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Deep Neck Infections
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Author: Alan D Murray, MD; Chief Editor: Arlen D Meyers, MD, MBA more...
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Overview
Workup
Treatment
Updated: Mar 28, 2014
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Background
History of the Procedure
Problem
Epidemiology
Etiology
Pathophysiology
Presentation
Relevant Anatomy
Contraindications
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Multimedia Library
References
Background
For centuries, the diagnosis and treatment of deep neck space infections have challenged
physicians and surgeons. The complexity and the deep location of this region make diagnosis
and treatment of infections in this area difficult. These infections remain an important health
problem with significant risks of morbidity and mortality. See the image below.
CT scan of the neck demonstrating left peritonsillar abscess.
See 10 Patients with Neck Masses: Identifying Malignant versus Benign, a Critical Images
slideshow, to help identify several types of masses.
History of the Procedure
In the past, infections of the deep neck spaces were associated with high rates of morbidity and
mortality. The overwhelming complication rate of the past has been reduced with the advent of
modern microbiology and hematology, the development of sophisticated diagnostic tools (eg,
CT, MRI), the effectiveness of modern antibiotics, and the continued development of medical
intensive care protocols and surgical techniques.
Problem
Infections of the deep neck spaces present a challenging problem for the following reasons:
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Complex anatomy: The anatomy of the deep neck spaces is highly complex and can make
precise localization of infections in this region difficult.
Deep location: The deep neck spaces are located deep within the neck. This makes
diagnosis of infections difficult because they are often covered by a substantial amount of
unaffected superficial soft tissue. Deep neck infections may be difficult to palpate and
impossible to visualize externally.
Access: Superficial tissues must be crossed to gain surgical access to the deep neck
spaces, placing all of the intervening neurovascular and soft tissue structures at risk of
injury.
Proximity: The deep neck spaces are surrounded by a network of structures that may
become involved in the inflammatory process. Neural dysfunction, vascular erosion or
thrombosis, and osteomyelitis are just a few of the potential sequelae that can occur with
involvement of surrounding nerves, vessels, bones, and other soft tissue.
Communication: The deep neck spaces have real and potential avenues of
communication with each other. Infection in one space can spread to adjacent spaces,
thus gaining access to increasingly larger portions of the neck. In addition, certain deep
neck spaces extend to other portions of the body (eg, mediastinum, coccyx), placing areas
outside of the head and neck at risk of involvement when these spaces are involved.
Epidemiology
Frequency
No accurate estimate of the frequency of deep neck space infections in the United States or
worldwide presently exists. However, to assume that the incidence of infection in the United
States is significantly lower than that of countries in which patients do not benefit from early
medical intervention is reasonable. The complication rate is also likely to be greater in areas
without wide access to modern medical treatment, including antibiotics, imaging modalities, and
intensive care support.
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.[1, 2, 3, 4] Causes of deep neck infections include the following:
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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 [5]
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.
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:
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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:
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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.[6] The following distribution results were revealed:
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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 study by Asmar of retropharyngeal abscess microbiology demonstrated polymicrobial culture
results in almost 90% of patients.[7] 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.[8]
Presentation
Obtain a detailed history from patients in whom deep neck space infection is suspected. Eliciting
a history of the following is important:
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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:
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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)
Relevant Anatomy
A detailed anatomic description of the major facial and deep neck spaces is beyond the scope of
this article. However, a thorough knowledge of this anatomy is necessary for accurate diagnosis
and treatment of these infections. The deep neck spaces are formed by fascial planes, which
divide the neck into real and potential spaces.
Fascial planes
Two main fascial divisions exist, the superficial cervical fascia and the deep cervical fascia.
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Superficial cervical fascia: The superficial fascia, which lies just deep to the dermis,
surrounds the muscles of facial expression. It includes the superficial musculoaponeurotic
system (SMAS) and extends from the epicranium to the axillae and chest. The space deep
to this layer contains fat, neurovascular bundles, and lymphatics. It does not constitute
part of the deep neck space system.
Deep cervical fascia: The deep cervical fascia encloses the deep neck spaces and is
further divided into 3 layers, the superficial, middle, and deep layers of the deep cervical
fascia.
o The superficial layer of the deep cervical fascia is an investing fascia that
surrounds the neck. It encompasses the sternocleidomastoid muscle, trapezius,
muscles of mastication, and submandibular and parotid glands. It is limited
superiorly by the nuchal ridge, mandible, zygoma, mastoid, and hyoid bones.
Inferiorly, it is bounded by the clavicles, sternum, scapula, hyoid, and acromion.
It contributes to the fascia covering the digastric muscle and to the lateral aspect
of the carotid sheath. In its course from the hyoid bone to the medial table of the
ramus of the mandible, it envelops the anterior belly of the digastric muscle and
forms the floor of the submandibular space. Laterally, this fascia helps to define
the parotid and masticator spaces.
o The middle layer of the deep cervical fascia has 2 divisions, muscular and
visceral. The muscular division surrounds the strap muscles (ie, sternohyoid,
sternothyroid, thyrohyoid, omohyoid) and the adventitia of the great vessels. The
visceral division surrounds the constrictor muscles of the pharynx and esophagus
to create the buccopharyngeal fascia and the anterior wall of the retropharyngeal
space. Both the muscular and visceral divisions contribute to the formation of the
carotid sheath. The middle layer also envelops the larynx, trachea, and thyroid
gland. It attaches to the base of the skull superiorly and extends inferiorly as low
as the pericardium via the carotid sheath.
o The deep layer of the deep cervical fascia is also subdivided into 2 divisions,
prevertebral and alar. The prevertebral division adheres to the anterior aspect of
the vertebral body and extends laterally to the transverse processes of the
vertebrae. The alar division lies between the prevertebral division and the visceral
division of the middle layer and defines the posterior border of the
retropharyngeal space. It surrounds the deep neck muscles and contributes to the
carotid sheath. Posteriorly, the muscular division of the middle layer of the deep
cervical fascia fuses with the alar division of the deep layer of the deep cervical
fascia at the level of thoracic vertebrae 1-2 (T1-T2).
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.
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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
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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.
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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.
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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.
Contraindications
No absolute contraindications to surgical drainage of deep neck space infections exist. However,
for patients experiencing airway compromise from the infection, the need to establish a safe
airway takes priority and should be addressed before initiating any other surgical procedures.
Once the airway has been secured, the surgical drainage procedure can be performed.
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