Chen YL, et al. J Laryngol Otol 2006

Treatment of
Submandibular space infection

Candida and Aspergillus species

should be considered if patient has
risk factors or no response to
broad-spectrum antibiotics (1-3)

1. Brook I. J Oral Maxillofac Surg 2004

2. Rega AJ, Aziz SR, Ziccardi VB. J Oral Maxillofac Surg 2006
3. Kuriyama T, Karasawa T, Nakagawa K, et al. Oral Microbiol Immunol 2002

Treatment of
Submandibular space infection

If collections of pus are identified, they can be drained

under radiographic guidance
Patients who do not respond to initial antibiotic therapy
surgical exploration and drainage, with
a cuffed tracheostomy in situ
Appropriate dental management of
apical abscesses by tooth extraction is important to allow
decompression of the nidus of infection

Surgical drainage of
Submandibular space abscess

Complications

Rapidly life
threatening because of
airway compromise

Warning signs

marked tachypnea with shallow

respirations
use of accessory muscles
orthopnea, dyspnea, stridor
the patient's sniffing position
to maximize airway patency

Complications

Artificial airway should be made

before an emergency develops

Use of paralytics may precipitate an occlusion of the airway

Awake intubation by fiberoptic bronchoscopy

is the most prudent approach

Awake tracheostomy, depending on the

clinical circumstance and availability of the specialist

Algorithm for management

of deep neck infections

History
Physical examination
Secure airway

Culture, IV antibiotics

CT scan
Small abscess

No abscess

Watch and wait

24-48 hours

Needle aspiration
culture and drainage
No

Impending
Complication?

Clinical
Improvement?

Yes
Continue antibiotics
+needle aspirations

Large abscess

Yes
No

Surgical incision
and drainage

Take Home Messages

Management

Management