Deep Neck Infections Treatment & Management

Airway

• The airway is the first priority of treatment.
• Addressing the airway may involve observation, endotracheal or nasotracheal intubation, tracheostomy, or cricothyroidotomy for emergent situations.
• Even in experienced hands, attempted oral or nasal endotracheal intubation in a patient with a deep neck space infection or abscess may be extremely difficult. The larynx and vocal cords may be difficult to visualize because of swollen pharyngeal walls and laryngeal displacement. Instrumentation can cause additional swelling. The potential exists for abscess rupture with intubation leading to aspiration, acute airway obstruction, or death. Other factors (eg, tracheal deviation, external airway compression, trismus, cervical spine rigidity) can produce difficulty with intubation.
• Patients presenting with impending respiratory distress should undergo a tracheostomy while under local anesthesia to secure a safe airway. A tracheostomy is safer, more conservative, and preferable to the development of respiratory compromise. Tracheostomy should be performed before any attempts at surgical drainage in these patients.

Cultures

• Obtain cultures whenever possible to help direct antimicrobial therapy.
• This may involve cultures of the neck, abscess fluid, and blood.

Volume and metabolic resuscitation

• Initiate these procedures in all patients with deep neck infection.
• Identify and address metabolic derangements during resuscitation.
• Address attention to other concurrent medical problems (eg, diabetes) early in the course of treatment.

Intravenous antibiotics

• Choose parenteral antibiotics to cover the most likely organisms.
• Initiate empiric regimens before culture results are obtained based on the local resistance patterns and most common etiologies.
• Cover gram-positive and gram-negative organisms and aerobic and anaerobic bacteria, including beta-lactamase producing organisms.
• Modify antibiotics according to culture and sensitivity results.
• A review of deep neck infections by Broughton indicated that 50% of deep neck infections can be managed nonsurgically in patients with small fluid collections and no respiratory compromise. Other studies by Plaza and McClay support the option of primary nonsurgical management for selected deep neck space abscesses, reserving surgical drainage for patients who do not improve within 48 hours of initiation of broad-spectrum intravenous antibiotics.^{[5, 6]} Most of these studies focus on retropharyngeal and parapharyngeal space abscesses.
• A review of current practices by Lalakea and Messner indicated that 60% of pediatric otolaryngologists recommend a trial of IV antibiotics before incision and drainage in selected pediatric patients with retropharyngeal abscesses.^[7] According to this review, clindamycin, ampicillin/sulbactam, and cefuroxime are currently the most commonly used antibiotics.
• IV antibiotics are administered until the patient is clinically improving and has been afebrile for at least 48 hours. After completion of an IV course of antibiotics, oral antibiotics are given.

Incision and drainage

• Incision and drainage is the cornerstone of therapy for the treatment of deep neck space abscesses.
• Establish a secure airway before initiating any surgical procedure.
• Perform incision and drainage for any frank abscess in patients with impending complications because of abscess formation and in patients with no improvement after 48-72 hours of IV antibiotics.
• Most deep neck spaces require a transcervical approach to facilitate adequate exposure of the abscess and for protection of the surrounding neurovascular structures. A study by Cable et al describes the successful use of image-guided surgical drainage of medial parapharyngeal space abscesses in the pediatric population to help localize infections in areas that are otherwise difficult to reach.^[8]
• Approach retropharyngeal abscesses by a transoral route when the abscess is small and focal. This approach requires attention to the airway to prevent aspiration of pus once the abscess cavity is entered.
• Quinsy tonsillectomy or tonsillectomy performed with infection in the peritonsillar space is controversial treatment for peritonsillar abscesses. Historically, tonsillectomy during acute infection was avoided because of concern about increased risk of postoperative hemorrhage. Several recent studies, such as those by Ungkanont et al and Dodds and Maniglia, suggest no increased morbidity from this procedure.^{[2, 9]}
• Many approaches are possible to the deep neck spaces. Description of the surgical incisions and technique of drainage is beyond the scope of this article. Every approach used must ensure adequate exposure and access to allow drainage without compromising surrounding structures. Abscess cavities should be copiously irrigated, débrided, and left open with a drain or packing to prevent reaccumulation. Once an abscess has been entered, cultures should be obtained to help direct antimicrobial therapy.

Needle aspiration

• FNA may be used in patients with small easily reachable abscesses or in patients who are too unstable to undergo general anesthesia.
• This procedure may require the assistance of CT scanning or ultrasound guidance.
• It may provide preliminary culture specimens before formal incision and drainage.

The most important preoperative considerations are stabilization of the airway, volume and metabolic resuscitation, and initiation of antibiotics.

Many possible surgical approaches to the deep neck spaces can be used. The approach used depends on the precise location of the abscess, the size of the collection, and its relation to the great vessels and other important anatomic structures of the neck.

Postoperatively, closely observe the patient for signs of a response to therapy. Reaccumulation of fluid must be recognized and treated with appropriate drainage procedures. Cultures and sensitivities must be monitored, and antibiotics must be tailored appropriately. The patient's airway must also be monitored closely for signs of obstruction. Finally, the patient must be monitored for signs of impending complications (see Complications).

Follow-up care for patients who have had a deep neck space infection consists of monitoring the complete resolution of the infection. Surgical sites must be monitored for complete healing and to ensure that reaccumulation of an abscess does not occur. Any question of redevelopment of an infection warrants re-imaging and possible reexploration.

Deep neck infections have many severe life-threatening potential complications. Deep neck infections that are not treated or are inadequately treated, those that extend to other deep neck spaces, and those that are complicated by a delay in diagnosis and treatment are at particular risk of complications, including the following:

• Airway obstruction from compression of the trachea
• Aspiration

  • This is particularly due to perforation of a retropharyngeal abscess with drainage of pus into the airway.
  • Aspiration may occur spontaneously or during endotracheal intubation.
• Vascular complications (ie, thrombosis of the internal jugular vein, carotid artery erosion and rupture)
• Mediastinitis from inferior spread along fascial lines
• Neurologic deficits: Cranial nerve dysfunction or dysfunction of the autonomic nerves in the neck can lead to problems such as hoarseness from involvement of the vagus in the carotid sheath or Horner syndrome from involvement of the sympathetic chain.
• Septic emboli: These emboli can lead to pulmonary, brain, or joint seeding and resultant abscesses.
• Septic shock
• Necrotizing cervical fasciitis: This is a fulminant infection involving necrosis of the connective tissue that spreads via fascial planes. It has particularly high morbidity and mortality rates.
• Osteomyelitis due to local spread to bones of the spine, mandible, or skull base
• Grisel syndrome (ie, inflammatory torticollis causing cervical vertebral subluxation)

Several studies have looked at factors that may cause an increase in the risk of complications from deep neck space infections. One study by Wang et al found a higher risk of complications in females, patients with neck swelling, and patients with associated respiratory symptoms. Another study by Huang et al suggests that diabetes and the presence of other underlying systemic diseases significantly increases the risk of complications.^[10] This finding was supported in a study by Chen et al, who found that not only did diabetes correlate with a higher complication rate but that it was also associated with a more severe clinical course involving more than one deep neck space and a longer hospitalization.^[11]

Patients treated for deep neck infections can be expected to fully recover as long as the infection is treated properly and in a timely manner. Patients whose treatment is delayed can expect a greater number of complications and a prolonged course of recovery. Once a deep neck infection has fully resolved, no particular predisposition exists for recurrence.

The greatest controversy regarding deep neck infections concerns whether all deep neck abscesses require surgical treatment or whether some abscesses can be treated medically. As previously discussed, articles by Broughton and Lalakea and Messner suggest that in selected cases involving patients with no signs of respiratory distress or other impending complications, some small deep neck abscesses can be treated with a trial of IV antibiotics alone, particularly in children.^{[12, 7]} Surgical therapy can be reserved for patients whose symptoms do not respond within 48 hours. However, this issue is still being debated in the literature, and clinical judgment must be used with each individual patient.