Deep neck spaces

Within the deep neck are 11 spaces created by planes of greater and lesser resistance
between the fascial layers. These spaces may be real or potential and may expand
when pus separates layers of fascia. The deep neck spaces communicate with each
other, forming avenues by which infections may spread. These spaces are described
briefly.
Parapharyngeal space
o The parapharyngeal space (ie, lateral pharyngeal space, pharyngomaxillary
space, pterygomaxillary space, pterygopharyngeal space) occupies an
inverted pyramidal area bounded by multiple components of the fascial
system. The inferior limitation of this space is the lesser cornua of the hyoid
bone; the entire space is situated superiorly with respect to the hyoid. The
superior margin of the space is the skull base. Its medial boundary is the
visceral division of the middle layer of deep cervical fascia around the
pharyngeal constrictor and the fascia of the tensor and levator muscles of the
velum palatini and the styloglossus. Laterally, the space is defined by the
superficial layer of the deep cervical fascia that overlies the mandible, medial
pterygoids, and parotid.
o The posterior border is formed by the prevertebral division of the deep layer
and by the posterior aspect of the carotid sheath at the posterolateral corner.
The anterior boundary is the interpterygoid fascia and the pterygomandibular
raphe. The parapharyngeal space can be subdivided into compartments by a
line extending from the medial aspect of the medial pterygoid plate to the
styloid process.
o The internal maxillary artery, inferior alveolar nerve, lingual nerve, and
auriculotemporal nerve comprise the anterior (ie, prestyloid) compartment.
Infections in this compartment often give significant trismus.
o The posterior (ie, poststyloid) compartment contains the carotid sheath (ie,
carotid artery, internal jugular vein, vagus nerve) and the glossopharyngeal
and hypoglossal nerves, sympathetic chain, and lymphatics. It also contains
the accessory nerve, which is somewhat protected from pathologic processes
in this region by its position behind the sternocleidomastoid muscle.
o The parapharyngeal space connects posteromedially with the retropharyngeal
space and inferiorly with the submandibular space. Laterally, it connects with
the masticator space. The carotid sheath courses through this space into the
chest. This space provides a central connection for all other deep neck
spaces. It is directly involved by lateral extension of peritonsillar abscesses
and was the most commonly affected space before the advent of modern
antibiotics.
o Infections can arise from the tonsils, pharynx, dentition, salivary glands, nasal
infections, or Bezold abscess (ie, mastoid abscess).
o Medial displacement of the lateral pharyngeal wall and tonsil is a hallmark of
a parapharyngeal space infection. Trismus, drooling, dysphagia, and
odynophagia are also commonly observed.
Retropharyngeal space
 o The retropharyngeal space is sometimes considered a third medial
compartment within the parapharyngeal space because the 2 communicate
laterally. This space lies between the visceral division of the middle layer of
the deep cervical fascia around the pharyngeal constrictors and the alar
division of the deep layer of deep cervical fascia posteriorly. It extends from
the skull base to the tracheal bifurcation around T2 where the visceral and
alar divisions fuse. It primarily contains retropharyngeal lymphatics.
o Infection may enter this space directly, as with traumatic perforations of the
posterior pharyngeal wall or esophagus, or indirectly, from the
parapharyngeal space. More than 60% of retropharyngeal abscesses in
children are caused by upper respiratory tract infections, whereas most
infections in adults in this region are caused by trauma and foreign bodies.
Other common sources of infection in the retropharyngeal space are the
nose, adenoids, nasopharynx, and sinuses.
o Infections of this space may drain into the prevertebral space and follow that
space into the chest. Mediastinitis and empyema ensue. Abscess in this
space may push forward, occluding the airway at the level of the pharynx. It
may appear as anterior displacement of one or both sides of the posterior
pharyngeal wall because of involvement of lymph nodes, which are
distributed lateral to the midline fascial raphe.
o Retropharyngeal lymph nodes tend to regress by about age 5 years, making
infection in this space much more common in children than adults.
Prevertebral space
o The prevertebral space is located anterior to the vertebral bodies and
posterior to the prevertebral division of the deep layer of the deep cervical
fascia. It lies just posterior to the danger space (see below). Laterally, it is
bounded by the fusion of the prevertebral fascia with the transverse
processes of the vertebral bodies. It extends from the skull base to the
coccyx.
o The most common etiology of prevertebral abscesses (other than extension
from other sites) is trauma, particularly iatrogenic instrumentation.
Involvement of the vertebrae can lead to osteomyelitis and spinal instability.
Danger space
o The danger space is immediately posterior to the retropharyngeal space and
immediately anterior to the prevertebral space, between the alar and
prevertebral divisions of the deep layer of the deep cervical fascia. It extends
from the skull base to the posterior mediastinum and diaphragm. Laterally, it
is limited by the fusion of the alar and prevertebral division with the transverse
processes of the vertebrae. Some authors consider the danger space a
component of the prevertebral space.
o Infections in this region may be extensions of retropharyngeal,
parapharyngeal, or prevertebral infections.
o Spread within the danger space tends to occur rapidly because of the loose
areolar tissue that occupies this region. This spread can lead to mediastinitis,
empyema, and sepsis.
Masticator space
 o The masticator space is situated laterally to the medial pterygoid fascia and
medially to the masseter muscle. It is bounded by the sphenoid bone, the
posterior aspect of the mandible, and the zygomatic arch. It lies inferiorly to
the temporal space and is anterolateral to the parapharyngeal space. It
contains the masseter, pterygoids, ramus and body of the mandible,
temporalis tendon, and the inferior alveolar vessels and nerve.
o Infection in the masticator space may spread to the parapharyngeal, parotid,
or temporal space.
o Infections here may be a result of dental infections, particularly of the third
mandibular molars, and have reportedly occurred from removal of suspension
wires following reduction and fixation of facial fractures.
o Trismus is commonly seen in the initial presentation and may be a long-term
sequela.
Submandibular space
o The submandibular space is bounded inferiorly by the superficial layer of the
deep cervical fascia extending from the hyoid to the mandible, laterally by the
body of the mandible, and superiorly by the mucosa of the floor of mouth.
o It is considered to have 2 subdivisions, the sublingual and submaxillary
spaces, which are divided by the mylohyoid muscle. The sublingual space
contains the sublingual gland, hypoglossal nerve, and Wharton duct. It is in
continuity with the submaxillary space via the posterior margin of the
mylohyoid muscle, around which pus can readily tract. The submaxillary
division is further subdivided by the anterior belly of the digastric into a central
submental compartment and a lateral submaxillary space.
o Infection in the submandibular space may be secondary to oral trauma,
submaxillary or sublingual sialadenitis, or dental abscess of mandibular teeth.
o The term Ludwig angina describes inflammation and cellulitis of the
submandibular space, usually starting in the submaxillary space and
spreading to the sublingual space via the fascial planes, not the lymphatics.
As the submandibular space is expanded by cellulitis or abscess, the floor of
the mouth becomes indurated, and the tongue is forced upward and
backward, causing airway obstruction. Ludwig angina does not require the
presence of a focal abscess. It typically includes bilateral involvement and
manifests with drooling, trismus, pain, dysphagia, submandibular mass, and
dyspnea or airway compromise caused by displacement of the tongue. This is
a life-threatening condition that requires tracheostomy for airway control.
Before antibiotics, the mortality rate of Ludwig angina was 50%. With modern
antimicrobial and surgical therapies, the mortality rate is less than 5%.
o Submandibular space infections may spread to the parapharyngeal space or
retropharyngeal space.
Carotid space
o The carotid (ie, visceral vascular) space is a potential space within the carotid
sheath containing the carotid artery, internal jugular vein, vagus nerve, and
sympathetic postganglionic fibers.
o This space may be affected indirectly from spread of infection from the
surrounding parapharyngeal space or directly by injection of drugs in those
 who abuse IV drugs. The resulting jugular vein thrombophlebitis sends septic
emboli to the heart and lungs. The carotid artery may thrombose, form an
aneurysm, or erode and rupture. Horner syndrome may occur because of
involvement of the cervical sympathetics in this space.
o Treatment may include anticoagulation and possibly the ligation of involved
vessels.
Pretracheal space
o The pretracheal (ie, anterior visceral) space is enclosed by the visceral
division of the middle layer of the deep cervical fascia and lies immediately
anterior to the trachea. It extends from the thyroid cartilage to the superior
mediastinum.
o Infections here are most commonly caused by perforation of the anterior
esophageal wall by endoscopic instrumentation, foreign bodies, or trauma.
o Infections cause dysphagia and odynophagia, pain, fever, and possible
hoarseness and airway obstruction.
Peritonsillar space
o This space is bounded by the tonsil medially and the superior constrictor
laterally. The anterior and posterior tonsillar pillars form the remaining borders
of this space.
o Peritonsillar abscesses are the most common deep neck space abscess and
represent a sequela of tonsillar infections.
o Individuals with peritonsillar abscesses typically exhibit trismus, pain,
odynophagia, drooling, a "hot potato" voice, and fever. They demonstrate
uvular deviation, palatal asymmetry, and displacement of the tonsil medially.
Note that the tonsillar erythema and exudates may be mild despite the
presence of an abscess.
o Patients who have had their tonsils removed effectively lose this space, but
they can still develop peritonsillar pathology.
o Peritonsillar abscesses are most commonly managed by incision and
drainage or by needle aspiration. Most commonly, interval tonsillectomy is
performed 4-12 weeks after resolution of the infection.
o Peritonsillar abscesses may spread to the parapharyngeal space if not
addressed promptly.
Parotid space
o The parotid space is enclosed by the superficial layer of the deep cervical
fascia. This is an incomplete enclosure because the superomedial aspect of
the gland is not covered. This discontinuity allows communication between
the parapharyngeal space and the parotid space.
o The parotid space is crossed by the external carotid artery, the posterior facial
vein, and the facial nerve.
o Infections in the parotid space often occur in dehydrated, debilitated patients
with poor oral hygiene who develop salivary duct obstruction.
o Pain, edema, and erythema in the region of the parotid are typically observed
with fever. Trismus is a later finding.
Temporal space
 o The temporal space lies between the temporalis fascia and the periosteum of
the temporal bone, and it contains the internal maxillary artery and the inferior
alveolar artery and nerve. The temporalis muscle effectively divides the space
into a deep and superficial compartment.
o Abscesses in this region are characterized by pain and trismus and may
exhibit deviation of the mandible.
o Incision and drainage may be accomplished by an approach 3 cm lateral to
the lateral canthus or by a horizontal brow incision.
Etiology
Before the widespread use of antibiotics, 70% of deep neck space infections
were caused by spread from tonsillar and pharyngeal infections. Today,
tonsillitis remains the most common etiology of deep neck space infections in
children, whereas odontogenic origin is the most common etiology in
adults. [2, 3, 4, 5] Causes of deep neck infections include the following:
Tonsillar and pharyngeal infections
Dental infections or abscesses
Oral surgical procedures or removal of suspension wires
Salivary gland infection or obstruction
Trauma to the oral cavity and pharynx (eg, gun shot wounds, pharynx
injury caused by falls onto pencils or Popsicle sticks, esophageal
lacerations from ingestion of fish bones or other sharp objects)
Instrumentation, particularly from esophagoscopy or bronchoscopy
Foreign body aspiration
Cervical lymphadenitis
Branchial cleft anomalies
Thyroglossal duct cysts
Thyroiditis
Mastoiditis with petrous apicitis and Bezold abscess
Laryngopyocele
IV drug use [6]
Necrosis and suppuration of a malignant cervical lymph node or mass
As many as 20-50% of deep neck infections have no identifiable source.
Other important considerations include patients who are immunosuppressed
because of human immunodeficiency virus (HIV) infection, chemotherapy, or
immunosuppressant drugs for transplantation. These patients may have
increased frequency of deep neck infections and atypical organisms, and they
may have more frequent complications.
A retrospective study by Alotaibi et al indicated that in patients with
odontogenic infection, criteria for hospital admission based on a risk of deep
neck space infection should include not just the well-known risk signsfever,
trismus, leukocytosis, swollen neck, dysphagia, dyspnea, and elevated C-
reactive protein levelsbut also the presence of mandibular (as opposed to
maxillary) odontogenic infection and/or dental abscess. The study included a
cohort of 97 patients. [7]

Pathophysiology
Deep neck space infections can arise from a multitude of causes. Whatever
the initiating event, development of a deep neck space infection proceeds by
one of several paths, as follows:
Spread of infection can be from the oral cavity, face, or superficial neck to
the deep neck space via the lymphatic system.
Lymphadenopathy may lead to suppuration and finally focal abscess
formation.
Infection can spread among the deep neck spaces by the paths of
communication between spaces.
Direct infection may occur by penetrating trauma.
Once initiated, a deep neck infection can progress to inflammation and
phlegmon or to fulminant abscess with a purulent fluid collection. This
distinction is important because the treatment of these 2 entities is very
different.
The signs and symptoms of a deep neck abscess develop because of the
following:
Mass effect of inflamed tissue or abscess cavity on surrounding
structures
Direct involvement of surrounding structures with the infectious process
For example, tonsillitis may lead to peritonsillar abscess. If not treated
successfully, peritonsillar abscess may spread to the lateral pharyngeal
space. From there, infection spreads to the posterior pharyngeal and
prevertebral spaces and into the chest. Mediastinitis and empyema may
ensue, leading to death. Alternatively, infection may spread from the lateral
pharyngeal space to the contents of the carotid sheath, leading to internal
jugular vein thrombosis, subacute bacterial endocarditis, pulmonary emboli,
carotid artery thrombosis and cerebrovascular insufficiency, or Horner
syndrome. Lateral pharyngeal space abscess alone may cause airway
obstruction at the level of the pharynx. Ungkanont et al reviewed 117 children
treated for deep neck infections during a 6-year period. [8] The following
distribution results were revealed:
Peritonsillar infections (49%)
Retropharyngeal infections (22%)
Submandibular infections (14%)
Buccal infections (11%)
Parapharyngeal space infections (2%)
 Canine space infections (2%)
The microbiology of deep neck infections usually reveals mixed aerobic and
anaerobic organisms, often with a predominance of oral flora. Both gram-
positive and gram-negative organisms may be cultured. Group A beta-
hemolytic streptococcal species (Streptococcus pyogenes), alpha-hemolytic
streptococcal species (Streptococcus viridans, Streptococcus
pneumoniae), Staphylococcus aureus, Fusobacterium nucleatum, Bacteroides
melaninogenicus, Bacteroides oralis, and Spirochaeta,
Peptostreptococcus, and Neisseria species often are found together in various
combinations. Pseudomonas species, Escherichia coli, and Haemophilus
influenzae are occasionally encountered.
A German study, by Cordesmeyer et al, of 63 patients with deep neck space
infections, found Streptococcus viridans to be the most prevalent aerobic
gram-positive pathogen to be isolated (26.7% of infections),
with Staphylococcus epidermidis and Staphylococcus aureus each being
isolated in 16.7% of infections. Among the aerobic gram-negative
pathogens, Escherichia coli, Klebsiella oxytoca, and Haemophilus
influenzae were the most frequently isolated. Malignancy was found in 1.6%
of patients. [9]
A study by Asmar of retropharyngeal abscess microbiology demonstrated
polymicrobial culture results in almost 90% of patients. [10] Aerobes were found
in all cultures, and anaerobes were found in more than 50% of patients. Other
studies have shown an average of at least 5 isolates from cultures.
May et al found evidence that biofilm phenotypes may be associated with the
pathogenesis of deep neck infections, as well as with the recalcitrance to
treatment experienced with larger deep neck abscesses. The investigators
obtained biopsy samples from abscess walls located in the deep neck spaces
of 14 patients undergoing surgical drainage. Scanning electron microscopy
revealed that 12 of the 14 tissue samples contained biofilm imbedded with
rod- and cocci-shaped bacteria.[11]

Presentation
Obtain a detailed history from patients in whom deep neck space infection is
suspected. Eliciting a history of the following is important:
Pain
Recent dental procedures
Upper respiratory tract infections (URTIs)
Neck or oral cavity trauma
Respiratory difficulties
Dysphagia
 Immunosuppression or immunocompromised status
Rate of onset
Duration of symptoms
Physical examination should focus on determining the location of the infection,
the deep neck spaces involved, and any potential functional compromise or
complications that may be developing. A comprehensive head and neck
examination should be performed, including examination of the dentition and
tonsils. The most consistent signs of a deep neck space infection are fever,
elevated WBC count, and tenderness. Other signs and symptoms largely
depend on the particular spaces involved and include the following:
Asymmetry of the neck and associated neck masses or
lymphadenopathy, which is present in almost 70% of pediatric
retropharyngeal abscesses according to a study by Thompson and
colleagues
Medial displacement of the lateral pharyngeal wall and tonsil caused by
parapharyngeal space involvement
Trismus caused by inflammation of the pterygoid muscles
Torticollis and decreased range of motion of the neck caused by
inflammation of the paraspinal muscles
Fluctuance that may not be palpable because of the deep location and
the extensive overlying soft tissue and muscles (eg, sternocleidomastoid
muscle)
Possible neural deficits, particularly of the cranial nerves (eg, hoarseness
from true vocal cord paralysis with carotid sheath and vagal involvement),
and Horner syndrome from involvement of the cervical sympathetic chain
Regularly spiking fevers (may suggest internal jugular vein
thrombophlebitis and septic embolization)
Tachypnea and shortness of breath (may suggest pulmonary
complications and warn of impending airway obstruction)

Laboratory Studies
See the list below:
A high index of suspicion is important when diagnosing a deep neck
space infection. A careful history and physical examination (see Clinical)
are critical to the workup. In addition, tests, including the following, may
be useful in the workup of a patient in whom a deep neck space infection
is suspected:
o Blood chemistries
o Complete blood cell count
 o Clotting profile (particularly important in patients who require surgical
drainage)
o Blood cultures (may be indicated in septic patients)
o Abscess cultures with Gram stains (critical to direct antimicrobial
therapy)

Imaging Studies
See the list below:
Lateral neck radiography
o These tests may reveal soft tissue swelling in the prevertebral region.
Lateral neck radiographs can also demonstrate radiopaque foreign
bodies, subcutaneous air, air fluid levels, and erosion of the vertebral
bodies.
o Prevertebral soft tissue thickening greater than 7 mm over C2 or
greater than 14 mm in children and 22 mm in adults over C6 is highly
suggestive of a retropharyngeal process.
Mandible series
o When a dental source of the infection is suggested, a Panorex can
help evaluate the patient for a dental abscess.
o Particular attention should be given to the second and third
mandibular molars because the apices of these teeth extend below
the mylohyoid line, giving them access to the submandibular space.
Chest radiography: To evaluate the mediastinum, check for
subcutaneous air or pneumomediastinum, displacement of the air stripe,
or concurrent pneumonia suggesting aspiration.
CT scanning
o CT scans with contrast are the gold standard in evaluation of deep
neck infections. The importance of CT scanning is highlighted in a
study by Crespo et al, who found that clinical examination alone
underestimated the extent of deep neck space infections in 70% of
patients. CT scans indicate the location, boundaries, and relation of
infection to surrounding neurovascular structures. Abscesses are
seen as low-density lesions with rim enhancement, occasional air
fluid levels, and loculations (see the images below). A study by Kirse
and Roberson also notes the association between irregularity of the
abscess wall on CT as predictive of pus within the cavity. [12] CT
scans are fast, relatively inexpensive, and fairly widely available
today. CT scanning of the chest may be helpful if extension into the
mediastinum is suspected.
 CT scan of the neck
demonstrating left peritonsillar abscess.

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 Right lateral
pharyngeal (parapharyngeal) abscess as seen on CT scan. Note the
medial extension in the retropharyngeal area.

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 Same patient as in the
previous image. Lower cut CT scan showing the abscess cavity. The
rim enhancement and partial loculation are well demonstrated.

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o A prospective, blinded study of the effectiveness of CT scanning in

diagnosing deep neck infections in adults over the age of 18 showed
that CT scan with contrast is 95% sensitive and 53% specific for
distinguishing a drainable fluid collection. When CT findings were
combined with clinical exam findings, the sensitivity remained about
95%, but the specificity increased to about 80%. The data regarding
the utility of CT scans in diagnosing deep neck infections in children
are not as clear as in adults.
MRI: Because of the increased time and expense involved in obtaining an
MRI result, MRI is not the initial modality of choice. However, when
obtained, MRI scans can give excellent soft tissue resolution to help
localize the region of involvement.
Ultrasound: Ultrasounds do not reveal anatomic details but can help
distinguish between phlegmon and abscess, give information about the
condition of surrounding vessels, and guide fine-needle aspiration (FNA)
attempts.
 Arteriography: This may be helpful when carotid, jugular, or innominate
involvement is suggested.

Medical Therapy

Airway
The airway is the first priority of treatment. [13] Addressing the airway may
involve observation, endotracheal or nasotracheal intubation, tracheostomy,
or cricothyroidotomy for emergent situations.
Even in experienced hands, attempted oral or nasal endotracheal intubation in
a patient with a deep neck space infection or abscess may be extremely
difficult. The larynx and vocal cords may be difficult to visualize because of
swollen pharyngeal walls and laryngeal displacement. Instrumentation can
cause additional swelling. The potential exists for abscess rupture with
intubation leading to aspiration, acute airway obstruction, or death. Other
factors (eg, tracheal deviation, external airway compression, trismus, cervical
spine rigidity) can produce difficulty with intubation.
Patients presenting with impending respiratory distress should undergo a
tracheostomy while under local anesthesia to secure a safe airway. A
tracheostomy is safer, more conservative, and preferable to the development
of respiratory compromise. Tracheostomy should be performed before any
attempts at surgical drainage in these patients.
Cultures
See the list below:
Obtain cultures whenever possible to help direct antimicrobial therapy.
This may involve cultures of the neck, abscess fluid, and blood.

Volume and metabolic resuscitation

See the list below:
Initiate these procedures in all patients with deep neck infection.
Identify and address metabolic derangements during resuscitation.
Address attention to other concurrent medical problems (eg, diabetes)
early in the course of treatment.
Intravenous antibiotics
See the list below:
Choose parenteral antibiotics to cover the most likely organisms.
Initiate empiric regimens before culture results are obtained based on the
local resistance patterns and most common etiologies.
 Cover gram-positive and gram-negative organisms and aerobic and
anaerobic bacteria, including beta-lactamase producing organisms.
Modify antibiotics according to culture and sensitivity results.
A review of deep neck infections by Broughton indicated that 50% of
deep neck infections can be managed nonsurgically in patients with small
fluid collections and no respiratory compromise. Other studies by Plaza
and McClay support the option of primary nonsurgical management for
selected deep neck space abscesses, reserving surgical drainage for
patients who do not improve within 48 hours of initiation of broad-
spectrum intravenous antibiotics. [14, 15]Most of these studies focus on
retropharyngeal and parapharyngeal space abscesses.
A review of current practices by Lalakea and Messner indicated that 60%
of pediatric otolaryngologists recommend a trial of IV antibiotics before
incision and drainage in selected pediatric patients with retropharyngeal
abscesses. [16]According to this review, clindamycin, ampicillin/sulbactam,
and cefuroxime are currently the most commonly used antibiotics.
IV antibiotics are administered until the patient is clinically improving and
has been afebrile for at least 48 hours. After completion of an IV course
of antibiotics, oral antibiotics are given.
Surgical Therapy

Incision and drainage

Incision and drainage is the cornerstone of therapy for the treatment of deep
neck space abscesses. Establish a secure airway before initiating any surgical
procedure.
Perform incision and drainage for any frank abscess in patients with
impending complications because of abscess formation and in patients with
no improvement after 48-72 hours of IV antibiotics.
Most deep neck spaces require a transcervical approach to facilitate adequate
exposure of the abscess and for protection of the surrounding neurovascular
structures. A study by Cable et al describes the successful use of image-
guided surgical drainage of medial parapharyngeal space abscesses in the
pediatric population to help localize infections in areas that are otherwise
difficult to reach.[17] A study by Dabirmoghaddam et al indicated that
ultrasonographically guided drainage of deep neck space abscesses leads to
shorter hospital stays than does incision and drainage, with the mean hospital
stay for the ultrasonography patients in the study being 5.47 days, compared
with 9.70 days for those who were treated with incision and drainage. [18]
Approach retropharyngeal abscesses by a transoral route when the abscess
is small and focal. This approach requires attention to the airway to prevent
aspiration of pus once the abscess cavity is entered.
Quinsy tonsillectomy or tonsillectomy performed with infection in the
peritonsillar space is controversial treatment for peritonsillar abscesses.
Historically, tonsillectomy during acute infection was avoided because of
concern about increased risk of postoperative hemorrhage. Several recent
studies, such as those by Ungkanont et al and Dodds and Maniglia, suggest
no increased morbidity from this procedure. [8, 19]
Many approaches are possible to the deep neck spaces. Description of the
surgical incisions and technique of drainage is beyond the scope of this
article. Every approach used must ensure adequate exposure and access to
allow drainage without compromising surrounding structures. Abscess cavities
should be copiously irrigated, dbrided, and left open with a drain or packing
to prevent reaccumulation. Once an abscess has been entered, cultures
should be obtained to help direct antimicrobial therapy.
Needle aspiration
FNA may be used in patients with small easily reachable abscesses or in
patients who are too unstable to undergo general anesthesia. This procedure
may require the assistance of CT scanning or ultrasound guidance. It may
provide preliminary culture specimens before formal incision and drainage.
Preoperative Details
The most important preoperative considerations are stabilization of the airway,
volume and metabolic resuscitation, and initiation of antibiotics.
Intraoperative Details
Many possible surgical approaches to the deep neck spaces can be used.
The approach used depends on the precise location of the abscess, the size
of the collection, and its relation to the great vessels and other important
anatomic structures of the neck.
Postoperative Details
Postoperatively, closely observe the patient for signs of a response to therapy.
Reaccumulation of fluid must be recognized and treated with appropriate
drainage procedures. Cultures and sensitivities must be monitored, and
antibiotics must be tailored appropriately. The patient's airway must also be
monitored closely for signs of obstruction. Finally, the patient must be
monitored for signs of impending complications (see Complications).
Follow-up
Follow-up care for patients who have had a deep neck space infection
consists of monitoring the complete resolution of the infection. Surgical sites
must be monitored for complete healing and to ensure that reaccumulation of
an abscess does not occur. Any question of redevelopment of an infection
warrants re-imaging and possible reexploration.
Complications
Deep neck infections have many severe life-threatening potential
complications. Deep neck infections that are not treated or are inadequately
treated, those that extend to other deep neck spaces, and those that are
complicated by a delay in diagnosis and treatment are at particular risk of
complications, including the following:
Airway obstruction from compression of the trachea
Aspiration
o This is particularly due to perforation of a retropharyngeal abscess
with drainage of pus into the airway.
o Aspiration may occur spontaneously or during endotracheal
intubation.
Vascular complications (ie, thrombosis of the internal jugular vein, carotid
artery erosion and rupture)
Mediastinitis from inferior spread along fascial lines
Neurologic deficits: Cranial nerve dysfunction or dysfunction of the
autonomic nerves in the neck can lead to problems such as hoarseness
from involvement of the vagus in the carotid sheath or Horner syndrome
from involvement of the sympathetic chain.
Septic emboli: These emboli can lead to pulmonary, brain, or joint
seeding and resultant abscesses.
Septic shock
Necrotizing cervical fasciitis: This is a fulminant infection involving
necrosis of the connective tissue that spreads via fascial planes. It has
particularly high morbidity and mortality rates.
Osteomyelitis due to local spread to bones of the spine, mandible, or skull
base
Grisel syndrome (ie, inflammatory torticollis causing cervical vertebral
subluxation)
Several studies have looked at factors that may cause an increase in the risk
of complications from deep neck space infections. One study by Wang et al
found a higher risk of complications in females, patients with neck swelling,
and patients with associated respiratory symptoms. Another study by Huang
et al suggests that diabetes and the presence of other underlying systemic
diseases significantly increases the risk of complications. [20] This finding was
supported in a study by Chen et al, who found that not only did diabetes
correlate with a higher complication rate but that it was also associated with a
more severe clinical course involving more than one deep neck space and a
longer hospitalization. [21]
Using multivariate statistical analysis of 282 cases of deep neck infection,
Staffieri et al concluded that in patients with such infections, the involvement
of more than 1 neck space was the only significant independent prognostic
factor for related complications. According to the study, the following factors
were associated with long hospital stays [22] :
Presence of comorbidities
Nonodontogenic sites of origin
Leukocyte counts above 11.0 cells 10 9/L at presentation
Need for both medical and surgical treatments
Outcome and Prognosis
Patients treated for deep neck infections can be expected to fully recover as
long as the infection is treated properly and in a timely manner. Patients
whose treatment is delayed can expect a greater number of complications and
a prolonged course of recovery. Once a deep neck infection has fully
resolved, no particular predisposition exists for recurrence.
Future and Controversies
The greatest controversy regarding deep neck infections concerns whether all
deep neck abscesses require surgical treatment or whether some abscesses
can be treated medically. As previously discussed, articles by Broughton and
Lalakea and Messner suggest that in selected cases involving patients with no
signs of respiratory distress or other impending complications, some small
deep neck abscesses can be treated with a trial of IV antibiotics alone,
particularly in children.[16, 23] Surgical therapy can be reserved for patients
whose symptoms do not respond within 48 hours. However, this issue is still
being debated in the literature, and clinical judgment must be used with each
individual patient.