Otolaryngology: Deep Neck Infection

Deep Neck Infection (DNI)

Definition

  • Infection of the Potential Fascial Planes & Spaces of the Head & Neck
  • Incidence Has Decreased with the Use of Antibiotics

Anatomy & Fascial Spaces

Causes

  • Dental Infections – Most Common Etiology in Adults
  • Waldeyer’s Ring (Tonsil) Infections – Most Common Etiology in Children
  • Parotid Gland Infections
  • Deep Cervical Lymph Node Infections
  • Middle Ear Infections
  • Sinus Infections

Presentation

  • Sore Throat
  • Neck Pain
  • Neck Swelling
  • Neck Stiffness
  • Trismus (Inability to Open the Jaw)
  • Torticollis (Wry Neck)
  • Dysphagia
  • Drooling
  • Stridor/Dyspnea Indicate Risk for Airway Obstruction

Site Specifics

  • Peritonsillar Abscess
    • Usually Does Not Obstruct
  • Parapharyngeal Abscess
    • Risk for Vascular Invasion (Through Carotid Sheath)
    • Risk for Mediastinal Spread (Through the Retropharyngeal & Danger Spaces)
  • Retropharyngeal Abscess
    • Airway Emergency
    • Risk for Mediastinal Spread (Directly & Through the Danger Space)
  • Ludwig’s Angina
    • Infection Involving the Submandibular Space
    • Characterized by Rapid Spread into Other Spaces
    • Presentation:
      • Alarmingly Rapid Speed of Spread
      • Swelling, Elevation & Displacement of the Tongue
      • Brawny Induration of the Submandibular Region
      • Usually Minimal-No Fluctuance Due to Speed of Cellulitic Process
    • High Risk for Airway Obstruction

Complications

  • Lemierre Syndrome – Thrombophlebitis of the Internal Jugular Vein
    • Most Common Organism: Fusobacterium necrophorum (Gram Negative Bacillus)
    • Bacteria Spreads from Tonsillar Vein to the Internal Jugular Vein
    • Endotoxin Induces Platelet Aggregation & Septic Thrombus
  • Cavernous Sinus Thrombosis
    • Caused by Retrograde Bacterial Spread from Upper Dentition or Paranasal Sinuses
    • Spreads by Valveless Ophthalmic Veins to the Cavernous Sinus
  • Carotid Artery Pseudoaneurysm
  • Mediastinitis

Diagnosis

  • Primarily Diagnosed by Imaging (CT)
  • May Not Be Easily Palpable by Physical Exam – Dense Superficial Fascial Layer

Treatment

  • Primary Initial Concern: Airway Management
    • Intubation Indications:
      • Signs of Near-Total Obstruction
      • > 50% Obstruction
      • Moderate-Severe Symptoms
  • Definitive Treatment: Empiric Antibiotics & Consider Surgical Drainage
  • Surgical Drainage:
    • Indications:
      • Antibiotic Failure After 48-72 Hours
      • Concern for Necrotizing Infection
      • Threatened Airway
      • Complications of DNI
    • Incision:
      • Transcervical – Most Common
      • Transoral – Consider for Peritonsillar or Retropharyngeal Space Infections
      • Need to Open All Involved Spaces
    • Leave Drains to Allow Continued Drainage
    • Extract Any Involved Teeth