What are the symptoms and treatment of a cervical abscess?

Symptoms and Treatment of Cervical Abscess

The most common symptoms of cervical abscess include pain, swelling, tenderness, fever, and depending on the location, dysphagia, odynophagia, neck stiffness, and potential airway compromise requiring urgent surgical drainage. 1

Types and Symptoms of Cervical Abscesses

Cervical abscesses can be categorized based on their anatomical location:

Peritonsillar Abscess

• Pain in throat and neck
• Difficulty swallowing (dysphagia)
• Painful swallowing (odynophagia)
• Muffled "hot potato" voice
• Trismus (limited mouth opening)
• Deviation of uvula to unaffected side
• Unilateral tonsillar enlargement with displacement

Retropharyngeal Abscess

• Neck pain and stiffness
• Odynophagia
• Fever
• Dysphagia
• Potential airway compromise (stridor, dyspnea)
• Limited neck extension
• Possible bulging of posterior pharyngeal wall 1

Parapharyngeal Abscess

• Neck swelling and pain
• Trismus
• Dysphagia
• Fever
• Medial displacement of lateral pharyngeal wall
• Potential extension to other spaces

Deep Cervical Abscess

• Neck swelling and erythema
• Fluctuance on palpation
• Systemic signs of infection
• Potential airway compromise in advanced cases

Diagnostic Approach

1. Clinical examination: Evaluate for neck swelling, tenderness, fluctuance, limited range of motion, and signs of systemic infection

2. Imaging:

   • CT scan is the preferred initial imaging modality to confirm presence and extent of abscess 2
   • MRI may provide better soft tissue definition in complex cases
   • Ultrasound can be useful for superficial abscesses and guided drainage

3. Laboratory studies:

   • Complete blood count (typically shows leukocytosis)
   • Blood cultures (positive in up to 28% of cases) 3
   • Inflammatory markers (elevated ESR, CRP)

Treatment Approach

Surgical Management

Surgical drainage is the cornerstone of treatment for cervical abscesses and should be performed promptly, with timing based on the presence and severity of sepsis. 2

• Incision and drainage: Primary treatment for most cervical abscesses 2

  • Approach depends on abscess location
  • Complete drainage is essential to prevent recurrence
  • Samples should be sent for aerobic and anaerobic cultures

• Timing considerations:

  • Emergent drainage for patients with:
    • Sepsis or septic shock
    • Airway compromise
    • Immunosuppression
    • Diabetes mellitus
    • Diffuse cellulitis
  • Within 24 hours for less severe presentations 2

Antibiotic Therapy

Empiric broad-spectrum antibiotic therapy with coverage of Gram-positive, Gram-negative, and anaerobic bacteria should be initiated alongside surgical drainage. 2

• Recommended regimens:

  • Metronidazole (for anaerobic coverage) plus a third-generation cephalosporin 2, 4
  • Metronidazole is particularly effective for Bacteroides fragilis infections resistant to other antibiotics 4

• Duration:

  • Typically 7-14 days depending on clinical response
  • May require longer treatment for complex or recurrent cases

Special Considerations

1. Tuberculous cervical abscess:

   • Total excision rather than simple incision and drainage is preferred
   • Requires 6 months of anti-tuberculous chemotherapy 5

2. Retropharyngeal abscess:

   • May require preventive tracheotomy (27% of cases in one study) 1
   • Close monitoring for descending mediastinitis

3. Outpatient management:

   • May be considered for fit, immunocompetent patients with small, well-localized abscesses without systemic signs of sepsis 2

Potential Complications

• Airway obstruction (requiring urgent intervention)
• Sepsis and bacteremia
• Extension to adjacent spaces
• Descending necrotizing mediastinitis
• Jugular vein thrombosis
• Carotid artery erosion
• Neurological complications (cranial nerve palsies)
• Recurrence (particularly with inadequate drainage)

Prevention of Recurrence

• Complete drainage of abscess cavity
• Appropriate duration of antibiotic therapy
• Treatment of underlying conditions (e.g., dental infections, periodontal disease)
• Follow-up imaging for complex cases

Early recognition and prompt treatment of cervical abscesses are essential to prevent life-threatening complications and improve outcomes.