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For further information, see CMDT Part 8-22: 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


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 ...

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