Deep Neck Space Infections

Dental infections occurring posterior to the second molar involve the submandibular space. This space is located beneath the mandible and contains the submandibular gland and lymph nodes. Infections in this area can cause swelling, pain, and difficulty in opening the mouth. Treatment usually involves antibiotics and drainage of the abscess if necessary. The other options, masseteric, sublingual, and parapharyngeal spaces, are not typically involved in dental infections occurring posterior to the second molar.

Most abscesses of the retropharyngeal space occur in children. This is due to the fact that retropharyngeal nodes disappear by about the age of 5 years. Most infections begin in the nose or nasopharynx and adenoids, and paranasal sinuses and drain to these nodes which go on to suppurate. There is consequently a history of an upper respiratory tract infection. Fever, dysphagia, odynophagia, nuchal rigidity, and airway compromise may occur.

The patient's presentation of spiking fevers, tenderness along the sternocleidomastoid muscle, neck stiffness, and septic arthritis, along with the CT scan findings of ring enhancement with a central area of lucency of the IJV, are consistent with Lemierre syndrome. This syndrome is characterized by septic thrombophlebitis of the internal jugular vein (IJV) following an oropharyngeal infection. It typically presents with fever, neck pain, and swelling, and can progress to septic emboli and abscess formation. The CT scan findings of ring enhancement with a central area of lucency of the IJV is a characteristic feature of septic thrombophlebitis in Lemierre syndrome.

Anterior visceral space infections are usually the result of perforations of the esophagus, due to instrumentation, foreign body, or external trauma. A suppurative thyroiditis may also be a source of infection. Laryngeal necrosis following radiation and infection can also be a potential source for such an infection.

The recommended time to take a patient to the OR for I&D (incision and drainage) of a neck abscess if there is failure to progress is 48 hours. This means that if there is no improvement in the patient's condition within 48 hours of initiating treatment, it is recommended to perform the surgical procedure to drain the abscess. This timeframe allows for a sufficient period of observation and conservative management before deciding on surgical intervention.

In cases where the visceral vascular space or the parapharyngeal space is involved, the astute physician may pick up the signs of Horner syndrome, which is characterized by ipsilateral ptosis, facial anhydrosis, and miosis due to the proximity of the sympathetic chain.

Mediastinitis is an inflammation of the tissues in the mediastinum, the area between the lungs. Despite antibiotic therapy, it still has a high rate of mortality. This could be due to several reasons, such as delayed diagnosis, difficulty in treating the infection due to the complex anatomy of the mediastinum, or the presence of underlying health conditions that make the infection harder to manage. The high mortality rate highlights the need for early recognition and aggressive treatment of mediastinitis.

Dental infections occurring anterior to the second molar involve the sublingual space. This space is located under the tongue and extends from the midline to the mandibular symphysis. It is a potential space that can become infected due to the spread of dental infections.

It appears that in infants younger than 9 months of age, Staphylococcus aureus is the predominant organism when abscesses that involve the anterior and posterior triangles of the neck are involved. They constituted 80% of cases in one study. S. aureus was found to be a predominant isolate, albeit at a lower rate of 56% in a study reported by Brook. This organism along with β-hemolytic streptococci was also reported by Ungkanont and colleagues, although the incidence was smaller.

In infants and children, rapidly progressive airway compromise is usually present along with fever and neck mass. In infants in particular, a high index of suspicion is important, because complaints such as sore throat, voice changes, and odynophagia may not be forthcoming as they are in older children. In this series, 21 of 22 patients had an elevated white blood cell (WBC) count. Serial WBC counts are a good way to monitor response to antibiotic therapy, and consequently, it is the preference of these authors that steroids not be used unless airway compromise is impending or present.