Deep neck infection
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Synonyms and keywords: cervical fascial space infection; DNI; perimandibular space infection
Overview
Pathophysiology
Anatomic Considerations of Deep Neck Spaces
Based on their spatial relation to the hyoid, deep neck spaces may be divided into three anatomic groups:[1][2]
- Spaces above the level of the hyoid
- Peritonsillar space
- – The peritonsillar space lies between the palatine tonsil and the lateral superior pharyngeal constrictor muscle and is bounded anteriorly and posteriorly by the tonsillar pillars. Infection of the peritonsillar space is commonly associated with tonsillitis in older children or young adults.[3]
- Submandibular space
- – The submandibular space encloses the space between the mandible and the hyoid and consists of two compartments: the supramylohyoid compartment and the inframylohyoid compartment. Infection of the submandibular space is typically caused by odontogenic pathogens, including Streptococcus viridans, Staphylococcus spp., Prevotella spp, and Peptostreptococcus spp.[4]
- – Ludwig's angina denotes the condition of rapidly spreading cellulitis in the submandibular space resulting in acute respiratory distress secondary to upper airway obstruction.
- Parapharyngeal space (lateral pharyngeal space or pharyngomaxillary space)
- – The parapharyngeal space lies between the middle layer and the superficial layer of deep cervical fascia. Infection of the parapharygeal space often arises from pharyngitis, tonsillitis, otitis, mastoiditis, parotitis, and cervical lymphadenitis.
- Masticator space (temporal space)
- – The masticator space locates between the pterygoid muscle medially and the masseter muscle laterally. Infection of the masticator space generally originates from the posterior mandibular molars.
- Buccal space
- – The buccal space lies between the buccinator muscle medially and the skin of the cheek laterally. Infection of the buccal space is often odontogenic in origin.
- Parotid space
- – The parotid space lies between the parapharyngeal space and the parotid fascia. Infection of the parotid space frequently stems from parotid duct obstruction or lymphadenitis.
- Spaces that involve the entire length of the neck
- Retropharyngeal space (retrovisceral space or retroesophageal space)
- – The retropharyngeal space is bounded by the carotid sheaths laterally and extends from the skull base to the mediastinum. Infection of the retropharyngeal space is typically polymicrobial in origin and commonly observed in children younger than 5 years.
- Danger space
- – The danger space lies between the alar fascia anteriorly and the prevertebral fascia posteriorly. Infection in the danger space tends to complicate mediastinitis, empyema, and sepsis.
- Prevertebral space
- – The prevertebral space extends between the prevertebral fascia and the underlying vertebral bodies. Infection in the prevertebral space may be secondary to Pott's disease or retropharyngeal and danger space infections.
- Carotid space (visceral vascular space)
- – The carotid space is encased by the carotid sheaths and harbors the carotid artery, internal jugular vein, cranial nerves IX, X, XI, and XII, and cervical sympathetic chain. Infection of the carotid space may result from disseminated infections of the adjacent spaces or direct inoculation.
- Spaces below the level of the hyoid
- Anterior visceral space (pretracheal space)
- – The anterior visceral space lies between the infrahyoid strap muscles and the esophagus. Infection of the anterior visceral space is commonly associated with traumatic insult to the anterior esophageal wall.
Causes
Natural History, Complications, and Prognosis
Complications
- Airway obstruction
- Spread of the infection to mediastenum, lungs, blood stream etc.,
- Thrombus formation in the arteries of the neck
Diagnosis
History
In the absence of acute respiratory distress, history taking should attempt to identify potential sources of the deep neck infection, such as any recent illness affecting oropharyngeal structures, dental caries or procedures, upper airway surgeries, penetrating injuries in the head and neck, or intravenous drug use. Other pertinent history includes host immune status (e.g., human immunodeficiency virus infection, recent use of chemotherapeutic agent or corticosteroids) and past medical history of chronic hepatitis, diabetes mellitus, rheumatic disorders, or hematologic malignancy. In these settings, patients are at an increased risk of rapidly progressive diseases or atypical clinical presentations not featured by marked inflammatory responses.
Signs and Symptoms
Symptoms may reflect generalized or local inflammatory processes in response to the infection. Fever, neck pain, and neck swelling are the most prevalent symptoms in adults. Dysphagia, odynophagia, drooling, hoarseness ("hot potato" voice), shortness of breath, trismus, or otalgia may also occur. Pediatric patients commonly present with fever, neck mass, neck stiffness, sore throat, drooling, or poor oral intake.[5][6]
Physical Examination
Laboratory Findings
Imaging Studies
- Plain radiograph of the neck
- Contrast-enhanced CT scan of the neck
Treatment
Medical Therapy
In light of the polymicrobial and rapidly progressive nature of deep neck infection, patients should receive timely empiric treatment with broad spectrum intravenous antibiotics covering Gram-positive cocci and Gram-negative bacilli with or without anaerobes. The choice of antibiotic regimen should be tailored based on clinical scenario, host immune status, and local antibiogram data. In immunocompromised state or nosocomial setting, pseudomonal coverage should be considered, with additional anaerobic coverage in fulminant odontogenic deep neck infections. Antimicrobial therapy should be deescalated as culture and susceptibility results permit.[7][8]
Community-Acquired Deep Neck Infection
Ampicillin-Sulbactam 1.5–3.0 g IV q6h OR Clindamycin 600–900 mg IV q8h OR Moxifloxacin 400 mg daily (if Eikenella is suspected)
Nosocomial Deep Neck Infection or Immunocompromised Host
Ticarcillin-Clavulanate 3.0 g IV q6h OR Pipercillin-Tazobactam 3.0 g IV q6h OR Imipenem-Cilastatin 500 mg IV q6h OR Ciprofloxacin 400 mg IV q12h OR Levofloxacin 750 mg IV q24h
Deep Neck Infection with High-Risk of MRSA
Clindamycin 600–900 mg IV q8h OR Trimethoprim-Sulfamethoxazole 10 mg/kg/day q8h AND Vancomycin 1.0 g IV q12h
Necrotizing Fasciitis
Ceftriaxone 2.0 g IV q8h AND Clindamycin 600–900 mg IV q8h AND Metronidazole 500 mg IV q6h
Related Chapters
References
- ↑ Vieira, Francisco; Allen, Shawn M.; Stocks, Rose Mary S.; Thompson, Jerome W. (2008-06). "Deep neck infection". Otolaryngologic Clinics of North America. 41 (3): 459–483, vii. doi:10.1016/j.otc.2008.01.002. ISSN 0030-6665. PMID 18435993. Check date values in:
|date=(help) - ↑ Flint, Paul (2015). Cummings otolaryngology--head & neck surgery. Philadelphia, PA: Elsevier/Saunders. ISBN 978-1455746965.
- ↑ Ungkanont, K.; Yellon, R. F.; Weissman, J. L.; Casselbrant, M. L.; González-Valdepeña, H.; Bluestone, C. D. (1995-03). "Head and neck space infections in infants and children". Otolaryngology--Head and Neck Surgery: Official Journal of American Academy of Otolaryngology-Head and Neck Surgery. 112 (3): 375–382. ISSN 0194-5998. PMID 7870436. Check date values in:
|date=(help) - ↑ Rega, Anthony J.; Aziz, Shahid R.; Ziccardi, Vincent B. (2006-09). "Microbiology and antibiotic sensitivities of head and neck space infections of odontogenic origin". Journal of Oral and Maxillofacial Surgery: Official Journal of the American Association of Oral and Maxillofacial Surgeons. 64 (9): 1377–1380. doi:10.1016/j.joms.2006.05.023. ISSN 0278-2391. PMID 16916672. Check date values in:
|date=(help) - ↑ Coticchia, James M.; Getnick, Geoffrey S.; Yun, Romy D.; Arnold, James E. (2004-02). "Age-, site-, and time-specific differences in pediatric deep neck abscesses". Archives of Otolaryngology--Head & Neck Surgery. 130 (2): 201–207. doi:10.1001/archotol.130.2.201. ISSN 0886-4470. PMID 14967751. Check date values in:
|date=(help) - ↑ Vural, Cetin; Gungor, Anil; Comerci, Susan (2003-06). "Accuracy of computerized tomography in deep neck infections in the pediatric population". American Journal of Otolaryngology. 24 (3): 143–148. ISSN 0196-0709. PMID 12761699. Check date values in:
|date=(help) - ↑ Flint, Paul (2010). Cummings otolaryngology head & neck surgery. Philadelphia, PA: Mosby/Elsevier. ISBN 978-0323052832.
- ↑ Vieira, Francisco; Allen, Shawn M.; Stocks, Rose Mary S.; Thompson, Jerome W. (2008-06). "Deep neck infection". Otolaryngologic Clinics of North America. 41 (3): 459–483, vii. doi:10.1016/j.otc.2008.01.002. ISSN 0030-6665. PMID 18435993. Check date values in:
|date=(help)