#47: Deep Dive into Deep Neck Infections with Dr. Travis Crook

March 30, 2022 | By Sam Masur

Summary

Join us for an outstanding conversation with Dr. Travis Crook to discuss all things neck infections. Find out how to use anatomy to differentiate between sources of infections, who to order further imaging on, how to treat neck infections, and what mimickers you don’t want to miss.

Credits

• Producer, Writer, Infographic: Cleo Rochat MD
• Executive Producer: Nick Lee MD
• Showrunner: Sam Masur MD
• Cover Art: Chris Chiu MD
• Hosts: Justin Berk MD, Chris Chiu MD
• Editor:Justin Berk MD; Clair Morgan of nodderly.com
• Guest(s): Travis Crook MD

Deep Neck Infection Pearls

1. Deep neck infections can be divided into three separate groups: anterior cervical, peritonsillar, and retropharyngeal; the infections are different, and should be treated differently
2. Physical exam is key: range of motion can help localize infection, and serial exams can help monitor improvement 
3. Take retropharyngeal abscesses seriously! Obtain CT imaging if concerned.
4. Use steroids with caution, but use when concerned about airway compromise 
5. Always keep malignancy on the differential in patients presenting with concerns for deep neck infection

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Deep Neck Infection Notes

Anatomic Framework

After ruling out possible anterior infections (submental, oral mucosa, periodontal), deep neck infections can be categorized by 3 potential spaces: 

1. Anterolateral (cervical chain lymph nodes)
2. Peritonsillar 
3. Prevertebral/retropharyngeal 

History & Red Flags on Presentation:

• Vaccine Status
• Fever
• Tenderness
• Acuity: Deep neck infections generally present acutely, with symptom in less than 3-5 days
• B Symptoms: head and neck malignancies, while rare, should be on the differential

Clinical Pearl: Tenderness is not the same as pain. Pain is what the patient experiences, tenderness is elicited on exam.

Using The Physical Exam to Locate Neck Infections

1. External exam for any obvious asymmetry
2. Palpation along the cervical chain lymph nodes for any warmth, tenderness, fluctuance, induration, firmness
   • Clinical Pearl: When palpating lymph nodes, feel underneath the belly of the sternocleidomastoid to avoid missing deeper lymph nodes
3. Open mouth [may be limited by trismus in deep neck infection] to observe for uvular deviation, distortion of anatomic architecture, asymmetry
   • Clinical Pearl: Uvular deviation in peritonsillar abscesses displaces uvula to the opposite side of the infection
4. Range of Motion
   • Neck Flexion → if there is pain on neck flexion, think about meningitis
   • Neck Extension → if there is pain on neck extension, think about retropharyngeal abscess
     • Clinical Pearl: Neck extension moves esophagus towards vertebral bodies and activates paravertebral muscles, both of which compress the retropharyngeal space. If there is an infection and swelling in the retropharyngeal area, extension of the neck will elicit pain on exam.
   • Lateral rotation → If there is pain on the ipsilateral side [look towards the right, pain on the right] → think about anterior cervical lymph node process
   • Lateral rotation → If there is pain on the contralateral side [look towards the right, pain on the left] → think about peritonsillar abscess
     • Clinical Pearl: Occasional retropharyngeal abscesses can also present with unilateral pain
   • Side bending [ear-to-shoulder] → if there is pain with side bending, think about trauma

Age of Presentation

• Anterior cervical infection: bimodal distribution due to varying etiologies. First peak at 3-4 years old, second peak at 9-11 years old.
  • Clinical pearl: If a teenager presents with an anterior cervical infection, broaden differential to include more uncommon pathogens as the infection etiology
• Peritonsillar abscess: common in teeneagers
• Retropharyngeal abscesses: around 2-3 years old, uncommon over 4 years old

Etiology of Infections

• Anterior cervical infections: commonly from direct extension, staph and strep are most likely organisms 
• Peritonsillar infections: consider oral flora and sinus organism bacterial invasion. Test for strep pharyngitis. Consider viral infection with bacterial superinfection in addition to staph and strep.
• Retropharyngeal infections: staphylococcus is less common in retropharyngeal infection. Higher suspicion for gram negative and anaerobic causative organisms.

Outpatient Considerations

• Any concern for airway involvement (ex: stridor), send to the ED
• Pay close attention to drooling, oral intake, voice changes (muffled, “hot potato” voice), trismus, decreased range of motion of the neck; if concerned, may warrant ED evaluation 
• “Hot potato” voice indicates that the patient is guarding secondary to pain
• Dr. Crook’s Expert Opinion: Concern for retropharyngeal infections should be evaluated in the hospital

Imaging in Deep Neck Infections

• Anterior cervical infections: can consider starting antibiotics prior to obtaining imaging. If evaluating for possible drainage, obtain ultrasound. CT scans can be helpful to define anatomy if undergoing drainage.
• Peritonsillar infections: does not require imaging, and can be drained at the bedside. Occasionally imaging can be helpful if concerned about a complication (ex: extension)
• Retropharyngeal infections: obtain CT of the neck for further imaging. A retropharyngeal abscess will appear on imaging as a hypodensity with a rim of enhancement.

X-ray of the neck can be used to evaluate if concerned about airway impingement

Complications of Deep Neck Infections

• Anterior cervical infections: can evolve into sepsis or bacteremia, potential to invade carotid 
• Peritonsillar infections: do not typically cause progression or complications
• Retropharyngeal infections: can present later in the course of illness, and are associated with complications such as extension and mediastinitis
  • Kawasaki disease can present with retropharyngeal edema, which can be misdiagnosed as an RPA (Nomura et al, 2014)

Management: Antibiotics for Deep Neck Infections

• Anterior cervical infections:
  • Pathogens: Staph, strep, anaerobes
  • Antibiotics: Clindamycin or Amoxicillin-clavulanate
• Peritonsillar infections:
  • Pathogens: Strep, staph
  • Antibiotics: Clindamycin or Amoxicillin-clavulanate
• Retropharyngeal infections:
  • Pathogens: Strep (pyogenes, mitis, viridans), Gram negatives, occasionally staph
  • Antibiotics: Ampicillin-sulbactam or Amoxicillin-clavulanate

Treatment duration: considerations include the depth of infection, how sick the patient is, and if source control is achieved (abscess drained). General timelines:

• Anterior cervical infections: 7-10+ days
• Peritonsillar infections: 7-10 days
• Retropharyngeal infections: 14+ days

Role for Steroids:  Consider steroids if concerned about airway compromise. Otherwise, use caution because they can mask symptoms and ability to monitor physical exams.

Other Considerations:

1. Unvaccinated patient → Epiglottitis
   • Present toxic appearing, tripoding, drooling, high fevers
   • In epiglottis, prioritizing securing the airway (intubation)
2. Infectious mimickers → tularemia, bartonella
3. Non-infectious mimickers → rheumatologic disease, malignancies

Goal

Listeners will learn how to differentiate the main sources of deep neck infections in children.

Learning objectives

After listening to this episode listeners will…  

1. Recall how to perform a physical exam of the neck and when to be concerned for infection
2. Learn important history-taking questions to ask for deep neck infections
3. Recognize when to obtain imaging in neck infections
4. Understand the difference between phlegmon and abscess
5. Understand the antibiotic treatment strategies for deep neck infections

Disclosures

Dr Crook  reports no relevant financial disclosures. The Cribsiders report no relevant financial disclosures. 

Citation

Rochat C, Crook T, Lee N, Masur S, Chiu C, Berk J. “#47: Deep Dive into Deep Neck Infections with Dr. Travis Crook”. The Cribsiders Pediatric Podcast. https:/www.thecribsiders.com/ March 30, 2022.