Deep neck infection
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Raviteja Guddeti, M.B.B.S [2]
Synonyms and keywords: cervical fascial space infection; perimandibular space infection
Overview
Deep neck infection refers to an infection or abscess located deep in the neck near the blood vessels, nerves, and muscles. Common causes of Deep neck infections include retropharyngeal abscess, parapharyngeal abscess, Ludwig's angina, among others.
Pathophysiology
Cervical fascia of the neck divides it into superficial and deep spaces. The deep space is in turn divided into many small spaces by deep fascia. Infection from head and neck structures spread to the lymph nodes present in these deep areas causing abscesses.
- Retropharyngeal space - lymph nodes that drain the adenoids, sinuses and nose are located in this space. Infections can result in spread of infection to these lymph nodes, and eventually abscess formation causing a Retropharyngeal abscess. It is common in children younger than 5 years.
- Peritonsillar space - this space is located above and behind the tonsils. Untreated Tonsillitis can cause an infection in this space. This infection occurs most frequently in young adults.
- Parapharyngeal space - this space is located on each side of the neck behind the Carotid arteries. Infections in this area are due to common upper respiratory infections that spread to the lymph nodes located in this space.
- Submandibular space - located under the jaw on each side, infection of this space is usually the result of a dental infection and is known as Ludwig's angina.
Causes
Symptoms
- Asymmetric swelling of the neck, face, under the jaw or back of the throat
- Fever
- Difficulty or pain when swallowing
- Drooling
- Voice change
- Decreased ability to move the neck
- Sick appearance
Complications
- Airway obstruction
- Spread of the infection to mediastenum, lungs, blood stream etc.,
- Thrombus formation in the arteries of the neck
Diagnosis
- Complete blood counts
- Differential counts
- ESR
- Blood cultures
- CT scan of the neck to know the extent of involvement.
- X-ray neck
- Dental radiography
Treatment
- Hospitalization
- Hydration
- I.V antibiotics
- Surgical drainage in unresponsive cases.
Medical Therapy
In light of the polymicrobial and rapidly progressive nature of deep neck infection, patients should receive timely 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 may be deescalated as culture and susceptibility results permit.
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