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

• Two major fascial layers: superficial cervical and deep cervical fascia
• The deep cervical fascia is divided into 3 layers: investing, pretracheal and prevertebral layers.
  • The carotid sheath consists of fascia from all three deep layers and surrounds the common carotid artery, internal jugular vein, and vagus nerve.
• Deep neck spaces are spaces between these deep layers.
  • The retropharyngeal space communicates laterally with the parapharyngeal space and may drain into the prevertebral space.
  • The danger space extends from the skull base to the posterior mediastinum and is posterior to the retropharyngeal space.

Overview of deep neck infections

References:^[1][2][3]

• Epidemiology
  • Most common deep neck infection
  • Most common in adolescents and young adults
• Etiology
  • Pathogens: Streptococcus pyogenes (most common), Streptococcus anginosus, viridans streptococci, Staphylococcus aureus, and Haemophilus species, often in a polymicrobial environment
  • Acute bacterial tonsillitis (see acute tonsillitis)
• Clinical features
  • Features of tonsillitis: fever, malaise, severe sore throat, dysphagia, and odynophagia
  • “Hot potato” voice (muffled speech), drooling, or halitosis
  • Trismus
  • Uvula shifted to the contralateral side, with inferior and medial displacement of tonsil
  • Unilateral fluctuant, swollen, erythematous tonsil with exudates (ipsilateral bulging of the palatine arch)
  • Ipsilateral cervical lymphadenopathy (and neck swelling)
• Diagnosis
  • Usually a clinical diagnosis
  • Gram stain and culture of aspirated abscess fluid, and throat culture to identify causative pathogen
  • Contrast-enhanced CT if there is a clinical suspicion of other diagnoses or complications
• Treatment
  • Airway management is always the first step!
  • IV antibiotics with good gram-positive and anaerobic coverage: empiric clindamycin or ampicillin-sulbactam .
  • Incision and drainage; or needle aspiration (surgical drainage): risk of airway obstruction, complications, or immunodeficiency.
  • Tonsillectomy indicated if:
    • Unresponsive to drainage and antibiotics
    • Recurrent tonsillitis or peritonsillar abscess, or other complications occur
    • Airway obstruction is present
• Complications
  • Can become life-threatening due to airway compromise
  • Further spread of infection into the parapharyngeal space (PPA), retropharyngeal space (RPA), mediastinum (mediastinitis), or fascia (necrotizing fasciitis)
  • Aspiration pneumonia
  • Internal jugular vein thrombosis or thrombophlebitis
  • Bacteremia and sepsis

References:^{[3][4][5][6][7][8][9][10][11]}

• Epidemiology
  • Most common in children < 5 years of age
  • ♂ > ♀
• Etiology
  • Pathogens: Streptococci (viridans streptococci, S. pneumoniae), staphylococci (including MRSA), Haemophilus influenzae, oral anaerobes (Peptostreptococci, Bacteroides species), often in a polymicrobial environment
  • Oropharyngeal infections
    • Dental infections (most commonly)
    • Acute tonsillitis
    • Peritonsillar abscess into the parapharyngeal space
    • Pharyngeal or salivary gland infections
• Clinical features
  • Features of peritonsillar abscess, especially trismus
  • Posterior space abscess: medial displacement of the lateral pharyngeal wall and tonsil
  • Anterior space abscess: indurated swelling below the angle of the mandible down to the hyoid bone
  • Respiratory distress: dyspnea, stridor
  • Limited cervical neck extension
• Diagnosis
  • Gram stain and culture of aspirated abscess fluid, and throat culture to identify causative pathogen
  • CT
    • Confirms diagnosis
    • Determines extent of infection
    • Enables CT-guided abscess aspiration, or drainage
• Treatment
  • Airway management is always the first step!
  • IV broad-spectrum antibiotics: ampicillin-sulbactam, penicillin G or ceftriaxone plus metronidazole, or clindamycin.
  • Surgical drainage
• Complications
  • Airway obstruction
  • Spread of infection to retropharyngeal space, carotid sheath (presents with torticollis) and then mediastinum (internal carotid artery erosion jugular vein thrombophlebitis, and mediastinitis), or cranial nerves (Horner syndrome, hoarseness, unilateral paresis of the tongue, and other neurologic deficits)
  • Aspiration pneumonia with spontaneous pus drainage
  • Bacteremia and sepsis

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

References:^{[1][3][6][12][13][14][15]}

• Epidemiology
  • Generally the most dangerous deep neck infection
  • Most common in children < 5 years of age
  • ♂ > ♀
  • Overall incidence in the U.S. has increased.
• Etiology
  • Pathogen: Streptococci (viridans Streptococci, S. pneumoniae), Staphylococci (including MRSA), Haemophilus influenzae, oral anaerobes (Peptostreptococci, Bacteroides species), often in a polymicrobial environment
  • Direct or indirect causes:
    • Contiguous or lymphatic spread from oral (most common) or upper respiratory tract infections
    • Local penetrating pharyngeal trauma; (e.g., from small bones such as of fish or chicken; , or medical instruments)
    • Spread from other deep neck infections (nasopharynx, sinuses, adenoids)
• Clinical features
  • Features of tonsillitis and trismus (minimal)
  • Neck asymmetry with unilateral swelling of the posterior pharyngeal wall; (possible fluctuance) → inability to extend neck
  • Torticollis
  • Anterior cervical lymphadenopathy
  • Respiratory distress
  • Infants may also present with lethargy, cough, poor intake, rhinorrhea, and agitation.
• Diagnosis
  • Contrast-enhanced CT: shows hypodense lesion in retropharyngeal space, soft-tissue swelling, peripheral ring enhancement, mass effect
    • Initial step if in no signs of respiratory compromise
    • Confirms diagnosis in patients with a suspicion of RPA and with a negative x-ray
    • Determine extent of infection to other spaces and presence of foreign bodies
    • Differentiate between cellulitis and abscess
  • Gram stain and culture of aspirated abscess fluid and blood to identify causative pathogen
  • Lateral neck x-ray: shows a widened prevertebral (soft tissue) space (gas in the retropharyngeal space and lordosis) ^[16]
• Differential diagnosis
  • Other deep neck infections
  • Trauma
  • Other causes of neck swelling or respiratory distress: anaphylaxis or angioedema, retropharyngeal tumors
  • Other causes of neck stiffness: meningitis, cervical spine osteomyelitis, dystonia
• Treatment
  • Airway management is always the first step; if the patient has signs of respiratory distress
  • Hospitalization for all children and any patient with respiratory compromise
  • IV broad-spectrum antibiotics: empiric options include ampicillin-sulbactam or clindamycin.
  • Needle aspiration or incision and drainage of abscess (surgical drainage) should be performed immediately in patients with a compromised airway or other life-threatening complications
• Complications
  • Airway obstruction
  • Spread of infection to carotid sheath; (internal carotid artery erosion, jugular vein thrombophlebitis) and then mediastinum (acute necrotizing mediastinitis with widened mediastinum on chest x-ray )
  • Infection can spread and enter the skull base (epidural abscess) or the posterior mediastinum (pericarditis).
  • Aspiration pneumonia
  • Atlantoaxial dislocation
  • Bacteremia and sepsis

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

References:^{[3][13][17][18][19][20][21][22][23]}

• There are no currently established guidelines available for the optimal empiric therapy for deep neck infections. ^[24]
• Empiric coverage should cover the gram-positive (e.g., Staphylococcus aureus, Streptococcus spp., viridans streptococci), gram-negative (Haemophilus influenzae), and anaerobic (e.g., Porphyromonas, Fusobacterium, Prevotella, Bacteroides, and Peptostreptococcus spp.) bacteria most commonly found in the oropharyngeal and odontogenic spaces.
• An individualized approach should take the following into account:
  • Local bacterial resistance patterns
  • Suspected focus of infection
  • Prior antibiotic treatment
  • Severity of the infection
• Possible regimens (for adults)
  • Amoxicillin-clavulanic acid PLUS metronidazole ^[25]
  • Ceftriaxone PLUS clindamycin ^[26]
  • Ceftriaxone PLUS metronidazole ^[26]
  • Cefuroxime PLUS clindamycin ^[27]
  • Penicillin G PLUS clindamycin PLUS gentamicin ^[26]
  • Piperacillin-tazobactam ^[24]
  • Meropenem ^[24]
  • Imipenem/cilastatin ^[24]
• If MRSA infection is suspected or the patient is immunosuppressed, consider the addition of one of the following: ^[24]
  • Vancomycin
  • Linezolid

• Secure airway
  • Anesthesia and/or ENT consult
  • Prepare for difficult airway
  • Consider steroids (e.g., dexamethasone ) if airway edema is present
  • Consider nebulized racemic epinephrine in patients with respiratory distress ^[28]
• IV access and obtain blood cultures (2 sets)
• Consider rapid test for group A streptococcus (for peritonsillar abscess).
• Start broad-spectrum antibiotics (see empiric antibiotic therapy for deep neck infections).
• ENT consultation to evaluate the need for ultrasound-guided needle aspiration, surgical drainage, or tonsillectomy.
• Dental consultation for evaluation of teeth as a potential source of infection
• Antipyretic therapy
• Pain management
• Continuous pulse oximetry
• Consider ICU admission for airway monitoring.

1. 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): p.259-268. doi: 10.1093/jpids/piv010 . | Open in Read by QxMD
2. 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): p.661-666. doi: 10.1177/0194599814568286 . | Open in Read by QxMD
3. Philpott CM, Selvadurai D, Banerjee AR. Paediatric retropharyngeal abscess. J Laryngol Otol. 2004; 118 (12): p.919-926.
4. Long SS, Pickering LK, Prober CG. Principles and Practice of Pediatric Infectious Disease. Elsevier ; 2012
5. 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): p.630-633.
6. Le T, Bhushan V, Chen V, King M. First Aid for the USMLE Step 2 CK. McGraw-Hill Education ; 2015
7. Thompson JW, Cohen SR, Reddix P. Retropharyngeal abscess in children: a retrospective and historical analysis. Laryngoscope. 1988; 98 (6 Pt 1): p.589-592. doi: 10.1288/00005537-198806000-00001 . | Open in Read by QxMD
8. 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.
9. 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.
10. 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.
11. 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.
12. Page NC, Bauer EM, Lieu JE. Clinical features and treatment of retropharyngeal abscess in children. Otolaryngol Head Neck Surg. 2008; 138 (3): p.300-306.
13. 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.
14. 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 . | Open in Read by QxMD
15. Kilty SJ, Gaboury I. Clinical predictors of peritonsillar abscess in adults. J Otolaryngol Head Neck Surg. 2008; 37 (2): p.165-168.
16. Galioto NJ. Peritonsillar abscess. Am Fam Physician. 2008; 77 (2): p.199-202.
17. Szuhay G, Tewfik TL. Peritonsillar abscess or cellulitis?: A clinical comparative paediatric study. J Otolaryngol. 1998; 27 (4): p.206-212.
18. Goldenberg NA, Knapp-clevenger R, Hays T, Manco-johnson MJ. Lemierre's and Lemierre's-like syndromes in children. Pediatrics. 2005; 116 (4): p.e543-548. doi: 10.1542/peds.2005-0433 . | Open in Read by QxMD
19. 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.
20. 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.
21. Bluestone CD, Casselbrant ML, Yellon RF et al. Pediatric Otolaryngology. Mcgraw-Hill Professional ; 2013
22. 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.
23. Hurley MC, Heran MK. Imaging studies for head and neck infections. Infect Dis Clin North Am. 2007; 21 (2): p.305-53, v-vi. doi: 10.1016/j.idc.2007.04.001 . | Open in Read by QxMD
24. Page C, Biet A, Zaatar R, Strunski V. Parapharyngeal abscess: diagnosis and treatment. Eur Arch Otorhinolaryngol. 2008; 265 (6): p.681-686. doi: 10.1007/s00405-007-0524-5 . | Open in Read by QxMD
25. 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): p.86-91. doi: 10.1164/ajrccm.164.1.2008090 . | Open in Read by QxMD
26. Brook I. Microbiology and Principles of Antimicrobial Therapy for Head and Neck Infections. Infect Dis Clin North Am. 2007; 21 (2): p.355-391. doi: 10.1016/j.idc.2007.03.014 . | Open in Read by QxMD
27. 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): p.208-213. doi: 10.1016/j.wjorl.2016.11.003 . | Open in Read by QxMD
28. 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 . | Open in Read by QxMD
29. 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 . | Open in Read by QxMD
30. Siewert JR. Chirurgie. Springer Verlag (2006)
31. de Virgilio C, Frank PN, Grigorian A. Surgery: A Case Based Clinical Review. Springer ; 2015
32. Schlossberg D. Clinical Infectious Disease. Cambridge University Press ; 2015
33. Walls R, Hockberger R, Gausche-Hill M. Rosen's Emergency Medicine - Concepts and Clinical Practice. Elsevier Health Sciences ; 2013
34. Marx J, Walls R, Hockberger R. Rosen's Emergency Medicine - Concepts and Clinical Practice E-Book. Elsevier Health Sciences ; 2013
35. Ferri FF. Ferri's Clinical Advisor. Elsevier Health Sciences ; 2013
36. Jameson JL, Fauci AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J. Harrison's Principles of Internal Medicine, Twentieth Edition (Vol.1 & Vol.2). McGraw-Hill Education / Medical ; 2018
37. Maroldi R, Farina D, Ravanelli M, Lombardi D, Nicolai P. Emergency Imaging Assessment of Deep Neck Space Infections. Seminars in Ultrasound, CT and MRI. 2012; 33 (5): p.432-442. doi: 10.1053/j.sult.2012.06.008 . | Open in Read by QxMD
38. Tabas, J & Reynolds, T. High Risk Emergencies: Emergency Medicine Clinics of North America. Saunders ; 2010 : p. 121
39. Harkani A, Hassani R, Ziad T, et al. Retropharyngeal Abscess in Adults: Five Case Reports and Review of the Literature. ScientificWorldJournal. 2011; 11 : p.1623-1629. doi: 10.1100/2011/915163 . | Open in Read by QxMD
40. Van TT, Naccache SN, Dien Bard J. The Brief Case: Retropharyngeal Abscess in a 14-Year-Old Caused by Fusobacterium necrophorum. J Clin Microbiol. 2018; 56 (12). doi: 10.1128/jcm.00487-18 . | Open in Read by QxMD
41. Allegrini D, Autelitano A, Nocerino E, Fogagnolo P, De Cillà S, Rossetti L. Grisel’s syndrome, a rare cause of anomalous head posture in children: a case report. BMC Ophthalmol. 2016; 16 (1). doi: 10.1186/s12886-016-0197-1 . | Open in Read by QxMD
42. Corsten MJ, Shamji FM, Odell PF, et al. Optimal treatment of descending necrotising mediastinitis. Thorax. 1997; 52 (8): p.702-708. doi: 10.1136/thx.52.8.702 . | Open in Read by QxMD
43. McLeod C, Stanley KA. Images in emergency medicine: retropharyngeal abscess.. West J Emerg Med. 2008; 9 (1): p.55.
44. Zaoutis, LB & Chiang VW. Comprehensive pediatric hospital medicine. Elselvier Health Sciences ; 2007
45. Bou-Assaly W. Computed tomography imaging of acute neck inflammatory processes. World J Radiol. 2010; 2 (3): p.91. doi: 10.4329/wjr.v2.i3.91 . | Open in Read by QxMD
46. Reid, J; Lee,E; Angelisa Paladin, A; Davros, W & Carrico C. Pediatric Radiology. OUP USA ; 2014 : p. 13
47. Tanaka K, Inokuchi R, Namai Y, Yahagi N. Retropharyngeal cellulitis in adolescence. BMJ Case Rep. 2013; 2013 (may17 1): p.bcr2013009684-bcr2013009684. doi: 10.1136/bcr-2013-009684 . | Open in Read by QxMD
48. Hansen BW, Ryndin S, Mullen KM. Infections of Deep Neck Spaces. Semin Ultrasound CT MR. 2020; 41 (1): p.74-84. doi: 10.1053/j.sult.2019.10.001 . | Open in Read by QxMD
49. Smith MM, Heubi CH. Infections of the Neck and Pharynx in Children. Curr Treat Options Pediatr. 2018; 4 (2): p.211-220. doi: 10.1007/s40746-018-0127-y . | Open in Read by QxMD
50. Schott CK, Counselman FL, Ashe AR. A Pain in the Neck: Non-traumatic Adult Retropharyngeal Abscess. J Emerg Med. 2013; 44 (2): p.329-331. doi: 10.1016/j.jemermed.2011.09.028 . | Open in Read by QxMD
51. Lander L, Lu S, Shah RK. Pediatric retropharyngeal abscesses: A national perspective. Int J Pediatr Otorhinolaryngol. 2008; 72 (12): p.1837-1843. doi: 10.1016/j.ijporl.2008.09.001 . | Open in Read by QxMD
52. Hochstim CJ, Messner AH. Pediatric Inflammatory Neck Mass. Current Treatment Options in Pediatrics. 2016; 2 (3): p.216-223. doi: 10.1007/s40746-016-0063-7 . | Open in Read by QxMD
53. Sudhanthar S, Garg A, Gold J, Napolova O. Parapharyngeal abscess: A difficult diagnosis in younger children. Clinical Case Reports. 2019; 7 (6): p.1218-1221. doi: 10.1002/ccr3.2209 . | Open in Read by QxMD
54. Duval M, Daniel SJ. Retropharyngeal and parapharyngeal abscesses or phlegmons in children. Int J Pediatr Otorhinolaryngol. 2008; 72 (12): p.1765-1769. doi: 10.1016/j.ijporl.2008.07.007 . | Open in Read by QxMD
55. Klug TE, Fischer ASL, Antonsen C, Rusan M, Eskildsen H, Ovesen T. Parapharyngeal abscess is frequently associated with concomitant peritonsillar abscess. European Archives of Oto-Rhino-Laryngology. 2013; 271 (6): p.1701-1707. doi: 10.1007/s00405-013-2667-x . | Open in Read by QxMD
56. Alaani A, Griffiths H, Minhas SS, Olliff J, Drake Lee AB. Parapharyngeal abscess: diagnosis, complications and management in adults. Eur Arch Otorhinolaryngol. 2004; 262 (4): p.345-350. doi: 10.1007/s00405-004-0800-6 . | Open in Read by QxMD
57. Blumberg JM, Judson BL. Surgical management of parapharyngeal space infections. Oper Tech Otolayngol Head Neck Surg. 2014; 25 (3): p.304-309. doi: 10.1016/j.otot.2014.04.014 . | Open in Read by QxMD
58. Johnston J, Stretton M, Mahadevan M, Douglas RG. Peritonsillar abscess: A retrospective case series of 1773 patients. Clin Otolaryngol. 2018; 43 (3): p.940-944. doi: 10.1111/coa.13070 . | Open in Read by QxMD
59. Marom T, Cinamon U, Itskoviz D, Roth Y. Changing trends of peritonsillar abscess. Am J Otolaryngol. 2010; 31 (3): p.162-167. doi: 10.1016/j.amjoto.2008.12.003 . | Open in Read by QxMD
60. Allen DZ, Rawlins K, Onwuka A, Elmaraghy CA. Comparison of inpatient versus outpatient management of pediatric peritonsillar abscess outcomes. Int J Pediatr Otorhinolaryngol. 2019; 123 : p.47-50. doi: 10.1016/j.ijporl.2019.04.025 . | Open in Read by QxMD
61. Sowerby LJ, Hussain Z, Husein M. The epidemiology, antibiotic resistance and post-discharge course of peritonsillar abscesses in London, Ontario. J Otolaryngol Head Neck Surg. 2013; 42 (1): p.5. doi: 10.1186/1916-0216-42-5 . | Open in Read by QxMD
62. Chin RL, Frazee BW, Coralic Z. Emergency Management of Infectious Diseases. Cambridge University Press ; 2018
63. Powell J, Wilson JA. An evidence-based review of peritonsillar abscess. Clin Otolaryngol. 2012; 37 (2): p.136-145. doi: 10.1111/j.1749-4486.2012.02452.x . | Open in Read by QxMD
64. Rao M, Linga R., Vishwanathan P. Anaesthetic management of difficult airway due to retropharyngeal abscess. Indian J Anaesth. 2010; 54 (3): p.246. doi: 10.4103/0019-5049.65376 . | Open in Read by QxMD
65. Cho SY, Woo JH, Kim YJ, et al. Airway management in patients with deep neck infections. Medicine. 2016; 95 (27): p.e4125. doi: 10.1097/md.0000000000004125 . | Open in Read by QxMD
66. Karkos PD, Leong SC, Beer H, Apostolidou MT, Panarese A. Challenging airways in deep neck space infections. Am J Otolaryngol. 2007; 28 (6): p.415-418. doi: 10.1016/j.amjoto.2006.10.012 . | Open in Read by QxMD
67. Tansey JB, Hamblin J, Mamidala M, et al. Dexamethasone Use in the Treatment of Pediatric Deep Neck Space Infections. Ann Otol Rhinol Laryngol. 2019; 129 (4): p.376-379. doi: 10.1177/0003489419890349 . | Open in Read by QxMD
68. Anand H Kulkarni, Swarupa D Pai, Basant Bhattarai, Sumesh T Rao, M Ambareesha. Ludwig's angina and airway considerations: a case report. Cases J. 2008; 1 (1). doi: 10.1186/1757-1626-1-19 . | Open in Read by QxMD
69. Hegenbarth MA. Preparing for Pediatric Emergencies: Drugs to Consider. Pediatrics. 2008; 121 (2): p.433-443. doi: 10.1542/peds.2007-3284 . | Open in Read by QxMD
70. Pluijms WA, van Mook WN, Wittekamp BH, Bergmans DC. Postextubation laryngeal edema and stridor resulting in respiratory failure in critically ill adult patients: updated review. Crit Care. 2015; 19 (1). doi: 10.1186/s13054-015-1018-2 . | Open in Read by QxMD
71. Duprey K, Rose J, Fromm C. Ludwig’s angina. Int J Emerg Med. 2010; 3 (3): p.201-202. doi: 10.1007/s12245-010-0172-1 . | Open in Read by QxMD
72. Jamiela A. McDonnough, Deawodi A. Ladzekpo, Iasson Yi, William R. Bond, Gezzer Ortega, Adedoyin O. Kalejaiye. Epidemiology and resource utilization of ludwig's angina ED visits in the United States 2006–2014. Laryngoscope. 2019; 129 (9): p.2041-2044. doi: 10.1002/lary.27734 . | Open in Read by QxMD
73. Nicholas Costain, Thomas J. Marrie. Ludwig's Angina. Am J Med. 2011; 124 (2): p.115-117. doi: 10.1016/j.amjmed.2010.08.004 . | Open in Read by QxMD
74. N. P L, V. N S, B. Jenkins. Ludwig's angina: need for including airways and larynx in ultrasound evaluation. BMJ Case Rep. 2014; 2014 (nov09 1): p.bcr2014206506-bcr2014206506. doi: 10.1136/bcr-2014-206506 . | Open in Read by QxMD
75. Arslan Fatma Zeynep, Altunkeser Ayşegul, Turgut Bekir, Erdogan Hasan. Ludwig's Angina: A Rapid Radiological and Clinical Nightmare. Clin Med Img Lib. 2017; 3 (3). doi: 10.23937/2474-3682/1510079 . | Open in Read by QxMD
76. Wael Hasan, David Leonard, John Russell. Ludwig's Angina—A Controversial Surgical Emergency: How We Do It. Int J Otolaryngol. 2011; 2011 : p.1-4. doi: 10.1155/2011/231816 . | Open in Read by QxMD
77. Edetanlen BE, Saheeb BD. Comparison of Outcomes in Conservative versus Surgical Treatments for Ludwig’s Angina. Med Princ Pract. 2018; 27 (4): p.362-366. doi: 10.1159/000490740 . | Open in Read by QxMD
78. Fleisher LA, Roizen MF. Essence of Anesthesia Practice E-Book. Elsevier Health Sciences ; 2010
79. Maharaj S, Ahmed S, Pillay P. Deep Neck Space Infections: A Case Series and Review of the Literature. Clin Med Insights Ear Nose Throat. 2019; 12 : p.117955061987127. doi: 10.1177/1179550619871274 . | Open in Read by QxMD
80. Flint PW, Haughey BH, Robbins KT, et al.. Cummings Otolaryngology - Head and Neck Surgery E-Book. Elsevier Health Sciences ; 2014
81. Wang B, Gao B-L, Xu G-P, Xiang C. Images of deep neck space infection and the clinical significance. Acta radiol. 2014; 55 (8): p.945-951. doi: 10.1177/0284185113509093 . | Open in Read by QxMD
82. McGahan JP, Schick MA, Mills L. Fundamentals of Emergency Ultrasound. Elsevier Health Sciences ; 2019
83. Kalmovich LM, Gavriel H, Eviatar E, Kessler A. Accuracy of Ultrasonography Versus Computed Tomography Scan in Detecting Parapharengeal Abscess in Children. Pediatr Emerg Care. 2012; 28 (8): p.780-782. doi: 10.1097/pec.0b013e3182627cff . | Open in Read by QxMD
84. Simard RD, Socransky S, Chenkin J. Transoral Point-of-Care Ultrasound in the Diagnosis of Parapharyngeal Space Abscess. J Emerg Med. 2019; 56 (1): p.70-73. doi: 10.1016/j.jemermed.2018.09.034 . | Open in Read by QxMD
85. Capps EF, Kinsella JJ, Gupta M, Bhatki AM, Opatowsky MJ. Emergency Imaging Assessment of Acute, Nontraumatic Conditions of the Head and Neck. Radiographics. 2010; 30 (5): p.1335-1352. doi: 10.1148/rg.305105040 . | Open in Read by QxMD
86. Lawrence R, Bateman N. Controversies in the management of deep neck space infection in children: an evidence-based review. Clin Otolaryngol. 2016; 42 (1): p.156-163. doi: 10.1111/coa.12692 . | Open in Read by QxMD
87. Cheng J, Elden L. Children with Deep Space Neck Infections. Otolaryngol Head Neck Surg. 2013; 148 (6): p.1037-1042. doi: 10.1177/0194599813482292 . | Open in Read by QxMD
88. Kanekar S, Mannion K. Imaging of Head and Neck Spaces for Diagnosis and Treatment, An Issue of Otolaryngologic Clinics, E-Book. Elsevier Health Sciences ; 2012
89. Flint PW, Haughey BH, Niparko JK, et al.. Cummings Otolaryngology - Head and Neck Surgery E-Book. Elsevier Health Sciences ; 2010
90. Haynes J, Arnold KR, Aguirre-Oskins C, Chandra S. Evaluation of neck masses in adults.. Am Fam Physician. 2015; 91 (10): p.698-706.
91. Bailey BJ, Johnson JT, Newlands SD. Head & Neck Surgery--otolaryngology. Lippincott Williams & Wilkins ; 2006
92. Bluestone, CD. Pediatric Otolaryngology. Gulf Professional Publishing ; 2003