• Clinical science
  • Clinician

Deep neck infections

Summary

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.

Overview

Basic anatomy of the neck

Overview of deep neck infections

Peritonsillar Abscess Parapharyngeal Abscess Retropharyngeal Abscess
Epidemiology
  • 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
Etiology
  • 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)
  • Features of tonsillitis
  • Sometimes trismus
  • Unilateral swelling of the posterior pharyngeal wall (possible fluctuance)
  • Neck asymmetry, with neck swelling and anterior cervical lymphadenopathy(→ inability to extend neck)
Diagnosis
  • Clinical diagnosis
  • CT
  • Lateral x-ray: widened prevertebral (soft tissue) space
  • CT
Treatment

References:[1][2][3]

Peritonsillar abscess

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

Parapharyngeal abscess

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

References:[1][3][12][6][13][14][15]

Retropharyngeal abscess

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

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

Empiric antibiotic therapy for deep neck infections

Acute management checklist

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last updated 10/09/2020
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