Deep Neck Space Infections

Author: Alexandra Murray, OMSIV
Ohio University Heritage College of Osteopathic Medicine

Since the advent of modern antibiotic use, deep neck space infections have decreased in occurrence; however, when these infections take place, the complications can be life threatening.[1-4] Because of the unique compartments of the cervical fascia, deep neck space infections can range in severity and have the potential to extend into the mediastinum. Based on how the infection propagates, these infections have the potential to cause upper airway edema, airway obstruction, mediastinitis, internal jugular vein septic thrombophlebitis, sepsis and septic embolization.[1,2]

Common Sources
Deep neck space infections can develop from infections of the teeth, salivary glands, nasal cavity, paranasal sinuses, pharynx and adenotonsillar tissues.[1,2] In children, adenoids and tonsillar infections are the most common source as they create a drainage pathway through the retropharyngeal lymph nodes resulting in retropharyngeal, parapharyngeal and peritonisllar space infections.1 In adults, dentoalveolar infections are the most common source of infection. In particular, infections of the lower second and third molars are dangerous because their roots spread directly into the submandibular space.[1] Other causes of deep neck space infections in adults include: pharyngitis, tonsillitis, sialoadenitis, trauma, foreing body ingestion, sinusitis, cervical lymphadenitis, middle ear infections, mastoid infections, and IV drug use.[2]

Diagnosis
Clinical presentations of deep neck space infections are widely variable and the complexity of the deep neck spaces can mask the severity of the infection.[1] Emergent signs and symptoms that require airway protection are neck swelling, neck stiffness, trismus, "hot potato voice," dyphagia and dyspnea.[1] Plain film X-rays are useful for initial screening and for quick assessment of airway compromise, whereas ultrasound can be used to differentiate between cellulitis and abscess. CT is the gold standard for diagnosis of deep neck space infection and can localize which compartments are affected. MRI takes more time to acquire than CT, but is a more specific for determining the extent of inflammation and edema.[1]

Treatment
The most serious complications of deep neck space infections are airway obstruction and spread of the infection to the mediastinum. For this reason, when deep neck space infections are suspected it is crucial that the airway be secured.[1-4] Patients with cellulitis and small abscesses can respond to antibiotics alone, but surgical drainage should be performed in patients with larger abscesses, Ludwig's angina, anterior visceral space involvement and in those who do not respond to antibiotic treatment.[3,4] Deep neck space infections are generally polymicrobial but recent reports suggest a high prevelance of staphyloccal species in the pediatric population.[1] In addition, Klebsiella pneumoniae and Streptococcus species are found to be more prevalent in diabetics.[1-4] Ultimately, choosing appropriate antibioitics based upon the likely microbiology of the infection is essentail for a successful outcome.

References:  

1.  Maroldi R et al. Emergency imaging assessment of deep neck space infections. Semin Ultrasound CT MR. 2012 Oct; 33(5):432-42.
2. 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 Mar-Apr;24(2):111-7.
3. Boscolo-Rizzo P et al. Deep neck infections: a constant challenge. ORL J Otorhinolaryngol Relat Spec. 2006;68(5):259-65.
4. Boscolo-Rizzo P, Da Mosto MC. Submandibular space infection: A potentially lethal infection. Int J Infect Dis. 2009 May;13(3):327-33.