Deep Neck Infections

Essentials of Diagnosis

• Marked acute neck pain and swelling

• Abscesses are emergencies because rapid airway compromise may occur

• May spread to the mediastinum or cause sepsis

General Considerations

• Ludwig angina

  • Most common neck space infection

  • Characterized by cellulitis of the sublingual and submaxillary spaces, often arising from infection of the mandibular dentition

• Deep neck abscesses

  • Most commonly originate from odontogenic infections

  • Other causes include

    • Suppurative lymphadenitis

    • Direct spread of pharyngeal infection

    • Penetrating trauma

    • Pharyngoesophageal foreign bodies

    • Cervical osteomyelitis

    • Intravenous injection of the internal jugular vein, especially in drug users

• Recurrent deep neck infection may suggest an underlying congenital lesion, such as a branchial cleft cyst

• Suppurative lymphadenopathy in middle-aged persons who smoke and drink alcohol regularly should be considered a manifestation of malignancy (typically metastatic squamous cell carcinoma) until proven otherwise

• Ludwig angina

  • Edema and erythema of the upper neck under the chin and often of the floor of the mouth

  • Tongue may be displaced upward and backward by the posterior spread of cellulitis

  • Coalescence of pus is often present in the floor of mouth; may lead to occlusion of the airway

• Deep neck abscesses

  • Usually present with marked neck pain and swelling

  • Fever is common but not always present

  • Untreated or inadequately treated, they may spread to the mediastinum or cause sepsis

  • Deep neck abscesses are emergencies because they may rapidly compromise the airway

• Lemierre syndrome

  • Rare

  • Usually associated with severe headache

Laboratory Findings

• Ludwig angina

  • Microbiologic isolates include streptococci, staphylococci, Bacteroides, and Fusobacterium

  • Patients with diabetes may have different flora, including Klebsiella, and a more aggressive clinical course

Imaging Studies

• Contrast-enhanced CT

  • Usually augments the clinical examination in defining the extent of the infection

  • Often distinguishes inflammation and phlegmon (requiring antibiotics) from abscess (requiring drainage)

  • Defines extent of an abscess

• CT with MRI may also identify thrombophlebitis of the internal jugular vein secondary to oropharyngeal inflammation (Lemierre syndrome)

• Presence of pulmonary infiltrates consistent with septic emboli in the setting of a neck abscess may suggest Lemierre syndrome or injection drug use, or both

• Ludwig angina

  • Usual doses of penicillin plus metronidazole, ampicillin-sulbactam, clindamycin, or selective cephalosporins are good initial choices for treatment

  • Culture and sensitivity data are then used to refine the choice

  • External drainage via bilateral submental incisions is required if the airway is threatened or when medical therapy has not reversed the process

• Deep neck abscesses

  • Airway should be secured

  • Intravenous antibiotics should be administered

  • Incision and drainage should be done

• Lemierre syndrome

  • Patients with Lemierre syndrome require prompt institution of antibiotics appropriate for Fusobacterium necrophorum as well as the more usual upper airway pathogens. The use of anticoagulation in treatment is of no proven benefit.

Therapeutic Procedures

• Intubation or tracheotomy may be used to secure the airway when the infection involves the

  • Floor of the mouth

  • Base of the tongue

  • Supraglottic or paraglottic space

• Tracheotomy is preferable in the patients with substantial pharyngeal edema, since attempts at intubation may precipitate acute airway obstruction

Complications

• Bleeding in association with a deep neck abscess

  • Very rare

  • However, it suggests carotid artery or internal jugular vein involvement

  • Requires prompt neck exploration both for drainage of pus and for vascular control

When to Refer

• Dental consultation is advisable to address the offending tooth or teeth in patients with Ludwig angina