Indian J Otolaryngol Head Neck Surg
(Jan–Mar 2015) 67(Suppl 1):S134–S137; DOI 10.1007/s12070-014-0802-7
ORIGINAL ARTICLE
Treatment and Prognosis of Deep Neck Infections
Seyyed Jafar Motahari • Rostam Poormoosa • Mehdi Nikkhah
Milad Bahari • Seyyed Mohsen Hosseini Shirazy •
Freshteh Khavarinejad
Received: 31 October 2014 / Accepted: 13 November 2014 / Published online: 27 November 2014
Ó Association of Otolaryngologists of India 2014
Abstract Deep neck infections could have serious threats
for life of patients, if not noticed adequately. Early diag-
nosis and correct treatment planning can save the patient’s
lives and prevent complications of disease extension and
also surgical procedures that in some instances may be
performed in an emergent situation with higher complica-
tion rates. Herein, we have studied 815 cases of deep neck
abscesses and infections with especial consideration to
treatment and prognosis. In a retrospective case review, we
studied 815 cases admitted in our medical center from 1998
until the year 2013. Only patients with abscesses or infec-
tions deeper than superficial layer of deep cervical fascia
were included in this study, based on the review of their
medical records. From 815 cases (485 males and 330
females) surgery was indicated and performed in 428 cases
and the rest were treated medically. In cases with dental
infections as the etiologic factor, dental procedures were
performed as early as possible (extraction in almost all
cases). Tracheostomy was performed in five cases. All of the
patients in medical treatment group and most of the surgi-
cally managed patients were discharged while were stable
with relative or complete resolution of their symptoms. One
of our patients, a 15 year old boy died with symptoms
suggestive for mediastinitis and air way compromise. Early
S. J. Motahari
R. Poormoosa
M. Nikkhah
Department of Otolaryngology, Mazandaran University
of Medical Sciences, Sari, Iran
M. Bahari (&)
S. M. H. Shirazy
Student Research Committee, Faculty of Medicine, Mazandaran
University of Medical Sciences, Sari, Iran
e-mail: miladbahari@ymail.com
F. Khavarinejad
Mazandaran University of Medical Sciences, Ghaemshahr, Iran
123
•
diagnosis and medical management can be effective in
treating deep neck infections. Dental infections and also
procedures are the major cause in our patients, although
tonsillitis and peritonsillar abscess also were important
leading causes with almost equal numbers in our series.
Extraction of the infected tooth as early as possible while
medical treatment is continued can be very helpful. In some
cases it may be necessary to perform surgical exploration of
the neck more than once, and finally, malignant neoplasia,
somewhere in the head and neck should be considered in
some cases, as in one of our patients with left side sub-
mandibular abscess whose underlying disorder was tongue
SCC with neck metastasis. Prognosis can be excellent in
both medically and surgically managed groups if started and
designed early and promptly.
Keywords Deep neck infection
Abscesses

Medical treatment
Surgical treatment
Introduction
Deep neck infections could have serious threats for life if
not noticed adequately. Most deep neck infections arise
from foci in the mucosal surfaces of the upper aerodigestive
tract or from a carious tooth [1]. Deep neck abscesses occur
in the potential spaces between the layers of deep cervical
fascia. Usually the results of cultures are polymicrobial but
as a whole, Streptococcus are the organisms most com-
monly cultured from deep neck abscesses [2].
In an immunocompromised patient, however other
uncommon organisms may be encountered [3]. Despite the
availability of antibiotics, deep neck space infections with
anaerobic germs (for example in Ludwig’s angina) still
Indian J Otolaryngol Head Neck Surg (Jan–Mar 2015) 67(Suppl 1):S134–S137 S135

carry the potential for significant morbidity and mortality Table 1 The spaces involved in cases of DNIs
with delayed treatment [4]. Space Number (%)
Although introduction of antibiotics and improvements
in oral hygiene have made deep neck infections occur less Submandibular 367 (45)
frequently today than in the past, but it is important to Peritonsillar 330 (40.5)
notice the patient because deep neck infections can cause Parapharyngeal 61 (7.5)
severe morbidity and also mortality [4]. Parotid 35 (4.3)
Early diagnosis and correct treatment planning can save Sublingual and submaxillary (Ludwig’s angina) 22 (2.7)
the patient’s life and prevent complications of disease
extension. Herein, we studied 815 cases of deep neck Table 2 Precipitating factors for DNIs
abscesses and infections with special considerations to
Precipitating factor Number (%)
treatment and prognosis. The aim of this study is to
determine the effectiveness of early and correct diagnosis Dental 286 (35.1)
and treatment of this serious threat of life, and also to Tonsillitis 247 (30.2)
present modalities involved in both medical and surgical Trauma
approaches. Nonsurgical 33 (4.1)
Surgical 17 (2.1)
Salivary stone and obstruction 25 (3.1)
Materials and Methods Branchial cyst 5 (0.6)
SCC of tongue 1 (0.1)
This was a retrospective study of all patients with diagnosis Unidentified 196 (24.1)
of the different kinds of deep neck space infections who
were admitted in Boo-Ali-Sina Hospital, a center of uni-
versity, in duration of 15 years (from 1998 until 2013). penetration in the oral cavity mucosa, and salivary stone. In
Only patients with abscesses or infections deeper than the 196 of our cases, no definitive or suggestive precipitating
superficial layer of deep cervical fascia were included in factor was identified.
this study. Information in the medical records, imagings or As precipitating systemic diseases, diabetes were seen in
reports by the radiologist, operation reports and other data 46 (5.6 %) and chronic renal failure (CRF) in 26 (3.1 %) of
were used to define the cases of deep neck infections and patients (Table 2).
include them in the study. CT scans of the neck had been In one of our patients, who had been presented with
performed in the majority of cases and the rest had con- submandibular abscess and severe trismus, after the initial
ventional radiographs. All patients were supervised or medical treatment with relative improvement of symptoms,
operated on by the authors. we found an ulcerated tumor in the tongue and metastatic
necrotic node in the submandibular space. The result of
biopsy and pathology report was SCC of the tongue.
Results Therefore, this rare presentation of a head and neck malig-
nancy should be considered in high risk patients with deep
Our survey found a total of 815 cases of deep neck neck infections.
infections. There were 485 (59.5 %) males and 330 Immediately after admission, medical management was
(40.5 %) females with average age of 26 ± 18.3 years at started. Treatment strategy was individualized for each
presentation (ranging from 5 months to 90 years). All patient (Table 3).
patients had fever at presentation. Perimandibular edema, High dose intravenous penicillin G, solely, or in combina-
pain in the involved region or in the neck, trismus, odyn- tion with metronidazole, or a combination of a cephalosporin
ophagia, dysphagia, shivering, respiratory distress and ot-
olgia were among other presenting symptoms in decreasing
Table 3 Kind of treatment of patients with DNIs
order. As is shown in Table 1, the most common involved
space was submandibular space (Table 1). Kind of treatment Number (%)
Dental infections were the most common etiologic fac- Medical 387 (47.5)
tor (see Table 2). Also, dental procedures were of impor- Surgical 428 (52.5) Neck exploration 290
tant and common factors. Tonsillitis and peritonsillar
Tooth extraction 158
abscess were the second most common leading cause in our
Tracheostomy 5
patients with only little difference. As is shown in Table 2,
Total 815
other underlying factors include trauma, foreign body

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S136 Indian J Otolaryngol Head Neck Surg (Jan–Mar 2015) 67(Suppl 1):S134–S137
(Ceftriaxone) and clindamycin used in the majority of patients
before the reports of sensitivity results. However, in some
patients with more serious problems, after infectious disease
consultation, other antibiotics were used in a number of
patients. Intravenous hydration and intensive care and control
of vital signs were performed in all patients. Five patients
underwent tracheostomy because of symptoms of airway
compromise. Any patient without improvement within
24–48 h of medical treatment underwent surgery. Surgical
exploration of the involved neck space was performed in 428
patients (we performed more than one procedure in some
patients). The rest of our patients completed treatment medi-
cally. It should be mentioned that in the medically and also
surgically treated patients with dental infections, extraction of
the diseased tooth was performed as soon as the patient’s
conditions permitted after starting treatment. Complications
were few (Table 4).
Unfortunately, one of our patients, a 15 years old boy
died with symptoms suggestive for mediastinitis. He had
been operated on his neck for parapharyngeal abscess a day
before and during the immediate post-surgical period, he
was stable and in relatively good condition. Nevertheless,
his conditions got suddenly aggravated and finally he died
before we could find any chance for operation.
Except this, respiratory problems in 63 patients and
airway obstruction leading us to perform tracheostomy in
five cases were other major complications. Other compli-
cations were not major and included bleeding after surgery
(four cases), transient marginal mandibular nerve paresis
(28 cases) and granulation tissue on the site of the incision.
No other vascular, neurologic, central, or systemic com-
plications had been occurred. One of the rare cases of SCC
of the tongue refused all of the proposed managements and
died about 2 months after the first presentation. The aver-
age period of hospitalization of patients was 5.2 days
(4.7 days in medical and 5.8 days in surgical treatment
groups).
All of the patients in medical treatment group and most
of the surgically managed patients were discharged while
were stable with resolution of their symptoms. Most of
our patients were followed for an average period of
8 weeks.
Table 4 Complications of DNIs
Complications Number
Morbidities
Airway obstruction (tracheostomy) 63 (5)
Transient marginal mandibular paresis 28
Scar and granulation tissue 17
Bleeding after operation 4
Mortality 1
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Discussion
Direct extension of infection through facial planes may
involve deep neck spaces (deeper than the superficial layer
of deep cervical fasciitis). Less commonly, such infections
are the result of perforation by foreign body or thrombo-
phlebitis [1].
Many vital organs are at risk of being involved and the
resultant respiratory, vascular, neurologic and systemic
complications endanger the life of the patient and if not
noticed in a well-timed manner, lead to death rapidly.
The major symptoms of infections in different deep neck
spaces are similar. In Ludwig’s angina, they include fever,
cervical pain, neck swelling, dysphagia and dyspnea, as in
parapharyngeal or submandibular space involvement [5].
However, when complications occur, specific signs and
symptoms could be found. Peritonsillitis and peritonsillar
abscess are commonly encountered emergencies in day to
day ENT practice [6], with just similar symptoms.
In one study, peritonsillar abscess is reported as the most
common deep neck infection in adolescents [7]. However,
usually odontogenic infections with involvement of the
submandibular space are the source of deep neck infections
in adults [4, 7].
Retropharyngeal infections, more commonly seen in
infants and young children may have different and confusing
symptoms with fever and restlessness at the initial phase.
Discovery of the underlying causative factors requires
imaging. The addition of CT to the initial work up provides
early detection of true underlying disease.
As is shown in Table 3, all of the medically treated
patients (47.5 % of cases) had deep neck cellulitis (fasci-
itis). In those with abscess formation in imaging studies
(52.5 % of cases) surgical interventions were performed.
Cross-sectional imaging is valuable in the evaluation of
abscess and the pathway of spread [1, 8]. However, in many
cases, a definite cause cannot be found. In our study, there
were 196 cases (24.1 %) in whom no definite cause was found.
Two main underlying factors were dental infections and ton-
sillitis (Table 2). An uncommon occurrence of acute retro-
pharyngeal abscess in an adult as a result of a retained foreign
body, (a large piece of wood impacted in neck in a road
accident) has reported [9]. Deep neck infections may be lethal
especially in immunocompromised hosts such as diabetic
patients. Unique features of DNIs in diabetic patients were as
older age, unclear source, involvement of multiple spaces and
higher complication rate, in a study. During the second half of
this century, intravenous drug abusers appeared as a new
group of patients at risk for DNIs [4, 10].
In six of our patients, the underlying cause of sub-
mandibular infection was SCC of the tongue, with necrotic
metastatic nodes in the submandibular space. In general,
malignancies presenting as abscesses are uncommon [11].
Indian J Otolaryngol Head Neck Surg (Jan–Mar 2015) 67(Suppl 1):S134–S137
There are reports of a neck abscess originating in meta-
static nodes from esophageal SCC and retropharyngeal
abscess in two cases of nasopharyngeal carcinoma [11, 12].
Deep neck infections require prompt treatment. After
taking a complete history, physical examination, fluid and
electrolyte resuscitation, laboratory and imaging studies,
medical treatment is initiated.
Treatment consists of ensuring adequate ventilation by
securing the airway, broad spectrum antibiotics, eradica-
tion of the source of infection, and if necessary, early
surgical decompression or drainage.
Initial antibiotics are administered before the culture
results have been obtained [5, 13]. High dose intravenous
penicillin G, combined with metronidazole, or a combi-
nation of ceftriaxone and clindamycin were very effective
in our study. Such combinations cover the oral mixed flora
responsible for DNIs. Penicillin would be the drug of
choice for aerobic Staphylococcus pyogenes, groups A, B,
C, G, and H Streptococcus and most Clostridia species.
Clindamycin will provide adequate therapy against anaer-
obes that are resistant to penicillin G. Gentamycin provides
antibiosis against most aerobic gram negative bacilli
including Pseudomonas aeroginosa [13].
When the clinical condition of the patient does not show
improvement during the first 24–48 h after initiation of
treatment (lowering of fever and decrease in severity of
trismus), or when fluctuation is noted, immediate and
extensive surgical treatment should be performed.
Different surgical techniques for neck exploration are
discussed here. It should be noted that anesthesia and airway
management may be difficult in these cases. A report of gush
of pus into the oral cavity and laryngospasm causing acute
upper airway obstruction is seen in the literature [14]. We
also have had critical and riskful times at the induction of
anesthesia in some of our emergency cases. Another clinical
point is about timing of tonsillectomy in patients with peri-
tonsillar abscess. Both ‘‘wait and observe’’ for a single iso-
lated attack of peritonsillar abscess, or surgery (quinsy or
delayed) are recommended [15]. We also performed tonsil-
lectomy after a delay of about 4 weeks, (or longer in some
patients) in all such cases. When an infection in the root of a
diseased tooth is the cause of a deep neck infection, extrac-
tion of the tooth should be performed as early as possible.
Finally, although malignant lymph node metastases
presenting as abscess are uncommon and have rarely been
described, a biopsy of the abscess wall is recommended.
Head and neck carcinoma should be considered in differ-
ential diagnosis of deep head and neck abscesses [13–15].
In this study, we considered 815 patients during a period
of 15 years. Our study revealed common and also rare
causes of deep neck infections. The prognosis among our
patients was good. Only one patient was expired, with
mortality rate of about 0.1 %.
S137
Conclusion
Early diagnosis and medical management can be effective
and lifesaving in deep neck infections. When there is a
dental source of infection, and while medical treatment is
continued, extraction of the infected tooth as early as
possible can be very helpful. However, when medical
management fails within the first 24–48 h, timely surgery
prevents extension of disease and life threatening compli-
cations. When fluctuance or complications occur, aggres-
sive surgical debridement should be performed.
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