Deep Neck Infections

 

What is a "deep neck" infection?

 

A "deep neck" infection refers to an infection or abscess (collection of pus) located deep under the skin near blood vessels, nerves, and muscles.

 

Where is the "deep neck" located?

 

There is a band of tissue in the neck called the cervical fascia, which divides the neck into superficial (just under the skin) and deep layers. The deep layer of the neck is then further subdivided into various spaces. A deep neck infection is an infection that is located in one of these spaces in the deep layer of the neck. Ear, Nose, and Throat surgeons are experts in the anatomy of the neck including these spaces.

Although a deep neck infection can be seen in any of the deep neck spaces, the most common spaces in which deep neck infections are found in children are:

 

RETROPHARYNGEAL SPACE

 

This space is located directly behind the mouth. The lymph nodes (infection fighting structures) that drain the ADENOIDS, SINUSES, nose, and pharynx (back of throat) are located in this space. Infections in any of these areas can result in spread of infection to these lymph nodes, resulting in lymphadenitis (infection of the lymph nodes) and abscess formation (collection of pus). The retropharyngeal lymph nodes become significantly smaller after five years of age; therefore, this infection is usually seen only in younger children. 

 

PERITONSILLAR SPACE

 

Located in the tissue around the tonsil in the back of the throat.

Infection in this space usually results from an untreated infection of the tonsils (TONSILLITIS). This type of infection is known as a peritonsillar abscess or quinsy (a collection of pus in the peritonsillar space) and is probably the most common type of deep neck infection. This infection can occur at any age. 

 

PARAPHARYNGEAL SPACE

 

It is located just to the side of the throat. Infections in this area are due to common upper respiratory infections that spread to the lymph nodes located in this space. If an infection in this area remains untreated, the neck swells and the child stops moving the neck, indicating pain. 

 

SUBMANDIBULAR SPACE

 

This space is located under the jaw on each side. Infection in this space is usually the result of a dental infection and is known as Ludwig's angina. It is more commonly seen in adolescents, but can also occur in younger children. 

 

What causes a deep neck infection?

 

In children, deep neck space infections are usually caused by more common infections, such as dental abscesses, tonsillitis, or respiratory infections that are located "above" these spaces that spread into these deep spaces by the lymphatic system (system that drains fluid in the body). Lymph nodes (contain disease fighting cells) in these spaces then become infected (lymphadenitis). 

Additionally, bacteria can be directly introduced to a deep neck space by trauma affecting the area (more commonly seen in adults).

Finally, an infection from one deep space may spread to another deep space directly.

 

What are the symptoms of a deep neck infection?

 

Some of the more common symptoms of a deep neck infection include:

  • Decreased ability to move the neck

  • Asymmetry of the neck and back of the throat

  • Difficulty or pain when swallowing

  • Drooling

  • Sick appearance

  • Fever

  • Swelling in the neck, under the jaw, or on the face.

Difficult or fast breathing may also be noted if airway involvement has occurred. 

 

What are the complications of a deep neck infection?

 

The complications of deep neck infections can be life threatening; therefore, early detection and treatment are of extreme importance.

Some of these complications include:

  • Airway obstruction -probably the most serious initial complication; a deep neck infection can create swelling that pushes in on the airway causing partial or complete obstruction (blockage) 

  • Spread of the infection - deep neck infections can spread to other deep neck spaces, as well as the mediastinum (middle chest cavity), lungs (empyema-pus in the lungs), bloodstream (sepsis), and bones (osteomyelitis) 

  • Thrombus (clot) formation in arteries and veins of the neck 

  • Nerve involvement - the nerves which affect vocal cord movement, eyelid closure, sweating, and pupil constriction may also be pressed upon causing nerve dysfunction 

 

How is a deep neck infection evaluated?

 

Because the infection is only noted by swelling in the neck a careful history and physical examination is important when suspecting a deep neck infection.

X-rays of the neck, teeth, and chest may also be indicated depending on the type of deep neck infection suspected. CT scans are the standard of care (test of choice) when evaluating the extent of a deep neck space infection. They give very accurate pictures of the infection's location, which is especially useful if surgical drainage of the infection is required.

 

How is a deep neck infection treated?

 

Because of the immediate threat of airway obstruction, most deep neck infections require hospitalization. When the airway is narrowed, an endotracheal (breathing tube passed through the mouth) or nasotracheal (breathing tube passed through the nose) tube may be placed to hold open the airway until the infection can be treated. In severe cases, when a breathing tube cannot be inserted, a TRACHEOTOMY may be temporarily required.

Most patients will have a history of decreased fluid and food intake, therefore fluids given by vein will usually be required.

All patients with deep neck infections are started on antibiotics given by vein. In a select group of patients, careful hospital observation and antibiotics may be enough to treat the infection. However, surgical drainage is required in some cases. 

When is an ear, nose, and throat specialist involved in the treatment of a deep neck abscess?

Because airway obstruction is always a concern with a deep neck infection, an ear, nose and throat specialist is usually consulted immediately to help manage the airway and determine whether surgical therapy is needed.

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