Overview and Management of Deep Neck Infections

• Infections of the head and neck:
  • Infections of the head and neck can range from minor to life-threatening.
  • A scoring system reflecting the need for hospitalization of such patients has been proposed.
• Normal head and neck flora:
  • The oral cavity is home to a large number of bacteria, including anaerobes and other species.
  • Changes in oral mucosal fibronectin production can lead to colonization of gram-negative organisms.
• Sites of deep head and neck infection:
  • Knowledge of local anatomy is critical in understanding and managing these infections.
  • Different anatomic areas can be involved, and infection can spread rapidly.
• Clinical syndromes:
  • Sinusitis can be caused by nosocomial organisms and requires broad-spectrum antimicrobial treatment.
  • Pharyngeal infections include Vincent angina and quinsy.
  • Acute epiglottitis is rare but can be a serious condition in children.
• Complications of nosocomial sinusitis:
  • Complications can include meningitis, brain abscess, osteomyelitis, or cavernous sinus thrombosis.
  • Infections can spread to other areas of the head and neck, resulting in further complications.
• Risk factors for deep neck space infection:
  • Uncontrolled dental infection, spread from other local structures, and local trauma can increase the risk.
  • The use of cetuximab, rituximab, and poor education/living far from care centers can also be risk factors.
• Treatment options for sinusitis, pharyngitis, and epiglottitis:
  • Broad-spectrum antibiotics are often used, and collaboration with an otolaryngologist is recommended.
  • Complications of nosocomial sinusitis depend on the specific anatomical area affected.
• Differentiating Features of Deep Neck Infections:
  • Fever and signs of systemic toxicity are common to all deep neck infections.
  • Predisposing factors include uncontrolled dental infections, IV catheter placement, and local trauma.
• Epiglottitis:
  • Epiglottitis is a serious condition characterized by the inflammation and swelling of the epiglottis.
  • Visualizing the epiglottis directly should not be attempted unless the ability to secure an airway immediately is certain.
• Retropharyngeal Infections:
  • Retropharyngeal infections occur in the area between the pharynx and the vertebrae.
  • Infection can spread within the retropharyngeal space and to distant sites.
  • Symptoms include fever, neck stiffness, and difficulty swallowing and breathing.
• Danger-Space Infection:
  • Danger-space infection occurs when infection spreads through the "danger space" which connects the base of the skull with the posterior mediastinum and diaphragm.
  • It can result in pleural or mediastinal infection and has a high mortality rate.
• Retropharyngeal Infection Bacteriology:
  • Retropharyngeal infections are caused by mixed aerobic/anaerobic oral bacteria.
  • In critically ill patients, antimicrobial coverage may need to be modified due to colonization with resistant pathogens.
• Submandibular Space Infection:
  • Submandibular space infection is commonly caused by infected lower molar teeth.
  • Symptoms include mouth pain, difficulty swallowing, and swollen tongue.
  • Late complications can be severe, including death from airway obstruction.
• Lateral Pharyngeal Space Infection:
  • Lateral pharyngeal space infection is a common deep neck infection.
  • It is more common in adults and can be caused by dental disease, injection drug use, trauma, or tonsillitis.
  • Symptoms include fever, pain, trismus, and systemic toxicity.
  • Infections of the posterior lateral pharyngeal space have different symptoms, such as parotid swelling and the risk of vital structure involvement.
• Descending Necrotizing Mediastinitis:
  • Downward spread of deep neck infections can result in necrotizing soft tissue infections of the chest wall and mediastinum.
  • It is a serious condition that requires urgent surgical intervention.
• Lemierre Syndrome: A Rare Complication of Dental or Deep Neck Infections:
  • Lemierre syndrome is a relatively rare condition that develops as a complication of dental or deep neck infections.
  • It most commonly affects individuals aged 40-60 years and is associated with mixed aerobic/anaerobic flora.
  • Risk factors for Lemierre syndrome include neutropenia, alcoholism, and diabetes mellitus.
  • The mortality rate is approximately 15-20%.
  • Early diagnosis is critical to minimize the risk of complications.
  • Blood cultures and empirical antianaerobic bacterial coverage should be obtained promptly.
  • Radiological diagnosis is typically made using CT scanning.
  • In some cases, surgical intervention may be necessary to control sepsis.
• Clinical Presentation and Diagnosis of Lemierre Syndrome:
  • Lemierre syndrome typically presents with fever and sore throat, followed by swollen and/or tender neck in cases of internal jugular vein involvement.
  • Pulmonary involvement may manifest as dyspnea and pleuritic chest pain.
  • Early diagnosis is critical to minimize the risk of infectious metastatic complications.
  • Blood cultures should be obtained promptly.
  • CT scanning is the most reliable radiological diagnostic method.
  • MRI scanning may be necessary to rule out intracerebral vein thrombosis in cases of mastoiditis.
  • Secondary complications may include carotid artery thrombosis or parotid gland infection.
  • The use of anticoagulants in Lemierre syndrome is still debatable.
• Treatment and Management Considerations for Lemierre Syndrome:
  • Broad-spectrum antibiotics with both aerobic and anaerobic coverage should be chosen.
  • Intraoral examination should be performed cautiously due to the risk of airway obstruction.
  • Patients may require surgical intervention, and collaboration with various specialists is essential.
  • Deep neck infections can threaten the airway and other vital structures.
  • Appropriate measures should be taken to secure the airway during patient transportation.
  • Community-acquired MRSA can be a cause of Lemierre syndrome.
  • The increasing role of socioeconomic risk factors in deep neck infection should be considered.
  • Prophylactic tonsillectomy may be beneficial in patients with predominance of anaerobes in peritonsillar abscesses.
• Key Points about Deep Neck Infections:
  • Deep infections of the head and neck are often polymicrobial, including both aerobic and anaerobic bacteria.
  • Intraoral inspection or attempts to palpate the posterior pharynx in such patients can precipitate acute airway occlusion.
  • Septic internal jugular vein thrombophlebitis is frequently caused by Fusobacterium necrophorum.
  • Deep neck infections can spread to the airway, deep vascular structures, and mediastinum.
  • Close collaboration with various specialists is essential for successful management.
  • The safety of performing an intraoral examination should be evaluated based on the risk of airway obstruction.
  • CT scanning is the most reliable method for radiological diagnosis.
  • In some cases, surgical intervention may be necessary.