Deep Neck Space Infections

  • Heather A. Osborn
  • Daniel G. Deschler


Deep neck space infections are medical and surgical emergencies. Failure to diagnose and treat these infections promptly may lead to complications such as carotid artery rupture, airway obstruction, systemic sepsis, and descending mediastinitis. This chapter reviews the deep fascial spaces of the neck, describes the clinical signs and symptoms of various deep neck space infections, and discusses the diagnostic workup, typical microbiology, initial empiric antibiotic choices, and optimal surgical management of these infections. With early diagnosis and appropriate treatment, most patients recover from these potentially life-threatening infections.


Deep neck space infections Submandibular abscess Submental abscess Sublingual abscess Danger space Prevertebral abscess Parapharyngeal abscess Retropharyngeal abscess Parotid abscess Peritonsillar abscess 


  1. 1.
    Affections. Diseases 1. Diseases 2—hippocrates. Harvard University Press. Accessed 8 Sept 2016.
  2. 2.
    Boscolo-Rizzo P, Marchiori C, Montolli F, Vaglia A, Da Mosto MC. Deep neck infections: a constant challenge. ORL J Otorhinolaryngol Relat Spec. 2006;68(5):259–65.CrossRefPubMedGoogle Scholar
  3. 3.
    Rega AJ, Aziz SR, Ziccardi VB. Microbiology and antibiotic sensitivities of head and neck space infections of odontogenic origin. J Oral Maxillofac Surg. 2006;64(9):1377–80.CrossRefPubMedGoogle Scholar
  4. 4.
    Celakovsky P, Kalfert D, Tucek L, Mejzlik J, Kotulek M, Vrbacky A, et al. Deep neck infections: risk factors for mediastinal extension. Eur Arch Otorhinolaryngol. 2014;271(6):1679–83.CrossRefPubMedGoogle Scholar
  5. 5.
    Johnson J. Bailey’s head and neck surgery: otolaryngology. fifth, two volume set edition. Philadelphia: LWW; 2013.Google Scholar
  6. 6.
    Larawin V, Naipao J, Dubey SP. Head and neck space infections. Otolaryngol Head Neck Surg. 2006;135(6):889–93.CrossRefPubMedGoogle Scholar
  7. 7.
    Staffieri C, Fasanaro E, Favaretto N, La Torre FB, Sanguin S, Giacomelli L, et al. Multivariate approach to investigating prognostic factors in deep neck infections. Eur Arch Otorhinolaryngol. 2014;271(7):2061–7.PubMedGoogle Scholar
  8. 8.
    Philpott CM, Selvadurai D, Banerjee AR. Paediatric retropharyngeal abscess. J Laryngol Otol. 2004;118(12):919–26.CrossRefPubMedGoogle Scholar
  9. 9.
    Har-El G, Aroesty JH, Shaha A, Lucente FE. Changing trends in deep neck abscess. A retrospective study of 110 patients. Oral Surg Oral Med Oral Pathol. 1994;77(5):446–50.CrossRefPubMedGoogle Scholar
  10. 10.
    Huang C-M, Huang F-L, Chien Y-L, Chen P-Y. Deep neck infections in children. J Microbiol Immunol Infect. 2015;15:627–33.Google Scholar
  11. 11.
    Santos Gorjón P, Blanco Pérez P, Morales Martín AC, Del Pozo de Dios JC, Estévez Alonso S, Calle de la Cabanillas MI. Deep neck infection. Review of 286 cases. Acta Otorrinolaringol Esp. 2012;63(1):31–41.CrossRefPubMedGoogle Scholar
  12. 12.
    Barratt GE, Koopmann CF, Coulthard SW. Retropharyngeal abscess—a ten-year experience. Laryngoscope. 1984;94(4):455–63.CrossRefPubMedGoogle Scholar
  13. 13.
    Brook I. Microbiology and management of peritonsillar, retropharyngeal, and parapharyngeal abscesses. J Oral Maxillofac Surg. 2004;62(12):1545–50.CrossRefPubMedGoogle Scholar
  14. 14.
    Sichel J-Y, Dano I, Hocwald E, Biron A, Eliashar R. Nonsurgical management of parapharyngeal space infections: a prospective study. Laryngoscope. 2002;112(5):906–10.CrossRefPubMedGoogle Scholar
  15. 15.
    Johnston D, Schmidt R, Barth P. Parapharyngeal and retropharyngeal infections in children: Argument for a trial of medical therapy and intraoral drainage for medical treatment failures. Int J Pediatr Otorhinolaryngol. 2009;73(5):761–5.CrossRefPubMedGoogle Scholar
  16. 16.
    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):780–2.CrossRefPubMedGoogle Scholar
  17. 17.
    Freling N, Roele E, Schaefer-Prokop C, Fokkens W. Prediction of deep neck abscesses by contrast-enhanced computerized tomography in 76 clinically suspect consecutive patients. Laryngoscope. 2009;119(9):1745–52.CrossRefPubMedGoogle Scholar
  18. 18.
    Miller WD, Furst IM, Sàndor GK, Keller MA. A prospective, blinded comparison of clinical examination and computed tomography in deep neck infections. Laryngoscope. 1999;109(11):1873–9.CrossRefPubMedGoogle Scholar
  19. 19.
    Vural C, Gungor A, Comerci S. Accuracy of computerized tomography in deep neck infections in the pediatric population. Am J Otolaryngol. 2003;24(3):143–8.CrossRefPubMedGoogle Scholar
  20. 20.
    Delides A, Manoli E, Papadopoulos M, Nikolopoulos T. Ultrasound-guided transoral drainage of a paediatric parapharyngeal abscess. J Laryngol Otol. 2014;128(12):1120–2.CrossRefPubMedGoogle Scholar
  21. 21.
    Sharma SD, Mahalingam S, Vassiliou L, Connor S, Fan K. Patterns of cervicofacial infections: analysis of the use of computed tomography. Oral Maxillofac Surg. 2014;18(2):201–6.CrossRefPubMedGoogle Scholar
  22. 22.
    Reynolds SC, Chow AW. Severe soft tissue infections of the head and neck: a primer for critical care physicians. Lung. 2009;187(5):271–9.CrossRefPubMedGoogle Scholar
  23. 23.
    Page C, Biet A, Zaatar R, Strunski V. Parapharyngeal abscess: diagnosis and treatment. Eur Arch Otorhinolaryngol. 2008;265(6):681–6.CrossRefPubMedGoogle Scholar
  24. 24.
    Ozbek C, Aygenc E, Tuna EU, Selcuk A, Ozdem C. Use of steroids in the treatment of peritonsillar abscess. J Laryngol Otol. 2004;118(6):439–42.CrossRefPubMedGoogle Scholar
  25. 25.
    Sichel JY, Gomori JM, Saah D, Elidan J. Parapharyngeal abscess in children: the role of CT for diagnosis and treatment. Int J Pediatr Otorhinolaryngol. 1996;35(3):213–22.CrossRefPubMedGoogle Scholar
  26. 26.
    Broughton RA. Nonsurgical management of deep neck infections in children. Pediatr Infect Dis J. 1992;11(1):14–8.CrossRefPubMedGoogle Scholar
  27. 27.
    de Marie S, Tjon A Tham RT, van der Mey AG, Meerdink G, van Furth R, van der Meer JW. Clinical infections and nonsurgical treatment of parapharyngeal space infections complicating throat infection. Rev Infect Dis. 1989;11(6):975–82.CrossRefPubMedGoogle Scholar
  28. 28.
    McClay JE, Murray AD, Booth T. Intravenous antibiotic therapy for deep neck abscesses defined by computed tomography. Arch Otolaryngol Head Neck Surg. 2003;129(11):1207–12.CrossRefPubMedGoogle Scholar
  29. 29.
    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):661–6.CrossRefPubMedGoogle Scholar
  30. 30.
    Woods CR, Cash ED, Smith AM, Smith MJ, Myers JA, Espinosa CM, et al. Retropharyngeal and parapharyngeal abscesses among children and adolescents in the United States: epidemiology and management trends, 2003–2012. J Pediatr Infect Dis Soc. 2016;5(3):259–68.CrossRefGoogle Scholar
  31. 31.
    Harkani A, Hassani R, Ziad T, Aderdour L, Nouri H, Rochdi Y, et al. Retropharyngeal abscess in adults: five case reports and review of the literature. Sci World J. 2011;11:1623–9.CrossRefGoogle Scholar
  32. 32.
    Novis SJ, Pritchett CV, Thorne MC, Sun GH. Pediatric deep space neck infections in U.S. children, 2000–2009. Int J Pediatr Otorhinolaryngol. 2014;78(5):832–6.CrossRefPubMedGoogle Scholar
  33. 33.
    Boucher C, Dorion D, Fisch C. Retropharyngeal abscesses: a clinical and radiologic correlation. J Otolaryngol. 1999;28(3):134–7.PubMedGoogle Scholar
  34. 34.
    Stone ME, Walner DL, Koch BL, Egelhoff JC, Myer CM. Correlation between computed tomography and surgical findings in retropharyngeal inflammatory processes in children. Int J Pediatr Otorhinolaryngol. 1999;49(2):121–5.CrossRefPubMedGoogle Scholar
  35. 35.
    Ravindranath T, Janakiraman N, Harris V. Computed tomography in diagnosing retropharyngeal abscess in children. Clin Pediatr (Phila). 1993;32(4):242–4.CrossRefGoogle Scholar
  36. 36.
    Brook I. Microbiology of retropharyngeal abscesses in children. Am J Dis Child 1960. 1987;141(2):202–4.Google Scholar
  37. 37.
    Carbone PN, Capra GG, Brigger MT. Antibiotic therapy for pediatric deep neck abscesses: a systematic review. Int J Pediatr Otorhinolaryngol. 2012;76(11):1647–53.CrossRefPubMedGoogle Scholar
  38. 38.
    Cramer JD, Purkey MR, Smith SS, Schroeder JW. The impact of delayed surgical drainage of deep neck abscesses in adult and pediatric populations. Laryngoscope. 2016;126(8):1753–60.CrossRefPubMedGoogle Scholar
  39. 39.
    Kirse DJ, Roberson DW. Surgical management of retropharyngeal space infections in children. Laryngoscope. 2001;111:1413–22.CrossRefPubMedGoogle Scholar
  40. 40.
    Sauer MW, Sharma S, Hirsh DA, Simon HK, Agha BS, Sturm JJ. Acute neck infections in children: who is likely to undergo surgical drainage? Am J Emerg Med. 2013;31(6):906–9.CrossRefPubMedGoogle Scholar
  41. 41.
    Cheng J, Elden L. Children with deep space neck infections: our experience with 178 children. Otolaryngol Head Neck Surg. 2013;148(6):1037–42.CrossRefPubMedGoogle Scholar
  42. 42.
    Lakshmi Narayana M, Azeem Mohiyuddin SM, Mohammadi K, Devnikar AV, Prasad KNV. Parotid abscess in children – a tertiary rural hospital experience. Int J Pediatr Otorhinolaryngol. 2015;79(12):1988–90.CrossRefPubMedGoogle Scholar
  43. 43.
    Guralnick WC, Donoff RB, Galdabini J. Tender parotid swelling in a dehydrated patient. J Oral Surg Am Dent Assoc 1965. 1968;26(10):669–75.Google Scholar
  44. 44.
    Petersdorf RG, Forsyth BR, Bernanke D. Staphylococcal parotitis. N Engl J Med. 1958;259(26):1250–4.CrossRefPubMedGoogle Scholar
  45. 45.
    Brook I. Acute bacterial suppurative parotitis: microbiology and management. J Craniofac Surg. 2003;14(1):37–40.CrossRefPubMedGoogle Scholar
  46. 46.
    Thiede O, Stoll W, Schmäl F. Klinische Aspekte der abszedierenden Parotitis. HNO. 2002;50(4):332–8.CrossRefPubMedGoogle Scholar
  47. 47.
    Takahashi A, Martini MZ, Seo J, de Oliveira Neto HG, Shinohara EH. Ultrasound-guided needle aspiration of parotid abscess. Indian J Dent Res. 2012;23(3):423–5.CrossRefPubMedGoogle Scholar
  48. 48.
    Hajiioannou JK, Florou V, Kousoulis P, Kretzas D, Moshovakis E. Reversible facial nerve palsy due to parotid abscess. Int J Surg Case Rep. 2013;4(11):1021–4.CrossRefPubMedPubMedCentralGoogle Scholar
  49. 49.
    Noorizan Y, Chew YK, Khir A, Brito-Mutunayagam S. Parotid abscess: an unusual cause of facial nerve palsy. Med J Malaysia. 2009;64(2):172–3.PubMedGoogle Scholar
  50. 50.
    Sabir Husin Athar PP, Yahya Z, Mat Baki M, Abdullah A. Facial nerve paralysis: a rare complication of parotid abscess. Malays J Med Sci. 2009;16(2):38–9.PubMedPubMedCentralGoogle Scholar
  51. 51.
    Kishore R, Ramachandran K, Ngoma C, Morgan NJ. Unusual complication of parotid abscess. J Laryngol Otol. 2004;118(5):388–90.CrossRefPubMedGoogle Scholar
  52. 52.
    Sivarajasingam V, Sharma V, Crean SJ, Shepherd JP. Ultrasound-guided needle aspiration of lateral masticator space abscess. Oral Surg Oral Med Oral Pathol Oral Radiol Endodontol. 1999;88(5):616–9.CrossRefGoogle Scholar
  53. 53.
    Kim E, Jeon JH, Shim YH, Lee K-S, Kim SY, Kim ER. Masticator space abscess in a 47-day-old infant. Korean J Pediatr. 2011;54(8):350–3.CrossRefPubMedPubMedCentralGoogle Scholar
  54. 54.
    Bahl R, Sandhu S, Singh K, Sahai N, Gupta M. Odontogenic infections: microbiology and management. Contemp Clin Dent. 2014;5(3):307–11.CrossRefPubMedPubMedCentralGoogle Scholar
  55. 55.
    Bakshi SS. Ludwig’s angina. Arch Dis Child. 2016;101(6):545.CrossRefPubMedGoogle Scholar
  56. 56.
    Raftopulos M, Jefferson N, Mackay S, Ashford B. A rare case of submandibular abscess complicated by stroke. JRSM Short Rep 2013 4(12):2042533313505513. CrossRefGoogle Scholar
  57. 57.
    Maroldi R, Farina D, Ravanelli M, Lombardi D, Nicolai P. Emergency imaging assessment of deep neck space infections. Semin Ultrasound CT MR. 2012;33(5):432–42.CrossRefPubMedGoogle Scholar
  58. 58.
    Lefler JE, Masullo LN. Lingual abscess in the setting of recent periodontal antibiotic injections. J Emerg Med. 2016;51(4):454–6.CrossRefPubMedGoogle Scholar
  59. 59.
    Fating NS, Saikrishna D, Vijay Kumar GS, Shetty SK, Raghavendra Rao M. Detection of bacterial flora in orofacial space infections and their antibiotic sensitivity profile. J Maxillofac Oral Surg. 2014;13(4):525–32.CrossRefPubMedGoogle Scholar
  60. 60.
    Candamourty R, Venkatachalam S, Babu MRR, Kumar GS. Ludwig’s Angina – an emergency: a case report with literature review. J Nat Sci Biol Med. 2012;3(2):206–8.CrossRefPubMedPubMedCentralGoogle Scholar
  61. 61.
    Britt JC, Josephson GD, Gross CW. Ludwig’s angina in the pediatric population: report of a case and review of the literature. Int J Pediatr Otorhinolaryngol. 2000;52(1):79–87.CrossRefPubMedGoogle Scholar
  62. 62.
    Misthos P, Katsaragakis S, Kakaris S, Theodorou D, Skottis I. Descending necrotizing anterior mediastinitis: analysis of survival and surgical treatment modalities. J Oral Maxillofac Surg. 2007;65(4):635–9.CrossRefPubMedGoogle Scholar
  63. 63.
    Prado-Calleros HM, Jiménez-Fuentes E, Jiménez-Escobar I. Descending necrotizing mediastinitis: systematic review on its treatment in the last 6 years, 75 years after its description. Head Neck. 2016;38(Suppl 1):E2275–83.CrossRefPubMedGoogle Scholar
  64. 64.
    Matsuki M, Matsuo M, Kaji Y, Okada N. An adult case of retropharyngeal cellulitis; diagnosis by magnetic resonance imaging. Radiat Med. 1998;16(4):289–91.PubMedGoogle Scholar
  65. 65.
    Adelson RT, Murray AD. Minimally invasive transoral catheter-assisted drainage of a danger-space infection. Ear Nose Throat J. 2005;84(12):785–6.PubMedGoogle Scholar
  66. 66.
    Debnam JM, Guha-Thakurta N. Retropharyngeal and prevertebral spaces. Otolaryngol Clin N Am. 2012;45(6):1293–310.CrossRefGoogle Scholar
  67. 67.
    Thakkar DDK, Khaladkar DS, Jantre DM, Thakkar DDK, Singh DA, Kulkarni DVM. Evaluation of neck lesions with MDCT – a case series. IOSR J Dent Med Sci. 2015;1(14):66–80.Google Scholar
  68. 68.
    Patel AA, Madigan L, Poelstra KA, Whang PG, Vaccaro AR, Harrop JS. Acute cervical osteomyelitis and prevertebral abscess after routine tonsillectomy. Spine J. 2008;8(5):827–30.CrossRefPubMedGoogle Scholar
  69. 69.
    Reihsaus E, Waldbaur H, Seeling W. Spinal epidural abscess: a meta-analysis of 915 patients. Neurosurg Rev. 2000;23(4):175–204.CrossRefPubMedGoogle Scholar
  70. 70.
    Curry WT, Hoh BL, Amin-Hanjani S, Eskandar EN. Spinal epidural abscess: clinical presentation, management, and outcome. Surg Neurol. 2005;63(4):364–71.CrossRefPubMedGoogle Scholar
  71. 71.
    Schlossberg D. Infections of the head and neck. Berlin: Springer Science & Business Media; 2012.Google Scholar
  72. 72.
    Brook I. Microbiology and management of deep facial infections and Lemierre syndrome. ORL J Otorhinolaryngol Relat Spec. 2003;65(2):117–20.CrossRefPubMedGoogle Scholar
  73. 73.
    Smoker WR, Harnsberger HR. Differential diagnosis of head and neck lesions based on their space of origin. 2. The infrahyoid portion of the neck. Am J Roentgenol. 1991;157(1):155–9.CrossRefGoogle Scholar
  74. 74.
    Ojiri H, Tada S, Ujita M, Ariizumi M, Ishii C, Mizunuma K, et al. Infrahyoid spread of deep neck abscess: anatomical consideration. Eur Radiol. 1998;8(6):955–9.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Heather A. Osborn
    • 1
    • 2
  • Daniel G. Deschler
    • 3
  1. 1.Department of Surgery (Otolaryngology)Yale Medical SchoolNew HavenUSA
  2. 2.Smilow Cancer HospitalYale New Haven HealthNew HavenUSA
  3. 3.Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear InfirmaryHarvard Medical SchoolBostonUSA

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