• Clinical science
  • Physician

Deep neck infections


Deep neck infections include peritonsillar abscess (PTA), parapharyngeal abscess (PPA), and retropharyngeal abscess (RPA). PTA commonly occurs in adolescents or young adults as a complication of acute tonstillitis. Clinical features include fever, sore throat, dysphagia, a “hot-potato” voice, and trismus (lockjaw). Diagnosis is primarily based on examination of the pharynx, which demonstrates a characteristic fluctuant, enlarged tonsil and contralateral deviation of the uvula. Antibiotics and incision and drainage of the abscess are the mainstay of treatment. PPA and RPA are more common in children < 5 years of age, and typically occur secondary to dental infections or upper respiratory infections, respectively. PPA and RPA both present with nonspecific features of tonsillitis. In addition, PPA may lead to medial displacement of the lateral pharyngeal wall and tonsil, while RPA may lead to unilateral swelling of the posterior pharyngeal wall. The diagnosis of PPA is made with CT, while RPA is usually confirmed with either lateral x-ray, which shows widening of the prevertebral space, or CT if x-ray is non-diagnostic. In both PPA and RPA, IV empiric antibiotic therapy is routinely administered and surgery may be necessary in certain cases. 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.


Basic anatomy of the neck

Overview of deep neck infections

Peritonsillar Abscess Parapharyngeal Abscess Retropharyngeal Abscess
  • 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
  • Contiguous or lymphatic spread from upper respiratory tract infections (most common) or other nearby infections
  • Local penetrating pharyngeal trauma
Clinical Features
  • Features of tonsillitis
  • “Hot potato” voice
  • Trismus
  • Uvula shifted to the contralateral side
  • Inflamed ipsilateral tonsil: fluctuant, swollen, erythematous with exudates (ipsilateral bulging of the palatine arch)
  • Clinical diagnosis
  • CT
  • Lateral x-ray: widened prevertebral (soft tissue) space
  • CT


Peritonsillar abscess


Parapharyngeal abscess

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


Retropharyngeal abscess

In patients with airway compromise, airway management should be performed before any other diagnostic or treatment measures!


Empiric antibiotic therapy for deep neck infections

Acute management checklist

  • 1. Murray AD. Deep Neck Infections. In: Meyers AD. Deep Neck Infections. New York, NY: WebMD. http://emedicine.medscape.com/article/837048-overview#a11. Updated January 12, 2016. Accessed January 28, 2017.
  • 2. Chang L, Chi H, Chiu NC, Huang FY, Lee KS. Deep neck infections in different age groups of children. J Microbiol Immunol Infect. 2010; 43(1). doi: 10.1016/S1684-1182(10)60007-2.
  • 3. Chow AW. Deep neck space infections. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/deep-neck-space-infections?source=search_result&search=deep%20neck%20infection&selectedTitle=1~24#H1. Last updated July 16, 2015. Accessed January 28, 2017.
  • 4. Wald ER. Peritonsillar cellulitis and abscess. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/peritonsillar-cellulitis-and-abscess?source=search_result&search=Peritonsillar%20Abscess&selectedTitle=1~42. Last updated January 17, 2017. Accessed January 28, 2017.
  • 5. Gosselin BJ. Peritonsillar Abscess. In: Geibel J. Peritonsillar Abscess. New York, NY: WebMD. http://emedicine.medscape.com/article/194863-overview#a6. Updated December 27, 2016. Accessed January 28, 2017.
  • 6. Long SS, Pickering LK, Prober CG. Principles and Practice of Pediatric Infectious Disease. Elsevier; 2012.
  • 7. Bluestone CD, Casselbrant ML, Yellon RF et al. Pediatric Otolaryngology. Mcgraw-Hill Professional; 2013.
  • 8. Kilty SJ, Gaboury I. Clinical predictors of peritonsillar abscess in adults. J Otolaryngol Head Neck Surg. 2008; 37(2): pp. 165–168. pmid: 19128606.
  • 9. Galioto NJ. Peritonsillar abscess. Am Fam Physician. 2008; 77(2): pp. 199–202. pmid: 18246890.
  • 10. Szuhay G, Tewfik TL. Peritonsillar abscess or cellulitis?: A clinical comparative paediatric study. J Otolaryngol. 1998; 27(4): pp. 206–212. pmid: 9711515.
  • 11. Goldenberg NA, Knapp-clevenger R, Hays T, Manco-johnson MJ. Lemierre's and Lemierre's-like syndromes in children. Pediatrics. 2005; 116(4): pp. e543–548. doi: 10.1542/peds.2005-0433.
  • 12. Page C, Biet A, Zaatar R, Strunski V. Parapharyngeal abscess: diagnosis and treatment. Eur Arch Otorhinolaryngol. 2008; 265(6): pp. 681–686. doi: 10.1007/s00405-007-0524-5.
  • 13. Woods CR, Cash ED, Smith AM, et al. Retropharyngeal and Parapharyngeal Abscesses Among Children and Adolescents in the United States: Epidemiology and Management Trends: 2003-2012. J Pediatric Infect Dis Soc. 2015; 5(3): pp. 259–268. doi: 10.1093/jpids/piv010.
  • 14. Sasaki CT. Parapharyngeal Abscess. http://www.merckmanuals.com/professional/ear,-nose,-and-throat-disorders/oral-and-pharyngeal-disorders/parapharyngeal-abscess. Updated October 1, 2016. Accessed January 30, 2017.
  • 15. Hurley MC, Heran MK. Imaging studies for head and neck infections. Infect Dis Clin North Am. 2007; 21(2): pp. 305–53, v–vi. doi: 10.1016/j.idc.2007.04.001.
  • 16. Le T, Bhushan V, Chen V, King M. First Aid for the USMLE Step 2 CK. McGraw-Hill Education; 2015.
  • 17. Kahn JH. Retropharyngeal Abscess. In: Shlamovitz GZ. Retropharyngeal Abscess. New York, NY: WebMD. http://emedicine.medscape.com/article/764421-overview#showall. Updated January 27, 2017. Accessed January 30, 2017.
  • 18. Wald ER. Retropharyngeal infections in children. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/retropharyngeal-infections-in-children. Last updated March 11, 2016. Accessed January 31, 2017.
  • 19. Sasaki CT. Retropharyngeal Abscess. http://www.merckmanuals.com/professional/ear,-nose,-and-throat-disorders/oral-and-pharyngeal-disorders/retropharyngeal-abscess. Updated October 1, 2016. Accessed January 31, 2017.
  • 20. Page NC, Bauer EM, Lieu JE. Clinical features and treatment of retropharyngeal abscess in children. Otolaryngol Head Neck Surg. 2008; 138(3): pp. 300–306. pmid: 18312875.
  • 21. Qureshi HA, Ference EH, Tan BK, Chandra RK, Kern RC, Smith SS. National trends in retropharyngeal abscess among adult inpatients with peritonsillar abscess. Otolaryngol Head Neck Surg. 2015; 152(4): pp. 661–666. doi: 10.1177/0194599814568286.
  • 22. Philpott CM, Selvadurai D, Banerjee AR. Paediatric retropharyngeal abscess. J Laryngol Otol. 2004; 118(12): pp. 919–926. pmid: 15667676.
  • 23. Thompson JW, Cohen SR, Reddix P. Retropharyngeal abscess in children: a retrospective and historical analysis. Laryngoscope. 1988; 98(6 Pt 1): pp. 589–592. doi: 10.1288/00005537-198806000-00001.
  • 24. Brook I. Microbiology and Principles of Antimicrobial Therapy for Head and Neck Infections. Infect Dis Clin North Am. 2007; 21(2): pp. 355–391. doi: 10.1016/j.idc.2007.03.014.
  • 25. Gujrathi AB, Ambulgekar V, Kathait P. Deep neck space infection – A retrospective study of 270 cases at tertiary care center. World Journal of Otorhinolaryngology - Head and Neck Surgery. 2016; 2(4): pp. 208–213. doi: 10.1016/j.wjorl.2016.11.003.
  • 26. Yang S-W. Deep neck abscess: an analysis of microbial etiology and the effectiveness of antibiotics. Infection and Drug Resistance. 2008: p. 1. doi: 10.2147/idr.s3554.
  • 27. McClay JE, Murray AD, Booth T. Intravenous Antibiotic Therapy for Deep Neck Abscesses Defined by Computed Tomography. Archives of Otolaryngology–Head & Neck Surgery. 2003; 129(11): p. 1207. doi: 10.1001/archotol.129.11.1207.
  • 28. Numa AH, et al. The Effect of Nebulized Epinephrine on Respiratory Mechanics and Gas Exchange in Bronchiolitis. Am J Respir Crit Care Med. 2001; 164(1): pp. 86–91. doi: 10.1164/ajrccm.164.1.2008090.
  • Endicott JN, Nelson RJ, Saraceno CA. Diagnosis and management decisions in infections of the deep fascial spaces of the head and neck utilizing computerized tomography. Laryngoscope. 1982; 92(6 Pt 1): pp. 630–633. pmid: 7087623.
  • Siewert JR. Chirurgie. Springer Verlag (2006).
last updated 01/19/2020
{{uncollapseSections(['UUXbcx', 'Xjc9_X0', 'n-X7B00', 'L-XwB00', '5Qci9X0', 'af1QkT0', 'GS1Bag0'])}}