Neck Abscess


Article Author:
Rachel McDowell
Mohammed Khadeer


Article Editor:
Matthew Hyser


Editors In Chief:
David Wood
Andrew Wilt
Hajira Basit


Managing Editors:
Avais Raja
Orawan Chaigasame
Khalid Alsayouri
Kyle Blair
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Abbey Smiley
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beenish Sohail
Hajira Basit
Phillip Hynes
Sandeep Sekhon


Updated:
7/3/2019 1:50:51 PM

Introduction

Infections of the deep neck tissues are complicated, in diagnosis, localization, access, and management. The anatomy of the neck is complex with critical structures of the airway, gastrointestinal system, and major vessels and nerves. The affected tissues may be deep and impossible to palpate or visualize externally. Nearby structures can become involved in the inflammation and lead to neurovascular, bony, or airway issues. It is crucial to understand different neck abscesses and how they may present as well as the best ways to treat them. [1],[2],[3]

Etiology

Historically, before antibiotics, tonsillitis and pharyngitis were the most frequent causes of deep neck space infections. Tonsillitis remains the most common cause of deep neck space infection in children, but in adults, an odontogenic origin is the most common. Other causes include oral surgical procedures, salivary gland infection or obstruction, trauma to the oral cavity or pharynx, instrumentation, foreign body aspiration, intravenous drug use, cervical lymphadenitis/suppuration of malignant lymph node or mass, branchial cleft anomalies, thyroglossal duct cyst, and others. There may be no clear source for 20% to 50% of deep neck infections. It is important to consider a suppressed immune system due to HIV/AIDS, chemotherapy, or immunosuppressant medications in these infections. [4]

Epidemiology

Deep neck infections are common. As they comprise many discrete entities, it is difficult to accurately estimate the number of deep neck space infections in the United States or worldwide. It would be reasonable to assume that incidence in the United States is lower than in countries where immunizations and/or early medical intervention for more superficial infections is unavailable. A study in 2009 by Adeil et al. estimated more than 3400 U.S. pediatric hospital admissions per year for deep neck space infection.

Peritonsillar abscess is most common in 20- to 40-year-olds. Children are not often affected by a peritonsillar abscess but can be if they are immuno-compromised. Females and males are affected equally. Chronic tonsillitis or multiple rounds of oral antibiotics may predispose a person to the formation of a peritonsillar abscess.

Parapharyngeal abscesses can develop in any age patient but are most common in children and adolescents. Immunocompromised adults are also at increased risk. [5]

Pathophysiology

There are different potential paths of infection in the neck. Oral cavity/face/superficial neck infection can spread via the lymphatic system to the deep tissues of the neck. Lymphadenopathy may cause suppuration and then focal abscess formation. Direct communication between tissues in the neck may occur. Finally, penetrating trauma can introduce infection to the deep tissues. 

After the spread of infection, either local inflammation or phlegmon may develop, or a fulminant abscess may form with a purulent collection of fluid. Signs of neck abscess in the deep tissues may result from either mass effect of inflamed tissue or abscess on the surrounding structures or from direct involvement of those structures with the infection. Examples of different types of spread include the following:

  1. A lateral pharyngeal space infection can spread to the carotid sheath, causing internal jugular vein thrombosis, which can lead to subacute bacterial endocarditis or other thromboembolic diseases
  2. Lateral pharyngeal space infection can lead to extensive edema causing respiratory compromise
  3. Tonsillitis may lead to a peritonsillar abscess, which may lead to a lateral/posterior pharyngeal infection that can then spread to the chest if untreated

This can lead to mediastinitis or empyema. Neck abscess can include peritonsillar infections, retropharyngeal infections, submandibular infections, buccal infections, parapharyngeal space infections, and canine space infections. The retropharyngeal, retroesophageal, and posterior mediastinum are all a continuous space for the spread of infection. 

Histopathology

Causative organisms for deep neck infections include gram-positive organisms, including but not limited to Streptococcus viridans, Staphylococcus epidermidis, and Staphylococcus aureus; and gram-negative organisms, including but not exclusively Escherichia coli, Klebsiella oxytoca, and Haemophilus influenza. In studies of retropharyngeal abscess, polymicrobial results were found in almost 90% of patients. Aerobes were found in all patients and anaerobes found in more than half. Anaerobes may include Peptostreptococcus, Fusobacterium, Prevotella, and Actinomyces. Other bacteria may include Lactobacillus, Bacteroides, and Propionibacterium, among others.

Some studies show cultures with an average of at least five isolates. There have been studies showing an association between the presence of biofilm and abscess development. [6]

History and Physical

Deep neck space abscess should be considered when patients describe any or many of the following:

  • Severe pain
  • Recent dental procedures
  • Upper respiratory infection
  • Neck or mouth trauma
  • Respiratory distress
  • Dysphagia or dysphonia
  • Immunosuppression
  • The rapid rate of onset
  • Prolonged duration of symptoms

Particular red flags include asymmetry of the neck, neck masses, lymphadenopathy, trismus, medial displacement of the lateral pharyngeal wall and tonsil, torticollis, cranial nerve involvement, spiking fevers, and tachypnea/shortness of breath.

Evaluation

CT imaging of the neck can offer help with confirming and localizing the presence of a deep neck infection. However, patients are often either too unstable for CT imaging or unable to lie flat on the CT table to have the CT performed. There may be situations where only a portable lateral soft tissue neck x-ray can be obtained, and this can help support the diagnosis of neck abscess without much help in localization.

In cases where an early neck abscess is suspected, an otolaryngologist may be called upon to perform direct laryngoscopy to ascertain the presence of swelling. [7]

Treatment / Management

Treatment involves adequate drainage of the abscess in the operating room. Also, antibiotic therapy is paramount. Because cultures are not available at the time of presentation, empiric antibiotics are started at presentation. A study in 2008 by Yang et al. found three comparable antibiotic regimens: (1) ceftriaxone and clindamycin (2) ceftriaxone and metronidazole, or (3) penicillin G and gentamicin and clindamycin.

In a 2015 Iranian study by Motahari, et al., 815 of 428 cases were managed surgically while the rest were managed medically. Tracheostomy was performed in five cases. One 15-year-old with symptoms suggestive of mediastinitis died of airway compromise a day after undergoing surgical management of parapharyngeal abscess. The study concluded that if medical management fails after 24 to 48 hours, or if fluctuance or any complications are present, prompt surgical management is indicated.

It is important to determine the underlying cause of the problem and to address that specifically. For example, with odontogenic infections, early dental extraction is crucial. Airway management must always be a consideration, as there is often swelling and distortion of anatomy, the surgical airway may be preferable. Certainly, in cases of deep neck infection, early notification of otolaryngology and anesthesia for airway backup is wise. For patients presenting with a compromised airway, prompt transfer to the operating room for simultaneous evaluation, airway management, and treatment may be life-saving. [8],[9]

Pearls and Other Issues

The anatomy of the neck is quite complex. Terms of review include:

The two main fascial planes are (1) superficial cervical fascia and (2) deep cervical fascia.

The deep neck spaces include the following:

  • Parapharyngeal space (i.e., lateral pharyngeal space/pharyngomaxillary space/pterygomaxillary space/pterygoid-pharyngeal space)
  • Retropharyngeal space
  • Prevertebral space
  • Danger space
  • Masticator space
  • Submandibular space
  • Carotid space, pretracheal space
  • Peritonsillar space
  • Parotid space
  • Temporal space

Enhancing Healthcare Team Outcomes

an interprofessional approach to neck infections

Deep neck infections are not uncommon in clinical practice. The problem is that they are sometimes missed, and this can have an enormous morbidity on the patient. Deep neck infections cannot only compromise the airways but also spread vertically to the brain, spinal cord, and the mediastinum. Because the majority of patients initially present to the primary care worker, it is important to have a streamlined process to ensure that the diagnosis is made promptly and the condition treated. Data from infections in the pediatric population reveal that by following clinical guidelines one can achieve a very low morbidity.[10] While there are no universal guidelines in the management of deep neck infections, current expert opinion reveals that an interprofessional group of health professionals can help achieve excellent outcomes.[11] Once a deep neck infection is suspected, the following healthcare workers need to be involved:

  • Radiologist to help determine the location and extent of the infection, and even help with drainage
  • ENT and/or thoracic surgeon to help with debridement
  • Laboratory technologist to identify the organisms involved
  • Anesthesiologist in case an airway is required
  • Infectious disease expert on determining the choice of antibiotics
  • Nurses to help monitor the patient’s vital signs, educate the family, and ensure infection precautions
  • Pharmacists to help follow the different types of medications and prevent drug interactions
  • Dietitian consult as the patient may not be able to eat and may require tube feedings

Outcomes

Since most deep neck infections are considered surgical emergencies, there are no randomized trials to determine the best procedure, antibiotic, or duration of treatment. The only definitive data is that surgery is recommended in almost all patients with neck abscess. The earlier the surgery, the better the outcomes. [12] [Level III]


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Neck Abscess - Questions

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Which of the following is the most frequent site of deep neck abscesses?



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Which of the following is NOT a potential sign of deep neck space infection?



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A 17-year-old male with a history of frequent sore throats presents with severe neck and throat pain, drooling, and trouble swallowing. His girlfriend states his voice sounds very different. Which of the following would be a reasonable antibiotic regimen to start for deep neck space abscess while waiting for a consult from otolaryngology?



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Which is not a safe option to secure a compromised airway?



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Which of the following is not true of the danger space of the neck?

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Attributed To: Contributed Illustration by Beckie Palmer



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A male is brought to the healthcare provider with severe throat pain. He recently had a dental procedure. Temperature 102.1 F, blood pressure is 110/82 mmHg, and the pulse is 101/min. The physical examination reveals left-sided neck swelling and torticollis. If left untreated, what deadly disease process may result from this condition?



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A male is brought to his healthcare provider with a sore throat. Her blood pressure is 82/52 mmHg, temperature 102.2 F, and the pulse is 112/min. The physical exam reveals right sided neck swelling and trismus. Which imaging modality can be performed for further evaluation of the patient's condition?



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A female with a history of diabetes is brought with severe neck pain, fever, and change in voice. Blood pressure is 112/72 mmHg, temperature 100.9 F, and the pulse is 102/min. The physical exam reveals poor dentition, cervical lymphadenopathy, but otherwise an unremarkable oropharyngeal exam. What is the most common cause of this patient's condition?



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A female is brought with a sore throat, neck swelling, and fever. Temperature is 102 F, the pulse is 110/min, and respiration is 24/min. The physical exam reveals an anxious appearing female who is drooling, has trismus, asymmetric neck swelling, and torticollis. What is the next step to manage this patient's condition?



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A male is brought with neck swelling and fever. The onset of symptoms was nine days ago. Temperature 102.3 F and pulse 123/min. Physical exam reveals right sided neck swelling and difficulty opening mouth due to pain. What else can be found on the physical exam as a consequence of delayed presentation of this patient's condition?



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Neck Abscess - References

References

Kim YY,Lee DH,Yoon TM,Lee JK,Lim SC, Parotid abscess at a single institute in Korea. Medicine. 2018 Jul     [PubMed]
Bansal AG,Oudsema R,Masseaux JA,Rosenberg HK, US of Pediatric Superficial Masses of the Head and Neck. Radiographics : a review publication of the Radiological Society of North America, Inc. 2018 Jul-Aug     [PubMed]
Alegbeleye BJ, Deep neck infection and descending mediastinitis as lethal complications of dentoalveolar infection: two rare case reports. Journal of medical case reports. 2018 Jul 7     [PubMed]
İsmi O,Yeşilova M,Özcan C,Vayisoğlu Y,Görür K, Difficult Cases of Odontogenic Deep Neck Infections: A Report of Three Patients. Balkan medical journal. 2017 Apr 5     [PubMed]
Mark R,Song S,Mark P, Taking heed of the 'danger space': acute descending necrotising mediastinitis secondary to primary odontogenic infection. BMJ case reports. 2018 May 30     [PubMed]
Jain A,Singh I,Meher R,Raj A,Rajpurohit P,Prasad P, Deep neck space abscesses in children below 5 years of age and their complications. International journal of pediatric otorhinolaryngology. 2018 Jun     [PubMed]
Argintaru N,Carr D, Retropharyngeal Abscess: A Subtle Presentation of a Deep Space Neck Infection. The Journal of emergency medicine. 2017 Oct     [PubMed]
García Callejo J,Redondo Martínez J,Civera M,Verdú Colomina J,Pellicer Zoghbi V,Martínez Beneyto MP, Management of thyroid gland abscess. Acta otorrinolaringologica espanola. 2018 Jun 8     [PubMed]
Ge XY,Liu LF,Lu C,Zhang AB,Wang ZX, [The diagnosis and treatment of neck abscess and mediastinal abscess following esophageal perforation induced by esophageal foreign body]. Lin chuang er bi yan hou tou jing wai ke za zhi = Journal of clinical otorhinolaryngology, head, and neck surgery. 2018 Feb     [PubMed]
Saluja S,Brietzke SE,Egan KK,Klavon S,Robson CD,Waltzman ML,Roberson DW, A prospective study of 113 deep neck infections managed using a clinical practice guideline. The Laryngoscope. 2013 Dec     [PubMed]
Boscolo-Rizzo P,Stellin M,Muzzi E,Mantovani M,Fuson R,Lupato V,Trabalzini F,Da Mosto MC, Deep neck infections: a study of 365 cases highlighting recommendations for management and treatment. European archives of oto-rhino-laryngology : official journal of the European Federation of Oto-Rhino-Laryngological Societies (EUFOS) : affiliated with the German Society for Oto-Rhino-Laryngology - Head and Neck Surgery. 2012 Apr     [PubMed]
Park MJ,Kim JW,Kim Y,Lee YS,Roh JL,Choi SH,Kim SY,Nam SY, Initial Nutritional Status and Clinical Outcomes in Patients with Deep Neck Infection. Clinical and experimental otorhinolaryngology. 2018 Jul 20     [PubMed]

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