Deep neck infections

Last updated: November 8, 2022

Summarytoggle arrow icon

Deep neck infections include peritonsillar abscess, parapharyngeal abscess (PPA), and retropharyngeal abscess (RPA). While uncommon, deep neck infections are clinically significant because of their potentially life-threatening complications, including the spread of infection to vital nearby structures and airway compromise. Early recognition, broad-spectrum IV antibiotic therapy, aggressive airway management, and urgent ENT consultation reduce the risk of complications and death from sepsis or airway compromise.

Overview of deep neck infections [1][2]
Peritonsillar abscess Parapharyngeal abscess Retropharyngeal abscess
  • An accumulation of pus between the muscles of the pharynx and the palatine tonsillar capsule [3]
  • A collection of pus lateral to the peritonsillar space and divided anteriorly and posteriorly into pre- and post-styloid compartments [2]
  • Most common in adolescents and young adults
  • Most common deep neck infection
  • Most common in children < 5 years of age
  • Most common in children < 5 years of age
Clinical Features
  • CT

Epidemiology [3]

  • Most frequently occurs in adults aged 20–40 years
  • The most common deep neck infection
  • Increased risk of airway obstruction in children with peritonsillar abscess

Etiology [4][5]

Clinical features [5][6]

Diagnostics [3][7]

Diagnosis is usually clinical. Obtain imaging if there is diagnostic uncertainty or concern for complications.

Microbiological studies

Evidence of pus on needle aspiration confirms the diagnosis.

Imaging [3]

  • Ultrasound neck (intraoral or transcutaneous) [9]
    • Indication: diagnostic uncertainty
    • Findings: irregular hypoechoic cavity with a defined circumference
  • CT or MRI neck with IV contrast [10]
    • Indication: clinical suspicion of other diagnoses or complications
    • Findings

Treatment [3][7]

Antibiotic therapy [3]

Abscess drainage [3]

Complications [12][13]

Disposition [11][14]

  • Outpatient management may be appropriate, unless there are risks for complications or previous outpatient therapy was unsuccessful

Epidemiology [15]

  • Most common in children < 5 years of age
  • >

Etiology [4]

Clinical features [16]

Diagnostics [2][11]

Treatment [18][19]

Systemic IV antibiotics with abscess drainage and supportive care are the mainstays of therapy.

Conservative treatment with IV antibiotics alone may be considered in select patients (e.g., clinically stable patients with a small abscess).

Complications [4]

Parapharyngeal infections can become life-threatening because of their proximity to the retropharyngeal space, carotid sheath, and airway!

Epidemiology [15][20]

  • Generally the most dangerous deep neck infection
  • Most common in children < 5 years of age
  • >
  • Overall incidence in the U.S. has increased.

Etiology [21]

Clinical features [22]

Diagnostics [23]

Imaging is required for diagnostic confirmation. Microbiological studies can help identify the causative pathogen.

Treatment [11][14][23]

Systemic IV antibiotics with abscess drainage and supportive care are the mainstays of therapy.

Airway management is always the first step if the patient has signs of respiratory distress.

Complications [27]

The differential diagnoses listed here are not exhaustive.

General principles

  • Infections are typically polymicrobial.
  • There are currently no guidelines on optimal empiric therapy for deep neck infections; Follow local protocols and consider early specialist consultation. [3][29]
  • Switch to targeted antibiotics once culture and sensitivity results are available.

Most common pathogens [29]

Example regimens (for adults) [3]

Empiric antibiotic therapy should be tailored to local antibiograms, suspected focus of infection, prior antibiotics, and disease severity.

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