Deep Neck Space Infections

Michael D. Puricelli, M.D.

Jeffrey B. Jorgensen, M.D.
Goals
Review fascia and fascial spaces to facilitate
understanding of how infections move
through the neck.
Provide current data on appropriate work-up
and management of deep neck space
infections.
Review key complications of deep neck space
infections.
Background
Dividing the extracranial head and neck into
different spaces dates back to the 1800s
Arose to resolve the inexplicable extension of
infections of the extracranial head and neck to
other areas
These studies led to detailed descriptions of
the cervical fascia and the numerous soft
tissue spaces that were contained within the
fascial layers.

History
Highly nuanced and complex
"the cervical fascia appear in a new form under
the pen of each author who attempts to describe
them, French anatomist Malgaigne in 1838.
Definition of fascia
a band of connective tissue that surrounds
structures (such as enveloping muscles), giving
rise to potential tissue spaces and pathways that
allow for infection to spread.
Niel S. Norton. Netters Head and Neck Anatomy for Dentistry. 2007
Deep Neck Space Infections

Deep Neck Space Infections

My Goal

Mukherji SK, Castillo M. A simplified approach to the spaces of the suprahyoid neck. Radiol Clin North Am. 1998
Sep;36(5):761-80, v. Review. PubMed PMID: 9747188.
Overview
Case Presentation
Fascial Planes of the Head and Neck
Deep Neck Spaces
Microbiology
Management
Complications of Infections
Case
ER consult
4 y/o female several days fever and neck
stiffness

What additional information would you like?
History
HPI
Inflammatory symptoms
Pain, fever, swelling, and redness
Onset and duration
Localizing symptoms
Dysphagia, odynophagia, drooling, hot
potato voice, hoarseness, dyspnea,
trismus, and ear pain
Risk Factors (source)
Peds - travel, pets, rodents, unpasturized
milk, uncooked meat, tuberculosis
exposure
Adult - recent dental work, upper airway
surgery or intubation, intravenous drug
use, sinusitis, pharyngitis, otitis, or blunt
or penetrating soft tissue trauma
Lymphoma
B-symptoms
PMH
Antibiotic allergies
Recent antibiotic therapy
Immunodeficiency
HIV, hepatitis, diabetes,
collagen vascular diseases,
hematologic malignancy, and
recent chemotherapy or
steroid
Cummings otolaryngology 5
th
Ed. Chapter 14 deep neck space infections
Case
Onset 4 days ago
Associated symptoms: purulent rhinorrhea, reduced oral
intake, pain with swallowing.
Denies hoarseness or voice changes. No trismus or ear
pain. No skin erythema/crepitus. No recent choking
episodes. No recent tonsillitis. No prior episodes. No recent
dental work, intubation/upper airway procedures,
penetrating trauma. No chest pain/dyspnea.
No Rx to date.
No immunodeficiency.

What are the most important things to look for on exam?


Physical Examination
Full examination, as in all patients.
High points:
Difficulty with mouth opening indicates inflammation spread
Parapharyngeal, pterygoid, or masseteric spaces.
Alveolar swelling and decayed, loose, tender, or broken teeth.
Floor of the mouth
Ludwigs angina.
Stensen's and Wharton's ducts
Upper dentition, paranasal sinuses, facial soft tissues
Facial and ophthalmic venous drainage
EOM and pupillary light reflex
Cummings otolaryngology 5
th
Ed. Chapter 14 deep neck space infections
Case
T: 38.9, respirations 24/min
No stridor/stertor.
CN 2-12 WNL.
Normal dentition.
No facial pain.
Nasal crusting. Pain with palpation of the neck.
Diffuse minimally enlarged lymphadenopathy.
EOMI, vision normal

What do you want to do next?
Case
WBC 18.2, 88% neutrophils
Mild prerenal azotemia

Case
http://emedicine.medscape.com/article/995851-overview
2 cm
Case
Management?
Medical
Surgical


Overview
Case Presentation
Fascial Planes of the Head and Neck
Deep Neck Spaces
Microbiology
Management
Complications of Infections
Fascia Planes of the Neck
Superficial Cervical Fascia
Deep Cervical Fascia
Superficial layer
Middle layer
Deep layer
Carotid Sheath
Mukherji SK, Castillo M. A simplified approach to the spaces of the suprahyoid neck. Radiol Clin North Am. 1998 Sep;36(5):761-80, v. Review. PubMed PMID: 9747188.
Vieira F, Allen SM, Stocks RM, Thompson JW. Deep neck infection. Otolaryngol Clin North Am. 2008 Jun;41(3):459-
83, vii. doi: 10.1016/j.otc.2008.01.002. Review. PubMed PMID: 18435993.
Vieira F, Allen SM, Stocks RM, Thompson JW. Deep neck infection. Otolaryngol Clin North Am. 2008 Jun;41(3):459-
83, vii. doi: 10.1016/j.otc.2008.01.002. Review. PubMed PMID: 18435993.
Superficial Cervical
Fascia
Superficial Cervical Fascia
Deep to the dermis
Envelops
Platysma and muscles of facial expression
Incorporates musculoaponeurotic system
Boundaries
Superior: zygomatic process
Inferior: clavicle, axillae, deltopectoral region

Cummings otolaryngology 5
th
Ed. Chapter 14 deep neck space infections
Vieira F, Allen SM, Stocks RM, Thompson JW. Deep neck infection. Otolaryngol Clin North Am. 2008 Jun;41(3):459-
83, vii. doi: 10.1016/j.otc.2008.01.002. Review. PubMed PMID: 18435993.
Vieira F, Allen SM, Stocks RM, Thompson JW. Deep neck infection. Otolaryngol Clin North Am. 2008 Jun;41(3):459-
83, vii. doi: 10.1016/j.otc.2008.01.002. Review. PubMed PMID: 18435993.
Superficial Layer of
Deep Cervical Fascia
Deep Cervical Fascia Superficial layer
Investing fascia

Envelopes
Trapezius, sternocleidomastoid, muscles of mastication
(masseter, pterygoids, temporalis)
Encloses parotid gland and covers the submandibular gland
Forms stylomandibular ligament: separates the parotid from
the submandibular gland
Contributes to the lateral aspect of the carotid sheath

Extent
Superior
Zygomatic arch and mandible
Inferior
Attaches to the clavicle, acromion, and spine of the scapula
Deeply
Extends along the temporal bone to the carotid canal

Cummings otolaryngology 5
th
Ed. Chapter 14 deep neck space infections
Anderson JC, Homan JA. Radiographic correlation with neck anatomy. Oral Maxillofac Surg Clin North Am. 2008 Aug;20(3):311-9. doi:
10.1016/j.coms.2008.02.001. Review. PubMed PMID: 18603193.
Vieira F, Allen SM, Stocks RM, Thompson JW. Deep neck infection. Otolaryngol Clin North Am. 2008 Jun;41(3):459-
83, vii. doi: 10.1016/j.otc.2008.01.002. Review. PubMed PMID: 18435993.
Vieira F, Allen SM, Stocks RM, Thompson JW. Deep neck infection. Otolaryngol Clin North Am. 2008 Jun;41(3):459-
83, vii. doi: 10.1016/j.otc.2008.01.002. Review. PubMed PMID: 18435993.
Middle Layer of Deep
Cervical Fascia
muscular division
Vieira F, Allen SM, Stocks RM, Thompson JW. Deep neck infection. Otolaryngol Clin North Am. 2008 Jun;41(3):459-
83, vii. doi: 10.1016/j.otc.2008.01.002. Review. PubMed PMID: 18435993.
Vieira F, Allen SM, Stocks RM, Thompson JW. Deep neck infection. Otolaryngol Clin North Am. 2008 Jun;41(3):459-
83, vii. doi: 10.1016/j.otc.2008.01.002. Review. PubMed PMID: 18435993.
Middle Layer of Deep
Cervical Fascia
visceral division
Deep Cervical Fascia Middle layer
Envelopes
Muscular division
Surrounds the strap muscles
(sternohyoid, sternothyroid,
thyrohyoid, omohyoid)
Visceral division
Surrounds the pharyngeal
constrictor muscles, buccinator,
larynx, trachea, esophagus, thyroid,
and parathyroid glands

Extent
Superior
Base of skull
Inferior
Mediastinum
Cummings otolaryngology 5
th
Ed. Chapter 14 deep neck space infections
Anderson JC, Homan JA. Radiographic correlation with neck anatomy. Oral Maxillofac Surg Clin North Am. 2008 Aug;20(3):311-9. doi:
10.1016/j.coms.2008.02.001. Review. PubMed PMID: 18603193.

Vieira F, Allen SM, Stocks RM, Thompson JW. Deep neck infection. Otolaryngol Clin North Am. 2008 Jun;41(3):459-
83, vii. doi: 10.1016/j.otc.2008.01.002. Review. PubMed PMID: 18435993.
Vieira F, Allen SM, Stocks RM, Thompson JW. Deep neck infection. Otolaryngol Clin North Am. 2008 Jun;41(3):459-
83, vii. doi: 10.1016/j.otc.2008.01.002. Review. PubMed PMID: 18435993.
Deep Layer of Deep
Cervical Fascia
Deep Cervical Fascia Deep layer
Prevertebral fascia
Two layers: alar and pre-vertebral

Envelopes
Paraspinous muscles, cervical
vertebrae

Extent:
Alar layer: skull base to
mediastinum
Pre-vertebral layer: skull base to the
coccyx
Cummings otolaryngology 5
th
Ed. Chapter 14 deep neck space infections
Anderson JC, Homan JA. Radiographic correlation with neck anatomy. Oral Maxillofac Surg Clin North Am. 2008 Aug;20(3):311-9. doi:
10.1016/j.coms.2008.02.001. Review. PubMed PMID: 18603193.
Vieira F, Allen SM, Stocks RM, Thompson JW. Deep neck infection. Otolaryngol Clin North Am. 2008 Jun;41(3):459-
83, vii. doi: 10.1016/j.otc.2008.01.002. Review. PubMed PMID: 18435993.
Vieira F, Allen SM, Stocks RM, Thompson JW. Deep neck infection. Otolaryngol Clin North Am. 2008 Jun;41(3):459-
83, vii. doi: 10.1016/j.otc.2008.01.002. Review. PubMed PMID: 18435993.
Carotid Sheath
Overview
Case Presentation
Fascial Planes of the Head and Neck
Deep Neck Spaces
Microbiology
Management
Complications of Infections
Fascial Spaces
Compartments regions of loose connective
tissue that fill the areas between the fascial
layers
Interconnectedness of these areas is debated
Some interconnect according to Cummings
No universally accepted naming system
Som, PM et. al Head and Neck Imaging 5
th
Ed.

Osborn TM, Assael LA, Bell RB. Deep space neck infection: principles of surgical management. Oral Maxillofac Surg Clin
North Am. 2008 Aug;20(3):353-65. doi: 10.1016/j.coms.2008.04.002. Review. PubMed PMID: 18603196.

Osborn TM, Assael LA, Bell RB. Deep space neck infection: principles of surgical management. Oral Maxillofac Surg Clin
North Am. 2008 Aug;20(3):353-65. doi: 10.1016/j.coms.2008.04.002. Review. PubMed PMID: 18603196.




Retropharyngeal
Prevertebral

Masticator

Parapharyngeal
Parotid
Carotid

STATDX.COM
Deep Neck Spaces
Anatomical
Suprahyoid
Infrahyoid
Transhyoid
Pathophysiologic
Sources
Sequential spread
Key Spaces
Parapharyngeal
Submandibular/sublingual
Retropharyngeal, danger, prevertebral, carotid
Parapharyngeal Space

Stambuk, HE. Patel, SG. Imaging of the Parapharyngeal Space. Otolaryngologic Clinics of North America. Vol 41. Iss 1. 2008
Hyoid
Skull base
Parapharyngeal Space
STATDX.COM
Lateral: parotid gland,
mandible, and lateral pterygoid
muscle

Posterior:
prevertebral
fascia
Anterior:
pterygomandibular
raphe and medial
pterygoid muscle
Medial:
superior
constrictor,
tensor, and
levator veli
palatini
muscles
Parapharyngeal space
Central connection for
the suprahyoid spaces
Medially peritonsillar
space
Inferiorly
submandibular space
Laterally masticator
space
Carotid sheath courses
through this space
Posteromedially
retropharyngeal space
Sublingual Space
Superior: Oral mucosa
Inferior:
Mylohyoid
Posterior:
Digastric and
stylomandibular
ligament
Hartmann, RW. Ludwigs Angina in Children. Am Fam Physician 1999 July 1;60(1) 109-112.
Submandibular Space
Hartmann, RW. Ludwigs Angina in Children. Am Fam Physician 1999 July 1;60(1) 109-112.
Superior:
Mylohyoid
Inferior:
Hyoid
Posterior:
Digastric and
stylomandibular
ligament

Lateral:
Platysma
and
mandible
Anterior:
Digastric

Submandibular and Sublingual Spaces
Functionally comprise a single space
Clinical significance:
The mylohyoid line
Tooth apices anterior to second molar: sublingual space
Second and third molars: submandibular
Ludwig described indurated edema of the
submandibular and sublingual areas with minimal throat
inflammation but without lymph node involvement or
suppuration. At that time, the condition was almost
always fatal. Hartmann

Hartmann, RW. Ludwigs Angina in Children. Am Fam Physician 1999 July 1;60(1) 109-112.

Google images: mylohyoid line
Submandibular and Sublingual Spaces

Hartmann, RW. Ludwigs Angina in Children. Am Fam Physician 1999 July 1;60(1) 109-112.
Retropharyngeal Space
Boundaries:
Superior: skull base
Inferior: mediastinum (fusion of middle cervical
fascia with alar fascia, near T4)
Anterior: Buccopharyngeal fascia
Posterior: Alar fascia
Lateral: Carotid sheath
Cummings otolaryngology 5
th
Ed. Chapter 14 deep neck space infections

Retropharyngeal Space
Clinical Significance
Direct spread from the parapharyngeal
space
Lymphatic spread from the paranasal
sinuses/nasopharyngeal region

Danger Space
Boundaries:
Superior: skull base
Inferior: diaphragm
Anterior: alar fascial layer of deep cervical fascia
Posterior: prevertebral fascial layer of deep
cervical fascia
Lateral: Transverse processes of vertebral
Cummings otolaryngology 5
th
Ed. Chapter 14 deep neck space infections

Danger Space
Clinical significance:
Potential for rapid inferior spread
Loose areolar tissue
Infectious infiltration from the
retropharyngeal, parapharyngeal, or
prevertebral spaces are the primary routes to
the danger space

Prevertebral Space
Boundaries:
Anterior: prevertebral fascia
Superior: Clivus
Inferior: Coccyx
Cummings otolaryngology 5
th
Ed. Chapter 14 deep neck space infections
Osborn TM, Assael LA, Bell RB. Deep space neck infection: principles of surgical management. Oral Maxillofac Surg Clin North Am. 2008 Aug;20(3):353-65. doi: 10.1016/j.coms.2008.04.002.
Review. PubMed PMID: 18603196.

Prevertebral Space
Clinical significance:
Dense areolar tissue
Mechanisms of spread
Infection of the vertebral bodies
Penetrating injuries.

Masticator Space
Enclosed by superficial layer of deep
cervical fascia
Boundaries:
Anterior buccal fat pad
Medial: Fascia medial to pterygoid
muscles
Lateral: Fascia lateral to masseter
Superior temporal fossa
Subspaces:
Mandible
Temporalis muscle
Cummings otolaryngology 5
th
Ed. Chapter 14 deep neck space infections
STATDX.COM

Masticator Space
Clinical significance:
Anterolateral to
parapharyngeal
space
Most commonly
from the third
mandibular molars
May involve
temporal space
with maxillary
molar infection

STATDX.COM
Cummings otolaryngology 5
th
Ed. Chapter 14 deep neck space infections


Peritonsillar Space
Boundaries:
Medial: capsule of the palatine tonsil
Lateral: superior constrictor muscle.
Anterior/posterior: anterior and posterior tonsillar
pillars
Inferior: posterior tongue
Cummings otolaryngology 5
th
Ed. Chapter 14 deep neck space infections
Peritonsillar Space
Clinical significance
Loose connective tissue
Readily spread to the
parapharyngeal space.

Wikipedia: Peritonsillar abscess
Parotid Space
Boundaries:
Lateral: superficial layer of deep cervical fascia
Medial: fascia, which does not enclose the
superomedial aspect of the gland
Cummings otolaryngology 5
th
Ed. Chapter 14 deep neck space infections
STATDX.COM

Parotid Space
Clinical significance
Parotid space is lateral
to the parapharyngeal
space.
Incomplete
superomedial border
permits communication
with the prestyloid
compartment of the
parapharyngeal space.

Carotid Space
Borders:
Carotid sheath
Cummings otolaryngology 5
th
Ed. Chapter 14 deep neck space infections
Carotid Space
Clinical significance:
Infection from the surrounding parapharyngeal space,
penetrating trauma, or intravenous drug use may
potentiate spread into this space.
Lincoln highway of the neck
Coined by Harris B. Mosher in 1929
Wikipedia: Lincoln highway
Anterior Visceral Space
Boundaries:
The visceral division of the middle layer of deep cervical fascia encloses the
anterior visceral space, or pretracheal space
Superior: thyroid cartilage
Inferior: mediastinum
Cummings otolaryngology 5
th
Ed. Chapter 14 deep neck space infections
Anterior Visceral Space
Clinical significance
Perforation of the anterior esophageal wall by endoscopic
instrumentation, foreign bodies, or trauma may introduce
infection to this space.
Direct spread from
submandibular space

Matching
Mechanism
Acute tonsillitis
Rhinosinusitis
Dental infection (upper)
Dental infection (lower)
2
nd
/3
rd
molar
Dental infection (lower)
anterior
Esophagoscopy


Space
Retropharyngeal/
Parapharyngeal
Sublingual
Submandibular
Masticator space
Retropharyngeal
Peritonsillar space

Matching
Mechanism
Acute tonsillitis
Rhinosinusitis
Dental infection (upper)
Dental infection (lower)
2
nd
/3
rd
molar
Dental infection (lower)
anterior
Esophagoscopy


Space
Retropharyngeal/
Parapharyngeal
Sublingual
Submandibular
Masticator space
Retropharyngeal
Peritonsillar space

Overview
Case Presentation
Fascial Planes of the Head and Neck
Deep Neck Spaces
Microbiology
Management
Complications of Infections
Microbiology
Usually mixed aerobic and anaerobic organisms,
predominance of oral flora.
Group A beta-hemolytic streptococcal species, alpha-hemolytic
streptococcal species, Staphylococcus aureus, Fusobacterium
nucleatum, Bacteroides melaninogenicus, Bacteroides oralis, and
Spirochaeta, Peptostreptococcus, and Neisseria species
Pseudomonas species, Escherichia coli, and Haemophilus influenzae
are occasionally encountered.
Increasing documentation of MRSA, especially within
pediatric patient populations
Higher gram negative incidence in diabetics
Thomason TS, Brenski A, McClay J, Ehmer D. The rising incidence of methicillin-resistant Staphylococcus aureus in pediatric neck abscesses.
Otolaryngol Head Neck Surg. 2007 Sep;137(3):459-64. PubMed PMID: 17765776.
Murray, AD et. Al. Deep Neck infections. Emedicine. Mar 12, 2012
Overview
Case Presentation
Fascial Planes of the Head and Neck
Deep Neck Spaces
Microbiology
Management
Complications of Infections
Imaging
CT scan is indicated in cases of a suspected deep neck space
infection
It has been suggested that size (>2 cm) is more predictive of a deep
neck abscess than the presence of a ring-enhancing lesion.
Lateral neck radiographs are less sensitive that CT and are not
recommended
Presence of an air-fluid level or greater than 5mm of thickening in a
child or greater than 7mm of thickening in an adult of the
prevertebral tissue at C2 indicate retropharyngeal infection until
proven otherwise
Ultrasound is more accurate than CECT in differentiating a drainable
abscess from cellulitis
May not visualize deeper lesions
Does not provide anatomic information necessary for planning surgery
Vieira, F. Allen, SM. Etal. Deep Neck Infection. Otolaryngol Clini N Am. 41 (2008) 459-483.
Cummings otolaryngology 5
th
Ed. Chapter 14 deep neck space infections
5 year retrospective review of suspected deep
neck space infections
89 patients identified, 13 excluded
Of 76, all had CT scans. fluid collection was present
in 65 people.
57 taken to surgery, rest treated with antibiotics
Negative if no pus or responded to antibiotics
All false positives were all less than 3.5 cm
Negative predictive value of CT 100%

Freling N, Roele E, Schaefer-Prokop C, Fokkens W. Prediction of deep neck abscesses by contrast-enhanced computerized tomography in 76 clinically suspect
consecutive patients. Laryngoscope. 2009 Sep;119(9):1745-52. doi: 10.1002/lary.20606. PubMed PMID: 19551850.
Medical Management
Airway, Airway, Airway
Loss of airway is a major source of mortality from deep neck infection
Aggressive management
Dyspnea, stridor, retractions
Impending airway compromise
Consider tracheostomy over intubation
Shorter overall hospital stay (4.8 vs 5.9 days) did not reach significance
Reduced cost by 60%
Fewer lost airways
Antibiotics
Steroids
Advocated by some
Felt to worsen hyperglycemia etc. by others
Cummings otolaryngology 5
th
Ed. Chapter 14 deep neck space infections
Potter JK, Herford AS, Ellis E 3rd. Tracheotomy versus endotracheal intubation for airway management in deep neck space infections. J Oral
Maxillofac Surg. 2002 Apr;60(4):349-54; discussion 354-5. Review. PubMed PMID: 11928085.
Recommended Antibiotics

Cummings otolaryngology 5
th
Ed. Chapter 14 deep neck space infections
Surgical Management
Indicated
(1) air-fluid level in the neck or evidence of gas-producing
organisms;
(2) abscess visualized in the fascial spaces of the head and neck;
(3) threatened airway compromise from abscess or phlegmon;
(4) failure to respond to 48 to 72 hours of empiric intravenous
antibiotic therapy.
Needle Aspiration
Transoral Incision and Drainage
Transcervical Incision and Drainage
The guiding principle of surgery for deep neck infection is
obtaining adequate access and drainage of the infected space
while minimizing risk to normal structures.
Cummings otolaryngology 5
th
Ed. Chapter 14 deep neck space infections
Cheng J, Elden L. Children with deep space neck infections: our experience with 178 children. Otolaryngol Head Neck Surg. 2013 Jun;148(6):1037-42. doi: 10.1177/0194599813482292.
Epub 2013 Mar 21. PubMed PMID: 23520072.
Overview
Case Presentation
Fascial Planes of the Head and Neck
Deep Neck Spaces
Microbiology
Management
Complications of Infections
Complications
Lemierre's Syndrome
Carotid Artery Pseudoaneurysm or Rupture
Mediastinitis
Necrotizing Fasciitis
Cummings otolaryngology 5
th
Ed. Chapter 14 deep neck space infections
Lemierre's Syndrome
Definition
Thrombophlebitis of the internal jugular vein
Origin
Carotid space infection
Microbiology
Gram-negative bacillus Fusobacterium necrophorum
Endotoxin induces platelet aggregation and septic thrombus formation.
Symptoms
Swelling and tenderness at the angle of the jaw and along the SCM, along with
signs of sepsis with pulmonary emboli
Imaging
Filling defect in the internal jugular system.
Treatment
Prolonged antimicrobial treatment +/- anticoagulation
Surgery limited to worsening clinical course despite appropriate medical
therapy
Vieira, F. Allen, SM. Etal. Deep Neck Infection. Otolaryngol Clini N Am. 41 (2008) 459-483.
Cummings otolaryngology 5
th
Ed. Chapter 14 deep neck space infections
Carotid Artery Pseudoaneurysm or
Rupture
Origin
Retropharyngeal or parapharyngeal spaces
Symptoms
Sentinel hemorrhages
Hemodynamic compromise
Protracted course
Hematoma
Other: pulsating neck mass, Horner's syndrome, palsies of
cranial nerves IX through XII
Treatment
Proximal control and ligation of the carotid artery.
?Role for interventional radiology
Vieira, F. Allen, SM. Etal. Deep Neck Infection. Otolaryngol Clini N Am. 41 (2008) 459-483.
Cummings otolaryngology 5
th
Ed. Chapter 14 deep neck space infections
Mediastinitis
Origin
Retropharyngeal, danger and prevertebral spaces
Anterior visceral space
Symptoms
Dyspnea, pleuritic chest pain, tachycardia, pleural effusion, mediastinal widening/air
Management
Broad-spectrum intravenous antibiotics
Drainage
Surgical Drainage
Optimal approach is somewhat debated
Bilateral cervical approach advocated by some with infection limited to the anterior-superior
mediastinum
Thoracotomy in cases that extend beyond the upper mediastinum or that involve more than
one mediastinal compartment
Corsten: analysis ofpatients with mediastinitis from cervical abscess showing mortality rate was 19%
among patients who underwent both cervical and thoracic drainage and 47% among those who
underwent cervical drainage alone
Corsten, MJ, Shamji, FM etal. Optimal treatment of descending necrotising mediastinitis. Thorax. 1997; 52:702-708
Vieira, F. Allen, SM. Etal. Deep Neck Infection. Otolaryngol Clini N Am. 41 (2008) 459-483.
Cummings otolaryngology 5
th
Ed. Chapter 14 deep neck space infections
Necrotizing Fasciitis
Definition
Infection that spreads along fascial planes and causes necrosis of connective tissue
Microbiology
Mixed including S pyogenes, Clostridium perfringens, others
MRSA
Symptoms
Fevers, skin changes (tender, edematous, erythematous), soft tissue crepitation
Later developing pale, anesthetic, dusky and blistering skin
Management
IV antibiotics
Aggressive and frequent debridement of necrotic tissue
Hyperbaric oxygen
Flanagan et al show that hyperbaric oxygen may decrease hospital stay 10 patient (9 received 1 did
not due to hemodynamic instability).
Multiple studies in other specialties literature showing no difference in amputation rate or mortality
Mortality
20% to 30% in treated patients
Vieira, F. Allen, SM. Etal. Deep Neck Infection. Otolaryngol Clini N Am. 41 (2008) 459-483.
Cummings otolaryngology 5
th
Ed. Chapter 14 deep neck space infections
Wolf, H, R M. Necrotizing Fasciitis of the Head and Neck. Head and Neck. December 2010
Flanagan, CE. Daramola, OO. Surgical debridement and adjunctive hyperbaric oxygen in cervical necrotizing fasciitis. Otolaryngology Heada dn Neck Surgery. 2009 140: 730.
Acknowledgement
I would like to thank Dr. Sindhwani of the
Department of Radiology for assistance in
obtaining some of the images used in this
presentation
The images obtained from STATDX.COM are
meant for educational purposes only.

References
Anderson JC, Homan JA. Radiographic correlation with neck anatomy. Oral Maxillofac Surg Clin North Am. 2008 Aug;20(3):311-9. doi:
10.1016/j.coms.2008.02.001. Review. PubMed PMID: 18603193
Biron VL, Kurien G, Dziegielewski P, Barber B, Seikaly H. Surgical vs ultrasound-guided drainage of deep neck space abscesses: a randomized
controlled trial: surgical vs ultrasound drainage. J Otolaryngol Head Neck Surg. 2013 Feb 26;42(1):18. doi: 10.1186/1916-0216-42-18. PubMed PMID:
23672735; PubMed Central PMCID: PMC3651187.
Cheng J, Elden L. Children with deep space neck infections: our experience with 178 children. Otolaryngol Head Neck Surg. 2013 Jun;148(6):1037-42.
doi: 10.1177/0194599813482292. Epub 2013 Mar 21. PubMed PMID: 23520072.
Corsten, MJ, Shamji, FM etal. Optimal treatment of descending necrotising mediastinitis. Thorax. 1997; 52:702-708
Cummings otolaryngology 5
th
Ed. Chapter 14 deep neck space infections
Flanagan, CE. Daramola, OO. Surgical debridement and adjunctive hyperbaric oxygen in cervical necrotizing fasciitis. Otolaryngology Heada dn Neck
Surgery. 2009 140: 730
Freling N, Roele E, Schaefer-Prokop C, Fokkens W. Prediction of deep neck abscesses by contrast-enhanced computerized tomography in 76 clinically
suspect consecutive patients. Laryngoscope. 2009 Sep;119(9):1745-52. doi: 10.1002/lary.20606. PubMed PMID: 19551850.
Hartmann, RW. Ludwigs Angina in Children. Am Fam Physician 1999 July 1;60(1) 109-112.
Miller WD, Furst IM, Sndor GK, Keller MA. A prospective, blinded comparison of clinical examination and computed tomography in deep neck
infections. Laryngoscope. 1999 Nov;109(11):1873-9. PubMed PMID: 10569425.
Mukherji SK, Castillo M. A simplified approach to the spaces of the suprahyoid neck. Radiol Clin North Am. 1998 Sep;36(5):761-80, v. Review.
PubMed PMID: 9747188.
Murray, AD et. Al. Deep Neck infections. Emedicine. Mar 12, 2012
Osborn TM, Assael LA, Bell RB. Deep space neck infection: principles of surgical management. Oral Maxillofac Surg Clin North Am. 2008
Aug;20(3):353-65. doi: 10.1016/j.coms.2008.04.002. Review. PubMed PMID: 18603196.
Potter JK, Herford AS, Ellis E 3rd. Tracheotomy versus endotracheal intubation for airway management in deep neck space infections. J Oral
Maxillofac Surg. 2002 Apr;60(4):349-54; discussion 354-5. Review. PubMed PMID: 11928085 Som, PM et. al Head and Neck Imaging 5
th
Ed.
Stambuk, HE. Patel, SG. Imaging of the Parapharyngeal Space. Otolaryngologic Clinics of North America. Vol 41. Iss 1. 2008
STATDX.COM
Thomason TS, Brenski A, McClay J, Ehmer D. The rising incidence of methicillin-resistant Staphylococcus aureus in pediatric neck abscesses.
Otolaryngol Head Neck Surg. 2007 Sep;137(3):459-64. PubMed PMID: 17765776.
Vieira F, Allen SM, Stocks RM, Thompson JW. Deep neck infection. Otolaryngol Clin North Am. 2008 Jun;41(3):459-83, vii. doi:
10.1016/j.otc.2008.01.002. Review. PubMed PMID: 18435993.
Wolf, H, R M. Necrotizing Fasciitis of the Head and Neck. Head and Neck. December 2010