How to manage a 40-year-old male with 5-day history of anterior neck swelling and fever?

Management of Anterior Neck Swelling with Fever in a 40-Year-Old Male

This patient requires urgent evaluation for deep neck infection with immediate imaging (CT neck with contrast) and empiric broad-spectrum antibiotics, as anterior neck swelling with fever in an adult represents a potentially life-threatening condition requiring prompt diagnosis and treatment. 1, 2, 3

Immediate Risk Stratification

This presentation demands urgent assessment because deep neck infections can rapidly progress to airway compromise, mediastinitis, or sepsis. 3, 4 The 5-day duration with persistent fever indicates this is not a simple viral syndrome and requires aggressive workup. 2

Critical Red Flags Present in This Case:

• Fever with neck swelling - suggests infectious process rather than neoplastic 1, 2
• Duration ≥5 days - beyond typical viral course, indicates established infection 2, 3
• Anterior location - may involve critical structures including airway and mediastinum 3, 4

Initial Assessment and Workup

Immediate Clinical Evaluation:

• Vital signs assessment - temperature, blood pressure, heart rate, respiratory rate, oxygen saturation to identify sepsis or impending airway compromise 5
• Airway evaluation - assess for stridor, dyspnea, drooling, or "hot potato" voice indicating potential obstruction 6
• Neck examination - document size, location, consistency (firm vs fluctuant), mobility, and presence of overlying skin changes 1, 2
• Oropharyngeal examination - look for trismus, uvular deviation, tonsillar asymmetry, or posterior pharyngeal wall swelling 6, 7

Essential Laboratory Studies:

• Complete blood count with differential - leukocytosis present in 78% of deep neck infections 4
• Complete metabolic panel - assess for electrolyte abnormalities, renal function, and hepatic involvement 5
• Inflammatory markers - elevated ESR and C-reactive protein support infectious etiology 1
• Blood cultures - if patient appears septic 3

Mandatory Imaging:

CT neck with IV contrast is the gold standard and must be obtained urgently. 1, 2 This imaging:

• Detects early bone changes, osteolysis, and endplate irregularities 1
• Identifies peripherally enhancing collections indicating abscess formation 1
• Assesses for epidural involvement and thecal sac compression 1
• Evaluates extent of infection and involvement of multiple spaces 3, 4
• Guides surgical planning if drainage required 2

Common Pitfalls to Avoid

Do not start empiric antibiotics for presumed "lymphadenitis" without imaging in an adult with persistent fever and neck swelling. 2 Most adult neck masses are neoplastic rather than infectious, but when infection is present with fever, it represents a surgical emergency. 2, 3

Do not perform open biopsy or fine-needle aspiration before completing imaging workup. 2 This disrupts tissue planes and complicates subsequent surgery if malignancy is present. 2

Do not delay imaging waiting for antibiotic response. 1, 2 Deep neck infections require early surgical drainage in 72.5-79.5% of cases with abscess formation. 3, 4

Empiric Antibiotic Therapy

While awaiting imaging results, initiate broad-spectrum IV antibiotics covering:

• Streptococcus viridans (most common pathogen, 33.9%) 3
• Klebsiella pneumoniae (33.9%, especially if diabetic) 3
• Staphylococcus aureus (27.3% in pediatric series, also common in adults) 7, 3
• Oral anaerobes (particularly if odontogenic source) 6, 3

Appropriate regimens include ampicillin-sulbactam or piperacillin-tazobactam, or clindamycin plus a third-generation cephalosporin. 6, 3

Definitive Management Based on Imaging

If Abscess Present (Most Likely):

Surgical drainage is the cornerstone of treatment and should not be delayed. 3, 4 Early surgical intervention combined with antibiotics achieved successful outcomes in 98.2% of cases. 4

• Incision and drainage with placement of draining tubes 8, 3
• Continue IV antibiotics for 7-10 days (mean hospitalization 7-7.9 days) 7, 3, 4
• Consider tracheostomy if airway compromise present (required in 18/30 patients with complications) 3

If Cellulitis Without Abscess Formation:

• IV antibiotics alone may be sufficient (successful in 20.5% of cases) 4
• Close monitoring for progression requiring surgical intervention 4
• Repeat imaging if no clinical improvement within 24-48 hours 4

High-Risk Features Requiring Intensive Monitoring

Patient Factors:

• Age >50 years - 52.4% of deep neck infections occur in this age group 3
• Diabetes mellitus - present in 20.5-34.1% of cases, associated with K. pneumoniae infection and longer hospital stays 3, 4
• Immunosuppression - HIV, chronic steroids, cancer 1, 9

Clinical Complications (16.2% incidence):

• Airway obstruction - requires immediate tracheostomy 3
• Mediastinitis - extension into superior mediastinum, may require chest tube drainage 8, 3
• Septic shock - mortality rate 1.6%, all deaths occurred in patients >72 years with systemic disease 3

Specific Etiologies to Consider

Odontogenic Source (31.3% of cases):

• Most common identifiable cause 3, 4
• Typically involves submandibular space initially 3, 4
• Requires dental consultation for source control 3

Upper Respiratory Tract Infection (30.5% of cases):

• Peritonsillar or parapharyngeal space involvement most common 7, 3
• May present with trismus and uvular deviation 6

Post-Procedural:

• Rare but serious complication of endotracheal intubation 8
• Can progress rapidly to mediastinitis 8

Note: In 32.1% of cases, the origin remains unknown despite thorough investigation. 4 This should not delay treatment.