Deep Neck Space Infections: Clinical Presentation and Management
Clinical Presentation
Deep neck space infections present most commonly with neck pain and swelling (89-91% of cases), along with odynophagia, dysphagia, and fever. 1, 2, 3
Key Symptoms to Identify
- Neck pain and visible neck swelling are the predominant presenting features 2, 3
- Odynophagia and dysphagia indicate pharyngeal or deep space involvement 4
- Fever suggests active infection requiring urgent intervention 2
- Trismus may indicate masticator space involvement 5
- Respiratory distress or stridor signals impending airway compromise requiring immediate action 1, 5
Anatomical Distribution
- Submandibular space is most frequently involved (26-67% of cases) 3, 4
- Ludwig's angina (bilateral submandibular/sublingual involvement) represents the most common presentation pattern (29%) 2
- Peritonsillar abscess is the second most common presentation 2
- Multiple space involvement occurs in approximately 30% of cases and carries higher complication risk 5, 4
Etiologic Sources
Odontogenic infections account for 34-64% of deep neck space infections, making dental pathology the primary source. 1, 2, 3, 4
- Tonsillar and pharyngeal infections are the second most common source (28%) 2
- Oropharyngeal sources occasionally involve mycobacteria, staphylococci, and gram-negative bacilli 1
- Exogenous infections are predominantly gram-negative bacilli and staphylococci 1
High-Risk Populations
- Diabetes mellitus is present in 11-27% of cases and significantly increases mortality risk 2, 3
- Immunocompromised patients require special attention due to rapid progression 2
- Elderly patients have higher complication rates 2
- Rural populations show higher incidence, likely related to poor dental hygiene and delayed care 2, 3
Diagnostic Approach
Imaging Strategy
Contrast-enhanced CT of the neck is the most reliable imaging modality for deep neck space infections, combining rapid acquisition with precise anatomical delineation and complication detection. 5
- CT neck with IV contrast should be performed in nearly all cases (85-98%) to identify location, extent, and character of infection 5, 4
- CT distinguishes drainable abscesses from cellulitis, guides surgical planning, and identifies multicompartment involvement 5
- Ultrasound is the gold standard for differentiating abscess from cellulitis in superficial lesions and can guide aspiration, but has field-of-view limitations for deep infections 5
- MRI is reserved for suspected epidural space involvement in pre/paravertebral infections or skull base extension 5
Microbiologic Diagnosis
Obtain aspirates or tissue biopsies from affected spaces using anaerobic transport containers—never use swabs, as they are inadequate specimens. 6, 1
- Request Gram stain on all specimens to evaluate adequacy, provide early presumptive diagnosis, and identify mixed aerobic-anaerobic infections 6, 1
- Streptococcus and Staphylococcus species are cultured in 50% of cases 2
- Mixed aerobic-anaerobic flora is typical of odontogenic sources, including Peptostreptococcus, Streptococcus viridans, and Streptococcus intermedius 1
- Blood cultures are preferred for epiglottitis—never swab the epiglottis due to risk of sudden airway occlusion 6, 1
Treatment Algorithm
Initial Management
All patients require immediate intravenous broad-spectrum antibiotics covering streptococci, staphylococci (including MRSA), gram-negative bacteria, and anaerobes. 1, 7, 4
- Start empiric IV antibiotics immediately before culture results, then adjust based on culture and sensitivity 2, 4
- Assess airway patency first—emergency tracheotomy is required in approximately 5% of cases 2
- Secure the airway early in patients with respiratory distress, extensive swelling, or infections involving vertically oriented spaces 5
Surgical Intervention
Surgical drainage is required in 55-90% of deep neck space infections and should be performed urgently for abscesses, multispace involvement, or clinical deterioration despite antibiotics. 2, 3, 4
Indications for Surgery
- Radiologically confirmed abscess requiring drainage 4
- Multiple space involvement (present in 30% of cases) 4
- Clinical deterioration after 24-48 hours of IV antibiotics 4
- Airway compromise or impending obstruction 5
- Complications such as descending mediastinitis or septic thrombophlebitis 1
Conservative Management
- Medical treatment alone is effective in 40% of cases when cellulitis without drainable abscess is present 4
- Continue IV antibiotics with close monitoring for progression 4
- Repeat imaging if clinical improvement does not occur within 48-72 hours 5
Life-Threatening Complications
Infections involving vertically oriented spaces (parapharyngeal, retropharyngeal, paravertebral) have the highest risk of life-threatening complications and require aggressive treatment. 5
Major Complications (occur in 14% of cases)
- Descending mediastinitis occurs in approximately 7% and requires combined cervical and thoracic surgical drainage 1
- Septic jugular vein thrombophlebitis (Lemierre syndrome) results from hematogenous spread 1, 2
- Airway obstruction is the most immediate life-threatening complication 1, 5
- Intracranial abscess can occur via direct extension 1
- Bacterial endocarditis may result from bacteremia 1
- Sepsis develops particularly with deep and organ/space infections 7
Critical Pitfalls to Avoid
- Never use swabs for specimen collection—they provide inadequate samples and miss anaerobic organisms 6, 1
- Never attempt to swab the epiglottis in suspected epiglottitis due to risk of sudden airway occlusion 6, 1
- Do not delay imaging—clinical examination alone cannot determine extent or identify complications 5, 4
- Do not underestimate diabetic patients—they require special attention due to rapid progression and higher mortality 2
- Do not miss multispace involvement—occurs in 30% of cases and requires more aggressive surgical approach 4
- Do not use non-contrast CT—contrast enhancement is essential for differentiating abscess from cellulitis and detecting vascular complications 5