Annals of Otology, Rhinology & Laryngology 119(3):181-187.

© 2010 Annals Publishing Company. All rights reserved.

Rational Diagnostic and Therapeutic Management of Deep

Neck Infections: Analysis of 233 Consecutive Cases
Gino Marioni, MD; Alberto Staffieri, MD; Saverio Parisi, MD;
Rosario Marchese-Ragona, MD; Andrea Zuccon, MD; Claudia Staffieri, MD;
Marianna Sari, MD; Chiara Speranzoni, MD; Cosimo de Filippis, MD;
Roberto Rinaldi, MD

Objectives: Although deep neck infections are less common nowadays because of the widespread use of antibiotics, they
continue to carry significant morbidity and mortality rates.
Methods: Between 2000 and 2008, deep neck infections were treated in 233 patients at the University of Padova. Cases
of peritonsillar abscess, superficial infections, infections due to external neck injuries, and infections in head and neck
tumors were excluded. Clinical, radiologic, laboratory, and microbiological assessments were analyzed.
Results: The site of origin was identified in 189 of the 233 cases (81.1 %), and the most common cause of deep neck
infection was dental infection (39.5%). Intravenous antibiotic therapy was given to 78 patients, and 155 required both
medical and surgical procedures. The bacteria most often isolated were gram-positive anaerobic cocci. None of our pa-
tients died of the deep neck infection or its complications.
Conclusions: It is worth emphasizing that airway support is the priority in patients with deep neck infections. Empirical'
antibiotic treatments must cover gram-positive and gram-negative aerobic and anaerobic pathogens. Surgical exploration
and drainage may be mandatory in selected cases at presentation or in cases that fail to respond to parenteral antibiotics
within the first 24 to 48 hours. It is important to perform cultures during operation to establish the pathogen(s) involved
and to obtain an antibiogram to tailor the antibiotic treatment.
Key Words: antibiotic, deep neck infection, diagnosis, surgical treatment.

INTRODUCTION pharyngotonsillar onset (9% to 16%)3.4 and a signif-

Deep neck infections spread along the fascial icantly higher prevalence of dental onset (38.8% to
planes and spaces of the head and neck region. De- 49% ).3,5.6 Infections due to anaerobic and gram-neg-
spite the widespread use of antibiotics for the early ative organisms have become more common than in
treatment of cervical infections and worldwide im- past publications in the oral and dental literature.?
provements in dental care and oral hygiene, deep The aim of the present study was to critically re-
neck infections remain relatively frequent. Life- view our diagnostic and therapeutic experience re-
threatening complications such as airway damage, lating to deep neck infections seen between 2000
jugular vein thrombosis, mediastinitis, pericarditis, and 2008 with a view to making some modem, ra-
pneumonia, and arterial erosion may develop be- tional diagnostic and therapeutic recommendations.
cause of delays in diagnosis and treatment. In re-
viewing several series of deep neck infections from METHODS
1994 to 2004, Yang et all calculated that the mortal- All available records concerning patients treated
ity rate for the group of patients with complications for deep neck infections at the Otolaryngology Sec-
ranged from 7.1% to 41.7%. tion of the University of Padova (a tertiary refer-
Changes in the causes and origins of deep neck ral academic center) between April 2000 and Sep-
infection, its bacteriology, and the associated sys- tember 2008 were reviewed. Peritonsillar abscess-
temic diseases have recently been emphasized.s In es, superficial infections, infections due to external
particular, there are reports of a lower prevalence of neck injuries (traumatic or surgical), and infections
From the Department of Medical and Surgical Specialties, Otolaryngology Section (Marioni, A. Staffieri, Marchese-Ragona, C. Staf-
fieri, Sari, Speranzoni, de Filippis), the Pediatric Dentistry Division, Castelfranco Veneto Hospital (Zuccon), and the Department of
Histology, Microbiology and Medical Biotechnologies (Parisi), University of Padova, and the Infectious and Tropical Diseases Divi-
sion, Padova General Hospital (Rinaldi), Padova, Italy.
Correspondence: Gino Marioni, MD, Dept of Medical and Surgical Specialties, Otolaryngology Section, University of Padova, Via
Giustiniani 2, 35128 Padova, Italy.

181
182 Marioni et al, Diagnosis & Treatment of Deep Neck Infections

TABLE 1. PATIENTS' PRESENTING SIGNS AND TABLE 2. ASSOCIATED SYSTEMIC DISEASES

SYMPTOMS OF DEEP NECK INFECTIONS Associated Diseases No. of Cases
Cases Hypertension 35
No. % Diabetes mellitus 19
Signs Heart diseases 17
Neck swelling 172 73.8 Chronic hepatitis 10
Fever 103 44.2 Autoimmune diseases 5
Trismus 66 28.3 Pulmonary diseases 5
Pharyngeal wall medialization 38 16.3 Central nervous system diseases 4
Facial swelling 30 12.9 Supra-aortic vessel stenosis 3
Oral swelling 26 11.2 Hypercholesterolemia 3
Gingival swelling 14 6.1 Thyroid disorders 3
Skin fistulization 10 4.3 Anemia 2
Tongue base swelling 7 3.0 Renal insufficiency 2
Pharyngeal swelling 5 2.1 Systemic vasculopathy 2
Hard palate swelling 3 1.3 Syphilis I
Laryngeal swelling 2 0.9 Tuberculosis I
Uvula edema 2 0.9 Gout I
Symptoms Osteoporosis I
N~~n IM~.2 Psychiatric disorders I
Odynophagia 119 51.1 Drug abuse 1
Dysphagia 95 40.8 None 155
Dyspnea 28 12.0
Dysphonia 24 10.3 157 of the 233 patients (67.4%) had been treated
Otalgia 17 7.3 by their general practitioners with broad-spectrum
Sialorrhea 14 6.1 oral antibiotics, 65 (27.9%) with oral steroids, and
Thoracic pain 3 1.3 28 (12.0%) with nonsteroidal anti-inflammatory
Given patient might have more than 1 sign or symptom. agents; 66 patients (28.3%) had not been previously
treated by their general practitioners. Hypertension
in head and neck tumors were excluded. A database (35 cases), diabetes mellitus (19), and heart disease
was constructed with Microsoft Excel 2003 (Micro- (17) were the most commonly associated morbidi-
soft, Redmond, Washington). ties (Table 2), and 155 patients (66.5%) had no as-
Over the period considered, 233 patients (138 sociated systemic diseases.
male, 95 female; mean age, 48.0 ± 19.6 years; medi- Oral exploration, upper aerodigestive tract en-
an age, 45 years) were hospitalized for deep neck in- doscopy, and contrast-enhanced CT were part of the
fections; 38 (16.3%) were from countries other than routine investigation. Orthopantography of the man-
Italy, ie, 18 from Eastern Europe, 12 from North dible was performed in 102 cases (43.8%), neck ul-
Africa, 5 from Central Africa, 2 from North Amer- trasonography in 80, and neck magnetic resonance
ica, and I from China. Their treatment was based imaging in 9. Submandibular space infection was
on clinical findings (oral cavity exploration, upper diagnosed in 156 cases (66.9%), parapharyngeal
aerodigestive tract endoscopy), radiologic exami- space infection in 96 (41.2%; Fig lA), and retro-
nation (contrast-enhanced computed tomography pharyngeal space infection in 17 (7.3%); the infec-
[CT], magnetic resonance imaging, ultrasonogra- tion involved more than 1 neck space in 35 cases
phy, and mandible orthopantography), and labora- (15.0%; Fig 2A). The site of origin of the deep neck
tory and microbiological evidence. infection was identified in 189 of the 233 patients
The present analysis considered the patients' signs (81.1 %). The most common cause of deep neck in-
and symptoms at presentation, the site of deep neck fection was dental infection, found in 92 of the 233
infection, radiologic findings, bacteriology, treat- cases (39.5%).· The pharyngotonsillar structures
ment, complications, and prognosis. were the second most common site of origin (38
cases; 16.3%), followed by the salivary glands (32
RESULTS cases; 13.7%), neck cysts (14 cases), the epiglot-
Neck pain, odynophagia, and dysphagia were the tis (9 cases), the hypopharynx (2 cases), a cervical
most commonly reported symptoms in our series, lymph node (1 case), and the thyroid gland (1 case).
and neck swelling, fever, and trismus were the signs The origin of infection remained unknown in 44 of
most frequently found (Table I). Before admission, the 233 patients (18.9%). The teeth responsible for
 Marioni et al, Diagnosis & Treatment ofDeepNeck Infections
the deep neck infections were the second mandibu-
lar molar in 35 patients (38.0%), the first molar in
33 (35.9%), the third molar in 23 (25.0%), and the
second premolar in 9 (9.8%); I or 2 teeth were in-
volved in each patient.
As for the laboratory investigations, the leuko-
cyte count was above normal (reference range, 4.5
to 11.0 cells x 109/L) in 133 of the 220 cases test-
ed (60.4%). The mean (±SD) leukocyte, neutrophil,
and lymphocyte counts were, respectively, 12.8 ±
5.2 cells x 109/L , 10.1 ± 5.0 cells x 109/L (reference
range, 1.8 to 7.7 cells x 109/L), and 1.6 ± 0.9 cells x
109/L (reference range, 1.0 to 4.8 cells x 109/L).
On the basis of their clinical evaluation and radio-
logic and laboratory evidence, 78 patients with deep
neck infections (33.5%) were treated with intrave-
183
Fig 1. Axial contrast-enhanced computed tomograph-
ic views. A) Left parapharyngea12.4 x 9.0-cm abscess
(white arrow) in 28-year-old male patient. B,C) Ab-
scess dimensions are significantly reduced after sur-
gical neck exploration, drainage, and drain placement
as seen at B) 3 days and C) 8 days after operation.
nous antibiotics alone (ampicillin sodium-sulbac-
tam sodium 1.5 g 4 times a day plus metronidazole
[Deflamon] 500 mg 4 times a day, or cefotaxime
sodium 2 g 3 times a day plus metronidazole 500
mg 4 times a day), with or without intravenous ste-
roids (intravenous betamethasone di-sodium phos-
phate,4 to 12 mg a day). Rehydration was given as
necessary. In the group of patients with odontogenic
deep neck infections who needed medical treatment
alone, theteeth involved only underwent restorative
and endodontic therapy.
The deep neck infection warranted medical and
surgical treatment in 155 cases (66.5%). Endo-oral
or oropharyngeal incision and drainage were used
in 101 cases, surgical neck exploration and drainage
in 50, tooth extraction in 36, thoracotomy in 4, im-
mediate tonsillectomy in I, and thoracoscopy in 1.
184 Marioni et aI, Diagnosis & Treatment of Deep Neck Infections

Fig 2.Axial contrast-enhanced computed tomographic views after fiberoptic nasotracheal intubation and na-
sogastric feeding tube placement. A) Multiple large fluid collections involving floor of mouth and parapha-
ryngeal and retropharyngeal spaces in 56-year-old male patient. B) Deep neck spaces 2 days after surgical
exploration, drainage, and drain placement.

A transcervical approach was used under general an- niae, Gemella morbillorum). No bacterial growth
esthesia in the patients who underwent surgical neck was identified in 35 cases. Two rare causes of deep
exploration. Open neck spaces were drained of pu- neck infection were diagnosed. One was Burkholde-
rulent material and necrotic fascial tissues and copi- ria cepacia, found in 2 immunocompetent patients
ously irrigated with saline solution. Suction drains with no cystic fibrosis (1 case was complicated by
were always installed. No significant complications
of the transcervical surgical procedures were re- TABLE 3. RESULTS OF CULTURES
corded. None of the patients required tracheotomy. Organisms No. of Cases
Fiberoptic nasotracheal intubation was performed Gram-positive anaerobic cocci 21
by the otolaryngological surgeon in patients who Streptococcus, viridans group 17*
needed general anesthesia for surgical procedures Staphylococcus epidermidis 10
if conventional endotracheal intubation was likely Gemella morbillorum 8
to prove difficult. After intubation, 23 patients re- Staphylococcus aureus 8
mained under intensive care for a mean of 4.7 days. Pseudomonas sp 7
Streptococcus, ~-hemolytic, group A or B 6
The results of bacterial cultures obtained during Klebsiella pneumoniae 5
operation were available for 115 of the 155 surgi- Enterococcus fecalis 2
cally treated cases. Microbiological investigations Corynebacterium sp 2
were not undertaken for 40 patients (mainly relating Burkholderia cepacia 2
to the earlier period, from 2000 to 2002). The most Streptococcus pneumoniae 2
commonly isolated bacterial organisms were gram- Veillonella sp I
positive anaerobic cocci (21 cases), followed by Proteus mirabilis I
Escherichia coli I
the viridans Streptococcus group of pathogens (17
Mycobacterium tuberculosis I
cases; ie, Streptococcus constellatus [11], Strepto-
Prevotella oris I
coccus anginosus [1], Streptococcus oralis [1], and
Fusobacterium nucleatum I
not-otherwise-specified viridans Streptococcus [4])
Acinetobacter baumanii I
and Staphylococcus epidermidis (to cases). Table Candida albicans 2
3 gives details of the findings in the bacterial cul- No growth 35
tures. Polymicrobial infections were diagnosed in More than I pathogen was isolated in some cases.
12 patients, and 5 different pathogens were isolat- *Including Streptococcus constellatus (11 cases). Streptococcus an-
ed in 1 case (Staphylococcus aureus, S epidermi- ginosus (1 case). Streptococcus oralis (1 case), and not otherwise
specified (4 cases).
dis, Pseudomonas aeruginosa, Klebsiella pneumo-
 Marioni et al, Diagnosis & Treatment 0/ Deep Neck Infections 185

TABLE 4. DIAGNOSED COMPLICATIONS OF DEEP TABLE 5. DEEP NECK INFECTION MICROBIOLOGY IN

NECK INFECTION FIVE PATIENTS WITH MEDIASTINITIS
Complications No .ofCases Organisms No.of Cases
Skin fistulization 14 Pseudomonas sp 3
Mediastinitis 5 Gram-positive anaerobic cocci I
Pleuritis 2 Streptococcus, viridans group 1
Respiratory insufficiency 2 Staphylococcus epidermidis 1
Cervical necrotizing fasciitis 1 Gemella morbillorum 1
Internal jugular vein thrombosis I Staphylococcus aureus 1
Renal insufficiency 1 Klebsiella pneumoniae 1
Skin rash 1 Burkholderia cepacia 1
More than I pathogen was isolated in some cases.
mediastinitis in a 77-year-old male patient with dia-
betes; the other was associated with a gram-positive the sites of origin of deep neck infections went un-
anaerobic cocci infection and complicated by cervi- identified in 56% of the cases described by Huang
cal necrotizing fasciitis in a 27-year-old female pa- et al lO and in 68% of those reported by Plaza Mayor
tient"). The other rare cause of deep neck abscess et al.'
was a multidrug-resistant Acinetobacter baumanii
infection that was treated with surgery and medica- Appropriate radiologic imaging can reveal in-
tion (intravenous tigecycline at an initial dose of 100 fection spreading between spaces, which may not
mg twice a day, then 50 mg),? be clinically apparent. Clinical examination alone
seems to underestimate the extent of disease in 70%
Twenty-five complications of deep neck infec- of cases.'! As in our series, contrast-enhanced CT
tions were diagnosed: skin fistulization was the is currently considered the radiologic assessment
most common (14 cases), followed by mediastini-
method of choice, providing valuable information
tis (5 cases). Other complications that occurred are
to help disclose the origin, location (also in relation
shown in Table 4. The microbiological findings in to the major vascular structures), and extent of deep
the 5 cases with deep neck infections complicated
neck infections. Contrast-enhanced CT is essential
by mediastinitis (mean leukocyte count, 25.5 ± 11.2
in distinguishing an abscess (an encapsulated hy-
cells x 109/L) are summarized in Table 5. podense heterogeneous lesion with more hypodense
None of our patients died of their deep neck in- central areas, with or without the presence of air)
fection or any related complications. The mean hos- from cellulitis or a phlegmon (a large hypodense le-
pital stay was 7.5 ± 5.6 days. After discharge, pa- sion with no peripheral wall and no purulent content
tients who had been on intravenous antibiotics for or gas)." Some authors have noted that a significant
less than 14 days while in hospital completed at CT criterion for identifying an abscess may be scal-
least a 2-week course of antibiotic therapy, usually loped edges, but the ability to recognize these un-
with oral amoxicillin-elavulanate potassium (I g 3 fortunately depends on the radiologist's experience,
times a day) or an alternative antibiotic chosen ac- and in any case the sign is usually a late occurrence
cording to their antibiogram. in abscess formation.P Investigations considering
large series have reported a positive correlation be-
DISCUSSION tween the contrast-enhanced CT findings and the in-
A modern, rational diagnostic and therapeutic ap- traoperative findings, ranging from 68% to 89% .12.13
proach to deep neck infections remains quite a con- Contrast-enhanced CT has been shown to identify
troversial issue, probably because most of the avail- impending airway complications before they are
able series are based on relatively limited numbers clinically detectable. Radiologic evidence of infec-
of patients or diverse clinical experiences developed tion extending to the suprasternal notch may be in-
over the course of 10 to 15 years. To reduce the risk dicative of mediastinal involvement, in which case
of a significant bias due to the heterogeneity of ret- contrast-enhanced CT should include the chest.
rospective series, we opted to investigate a large se-
Ultrasonography or magnetic resonance imaging
ries (233 cases) of deep neck infections treated con-
can also be used to diagnose deep neck infections.
secutively by the same surgical staff over a limited
Although ultrasonography is portable, inexpensive,
period. and readily available at most institutions and entails
Rational Approach to Diagnosis. The clinical and no exposure to radiation, it takes a highly skilled
radiologic diagnostic protocols for deep neck infec- operator to diagnose a deep neck infection. Ultra-
tions need to be improved. Even in recent reports, sonography reveals adenitis well, but it cannot al-
186 Marioni et at, Diagnosis & Treatment of Deep Neck Infections
ways identify small or deep abscesses, and it cannot
provide the specific anatomic information needed to
plan surgical procedures. Magnetic resonance imag-
ing is not often used for imaging of deep neck infec-
tions. It has much the same prognostic value as CT,
but it is more expensive.l- and it takes longer, so
that children and distressed patients need sedation,
which increases the likelihood of airway involve-
ment.'?
The recently increased prevalence of deep neck
infections of dental origin has necessarily prompted
the introduction of other investigations in modern di-
agnostic protocols. In the series of Stalfors et al,5 the
site of origin of deep neck infections was identified
in all but 6.9% of the 72 cases considered; in com-
menting on this brilliant result, the authors empha-
sized the decisive role of close clinical cooperation
with the dental surgeons. In our series of 233 cases,
the site of origin of infection was not identified in
19.9% of cases, and the use of orthopantography ac-
counted for the globally good accuracy in identify-
ing the origin of infections in the deep neck spaces.
The role of orthopantography of the mandible has
been sadly neglected even in very recent guidelines
on the diagnosis of deep neck infections.!" Dental
CT scans might be a valid alternative to orthopan-
tography'>; in particular, they appear to be an ef-
fective tool for investigating pathways of infection
originating from pericoronitis of an impacted man-
dibular third molar.!" Dental CT can be performed
with a conventional CT scanner, a spiral CT scanner,
or a dedicated CT scanner. Dental CT can easily rec-
ognize periapical infection as an enlargement of the
periodontal space or as a small osteolytic reaction
around the root's tip.'?
Rational Approach to Medical Treatment. In our
series, the relatively high incidence, among the oral
pathogens isolated, of gram-positive anaerobic coc-
ci (21 cases), viridans Streptococcus (17), G mor-
billorum (8), and Prevotella oris (I) was consistent
with the high rate of clinically and radiological-
ly confirmed deep neck infections of dental origin
(39.5%).
Empirical antimicrobial therapy is routinely in-
stituted before any definitive results of cultures be-
come available, and this empirical antibiotic treat-
ment should cover most of the gram-positive and
gram-negative aerobic and anaerobic pathogens im-
plicated in deep neck infections, in light of the rising
incidence of polymicrobial infections. In our series,
intravenous steroids (betamethasone) were used for
a few days in 43 patients with severe local edema
to relieve symptoms such as throat pain, dysphagia,
and trismus. Page et aP8 also administered intrave-
nous steroid therapy in all patients with a parapha-
ryngeal abscess. The pathogen test results and anti-
biograms based on cultures of material obtained dur-
ing operation usually become available 72 hours or
more after surgery. At that time it is mandatory to re-
place the initial broad-spectrum antibiotic treatment
with an antibiotic to which the pathogen(s) have a
known susceptibility. As reported previously, micro-
biological investigations were performed systemati-
cally in our series for cases treated surgically after
2002. This practice definitely improved the efficacy
of the medical treatment administered, as illustrated
by the fact that our patients' mean hospital stay was
8.3 ± 6.2 days in 2000 to 2002 and dropped to 7.1 ±
5.3 days in 2003 to 2008; the I-sided t-test showed a
trend toward shorter hospital stays (p =0.07).
After discharge, patients should complete their
course of antibiotic therapy (for at least 2 weeks
in all), ideally with oral antibiotics tailored to their
antibiograms. In patients with deep neck infections
of dental origin who need only medical treatment
while in hospital, restorative and endodontic therapy
for the teeth involved is usually sufficient.
Rational Approach to Surgical Treatment. It is
worth emphasizing the priority of airway support
in patients with deep neck infections. Fiberoptic
nasotracheal intubation, performed by experienced
otolaryngological surgeons using topical anesthesia,
is especially useful in patients with severe trismus,
although it is often made difficult by edema, copi-
ous secretions, and/or blood. Tracheotomy under lo-
cal anesthesia is indicated for severe airway obstruc-
tion, for massive soft tissue edema that prevents en-
dotracheal intubation, or when repeated intubation
attempts fail. Separate incisions should be used for
the tracheotomy and anterior neck drainage proce-
dures to avoid having the infection spread into the
mediastinum.!'
Surgical exploration and drainage may be man-
datory already at presentation (particularly when
contrast-enhanced CT shows a significant, encap-
sulated, hypodense, heterogeneous lesion, or when
prevertebral, anterior visceral, or carotid space in-
volvement or a potentially life-threatening compli-
cation such as descending mediastinitis or jugular
vein thrombosis is diagnosed), or in cases in which
clinical and laboratory findings show a failure to
respond to parenteral antibiotics within 24 to 48
hours. Multiple surgical explorations and drainages
may be needed before any significant improvement
is seen in a patient's condition. In the relatively fre-
quent deep neck infections of dental origin, the teeth
involved should be extracted without delay whenev-
er there is evidence of pericoronitis, extended peri-
odontal lesions, or destructive caries not amenable
to endodontic therapy.
 Marioni et al, Diagnosis & Treatment of Deep Neck Infections
Acknowledgment: The authors thank Frances Coburn for checking the English version of this article.
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