Practice Essentials
For centuries, the diagnosis and treatment of deep neck space infections have challenged physicians and surgeons. The complexity and the deep location of this region make diagnosis and treatment of infections in this area difficult. These infections remain an important health problem with significant risks of morbidity and mortality. A careful history and physical examination are critical to the workup in deep neck space infections. The airway is the first priority of treatment. [1] See the image below.
CT scan of the neck demonstrating left peritonsillar abscess.
Signs and symptoms of deep neck space infections
The most consistent signs of a deep neck space infection are fever, elevated white blood cell (WBC) count, and tenderness. Other signs and symptoms largely depend on the particular spaces involved and include the following:
Asymmetry of the neck and associated neck masses or lymphadenopathy, which is present in almost 70% of pediatric retropharyngeal abscesses according to a study by Thompson and colleagues
Medial displacement of the lateral pharyngeal wall and tonsil caused by parapharyngeal space involvement
Trismus caused by inflammation of the pterygoid muscles
Torticollis and decreased range of motion of the neck caused by inflammation of the paraspinal muscles
Fluctuance that may not be palpable because of the deep location and the extensive overlying soft tissue and muscles (eg, sternocleidomastoid muscle)
Possible neural deficits, particularly of the cranial nerves (eg, hoarseness from true vocal cord paralysis with carotid sheath and vagal involvement), and Horner syndrome from involvement of the cervical sympathetic chain
Regularly spiking fevers (may suggest internal jugular vein thrombophlebitis and septic embolization)
Tachypnea and shortness of breath (may suggest pulmonary complications and warn of impending airway obstruction)
Workup in deep neck space infections
Workup in deep neck space infections
In addition to a history and physical examination, laboratory studies, including the following, may be useful in the workup of a patient in whom a deep neck space infection is suspected:
Blood chemistries
Complete blood cell count
Clotting profile (particularly important in patients who require surgical drainage)
Blood cultures (may be indicated in septic patients)
Abscess cultures with Gram stains (critical to direct antimicrobial therapy)
CT scans with contrast are the gold standard in imaging evaluation of deep neck infections.
Management of deep neck space infections
The airway is the first priority of treatment. [1] Addressing the airway may involve observation, endotracheal or nasotracheal intubation, tracheostomy, or cricothyroidotomy for emergent situations. [2]
With regard to intravenous antibiotic management, choose parenteral antibiotics to cover the most likely infecting organisms. Initiate empiric regimens before culture results are obtained based on the local resistance patterns and most common etiologies.
Cover gram-positive and gram-negative organisms and aerobic and anaerobic bacteria, including beta-lactamase–producing organisms. [3] Modify antibiotics according to culture and sensitivity results.
Incision and drainage is the cornerstone of therapy for the treatment of deep neck space abscesses. Establish a secure airway before initiating any surgical procedure.
Fine-needle aspiration (FNA) may be used in patients with small, easily reachable abscesses or in patients who are too unstable to undergo general anesthesia.
