Deep Neck Abscesses - Clinical Tree

Introduction

The potential for a seemingly benign entity like an infected tooth, tonsil, or skin lesion to cause life-threatening illness is due to the complex relationship between the spaces of the neck. Deep neck infection (DNI) may result from any of the above and can extend into the mediastinum and beyond when these spaces are involved. Aggressive bacterial species, inadequate host defenses, and access to medical care all contribute to the development of deep neck infections and make management difficult. Understanding the relationship of the potential spaces of the neck to each other, as well as the most common pathogens, is key to successful treatment of this problem.

Key Operative Learning Points

Knowledge of the anatomy and relationships between the deep neck spaces is necessary to adequately drain the neck during incision and drainage (I&D).
Failure to drain pockets of infection will prolong recovery or lead to complications.
Deep neck abscesses are often fulminating and can lead to rapid changes in status by causing airway obstruction, vascular compromise, or sepsis and need to be treated in an urgent manner.
Tracheostomy is often required for safe airway management.

Preoperative Period

Patients with DNI typically have localized pain and swelling, fever, and an elevated white blood cell counts. All patients undergo a computed tomography (CT) scan to assess the extent of disease, unless airway compromise dictates otherwise. If an aspirate is available for Gram stain analysis, this is helpful in identifying pathogens before empiric antibiotics are administered. Otherwise, intravenous antibiotics should be administered and chosen on the presumed site of origin. Oropharyngeal abscess requires coverage of beta-lactamase producing streptococcal and staphylococcal organisms; oral infections require coverage of anaerobic bacteria. Use of antibiotics with coverage of anaerobes and beta-lactamase–producing microbes provides good broad-spectrum coverage for most cases.

History

1.
History of present illness
- a.
  Duration of symptoms
- b.
  Odynophagia or dysphagia
- c.
  Dental history—periodontal disease, fractured teeth, periapical abscess, carious teeth
- d.
  Preceding upper respiratory tract infection or trauma
2.
Past medical history
- a.
  Diabetes mellitus
- b.
  Other forms of immunocompromised states—HIV, iatrogenic (chemotherapy)
3.
Medications
- a.
  Antibiotics
- b.
  Anticoagulants

Physical Examination

1.
Airway
- a.
  Flexible fiberoptic laryngoscopy to assess for pa-tency
- b.
  Presence of swelling of the posterior pharyngeal wall
2.
Neck
- a.
  Extent and location of edema
- b.
  Presence of fluctuance, tenderness, erythema
3.
Oral cavity
- a.
  Gingival swelling and erythema, purulent discharge near carious teeth
- b.
  Edema of the floor of the mouth with retrodisplacement of the tongue
4.
Oropharynx
- a.
  Bulging of the soft palate/tonsil
- b.
  Trismus

Imaging

1.
Preferred for rapid procurement of images (over MRI)
2.
Contraindicated if the airway is unstable
3.
Recommend use of contrast
4.
Standard 3-mm cuts

Indications

Abscess with airway compromise
Sepsis
Smaller abscess with lack of response to IV antibiotics
Lack of resolution that will require revision surgery

Contraindications

Hemodynamic instability

Preoperative preparation

1.
Evaluate imaging to determine the extent of the abscess
2.
Culture–If the patient is stable, obtain an aspirate at the bedside to initiate Gram stain and culture studies.
3.
Antibiotics–Empiric administration of intravenous antibiotics that provide aerobic and anaerobic coverage
4.
Manage any airway compromise

Operative Period

Anesthesia

Management of impending airway collapse in the patient with a deep neck abscess takes precedence over all other considerations.
Tracheotomy is achieved with the patient awake with the anesthesiologist prepared to administer general anesthesia once the airway is secured.
Sedation is contraindicated as it may lead to further collapse of the airway.

Positioning

The patient is placed in the supine position with a shoulder roll used to gently extend the neck.

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