Deep Neck Infections

Key Features

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

Clinical Findings

• 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

Diagnosis

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

Treatment

• 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 ...