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; DNI; 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.
Anatomic Considerations
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.[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]
- 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.
- 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 (CN 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.
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
Diagnosis
History
Pertinent history includes host immune status (such as human immunodeficiency virus infection and 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
- 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 should be deescalated as culture and susceptibility results permit.[5][6]
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
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) - ↑ 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)