Deep neck infections

Last updated: September 11, 2023

Summarytoggle arrow icon

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.

Overviewtoggle arrow icon

Overview of deep neck infections [1][2]
Peritonsillar abscess Parapharyngeal abscess Retropharyngeal abscess
  • An accumulation of pus between the muscles of the pharynx and the palatine tonsillar capsule [3]
  • A collection of pus lateral to the peritonsillar space and divided anteriorly and posteriorly into pre- and post-styloid compartments [2]
  • Most common in adolescents and young adults
  • Most common deep neck infection
  • Most common in children < 5 years of age
  • Most common in children < 5 years of age
Clinical Features
  • CT

Emergency airway management of deep neck infectionstoggle arrow icon

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

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

Peritonsillar abscesstoggle arrow icon

Epidemiology [3]

  • Most frequently occurs in adults aged 20–40 years
  • The most common deep neck infection
  • Increased risk of airway obstruction in children with peritonsillar abscess

Etiology [7][8]

Clinical features [8][9]

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

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

Treatment [3][11]

Antibiotic therapy [3]

Abscess drainage [3]

Complications [17][18]

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]

Parapharyngeal abscesstoggle arrow icon

Epidemiology [20]

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

Etiology [7]

Clinical features [21]

Diagnostics [2][15]

Treatment [23][24]

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

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

Complications [7]

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

Retropharyngeal abscesstoggle arrow icon

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]

Clinical features [27]

Diagnostics [28]

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

Treatment [15][19][28]

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

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

Complications [32]

Differential diagnosestoggle arrow icon

The differential diagnoses listed here are not exhaustive.

Empiric antibiotic therapy for deep neck infectionstoggle arrow icon

General principles

  • Infections are typically polymicrobial.
  • There are currently no guidelines on optimal empiric therapy for deep neck infections; Follow local protocols and consider early specialist consultation. [3][34]
  • Switch to targeted antibiotics once culture and sensitivity results are available.

Most common pathogens [34]

Example regimens (for adults) [3]

Empiric antibiotic therapy should be tailored to local antibiograms, suspected focus of infection, prior antibiotics, and disease severity.

Acute management checklisttoggle arrow icon

Referencestoggle arrow icon

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