What is the recommended treatment for suspected infection or abscess in the spaces of the neck?

Management of Suspected Neck Space Infections

For suspected infections or abscesses in the spaces of the neck, prompt diagnosis with imaging and appropriate antibiotic therapy with surgical drainage is the recommended treatment approach.

Diagnostic Approach

Initial Assessment

• Identify patients at increased risk: diabetes mellitus, IV drug use, cancer, HIV, dialysis 1
• Look for suspicious physical examination characteristics:
  • Fixation to adjacent tissues
  • Firm consistency
  • Size >1.5 cm
  • Ulceration of overlying skin 1
• Evaluate for signs of bacterial infection:
  • Fever
  • Leukocytosis
  • Elevated ESR/CRP 1

Imaging

1. MRI with and without IV contrast is the preferred initial imaging modality for suspected neck infections due to:

   • Superior sensitivity (96%) and specificity (94%)
   • Excellent tissue characterization
   • Better visualization of paraspinal and epidural inflammation 2

2. CT with IV contrast is recommended when:

   • MRI is unavailable or contraindicated
   • Presurgical planning is needed
   • For image-guided biopsy 2

3. Ultrasound is useful for:

   • Differentiating abscesses from cellulitis in superficial infections
   • Image-guided aspiration of superficial collections 2

Treatment Approach

Antibiotic Therapy

• Do not routinely prescribe antibiotics for neck masses unless there are signs and symptoms of bacterial infection 1
• When infection is suspected, use antibiotics that cover:
  • Streptococci (primary pathogen)
  • Oral anaerobes 1, 3

Surgical Management

• Incision and drainage is the recommended treatment for:
  • Abscesses
  • Large furuncles
  • Carbuncles 1
• Collection of aspirate or biopsy material from affected tissues is essential for:
  • Accurate etiologic diagnosis
  • Avoiding contamination with mucosal flora 1

Special Considerations for Deep Neck Space Infections

Odontogenic Infections

• These can spread to involve:
  • Peritonsillar and pharyngeal abscesses
  • Deep spaces (retropharyngeal, parapharyngeal, submandibular, sublingual)
  • Cervical lymphadenitis 1
• Complications can occur by:
  • Hematogenous spread
  • Direct extension (Lemierre syndrome, bacterial endocarditis, intracranial abscess, mediastinitis) 1

Specimen Collection

• Place aspirate/biopsy in anaerobic transport container
• Request Gram-stained smears to:
  • Evaluate specimen adequacy
  • Provide early presumptive diagnosis
  • Identify mixed aerobic and anaerobic infections 1

Monitoring and Follow-up

• Monitor for potential complications:
  • Airway obstruction
  • Mediastinitis
  • Septic embolization
  • Dural sinus thrombosis
  • Intracranial abscess 4
• Higher risk infections include those that:
  • Transgress fascial boundaries
  • Spread along vertically oriented spaces (parapharyngeal, retropharyngeal, paravertebral) 4

Clinical Pearls and Pitfalls

• Avoid diagnostic delay which can lead to significant morbidity and mortality
• Do not assume cystic neck masses are benign; continue evaluation until diagnosis is obtained 1
• Recognize that early symptoms often do not reflect disease severity 4
• Consider examination under anesthesia of the upper aerodigestive tract before open biopsy for patients without a clear diagnosis 1

By following this structured approach to diagnosis and treatment of neck space infections, clinicians can effectively manage these potentially serious conditions while minimizing complications.