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Recognizing and treating deep neck infection Jonas T. Johnson & Harvey M. Tucker To cite this article: Jonas T. Johnson & Harvey M. Tucker (1976) Recognizing and treating deep neck infection, Postgraduate Medicine, 59:6, 95-100, DOI: 10.1080/00325481.1976.11714389 To link to this article:

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• Infections of the prevertebral, retropharyngeal, and parapharyngeal spaces are known as deep neck abscesses. These infections merit special consideration because of the lifethreatening complications that may result iftreatment is delayed or inadequate. In the preantibiotic era, physicians encountered such infections fairly often, and they weil understood the need for earl y recognition and prompt intervention. In recent years, however, deep neck infection bas become a less common occurrence and knowledge aboutit is now generally obtained from textbooks or from an occasional reported case. This review of the problem of deep neck abscess should serve as a reminder of the importance of earl y diagnosis and treatment of a potentially lethal condition.

recognizing and treating deep neck infection Jonas T. Johnson, MD Harvey M. Tucker, MD State University of New York Upstate Medical Center Syracuse, New York

Anatomie Considerations

An understanding of the fascia! planes that divide the neck into potential spaces and compartments is requisite to the diagnosis and subsequent management of deep neck abscess. Connective tissue envelops ali viscera; a fascia! plane represents only a condensation of such connective tissue into a thicker sheath. Among the many fascial sheaths, planes, and spaces that have been described, sorne are more real in a functional sense than others. For purposes of this discussion, it is important to realize that infection and abscess formation may cause pressure, and the limits of spaces are thus defined by the planes of greatest resistance. Fasciae of the neck-The contents of the neck are enclosed in a fascial envelope referred to as the superficial or investing fascia. The superficial fascia is contiguous with the platysma muscle and is to be distinguished from the superficiallayer of the deep cervical fascia. The latter consists of three layers (figure l ): a superficiallayer originating along the nuchalline and spinous processes of the cervical vertebrae and enveloping the neck to include the trapezius, stemocleidomastoid, and strap muscles; a middle layer surrounding the larynx, pharynx, and thyroid gland; and a deep fascia} layer lying anterior to the vertebrae and paraspinal muscles. Portions of ali three unite to form the carotid sheath (figure 1 inset A), called the Lincoln Highway of the body 1 as it is an avenue to the mediastinum. Prevertebral space-The deep fascial layer (which envelops the paraspinal muscles) is attached to the transverse

Vol. 59 • No. 8 • June 1978 • POSTQRADUATE IEDICINE

Deep neck infection has ominous implications if not detected and treated in an early stage. The anatomie relationships of head and neck spaces encourage spread of infection. Immediate hospitalization and constant monitoring of the patient after diagnosis are mandatory.


Figure 1. Transverse section of neck showing layers of deep cervical fascia. Spaces and fasciae are schematically exaggerated. lnset A shows how layers converge to form carotid sheath. lnset B shows how deep fascial layer splits to form alar and prevertebral components that enclose prevertebral space.


Thyroid gland

Stemocleidomastoid muscle r :nrnm''" carotid artery

~~--Vagus nerva •--~-Omohyoid


1 Carotid sheath

Alar component ~

Anterior scalene muscle

lnset A

processes of the cervical vertebrae laterally and splits to form an alar and a prevertebral layer anterior to the vertebral bodies (figure 1 inset B). Between these layers is the prevertebral space. This potential space provides easy access for extension of infection from the diaphragm to the base of the skull, and bas therefore become known as the danger space. Retropharyngeal space- The retropharyngeal space lies in the midline anterior to the alar component of the deep fascial layer and behind the posterior pharyngeal wall (figures 2 and 3). lt proceeds inferiorly from the base of the skull to approximately the level of the tracheal bifurcation (C-6 toT -2). Medially, the superior constrictor muscle adheres to the prevertebral fascia to form a raphe. Thus, an abscess in this space tends to form to one side or the other of the midline. Connective tissue, fat, and lymph nodes are normally found in the retropharyngeal space. The lymph nodes drain chiefly the nose, paranasal sinuses, nasopharynx, and eustachian tubes. 2 The involution of these nodes that occurs at about the age of puberty explains the marked decrease in incidence of ab-


lnset B

scess of the retropharyngeal space in adults as compared with its rate of occurrence in children.3•4 Active infection of the retropharyngeal space may break through into the mediastinum or into the bilaterally situated lateral pharyngeal space. Lateral pharyngeal space-The lateral pharyngeal space (figures 3 and 4) is coneshaped, having its apex at the hyoid bone where the fascia attaches. Its base is the petrous portion of the temporal bone at the base of the skull. The lateral pharynge al musculature forms the medial wall, and the mandible, internai pterygoid muscles, and parotid gland form the lateral wall. The pterygomandibular raphe is the anterior boundary. Posteriori y lie the middle and deep layers of the deep cervical fascia and, in part, the carotid sheath (figures 3 and 4b). The carotid sheath and its contents pierce the cone at its vertex and run to the mediastinum. The lateral pharyngeal space is divided into prestyloid and poststyloid compartments by the styloid bone and styloid muscles. However, the compartments communicate both

P08TGAADUATE IEDICINE • June 1978 • Vol. 59 • No. 8

Figure 2. Sagittal section of lower portion of Key

head showing retropharyngeal space that extends from base of skull to tracheal bifurcation.

Superficial layer

Figure 3. Oblique section of top of neck shows continuity of peripharyngeal spaces and the potential for spread of infection from one to another.


.! Middle (pretracheal) layer 1 ' ...


Deep (prevertebral and alar) layer

Spaces Prevertebral f'j,;> ·· ·"" ·1 Retropharyngeal

Figure 4. Lateral pharyngeal space. a. Frontal section close to angle of jaw. b. Frontal section behind ramus of mandible. Note relationship of space to parotid gland. Figures 1 through 4 reproduced with permission from Hollinshead WH: Anatomy for Surgeons. Vol 1: The Head and Neck. Ed 2. New York, Harper & Row, Publishers, 1968.

Lateral pharyngeal Submandibular



Internai jugular vein, carotid artery

Parotid gland

Submandibular gland Mylohyoid - - - muscle



4b Temporal bone

Parotid gland Soft palate

Pharyngeal wall Tons il

Digastric and stylohyoid muscle Sternocleidomastoid muscle

Greater cornu of hyoid

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table 1. diagnostic symptoms of deep neck abscess Prevertebrel or retropharyngeal apace Bulging posterior pharyngeal wall Drooling Dysphagia "Hot potato" voice Posturing of neck to rear or to one side

Latarel pharyngeal apace Bulging lateral pharyngeal wall Dysphagia Neck mass Trismus

above and below these muscles. The anterior compartment contains connective tissue, fat, and lymph nodes and is the space sometimes occupied by the so-called dumbbell tumor of the parotid. The poststyloid compartment is tranversed by the carotid artery, the jugular vein, and the ninth, tenth, 1lth, and 12th cranial nerves and the cervical sympathetic nerves. Inferiorly, the lateral pharyngeal space communicates with the spaces about the tongue (figure 3). Sublingual abscesses spread to the neck by means of this route. Etlology

Deep neck abscesses most often originate from local trauma or, by means oflymphatic spread, from foci of infection in the teeth, sinuses, nasopharynx, mastoid, tonsils, or oropharynx. It is noteworthy, however, th at in approximately 50% of cases no source of infection can be identified. 5 An abscess in the prevertebral space is in sorne ways a special case: A primary infection of the vertebrae, 3 particu1arly one of tuberculous origin, is almost always the cause. The organisms most often implicated in deep neck abscess areStaphylococcus aureus and beta-hemolytic streptococci. 5 •6 Mycobacterium tuberculosis is now rarely found. Other organisms are sporadically identified, and performing culture studies of material obtained from suspected sites of infection is imperative. The use of increasingly sophisticated laboratory techniques has led to speculation that anaerobie bacteria, especially Bacteroides, are commonly present in deep neck abscesses and may, in fact, be the primary culprits. 6 - 8


Differentiai Dlagnosls

The diagnosis of infection or abscess in the neck would appear to be fairly straightforward. Nevertheless, confusion can arise, especially in this era of tumor-conscious physicians who are unaccustomed to dealing with deep neck infection. Other mass lesions which may present in the deep neck spaces include hematomas, 9 • 10 parotid tumors, 11 neurogenic tumors, 12 and carotid artery aneurysms. 3 • 13 It is sometimes difficult to differentiate a deep neck infection from a more superficial infection. A history of sore throat or upper respiratory infection or both, followed by fever and dysphagia, should alert the physician to the possibility of deep neck abscess. Symptoms characterizing infection of the prevertebral, retropharyngeal, and lateral pharyngeal spaces are shown in table 1. Physical examination is often limited by trismus. Once the mouth is open, the posterior or lateral pharyngeal wall can be seen to bulge or a mass can be palpated. With abscess of the lateral pharyngeal space, trismus is marked because the inflammatory process in volves the muscles of mastication. The tonsils may appear normal but are usually displaced toward the midline, as is the lateral pharyngeal wall. The retromandibular portion of the parotid gland may be displaced laterally and th us be noted as a mass on neck examination. Soft-tissue films of the neck are usually helpful in diagnosing retropharyngeal abscess. 2 •4 Whorley and colleagues14 have pointed out that the normal thickness of the soft-tissue mass overlying C-2, as seen on lateral neck x-ray film, should measure between 1 and 7 mm (average 3.4 mm) (figure 5). The thickness of tissue overlying C-6 should be 9 to 22 mm (average 14 mm). For children under 15 years of age the dimensions at C-2 are the same but at C-6 range from 5 to 14 mm (average 9 mm). In small children, soft-tissue fùms of the neck must be carefully interpreted, as redundant soft tissue may be present. Neck x-ray fùms are also helpful in that they permit inspection of the vertebrae in a search for the possible source of an abscess of the prevertebral space.

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The magnitude of the complications that occasionally occur with deep neck abscess make early diagnosis and treatment of this condition mandatory. Be cause of the anatomie relationships pointed out previously, an abscess of a parapharyngeal space may involve the cervical sympathetic nerves, the vagus nerve, or the hypoglossal nerve, leading to the development of Homer's syndrome, hoarseness, and unilateral tongue paralysis, respective} y. Involvement of the glossopharyngeal nerve is difficult to assess; the spinal accessory nerve, lying deeper, usually escapes injury. Vascular involvement is a real, although fortunately rare, complication. A spiking febrile course is consistent with septic thrombophlebitis of the internai jugular vein, wh ile hematoma of the tissues or even frank arterial bleeding may occur and indicates erosion of a major artery.Ia,IS-17 An abscess of the retropharyngeal space may spontaneously drain into the pharynx, posing a threat of aspiration. Thus, before such an event can take place, it is desirable to institute controlled drainage. Spread of infection into the mediastinum via the retropharyngeal space or along the carotid sheath is ominous and has a mortality approaching 35%, even in patients given the best of treatment. 18 Treatment

Ali patients with deep neck abscess require immediate hospitalization. They must be observed for possible airway obstruction and tracheostomy may be indicated. Therapy consists of antibiotic and intravenous fluid administration and should be begun intensively as soon as appropriate material for cultures has been taken. Penicillin is usually a good ftrst choice. As stressed by Beck19 30 years ago, ''Chemotherapy should not be withheld merely to satisfy the curiosity as to the type of infection." In uncomplicated cases, therapy may be continued for 12 to 24 hours. Patients need constant monitoring and reevaluation of their status in close consultation with surgical personnel. Drainage should not be withheld unless there is clear evidence of improvement.

Vol. 59 • No. 8 • June 1978 •


Figure 58. X-ray film of cervical spine. Note normal dimensions of soft-tissue mass overlying C-2 and C-6. b. Thickened soft-tissue mass overlying cervical spine suggests abscess of retropharyngeal space.

Fluctuance of the lateral pharyngeal space may not become evident even in the presence of gross abscess, due to the overlying thick stemocleidomastoid muscle. Deep neck infections that are discovered while still in the cellulitic stage may be controlled with antibiotics alone. 20 However, our experience and that of others8•20 indicates that only between 10% and 15% of cases can be managed in this way. Th us, antibiotic therapy must be


Jonas T. Johnson

Harvey M. Tucker

Dr. Johnson is a resident and Dr. Tucker was formerly an associate professer in the department of otolaryngology and communication sciences, State University of New York Upstate Medical Center, Syracuse, New York. Dr. Tucker is now professer and chairman, department of otolaryngology and communicative disorders, The Cleveland Clinic, Cleveland.

considered as an adjunct to surgery and not as suitable therapy in and of itself. The onset of complications dictates even more aggressive management. In septic thrombophlebitis, antibiotics are given in high doses after cultures of blood and of material from the abscess cavity have been made. If no improvement is seen, the jugular vein should be ligated, the involved portion re-

moved, and appropriate drainage instituted as soon as possible. Sorne authors 15 advocate the more ''conservative'' approach of attempting to control the process with anticoagulants. We feel such an approach is radical rather than conservative, since it allows greater threat to life through septic embolism or propagation of clot. In such instances, surgery is, in fact, the more conservative approach. Carotid artery erosion necessitates ligation of the carotid artery, as patch or replacement grafts have no place in this infected setting. This course of action, necessary to prevent fatal hemorrhage, 15 - 17 is not without its own complications and requires the attendance of a physician cognizant in the surgical treatment of infected vessels. Summary

Deep neck abscess is a relatively infrequent entity in the antibiotic era. For this very reason, it is even more dangerous than in years past, since it may go unrecognized. Early diagnosis and intervention are critical. Once complications set in, morbidity and mortality are devastatingly high. • Address reprint requests to Jonas T. Johnson, MD, Department of Otolaryngology, State University Hospital of the Upstate Medical Center, 750 East Adams St, Syracuse, NY 13210.

References 1. Mosher HP: The submaxillary fos sa approach to deep pus in the neck. Trans Am Acad Ophthalmol Otolaryngol, 1929, pp 19-36 2. Goss CM (Editor): Gray's Anatomy of the Human Body. Ed 29. Philadelphia, Lea & Febiger, 1973, p 741 3. Bosley RJ: Acute retropharyngeal abscesses in children: Report of a case. Laryngoscope 72:207-217, 1962 4. Bryan CS, King BG Jr, Bryan! RE: Retropharyngeal infection in adults. Arch Intem Med 134:126-130, 1974 5. Wright NL: Cervical infections. Am J Surg 113:379-386, 1967 6. Sprinkle PM, Veltri RW, Kanton LM: Abscesses of the head and neck. Laryngoscope 84:1142-1148, 1974 7. Monaldo U, Bellome J, Zegarelli DJ, et al: Bacteroides infection of the mandible with secondary spread to the neck. J Oral Surg 32:370-372, 1974 8. Levitt GW: The surgical treatment of deep neck infections. Laryngoscope 81:403-411, 1971 9. Feild JR, DeSaussure RL Jr: Retropharyngeal hemorrhage with respiratory obstruction following arteriography: Case report. J Neurosurg 22:610-611, 1965 10. Owens DE, Calcaterra TC Aarstad RA: Retropharyngeal hematoma. Arch Otolaryngol 101:565-568, 1975 Il. Work WP, Oates GA: Tumors of the parotid gland and


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parapharyngeal space. Otolaryngol Clin North Am: Oct, 1969, pp 497-513 Conley JJ: Neurogenous tumors in the neck. Arch Otolaryngol 67:167-180, 1955 Eneroth CM, Tham R: Pseudoaneurysm of the internai carotid artery: A waming of a septic erosion. Acta Otolaryngol 72:445-450, 1971 Whorley MH, Bruwer AJ, Baker HL: The lateral roentgenogram of the neck. Radiology 77:350-356, 1958 Alexander DW, Leonard JR, Trail ML: Vascular complications of deep neck abscesses: A report of four cases. Laryngoscope 78:361-370, 1968 Langenbrunner DJ, Dajani S: PharyngomaxiUary space abscess with carotid artery erosion. Arch Otolaryngol 94:447-457, 1971 McCoy G, Barsocchini LM: Experiences in carotid artery occlusion. Laryngoscope 78:1195-1210, 1968 Pearse HE Jr: Mediastinitis following cervical suppuration. Ann Surg 108:588-607, 1938 Beek AL: Deep neck infections. Ann 0to1 Rhinol Laryngol 56:439-481, 722-765, 1947 - - : The influence of the chemotherapeutic and antibiotic drugs on the incidence and course of deep neck infections. Ann Otol Rhinol Laryngol61:515-532, 1952

POSTGRADUATE IIEDICINE • June1978 • Vol. 59 • No. 8

Recognizing and treating deep neck infection.

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