Deep Space Neck Infections in the ED

Deep Space Neck Infections!

Anatomy

Image from:

http://www.uptodate.com/contents/image?imageKey=PEDS%2F74998&topicKey=ID%2F3415&rank=1~17&source=see_link&search=deep+neck+infection&utdPopup=true

Types

Peritonsillar space (abcess)

Parotid space

Submandibular space (Ludwig’s angina)

Pretracheal space

Prevertebral space

Parapharyngeal space

Retropharyngeal & danger space

History & Physical Exam Findings

– Dysphagia                                                                   – Drooling

– Odynophagia                                                               – Paratonsillar or pharyngeal bulge

– Dyspnea +/- stridor if airway obstruction present           – Displaced uvula

-Toxic appearance                                                         – Trismus

– Fever                                                                           – Unilateral tongue paresis

– Muffled or hoarse voice

Imaging

Lateral neck XR

• Prevertebral soft tissue should be less than 5mm or <1/3 the width of C4 vertebral body

Bedside ultrasound

• Can be used to search for a fluid collection suggesting underlying abcess

CT Neck & Chest

Microbiology

Polymicrobial – consider flora from source of infection

• Anaerobic predominance with anterior soft tissue infections that infiltrate the deep neck space
  • viridians, S. pyogenes, Fusobacterium, Peptostreptococcus, Prevotella
• Gram + predominance with vertebral infections that advance into prevertebral space
  • aureas most common
• Immunocompromised (DM, EtOH abuse, IVDA, immunosuppresion tx):
  • Greater risk of S. aureas, Pseudomonas, ESBL-Enterobacteriaceae

Management – In general, always consider where infection may have originated from

*IV abx for 2-3 weeks

• Parapharyngeal/Retropharyngeal source
  • Immunocompetent à Augmentin
  • Immocompromised à Cefepime + Flagyl or Meropenem or Zosyn
• Prevertebral source
  • Immunocompetent à Nafcillin or Vancomycin + Gentamicin/Ciprofloxacin/Timentin
  • Immunocompromised à Vancomycin/Linezolid + Zosyn/Meropenem/Cefepime & Flagyl

*Image-guided drainage

Complications

Carotid sheath involvement – resulting from infections of parapharyngeal space and/or submandibular space

• Arteritis à be wary of the sick patient with torticollis!!!
• False aneurysm
• Rupture

Suppurative jugular thrombophlebitis (Lemierre’s syndrome)

• Septic pulmonary emboli, persistent fever despite abx

Necrotizing mediastinits – resulting from infections of retropharyngeal and/or danger space

• Empyema
• Pleural/pericardial effusion

References:

• Chow, AW. (9/17/13). Deep Space Neck Infections. Up To Date. Retrieved 6/28/15 from http://www.uptodate.com/contents/deep-neck-space-infections?source=search_result&search=deep+neck+space+infections&selectedTitle=1~17

• Murray, AD. (3/28/14). Deep Neck Infections. Medscape. Retrieved 6/28/15 from http://emedicine.medscape.com/article/837048-overview

The following two tabs change content below.

• Bio
• Latest Posts

yon.yohannes

Latest posts by yon.yohannes (see all)

• The Critically Ill “Tox Patient” - June 2, 2016
• Shoulder Dislocations in Austere Environments – A Novel Approach - May 12, 2016
• Management of Atrial Flutter with Rapid AV Conduction - March 16, 2016