Deep neck infections

Diagnostic approach

• ABCDE survey
• Targeted clinical evaluation
• CBC
• BMP
• Blood cultures
• Bacterial culture of abscess aspirate
• CT neck with IV contrast

Red flag features

• Clinical features of sepsis
• Signs of respiratory distress
• Signs of airway obstruction
• Trismus
• Torticollis

Management checklist

• Perform emergency airway management of deep neck infections.
• Start empiric antibiotic therapy for deep neck infections.
• Consider corticosteroids (e.g., dexamethasone ).
• Provide supportive care (e.g., pain management, antipyretic therapy, IV fluid therapy).
• Consult ENT and/or oral maxillofacial surgery for abscess drainage.
• Consult dentistry for abscesses with an odontogenic source.

Deep neck infections include peritonsillar abscess, parapharyngeal abscess (PPA), and retropharyngeal abscess (RPA). While uncommon, deep neck infections are clinically significant because of their potentially life-threatening complications, including the spread of infection to vital nearby structures and airway compromise. Consultation with airway specialists is recommended if there are clinical features of airway compromise. Early recognition, aggressive airway management, broad-spectrum IV antibiotic therapy, and urgent ENT consultation for abscess drainage and/or other surgical interventions reduce the risk of complications and death from sepsis or airway compromise.

Anticipate a difficult airway as a result of anatomical distortion caused by the infection. ^[4][5]

• Assess the airway: Check for signs of airway compromise.
• If the airway must be secured: Consult an airway specialist urgently.
  • Preferred method: awake fiberoptic intubation in the operating room ^[4][6]
  • Prepare for a difficult intubation, e.g., ensure intubation adjuncts are immediately available.
  • Exercise caution with direct laryngoscopy, as it can precipitate airway compromise. ^[5]
  • Anticipate the need for an emergency surgical airway; see “Cricothyrotomy” for detailed procedural guidance. ^[5]
• No immediate concern for airway compromise: Reassess the airway regularly.

Direct laryngoscopy can worsen airway edema, rupture the abscess, and/or precipitate complete airway obstruction.

Peritonsillar abscess, also known as quinsy, is the most common deep neck infection.

Epidemiology ^[3]

• Most frequently occurs in adults aged 20–40 years
• Increased risk of airway obstruction in children with peritonsillar abscess

Etiology ^[7][8]

• Pathogens: Streptococcus pyogenes (most common), Streptococcus anginosus, viridans streptococci, Staphylococcus aureus, and Haemophilus species, often in a polymicrobial environment
• Acute bacterial tonsillitis (see acute tonsillitis)

Clinical features ^[8][9]

• Features of tonsillitis: fever, malaise, severe sore throat, dysphagia, and odynophagia
• “Hot potato” voice (muffled speech), drooling, or halitosis
• Trismus
• Uvula shifted to the contralateral side, with inferior and medial displacement of tonsil
• Unilateral fluctuant, swollen, erythematous tonsil with exudates (ipsilateral bulging of the palatine arch)
• Ipsilateral ear pain
• Ipsilateral cervical lymphadenopathy (and neck swelling)

Palpate with a gloved index finger for peritonsillar fluctuance to distinguish an abscess from cellulitis. ^[10]

Diagnostics ^[3][11]

Peritonsillar abscess is typically a clinical diagnosis; obtain imaging if there is diagnostic uncertainty and/or concern for complications.

Microbiological studies

• Bacterial culture of abscess aspirate can help to direct therapy for the causative pathogen.
• Obtain a rapid group A streptococcus antigen detection test. ^[12]
• Consider obtaining EBV serology to rule out infectious mononucleosis.

Evidence of pus on needle aspiration confirms the diagnosis.

Imaging ^[3]

• Ultrasound neck (intraoral or transcutaneous) ^[13]
  • Indication: diagnostic uncertainty
  • Findings: irregular hypoechoic cavity with a defined circumference
• CT or MRI neck with IV contrast ^[14]
  • Indication: clinical suspicion of other diagnoses or complications
  • Findings
    • Fluid collection adjacent to tonsil with rim enhancement
    • Uvula deviation
    • May show extension of abscess beyond the peritonsillar space ^[3]
    • May show complications (e.g., internal jugular thrombosis, carotid sheath abscess erosion)

Treatment ^[3][11]

• Patients with respiratory distress: prompt airway management
• Systemic antibiotics (IV or oral) with abscess drainage are the mainstay of therapy.
• Consult ENT and/or oral maxillofacial surgery for consideration of abscess drainage.
• Provide supportive care (e.g., pain management, antipyretic therapy, IV fluid therapy)
• Consider corticosteroids (e.g., dexamethasone ) to reduce inflammation. ^[3][15]

Antibiotic therapy ^[3]

• Start empiric antibiotic therapy for deep neck infections.
  • Target coverage for aerobes (e.g., Streptococcus spp.) and anaerobes.
  • E.g., clindamycin or ampicillin/sulbactam ) ^[3]
• Tailor to culture and sensitivity results.
• Duration: 10–14 days

Abscess drainage ^[3]

• Indications ^[10]
  • Obvious abscess (unless it is < 1 cm and there is no drooling, trismus, or muffled voice)
  • Suspected abscess with signs of sepsis or signs of airway compromise
  • Lack of rapid response to medical therapy
• Contraindications: severe trismus, coagulopathy ^[10]
• Method
  • Preferred: needle aspiration or incision and drainage
  • Tonsillectomy: may be indicated in certain groups of children and/or for recurrent or treatment-resistant abscesses ^[3][16]

Complications ^[17][18]

• Can become life-threatening due to airway compromise
• Further spread of infection into the parapharyngeal space (PPA), retropharyngeal space (RPA), mediastinum (mediastinitis), or fascia (necrotizing fasciitis)
• Aspiration pneumonia
• Internal jugular vein thrombosis or thrombophlebitis
• Bacteremia and sepsis

Disposition ^[15][19]

• Outpatient management may be appropriate, unless there are risks for complications or previous outpatient therapy was unsuccessful.
• Consider admission for patients who, e.g.: ^[6]
  • Have sepsis, immunocompromise, and/or signs of airway compromise
  • Have evidence of abscess extension beyond the peritonsillar region on CT

Epidemiology ^[20]

• Most common in children < 5 years of age
• ♂ > ♀

Etiology ^[7]

• Pathogens: streptococci (viridans streptococci, S. pneumoniae), staphylococci (including MRSA), Haemophilus influenzae, oral anaerobes (peptostreptococci, Bacteroides species), often in a polymicrobial environment
• Oropharyngeal infections
  • Dental infections (most commonly)
  • Acute tonsillitis
  • Peritonsillar abscess through the superior constrictor muscle into the parapharyngeal space
  • Pharyngeal or salivary gland infections

Clinical features ^[21]

• Features of peritonsillar abscess, especially trismus
• Posterior space abscess: medial displacement of the lateral pharyngeal wall and tonsil
• Anterior space abscess: indurated swelling below the angle of the mandible down to the hyoid bone
• Respiratory distress: dyspnea, stridor
• Limited cervical neck extension

Diagnostics ^[2][15]

• Imaging: required for diagnostic confirmation ^[22]
  • CT neck with IV contrast (preferred) may show: ^[22][23]
    • Hypodense collection with rim enhancement in the lateral pharyngeal space
    • Single or multiloculated lesion with central fluid and/or air
  • MRI neck ^[2]
    • Indication: concern for complications
    • Findings: similar to CT but with better visualization of soft tissue (e.g., for cellulitis) ^[15]
• Microbiological studies (e.g., bacterial culture of abscess aspirate): can help to direct therapy for the causative pathogen

Treatment ^[23][24]

Systemic IV antibiotics with abscess drainage and supportive care are the mainstays of therapy.

• Patients with respiratory distress: prompt airway management
• Start empiric IV broad-spectrum antibiotics: see “Empiric antibiotic therapy for deep neck infections” for more detail and dosing.
• Switch to targeted antibiotics based on culture and sensitivity results.
• Most patients require surgical drainage or image-guided drainage: Consult ENT and/or oral maxillofacial surgery.
• Provide supportive care (e.g., pain management, antipyretic therapy, IV fluid therapy)
• Consider corticosteroids (e.g., dexamethasone ) to reduce inflammation. ^[3][15]
• Consult dentistry for abscesses with an odontogenic source for possible removal of the infected tooth.
• Patients should be managed as inpatients.

Conservative treatment with IV antibiotics alone may be considered in select patients (e.g., clinically stable patients with a small abscess).

Complications ^[7]

• Airway obstruction
• Spread of infection to retropharyngeal space, carotid sheath (presents with torticollis) and then mediastinum (internal carotid artery erosion jugular vein thrombophlebitis, and mediastinitis), or cranial nerves (Horner syndrome, hoarseness, unilateral paresis of the tongue, and other neurologic deficits)
• Aspiration pneumonia with spontaneous pus drainage
• Bacteremia and sepsis

Parapharyngeal infections can become life-threatening because of their proximity to the retropharyngeal space, carotid sheath, and airway!

Epidemiology ^[20][25]

• Generally the most dangerous deep neck infection
• Most common in children < 5 years of age
• ♂ > ♀
• Overall incidence in the U.S. has increased.

Etiology ^[26]

• Pathogen: streptococci (viridans streptococci, S. pneumoniae), staphylococci (including MRSA), Haemophilus influenzae, oral anaerobes (peptostreptococci, Bacteroides species), often in a polymicrobial environment
• Direct or indirect causes
  • Contiguous or lymphatic spread from oral (most common) or upper respiratory tract infections
  • Local penetrating pharyngeal trauma; (e.g., from small bones such as of fish or chicken, or medical instruments)
  • Spread from other deep neck infections (nasopharynx, sinuses, adenoids)

Clinical features ^[27]

• Features of tonsillitis and trismus (minimal)
• Neck asymmetry with unilateral swelling of the posterior pharyngeal wall; (possible fluctuance) → inability to extend neck
• Torticollis
• Anterior cervical lymphadenopathy
• Respiratory distress
• Infants may also present with lethargy, cough, poor intake, rhinorrhea, and agitation.

Diagnostics ^[28]

Imaging is required for diagnostic confirmation. Microbiological studies can help identify the causative pathogen.

• CT neck with IV contrast (preferred study) ^[22]
  • Indication: suspicion of RPA with a negative x-ray
  • Findings ^[29]
    • Hypodense fluid collection with ring enhancement in the retropharyngeal space
    • Posterior pharynx wall with anterior displacement
    • May detect spread of infection to other spaces and the presence of foreign bodies
    • Differentiates between cellulitis and abscess
• Lateral x-ray neck ; ^[29][30]
  • Indication: initial screening study in patients with airway compromise or if there is a low level of suspicion for RPA
  • Findings
    • Widened prevertebral (soft tissue) space with gas or air-fluid levels
    • Lordosis
    • Evidence of foreign body, if present
• MRI neck ^[2][15]
  • Indication: contraindication to CT
  • Findings are similar to CT with improved detection of:
    • Soft tissue changes (e.g., necrosis)
    • Complications (e.g., extension of abscess to prevertebral space)
• Microbiological studies (e.g., bacterial culture of abscess aspirate): can help to direct therapy for the causative pathogen

Treatment ^[15][19][28]

Systemic IV antibiotics with abscess drainage and supportive care are the mainstays of therapy.

• Patients with respiratory distress: prompt airway management
• Start broad-spectrum empiric antibiotics (e.g., clindamycin or ampicillin/sulbactam ): See “Empiric antibiotic therapy for deep neck infections.”
• Switch to targeted antibiotics based on culture and sensitivity results. ^[28]
• Adult patients usually require needle aspiration or surgical drainage: Consult ENT and/or maxillofacial surgery. ^[15][28][31]
• Consult dentistry for abscesses with an odontogenic source for possible removal of the infected tooth.
• Provide supportive care (e.g., pain management, antipyretic therapy, IV fluid therapy)
• Consider corticosteroids (e.g., dexamethasone ) to reduce inflammation. ^[3][15]
• Patients should be managed as inpatients.

Airway management is always the first step if the patient has signs of respiratory distress.

Complications ^[32]

• Airway obstruction
• Spread of infection to carotid sheath including internal carotid artery erosion and jugular vein thrombophlebitis (Lemierre syndrome)
• Descending mediastinitis (acute necrotizing mediastinitis); . May be visible on chest x-ray as a widened mediastinum +/- bilateral pleural effusions
• Infection can spread and enter the skull base (epidural abscess) or the posterior mediastinum (pericarditis).
• Aspiration pneumonia
• Atlantoaxial dislocation
• Bacteremia and sepsis

• Throat pain
  • Tonsillitis
  • Pharyngitis
  • Epiglottitis
• Painful neck mass ^[33]
  • Cervical adenitis
  • Cat-scratch disease
  • Acute purulent sialadenitis
• Neck swelling or respiratory distress
  • Anaphylaxis or angioedema
  • Retropharyngeal tumors
• Neck stiffness
  • Meningitis
  • Cervical spine osteomyelitis
  • Dystonia

The differential diagnoses listed here are not exhaustive.

General principles

• Infections are typically polymicrobial. ^[6]
• There is a lack of consensus on the optimal empiric antibiotic regimen and duration. ^[34]
• Treatment should be individualized in consultation with an infectious disease specialist. ^[35]
• Switch to targeted antibiotics once culture and sensitivity results are available. ^[34]

Tailor empiric antibiotic therapy to local antibiograms, suspected pathogen, prior antibiotic use, and disease severity.

Most common pathogens ^[36]

• Gram-positive: e.g., Staphylococcus aureus, Streptococcus spp., viridans streptococci
• Gram-negative: e.g., Haemophilus influenzae
• Anaerobic: e.g., Porphyromonas, Fusobacterium, Prevotella, Bacteroides, and Peptostreptococcus spp.

Example regimens (for adults) ^[3]

• Immunocompetent patients
  • Amoxicillin/clavulanic acid ^[3]
  • Ampicillin/sulbactam ^[3]
  • Ceftriaxone PLUS metronidazole ^[3]
  • Penicillin allergy: clindamycin
• Suspected MRSA infection ^[3]
  • Vancomycin OR linezolid
  • PLUS metronidazole
• Severe disease, concern for MDRO, and/or immunocompromised patients ^[3][36]
  • Vancomycin
  • PLUS piperacillin/tazobactam OR meropenem

Empiric antibiotic regimen for children ^[35][37]

• Suspected tonsillar or pharyngeal source: ^[35]
  • Clindamycin (off-label) ^[37]
  • Ampicillin-sulbactam (off-label)
• Suspected odontogenic source:
  • Penicillin G (off-label)
  • PLUS metronidazole (off-label) OR clindamycin (off-label) ^[35][38]
• Severe disease or suspected MRSA: Add vancomycin (off-label) OR linezolid (off-label). ^[6][35]