P1L1TB29#y1

Infectious Diseases

9. DEEP NECK INFECTIONS

I. ANATOMY OF DEEP NECK SPACES III. HIGH YIELD: CLINICAL COMPARISON OF V. DIAGNOSTIC APPROACH TO DEEP NECK INFECTIONS
A. PERITONSILLAR SPACE DEEP NECK INFECTIONS A. ASSESS THE SOURCE OF THROAT PAIN
B. PARAPHARYNGEAL SPACE IV. COMPLICATIONS OF DEEP NECK VI. TREATMENT OF DEEP NECK INFECTIONS
C. RETROPHARYNGEAL SPACE INFECTIONS A. IV ANTIBIOTICS
D. SUBMANDIBULAR SPACE A. AIRWAY OBSTRUCTION B. ABSCESS DRAINAGE
II. TYPES OF DEEP NECK INFECTIONS B. CAROTID SHEATH INVOLVEMENT
A. PERITONSILLAR ABSCESS (PTA) C. ACUTE NECROTIZING MEDIASTINITIS
B. PARAPHARYNGEAL ABSCESS (PPA) D. SEPSIS
C. RETROPHARYNGEAL ABSCESS (RPA)
D. LUDWIG ANGINA
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I. Anatomy of deep neck spaces 00:52

A. Peritonsillar Space C. Retropharyngeal space

Definition: Definition:
o Space between tonsillar capsule and superior pharyngeal o Space between buccopharyngeal fascia and alar fascia
constrictor Clinical Correlation:
Clinical Correlation: o Abscess in retropharyngeal space (retropharyngeal abscess)
o Abscess in peritonsillar space (peritonsillar abscess)

B. Parapharyngeal space D. Submandibular space

Definition: Definition:
o Anterior parapharyngeal space o Sublingual space + Submaxillary space
▪ Space anterior to styloid process contains fat and muscle ▪ Sublingual space
(e.g. medial pterygoid) • Space above mylohyoid and below tongue
o Posterior parapharyngeal space ▪ Submaxillary space
▪ Space posterior to styloid process contains carotid sheath • Space below mylohyoid and contained by anterior cervical
Clinical Correlation: fascia
o Abscess in parapharyngeal space (parapharyngeal abscess) Clinical Correlation:
o Necrotizing cellulitis in submandibular space (Ludwig's angina)

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II. Types Of Deep Neck Infections 25:23

A. Peritonsillar Abscess (PTA)

Etiology:
o Acute tonsillopharyngitis due to Group A Streptococcus (GAS)
Pathophysiology:
o Infection spreads to the space between the
tonsillar capsule and the superior pharyngeal
constrictor muscle → Inflammation in peritonsillar
space → Pus accumulates in this space causing
mass effect on tonsils and uvula and direct
irritation of medial pterygoid nearby
Classic Findings:
o Sore throat, drooling, fever and muffled voice
o Trismus (due to medial pterygoid irritation)
o Tonsillar swelling and uvular deviation (mass effect from
abscess)

B. Parapharyngeal Abscess (PPA)

Etiology:
o Dental Infection (most common in adults)
▪ Specifically, infection of the 2nd and 3rd mandibular molars
o Acute Tonsillopharyngitis/ Peritonsillar Abscess (most common
in peds)
▪ Infection often spreads from the PTA through the superior
pharyngeal constrictor
o Sialadenitis
▪ Infection of the parotids or submandibular glands crosses
fascial boundaries to reach the parapharyngeal space
Pathophysiology:
o Infection spreads to the anterior and/or posterior
parapharyngeal space → Inflammation in parapharyngeal space
→ Pus accumulates in this space → Swelling of the pharyngeal
wall creates a mass effect
▪ Anterior parapharyngeal space swelling → Irritates the
medial pterygoid
▪ Posterior parapharyngeal space swelling → Irritated carotid
sheath
Classic Findings:
o Sore throat, drooling, fever and muffled voice
o Trismus (due to medial pterygoid irritation)
o Medial pharyngeal displacement (mass effect from abscess)
o Neck swelling at angle of mandible (mass effect from abscess)

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 C. Retropharyngeal Abscess (RPA)
Etiology:
o Upper respiratory tract infections
(Most common in peds < 6 years)
▪ Examples: Tonsillopharyngitis, ARS, AOM
o Trauma (Most common in adults)
▪ Examples: Fish/chicken bone puncture or medical
instrumentation (e.g., intubation or endoscopy)
o Contiguous spread from adjacent deep neck infection
(e.g., PPA or PTA)
Pathophysiology:
o Two mechanisms:

a) Lymphatic Pathway
(Common in Pediatrics)
o Pathogens drain from a primary URTI into lymphatics → Drain
into nodes of Rouviere → Suppurative adenitis → Pus breaks
out of lymph nodes into retropharyngeal space → Midline
posterior pharyngeal bulge creates mass effect leading to:
▪ Pharyngeal compression
▪ Irritation of prevertebral muscles
▪ Penetration of the alar fascia

b) Non-Lymphatic Pathway
(Common in Adults)
o Direct inoculation (e.g., trauma) or contiguous spread of
infection from nearby deep neck spaces into the
retropharyngeal space → Cellulitis/phlegmon formation →
Organized abscess in the retropharyngeal space

Classic Findings:
o Sore throat, drooling, fever and muffled voice
o Posterior pharyngeal bulging (mass effect from abscess)
o Refusal to extend neck (irritation of prevertebral muscles)

D. Ludwig Angina
Etiology:
o Dental infections (~90% of cases)
▪ Specifically, infection of the 2nd and 3rd mandibular molars
Pathophysiology:
o Infection spreads to the submandibular space and rapidly
crosses midline to involve both spaces → Cellulitis occurs in
these spaces → Swelling in these spaces displaces the tongue
posteriorly and superiorly, resulting in:
▪ Pharyngeal/laryngeal obstruction
Classic Findings:
o Pain in floor of mouth, drooling, fever and muffled voice
o Swelling of tongue with superior and posterior displacement
o Neck swelling with woody induration
▪ Due to spread of necrotizing cellulitis in soft tissue in neck
confined by cervical fascia

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 Type of abscess/cellultiis Most common pathogens

Peritonsillar abscess (PTA)

- Streptococcus species
Parapharyngeal abscess (PPA) (e.g., pyogenes and viridans)
- Staphylococcus aureus
Retropharyngeal abscess (RPA) - Anaerobes
(bacteroides and fusobacterium)
Ludwig Angina

Important Note:
- PTA is often more streptococcus dominant
- PPA, RPA, and Ludwig angina are more clearly polymicrobial

III. High yield: Clinical comparison of deep neck infections

PTA PPA RPA Ludwig Angina
Posterior Erythema and edema of the floor
Contralateral uvula Medial displacement of the
Oral exam pharyngeal wall of the mouth with an elevated
deviation lateral pharyngeal wall
swelling tongue

Trismus More common Less common

Neck Refusal to extend

Normal Mass below the jaw angle Bilateral “woody’ neck induration
position/Swelling the neck

Airway obstruction
Low risk Moderate risk Highest risk
(e.g., stridor)

Common Clinical Findings:

Fever, throat pain, odynophagia, drooling, muffled “hot potato” voice

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IV. Complications of Deep Neck Infections 59:09

A. Airway Obstruction
Pathophysiology:
o Abscess, mass effect, and surrounding edema physically
narrow the pharyngeal lumen, obstructing airflow into the
laryngeal inlet
Important note:
RPA and Ludwig angina pose the greatest concern for airway
obstruction!
Clinical Presentation:
o Stridor
o Dyspnea
o Respiratory distress
▪ Tachypnea, ↑Work of breathing, retractions, nasal flaring

B. Carotid Sheath Involvement

Pathophysiology:
o PPA in the posterior parapharyngeal space directly irritates the
components of the carotid sheath:
▪ ICA
▪ IJV
▪ CN IX-XII
▪ Sympathetic plexus

Clinical Presentation:

a) IJV Involvement b) CN-IX-XII involvement

o Septic thrombophlebitis of IJV (e.g. Lemierres syndrome) o CN IX palsy → Loss of gag reflex and dysphagia
seen with infection by Fusobacterium necrophorum o CN X palsy → Dysphagia and hoarseness(Dysphonia)/
▪ Tenderness over the IJV ( cord-like neck mass) vocal cord paralysis
▪ Septic pulmonary emboli (pleuritic chest pain, dyspnea) o CN XI palsy → Shoulder droop (Trapezius weakness)
o CN XII palsy → Tongue deviation
(towards the side of the lesion)

c) Sympathetic Plexus Involvement

o Horner syndrome
▪ Ptosis
▪ Miosis
▪ Anhidrosis

d) ICA Involvement
o Erosion or pseudoaneurysm of
the ICA
▪ TIA/CVA (rare)

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 C. Acute Necrotizing Mediastinitis D. Sepsis
Pathophysiology: Pathophysiology:
o RPA breaches the alar fascia and enters the danger space → o Bacteria seed the bloodstream from abscess → Systemic
Gravity and negative intrathoracic pressure pull pus into the inflammatory response occurs → ↑IL-1, IL-6, TNF-⍺ released
posterior mediastinum → Infection spreads to the pleura and resulting in:
pericardium in the mediastinum ▪ ↑Capillary leak and ↑Vasodilation
Clinical Presentation: ▪ Hypothalamic activation
o Fever, retrosternal chest pain, along with dyspnea ▪ ↑Production of WBCs from the bone marrow
o Pleural or pericardial effusions Clinical Presentation:
o Hammans' sign: Crepitus due to subcutaneous emphysema in o Hypotension
the neck or chest ▪ ↑Risk of multisystem organ failure
o Imaging: CXR demonstrates a widened mediastinum, and CT of ▪ Results in reflex tachycardia and tachypnea
the neck and chest reveals mediastinal fluid collections with o Fever
associated gas o Leukocytosis

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1:33:45
V. diagnostic Approach to Deep Neck Infections

A. Assess the Source of Throat Pain

1. Assess for Red Flag Signs or Airway Compromise
Indications:
o Throat pain, PLUS one of the following:

Abnormal Findings:
o Throat pain with (+) red flag signs → Consider deep neck
infections (DNIs)
o Throat pain with (-) red flag signs → Consider uncomplicated
tonsillopharyngitis

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2. Perform Oral and Neck Exam
Indications:
o Throat pain with (+) red flag signs of DNI:
▪ Trismus
▪ Muffled voice
▪ Drooling
Abnormal Findings:

a) Ludwig Angina b) PTA c) PPA

o Oral exam: Pus on the floor of the o Oral exam: Tonsilar swelling and o Oral exam: Medial displacement of
mouth with an elevated tongue contralateral uvular deviation the lateral pharyngeal
o Neck exam: Bilateral “woody” neck o Neck exam: Normal o Neck exam: Mass below the jaw angle
induration

d) RPA
o Oral exam: Posterior pharyngeal wall swelling
o Neck exam: Refusal to extend the neck and prefers slight neck
flexion

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3. Obtain a CT Neck with IV Contrast
Indications:
o Suspicion of PPA or RPA
Abnormal Findings:

a) PPA b) RPA
o Hypodense fluid collection with ring enhancement in the o Hypodense fluid collection with ring enhancement in the
parapharyngeal space retropharyngeal space

4. Obtain a Culture of Abscess Aspiration

Indications:
o Diagnosis of deep neck infections
Abnormal Findings:
o (+) Culture confirms a particular pathogen guiding antibiotic choice

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VI. Treatment of Deep Neck Infections 1:50:10

A. Antibiotics
Therapies: Purpose:
o Ampicillin-sulbactam (first line) o Prevent further complications:
o Clindamycin (2nd line if PCN allergy) ▪ Spread of abscess to other deep neck spaces
Indication: ▪ Airway obstruction
o Ampicillin-sulbactam ▪ Carotid sheath involvement
▪ Any deep neck infection (e.g., PTA, PPA, RPA, and Ludwig ▪ Descending necrotizing mediastinitis
angina) ▪ Sepsis

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B. Abscess Drainage
Therapies:

a) Needle Aspiration

b) Incision and Drainage

i) External Approach ii) Transoral Approach

Indications: o Prevent further complications:

o Surgical drainage ▪ Spread of abscess to other deep neck spaces
▪ PTA: Standard of care ▪ Airway obstruction
▪ PPA: If a large abscess (> 2.5cm), septic, airway obstruction, ▪ Carotid sheath involvement
or failing antibiotics after 48 hours ▪ Descending necrotizing mediastinitis
• Abscess medial to carotid sheath → Transoral approach ▪ Sepsis
• Abscess lateral to carotid sheath → External approach
▪ RPA: If a large abscess (> 2.5 cm), septic airway obstruction,
or failing antibiotics after 48 hours
• Abscess above C3 vertebrae → Transoral approach
• Abscess below C3 vertebrae → External approach
▪ Ludwig angina: Airway obstruction or an abscess is observed
on imaging
▪
Purpose:

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 Monitoring:
o Airway monitoring is most crucial in this patient population
▪ (+) Signs of airway obstruction arise → Immediately secure the airway
• Airway management:

c) Endotracheal Intubation
i) Standard for PTA, PPA, RPA ii) Awake Fiberoptic in Ludwig Angina

d) Cricothyroidotomy (Worst-Case Scenario)

o Monitor vital signs and lactate levels for any signs of sepsis/septic shock
o Monitor for complications of the underlying deep neck infection:
▪ Pulmonary nodules on CXR/CT (due to septic emboli), Tender “cord-like”
SCM and CN deficits → Carotid sheath involvement
▪ Retrosternal chest pain → Descending mediastinitis
o Monitor for clinical improvement with IV antibiotics, and if no improvement:
▪ Consider repeat imaging (CT neck) and possible abscess drainage

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