What is the initial management for a patient with suspected deep neck infection, presenting with fever, trismus, and elevated white blood cell count (leukocytosis)?

Management of Deep Neck Infection

The patient requires immediate airway management and contact with the airway team should be the first priority due to signs of impending airway compromise.

Clinical Presentation and Assessment

The patient presents with classic signs of a deep neck infection with potential airway compromise:

• Fever for three days
• Pain across jaw
• Redness extending down neck and chest
• Trismus (inability to open mouth)
• Drooling
• Submandibular space tenderness and induration
• Leukocytosis (WBC 15,400)

These findings strongly suggest a deep neck infection, likely involving multiple spaces, with potential for rapid deterioration and airway obstruction.

Management Algorithm

1. Immediate Airway Management

• Contact airway team immediately for potential difficult airway management
• Prepare for possible emergent intubation or surgical airway if signs of respiratory distress develop
• Position patient upright to maximize airway patency

2. Imaging

• After airway is secured or deemed stable, obtain CT scan of neck and chest with contrast
• CT is essential to:
  • Identify the extent of infection
  • Locate abscesses requiring drainage
  • Evaluate for mediastinal extension
  • Guide surgical planning 1

3. Empiric Antibiotic Therapy

• Start broad-spectrum IV antibiotics immediately after securing the airway and obtaining cultures
• Recommended regimen:
  • IV vancomycin (to cover MRSA) PLUS
  • β-lactam/β-lactamase inhibitor OR 3rd generation cephalosporin plus metronidazole (for oral anaerobes) 2

4. Surgical Management

• Prepare for surgical drainage once airway is secured and imaging completed
• Multiple surgical procedures may be required for adequate drainage 3
• Regular planned surgical revisions with local drainage and lavage may be necessary 4

5. Supportive Care

• IV fluid resuscitation
• Pain management
• Close monitoring in ICU setting

Rationale for Prioritizing Airway Management

Deep neck infections can rapidly progress to life-threatening airway obstruction. The patient's presentation with trismus, drooling, and submandibular space involvement indicates high risk for airway compromise. Studies have shown that patients with deep neck infections involving the submandibular space and mediastinal extension frequently require tracheostomy (82% of cases with mediastinal involvement) 4.

The presence of trismus (limited mouth opening) is particularly concerning as it suggests significant inflammation that may compromise the airway and make intubation difficult if delayed. Drooling indicates inability to handle secretions, another warning sign of impending airway obstruction.

Important Considerations

• Do not delay airway management to obtain imaging or start antibiotics if there are signs of respiratory distress
• Dexamethasone may be considered to reduce inflammation but should not delay definitive airway management and surgical consultation
• Patients with deep neck infections often require prolonged hospitalization (average 39.78 days for cases with mediastinal involvement) 4
• The mortality rate can be kept low (1.83%) with appropriate and aggressive management 4

Common Pitfalls to Avoid

1. Underestimating the extent of infection based on clinical examination alone - CT imaging typically reveals more extensive involvement than clinically apparent (90% of cases involve multiple spaces) 1

2. Delaying airway management - progressive swelling can rapidly lead to complete airway obstruction

3. Inadequate surgical drainage - these infections often require multiple drainage procedures 3, 4

4. Failure to consider mediastinal extension - deep neck infections can spread to the mediastinum, significantly increasing morbidity and mortality