Deep Neck Space Infections

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Deep Neck Space Infections

Head and Neck Surgery
Author Credentials 

Linda X. Yin, MD
Department of Otolaryngology – Head and Neck Surgery
Mayo Clinic
Rochester, MN

 

Module Summary

Infections of the deep neck occur in a very anatomically complex area. Multiple potential spaces and routes of entry can readily allow the spread of infections from the oral cavity, oropharynx, and salivary glands into the deep neck compartments. Infections can occur both in the pediatric and adult population, for which differences in etiologies and management decisions must be carefully considered. While both medical therapy and surgical management are appropriate, each patient’s risk for complications is different, and the impact of age, site of etiology, clinical course, and systemic diseases must all be factored into clinical decision-making. Complications from deep neck infections can be emergent and critical, including the potential for airway compromise and septic shock. A thorough understanding of the anatomy, microbiology, and treatment of this disease is necessary in the care of these patients.

Module Learning Objectives 
  1. Learn the complex anatomy of the deep neck – its fascial planes and potential neck spaces. Understand how infections of the oral cavity, oropharynx, and salivary glands can extend into these deep compartments
  2. Describe the microbiology of deep neck space infections, and name the predominant causative organisms in the general population and special populations such as pediatrics and diabetics
  3. Discuss the appropriate workup of a patient with a deep neck space infection – including clinical exam, laboratory and microbiology studies, and imaging
  4. Describe the conservative and surgical management of deep neck space infections, recognizing the complexities of clinical decision making, which should be individualized for each patient
  5. List some potential complications of deep neck space infections, how to recognize them, and how to mange them

 

Anatomy
  1. Describe the fascial planes of the deep neck and the potential spaces they create (i.e. layers of deep cervical fascia – superficial, middle, deep)
  2. List the deep spaces of the neck and their boundaries
  3. Understand the concept of the “danger space” and clinical implications of infections in this area

 

References:

  1. Debnam JM, Guha-Thakurta N. Retropharyngeal and prevertebral spaces: anatomic imaging and diagnosis. Otolaryngol Clin North Am. 2012;45(6):1293-1310. doi:10.1016/j.otc.2012.08.004
  2. Stiernberg CM. Deep-neck space infections. Diagnosis and management. Arch Otolaryngol Head Neck Surg. 1986;112(12):1274-1279. 
  3. Osborn TM, Assael LA, Bell RB. Deep space neck infection: principles of surgical management. Oral Maxillofac Surg Clin North Am. 2008;20(3):353-365. 

 

 

Etiology
  1. Understand the significance in site of etiology of the deep neck space infection and its implications on management
    • Odontogenic infections
    • Tonsillitis
    • Salivary gland infections
  2. Describe the etiology of deep neck space infections related to illicit injection drug use

 

References:

  1. Favaretto N, Fasanaro E, Staffieri A, et al. Deep neck infections originating from the major salivary glands. Am J Otolaryngol. 2015;36(4):559-564. 
  2. Biller JA, Murr AH. The importance of etiology on the clinical course of neck abscesses. Otolaryngol Head Neck Surg. 2004;131(4):388-391. 
  3. Bottin R, Marioni G, Rinaldi R, Boninsegna M, Salvadori L, Staffieri A. Deep neck infection: a present-day complication. A retrospective review of 83 cases (1998-2001). Eur Arch Otorhinolaryngol. 2003;260(10):576-579. 

 

 

Basic Science
  1. Name the most common organisms that cause infections of the deep neck
    • Special considerations in diabetic, pediatric patients
  2. Recognize the polymicrobial nature of deep neck space infections

 

References:

  1. Huang TT, Tseng FY, Liu TC, Hsu CJ, Chen YS. Deep neck infection in diabetic patients: comparison of clinical picture and outcomes with nondiabetic patients. Otolaryngol Head Neck Surg. 2005;132(6):943-947. 
  2. Duggal P, Naseri I, Sobol SE. The increased risk of community-acquired methicillin-resistant Staphylococcus aureus neck abscesses in young children. Laryngoscope. 2011;121(1):51-55.
  3. Stiernberg CM. Deep-neck space infections. Diagnosis and management. Arch Otolaryngol Head Neck Surg. 1986;112(12):1274-1279. 
  4. Osborn TM, Assael LA, Bell RB. Deep space neck infection: principles of surgical management. Oral Maxillofac Surg Clin North Am. 2008;20(3):353-365. 

 

 

Incidence
  1. Describe the modern epidemiology of deep neck space infections in the United States, and changing trends in the etiology and microbiology of disease
  2. Recognize the different epidemiology of adult and pediatric deep neck space infections

 

References:

  1. Kirse DJ, Roberson DW. Surgical management of retropharyngeal space infections in children. Laryngoscope. 2001;111(8):1413-1422.
  2. Parhiscar A, Har-El G. Deep neck abscess: a retrospective review of 210 cases. Ann Otol Rhinol Laryngol. 2001;110(11):1051-1054. 
  3. Shimizu Y, Hidaka H, Ozawa D, et al. Clinical and bacteriological differences of deep neck infection in pediatric and adult patients: Review of 123 cases. Int J Pediatr Otorhinolaryngol. 

 

Patient Evaluation
  1. List some common presenting symptoms in patients with deep neck space infections
  2. Describe the physical exam required for the diagnosis and evaluation of deep neck space infections

 

References:

  1. Shanti RM, Aziz SR. Should we wait for development of an abscess before we perform incision and drainage?. Oral Maxillofac Surg Clin North Am. 2011;23(4):513-v. 
  2. Peterson LJ. Contemporary management of deep infections of the neck. J Oral Maxillofac Surg. 1993;51(3):226-231.
  3. Plaza Mayor G, Martínez-San Millán J, Martínez-Vidal A. Is conservative treatment of deep neck space infections appropriate?. Head Neck. 2001;23(2):126-133. 

 

 

Laboratory Studies
  1. List some common laboratory findings seen in patients with deep neck infection (i.e. WBC, CRP)
  2. List the components of the LRINEC scores and discuss how this can aid in the early detection of cervical necrotizing fasciitis

 

References:

  1. Wang LF, Kuo WR, Tsai SM, Huang KJ. Characterizations of life-threatening deep cervical space infections: a review of one hundred ninety-six cases. Am J Otolaryngol. 2003;24(2):111-117. 
  2. Sandner A, Moritz S, Unverzagt S, Plontke SK, Metz D. Cervical Necrotizing Fasciitis--The Value of the Laboratory Risk Indicator for Necrotizing Fasciitis Score as an Indicative Parameter. J Oral Maxillofac Surg. 2015;73(12):2319-2333. 

 

Imaging
  1. List some imaging modalities that can be used to work up deep neck space infections
  2. Describe the utility of contrast-enhanced CT scans, and their accuracy in distinguishing cellulitis from abscess formation in the deep neck

 

References:

  1. Miller WD, Furst IM, Sàndor GK, Keller MA. A prospective, blinded comparison of clinical examination and computed tomography in deep neck infections. Laryngoscope. 1999;109(11):1873-1879. 
  2. Lazor JB, Cunningham MJ, Eavey RD, Weber AL. Comparison of computed tomography and surgical findings in deep neck infections. Otolaryngol Head Neck Surg. 1994;111(6):746-750. 
  3. Quinn NA, Olson JA, Meier JD, et al. Pediatric lateral neck infections - Computed tomography vs ultrasound on initial evaluation. Int J Pediatr Otorhinolaryngol. 2018;109:149-153.

 

Treatment
  1. List some patient factors that should be considered when choosing a medical therapy vs. surgical therapy for deep neck space infections
    • Systemic diseases and other comorbidities (i.e. Diabetes mellitus, HIV)
    • Patient age (elderly patients, pediatric patients)
  2. Discuss clinical circumstances which allow for conservative therapy, and others which mandate more urgent surgical intervention

 

References:

  1. Huang TT, Tseng FY, Liu TC, Hsu CJ, Chen YS. Deep neck infection in diabetic patients: comparison of clinical picture and outcomes with nondiabetic patients. Otolaryngol Head Neck Surg. 2005;132(6):943-947. 
  2. Cheng J, Elden L. Children with deep space neck infections: our experience with 178 children. Otolaryngol Head Neck Surg. 2013;148(6):1037-1042. 
  3. Shanti RM, Aziz SR. Should we wait for development of an abscess before we perform incision and drainage?. Oral Maxillofac Surg Clin North Am. 2011;23(4):513-v. 
  4. Boscolo-Rizzo P, Marchiori C, Zanetti F, Vaglia A, Da Mosto MC. Conservative management of deep neck abscesses in adults: the importance of CECT findings. Otolaryngol Head Neck Surg. 2006;135(6):894-899. 

 

Medical Therapies
  1. List the optimal empiric antibiotic therapy that should be started in deep neck space infections
  2. Describe patient factors associated with failure of medical therapy

 

References:

  1. Huang TT, Liu TC, Chen PR, Tseng FY, Yeh TH, Chen YS. Deep neck infection: analysis of 185 cases. Head Neck. 2004;26(10):854-860. 
  2. Cheng J, Elden L. Children with deep space neck infections: our experience with 178 children. Otolaryngol Head Neck Surg. 2013;148(6):1037-1042. 
  3. Peterson LJ. Contemporary management of deep infections of the neck. J Oral Maxillofac Surg. 1993;51(3):226-231.
  4. Plaza Mayor G, Martínez-San Millán J, Martínez-Vidal A. Is conservative treatment of deep neck space infections appropriate?. Head Neck. 2001;23(2):126-133. 

 

Surgical Therapies
  1. Describe the surgical treatment options available for deep neck abscesses (i.e. needle aspiration, incision & drainage)
  2. Describe surgical approaches to the deep neck (intraoral, transcervical)
  3. List some potential complications of incision and drainage for deep neck abscesses

 

References:

  1. Hamiter M, Manzi B, Gungor A. Needle aspiration as primary surgical treatment of pediatric deep neck space abscesses. Am J Otolaryngol. 2019;40(6):102296. 
  2. Osborn TM, Assael LA, Bell RB. Deep space neck infection: principles of surgical management. Oral Maxillofac Surg Clin North Am. 2008;20(3):353-365. 

 

Complications
  1. Describe the airway management challenges in deep neck space infections and the role of alternatives to direct laryngoscopy
    • Awake tracheostomy
    • Awake fiberoptic intubation
  2. Discuss patient factors that may influence length of stay and prognosis after treatment of a deep neck space infection.
  3. Understand how to recognize and manage necrotizing fasciitis from a deep cervical infection

 

References:

  1. Karkos PD, Leong SC, Beer H, Apostolidou MT, Panarese A. Challenging airways in deep neck space infections. Am J Otolaryngol. 2007;28(6):415-418. 
  2. O'Brien KJ, Snapp KR, Dugan AJ, Westgate PM, Gupta N. Risk factors affecting length of stay in patients with deep neck space infection [published online ahead of print, 2019 Nov 25]. Laryngoscope. 
  3. Roccia F, Pecorari GC, Oliaro A, et al. Ten years of descending necrotizing mediastinitis: management of 23 cases. J Oral Maxillofac Surg. 2007;65(9):1716-1724. 

 

Review
  1. Where is the “danger” space located, and what is its clinical significance?
  2. What are the most common sources of origin for infections of the deep neck?
  3. Name some differences in the etiology, presentation, and management of deep neck space infections in pediatric and adult patients.
  4. List the components of the LRINEC score. What is this used for?
  5. Compare and contrast the pros and cons of ultrasonography vs. CT scan for imaging of deep neck space infections
  6. A 45-year-old man with a history of diabetes mellitus (Hg A1c of 10.3) presents to the emergency department with fever, chills, dysphagia, and odynophagia. He is diagnosed with a parapharyngeal abscess. What should the next steps of management be? Which empiric antibiotics should be started?