, Volume 187, Issue 5, pp 271–279 | Cite as

Severe Soft Tissue Infections of the Head and Neck: A Primer for Critical Care Physicians

  • Steven C. ReynoldsEmail author
  • Anthony W. Chow


Patients with severe infections of the potential spaces of the head and neck are commonly managed in the ICU. These infections may present with devastating complications such as airway obstruction, jugular septic thrombophlebitis, lung abscess, upper airway abscess rupture with asphyxiation, mediastinitis, pericarditis, and septic shock. A thorough understanding of the anatomy and microbiology of these infections is essential for proper management of these patients. Retropharyngeal, danger, prevertebral, lateral pharyngeal, and submandibular space infections and their site-specific clinical manifestations, complications, and therapeutic interventions are discussed.


Submandibular space infections Lateral pharyngeal space infections Parapharyngeal infections Retropharyngeal space infections Danger space infections Prevertebral abscesses Head and neck infections Deep cervical infections 



Thanks to Dr. Peter Phillips, MD, and Dr. Tim Lau, PhD, for their thoughtful feedback and suggestions after reviewing the initial manuscript.


  1. 1.
    Vieira F, Allen SM, Stocks RM, Thompson JW (2008) Deep neck infection. Otolaryngol Clin North Am 41(3):459–483PubMedCrossRefGoogle Scholar
  2. 2.
    Agarwal AK, Sethi A, Sethi D, Mrig S, Chopra S (2007) Role of socioeconomic factors in deep neck abscess: a prospective study of 120 patients. Br J Oral Maxillofac Surg 45(7):553–555. doi: 10.1016/j.bjoms.2007.01.001 PubMedCrossRefGoogle Scholar
  3. 3.
    Larawin V, Naipao J, Dubey SP (2006) Head and neck space infections. Otolaryngol Head Neck Surg 135(6):889–893. doi: 10.1016/j.otohns.2006.07.007 PubMedCrossRefGoogle Scholar
  4. 4.
    Brook I (2004) Microbiology and management of peritonsillar, retropharyngeal, and parapharyngeal abscesses. J Oral Maxillofac Surg 62(12):1545–1550. doi: 10.1016/j.joms.2003.12.043 PubMedCrossRefGoogle Scholar
  5. 5.
    Har-El G, Aroesty JH, Shaha A, Lucente FE (1994) Changing trends in deep neck abscess. A retrospective study of 110 patients. Oral Surg Oral Med Oral Pathol 77(5):446–450. doi: 10.1016/0030-4220(94)90221-6 PubMedCrossRefGoogle Scholar
  6. 6.
    Huang TT, Tseng FY, Yeh TH, Hsu CJ, Chen YS (2006) Factors affecting the bacteriology of deep neck infection: a retrospective study of 128 patients. Acta Otolaryngol 126(4):396–401. doi: 10.1080/00016480500395195 PubMedCrossRefGoogle Scholar
  7. 7.
    Brook I, Hunter V, Walker RI (1984) Synergistic effect of bacteroides, clostridium, fusobacterium, anaerobic cocci, and aerobic bacteria on mortality and induction of subcutaneous abscesses in mice. J Infect Dis 149(6):924–928PubMedGoogle Scholar
  8. 8.
    Coulthard M, Isaacs D (1991) Retropharyngeal abscess. Arch Dis Child 66(10):1227–1230. doi: 10.1136/adc.66.10.1227 PubMedCrossRefGoogle Scholar
  9. 9.
    Brook I (2004) Beta-lactamase-producing bacteria in mixed infections. Clin Microbiol Infect 10(9):777–784. doi: 10.1111/j.1198-743X.2004.00962.x PubMedCrossRefGoogle Scholar
  10. 10.
    Lin HT, Tsai CS, Chen YL, Liang JG (2006) Influence of diabetes mellitus on deep neck infection. J Laryngol Otol 120(8):650–654. doi: 10.1017/S0022215106001149 PubMedCrossRefGoogle Scholar
  11. 11.
    Wang LF, Kuo WR, Tsai SM, Huang KJ (2003) Characterizations of life-threatening deep cervical space infections: a review of one hundred ninety-six cases. Am J Otolaryngol 24(2):111–117. doi: 10.1053/ajot.2003.31 PubMedCrossRefGoogle Scholar
  12. 12.
    Rega AJ, Aziz SR, Ziccardi VB (2006) Microbiology and antibiotic sensitivities of head and neck space infections of odontogenic origin. J Oral Maxillofac Surg 64(9):1377–1380. doi: 10.1016/j.joms.2006.05.023 PubMedCrossRefGoogle Scholar
  13. 13.
    Flynn TR, Shanti RM, Levi MH, Adamo AK, Kraut RA, Trieger N (2006) Severe odontogenic infections, part 1: prospective report. J Oral Maxillofac Surg 64(7):1093–1103. doi: 10.1016/j.joms.2006.03.015 PubMedCrossRefGoogle Scholar
  14. 14.
    Flynn TR, Shanti RM, Hayes C (2006) Severe odontogenic infections, part 2: prospective outcomes study. J Oral Maxillofac Surg 64(7):1104–1113. doi: 10.1016/j.joms.2006.03.031 PubMedCrossRefGoogle Scholar
  15. 15.
    Sato K, Izumi T, Toshima M, Nagai T, Muroi K, Komatsu N, Ozawa K (2005) Retropharyngeal abscess due to methicillin-resistant Staphylococcus aureus in a case of acute myeloid leukemia. Intern Med 44(4):346–349. doi: 10.2169/internalmedicine.44.346 PubMedCrossRefGoogle Scholar
  16. 16.
    Kobayashi KI, Haruta T, Kubota M, Nishio T (2002) A case of retropharyngeal abscess caused by penicillin-resistant Streptococcus pneumoniae. J Infect 44(4):267–269. doi: 10.1053/jinf.2002.0991 PubMedCrossRefGoogle Scholar
  17. 17.
    Frazee BW, Lynn J, Charlebois ED, Lambert L, Lowery D, Perdreau-Remington F (2005) High prevalence of methicillin-resistant Staphylococcus aureus in emergency department skin and soft tissue infections. Ann Emerg Med 45(3):311–320. doi: 10.1016/j.annemergmed.2004.10.011 PubMedCrossRefGoogle Scholar
  18. 18.
    Zetola N, Francis JS, Nuermberger EL, Bishai WR (2005) Community-acquired methicillin-resistant Staphylococcus aureus: an emerging threat. Lancet Infect Dis 5(5):275–286. doi: 10.1016/S1473-3099(05)70112-2 PubMedCrossRefGoogle Scholar
  19. 19.
    Wertheim HF, Melles DC, Vos MC, van Leeuwen W, van Belkum A, Verbrugh HA, Nouwen JL (2005) The role of nasal carriage in Staphylococcus aureus infections. Lancet Infect Dis 5(12):751–762. doi: 10.1016/S1473-3099(05)70295-4 PubMedCrossRefGoogle Scholar
  20. 20.
    Fleisch AF, Nolan S, Gerber J, Coffin SE (2007) Methicillin-resistant Staphylococcus aureus as a cause of extensive retropharyngeal abscess in two infants. Pediatr Infect Dis J 26(12):1161–1163. doi: 10.1097/INF.0b013e3181461b3a PubMedCrossRefGoogle Scholar
  21. 21.
    Thomason TS, Brenski A, McClay J, Ehmer D (2007) The rising incidence of methicillin-resistant Staphylococcus aureus in pediatric neck abscesses. Otolaryngol Head Neck Surg 137(3):459–464. doi: 10.1016/j.otohns.2007.05.010 PubMedCrossRefGoogle Scholar
  22. 22.
    Kuriyama T, Karasawa T, Nakagawa K, Nakamura S, Yamamoto E (2002) Antimicrobial susceptibility of major pathogens of orofacial odontogenic infections to 11 beta-lactam antibiotics. Oral Microbiol Immunol 17(5):285–289. doi: 10.1034/j.1399-302X.2002.170504.x PubMedCrossRefGoogle Scholar
  23. 23.
    Chen MK, Wen YS, Chang CC, Huang MT, Hsiao HC (1998) Predisposing factors of life-threatening deep neck infection: logistic regression analysis of 214 cases. J Otolaryngol 27(3):141–144PubMedGoogle Scholar
  24. 24.
    Boscolo-Rizzo P, Da Mosto MC (2009) Submandibular space infection: a potentially lethal infection. Int J Infect Dis 13(3):322–333CrossRefGoogle Scholar
  25. 25.
    Ovassapian A, Tuncbilek M, Weitzel EK, Joshi CW (2005) Airway management in adult patients with deep neck infections: a case series and review of the literature. Anesth Analg 100(2):585–589. doi: 10.1213/01.ANE.0000141526.32741.CF PubMedCrossRefGoogle Scholar
  26. 26.
    Karkos PD, Leong SC, Beer H, Apostolidou MT, Panarese A (2007) Challenging airways in deep neck space infections. Am J Otolaryngol 28(6):415–418. doi: 10.1016/j.amjoto.2006.10.012 PubMedCrossRefGoogle Scholar
  27. 27.
    Yuen HW, Loy AH, Johari S (2007) Urgent awake tracheotomy for impending airway obstruction. Otolaryngol Head Neck Surg 136(5):838–842. doi: 10.1016/j.otohns.2006.12.012 PubMedCrossRefGoogle Scholar
  28. 28.
    Potter JK, Herford AS, Ellis E 3rd (2002) Tracheotomy versus endotracheal intubation for airway management in deep neck space infections. J Oral Maxillofac Surg 60(4):349–354 discussion 354-355PubMedCrossRefGoogle Scholar
  29. 29.
    Meyers BR, Lawson W, Hirschman SZ (1972) Ludwig’s angina. case report, with review of bacteriology and current therapy. Am J Med 53(2):257–260. doi: 10.1016/0002-9343(72)90134-9 PubMedCrossRefGoogle Scholar
  30. 30.
    Fischmann GE, Graham BS (1985) Ludwig’s angina resulting from the infection of an oral malignancy. J Oral Maxillofac Surg 43(10):795–796. doi: 10.1016/0278-2391(85)90337-4 PubMedCrossRefGoogle Scholar
  31. 31.
    Tsuji T, Shimono M, Yamane G, Noma H (1984) Ludwig’s angina as a complication of ameloblastoma of the mandible. J Oral Maxillofac Surg 42(12):815–819. doi: 10.1016/0278-2391(84)90352-5 PubMedCrossRefGoogle Scholar
  32. 32.
    Levitt GW (1970) Cervical fascia and deep neck infections. Laryngoscope 80(3):409–435PubMedGoogle Scholar
  33. 33.
    Rothwell BR (1985) Odontogenic infections. Emerg Med Clin North Am 3(1):161–178PubMedGoogle Scholar
  34. 34.
    Megran DW, Scheifele DW, Chow AW (1984) Odontogenic infections. Pediatr Infect Dis 3(3):257–265PubMedGoogle Scholar
  35. 35.
    Reynolds SC, Chow AW (2007) Life-threatening infections of the peripharyngeal and deep fascial spaces of the head and neck. Infect Dis Clin North Am 21(2):557–576. doi: 10.1016/j.idc.2007.03.002 PubMedCrossRefGoogle Scholar
  36. 36.
    Scully RE, Galdabini JJ, McNeely BU (1975) Case records of the Massachusetts General Hospital: weekly clinicopathological exercises. case 33–1975. N Engl J Med 293(8):394–399PubMedCrossRefGoogle Scholar
  37. 37.
    Blum DJ, McCaffrey TV (1983) Septic necrosis of the internal carotid artery: a complication of peritonsillar abscess. Otolaryngol Head Neck Surg 91(2):114–118PubMedGoogle Scholar
  38. 38.
    Wills PI, Vernon RP Jr (1981) Complications of space infections of the head and neck. Laryngoscope 91(7):1129–1136. doi: 10.1288/00005537-198107000-00010 PubMedCrossRefGoogle Scholar
  39. 39.
    Ramsey PG, Weymuller EA (1985) Complications of bacterial infection of the ears, paranasal sinuses, and oropharynx in adults. Emerg Med Clin North Am 3(1):143–160PubMedGoogle Scholar
  40. 40.
    Knouse MC, Madeira RG, Celani VJ (2002) Pseudomonas aeruginosa causing a right carotid artery mycotic aneurysm after a dental extraction procedure. Mayo Clin Proc 77(10):1125–1130. doi: 10.4065/77.10.1125 PubMedCrossRefGoogle Scholar
  41. 41.
    Sichel JY, Dano I, Hocwald E, Biron A, Eliashar R (2002) Nonsurgical management of parapharyngeal space infections: a prospective study. Laryngoscope 112(5):906–910. doi: 10.1097/00005537-200205000-00023 PubMedCrossRefGoogle Scholar
  42. 42.
    Sakaguchi M, Sato S, Ishiyama T, Katsuno S, Taguchi K (1997) Characterization and management of deep neck infections. Int J Oral Maxillofac Surg 26(2):131–134. doi: 10.1016/S0901-5027(05)80835-5 PubMedCrossRefGoogle Scholar
  43. 43.
    McClay JE, Murray AD, Booth T (2003) Intravenous antibiotic therapy for deep neck abscesses defined by computed tomography. Arch Otolaryngol Head Neck Surg 129(11):1207–1212. doi: 10.1001/archotol.129.11.1207 PubMedCrossRefGoogle Scholar
  44. 44.
    Boscolo-Rizzo P, Marchiori C, Montolli F, Vaglia A, Da Mosto MC (2006) Deep neck infections: a constant challenge. ORL J Otorhinolaryngol Relat Spec 68(5):259–265. doi: 10.1159/000093095 PubMedGoogle Scholar
  45. 45.
    Boscolo-Rizzo P, Marchiori C, Zanetti F, Vaglia A, Da Mosto MC (2006) Conservative management of deep neck abscesses in adults: the importance of CECT findings. Otolaryngol Head Neck Surg 135(6):894–899. doi: 10.1016/j.otohns.2006.05.013 PubMedCrossRefGoogle Scholar
  46. 46.
    Brazier JS (2006) Human infections with Fusobacterium necrophorum. Anaerobe 12(4):165–172. doi: 10.1016/j.anaerobe.2005.11.003 PubMedCrossRefGoogle Scholar
  47. 47.
    Chirinos JA, Lichtstein DM, Garcia J, Tamariz LJ (2002) The evolution of Lemierre syndrome: report of 2 cases and review of the literature. Medicine (Baltimore) 81(6):458–465. doi: 10.1097/00005792-200211000-00006 CrossRefGoogle Scholar
  48. 48.
    Dool H, Soetekouw R, van Zanten M, Grooters E (2005) Lemierre’s syndrome: three cases and a review. Eur Arch Otorhinolaryngol 262(8):651–654. doi: 10.1007/s00405-004-0880-3 PubMedCrossRefGoogle Scholar
  49. 49.
    Sinave CP, Hardy GJ, Fardy PW (1989) The Lemierre syndrome: suppurative thrombophlebitis of the internal jugular vein secondary to oropharyngeal infection. Medicine (Baltimore) 68(2):85–94. doi: 10.1097/00005792-198903000-00002 Google Scholar
  50. 50.
    Endo S, Tsubochi H, Nakano T, Sohara Y (2008) Descending necrotizing mediastinitis secondary to retropharyngeal abscess without cervical spread. Gen Thorac Cardiovasc Surg 56(1):25–27. doi: 10.1007/s11748-007-0182-y PubMedCrossRefGoogle Scholar
  51. 51.
    Barratt GE, Koopmann CF Jr, Coulthard SW (1984) Retropharyngeal abscess—a ten-year experience. Laryngoscope 94(4):455–463. doi: 10.1288/00005537-198404000-00003 PubMedCrossRefGoogle Scholar
  52. 52.
    Misthos P, Katsaragakis S, Kakaris S, Theodorou D, Skottis I (2007) Descending necrotizing anterior mediastinitis: analysis of survival and surgical treatment modalities. J Oral Maxillofac Surg 65(4):635–639. doi: 10.1016/j.joms.2006.06.287 PubMedCrossRefGoogle Scholar
  53. 53.
    Takao M, Ido M, Hamaguchi K, Chikusa H, Namikawa S, Kusagawa M (1994) Descending necrotizing mediastinitis secondary to a retropharyngeal abscess. Eur Respir J 7(9):1716–1718. doi: 10.1183/09031936.94.07091716 PubMedCrossRefGoogle Scholar
  54. 54.
    Sandner A, Borgermann J, Kosling S, Silber RE, Bloching MB (2007) Descending necrotizing mediastinitis: early detection and radical surgery are crucial. J Oral Maxillofac Surg 65(4):794–800. doi: 10.1016/j.joms.2005.11.075 PubMedCrossRefGoogle Scholar
  55. 55.
    Chow AW (2005) Life-threatening infections of the head, neck and upper respiratory tract. In: Hall JB, Schmidt GA, Wood LD (eds) Principles of critical care, 3rd edn. McGraw-Hill, New York, pp 881–896Google Scholar
  56. 56.
    Plaza Mayor G, Martinez-San Millan J, Martinez-Vidal A (2001) Is conservative treatment of deep neck space infections appropriate? Head Neck 23(2):126–133. doi: 10.1002/1097-0347(200102)23:2<126::AID-HED1007>3.0.CO;2-N PubMedCrossRefGoogle Scholar
  57. 57.
    Ungkanont K, Yellon RF, Weissman JL, Casselbrant ML, Gonzalez-Valdepena H, Bluestone CD (1995) Head and neck space infections in infants and children. Otolaryngol Head Neck Surg 112(3):375–382. doi: 10.1016/S0194-5998(95)70270-9 PubMedCrossRefGoogle Scholar
  58. 58.
    Courtney MJ, Mahadevan M, Miteff A (2007) Management of paediatric retropharyngeal infections: non-surgical versus surgical. ANZ J Surg 77(11):985–987. doi: 10.1111/j.1445-2197.2007.04295.x PubMedCrossRefGoogle Scholar
  59. 59.
    Adelson RT, Murray AD (2005) Minimally invasive transoral catheter-assisted drainage of a danger-space infection. Ear Nose Throat J 84(12):785–786PubMedGoogle Scholar
  60. 60.
    Bulut M, Balci V, Akkose S, Armagan E (2004) Fatal descending necrotising mediastinitis. Emerg Med J 21(1):122–123. doi: 10.1136/emj.2003.002865 PubMedCrossRefGoogle Scholar
  61. 61.
    Grewal S, Hocking G, Wildsmith JA (2006) Epidural abscesses. Br J Anaesth 96(3):292–302. doi: 10.1093/bja/ael006 PubMedCrossRefGoogle Scholar
  62. 62.
    Pina MA, Modrego PJ, Uroz JJ, Cobeta JC, Lerin FJ, Baiges JJ (2001) Brucellar spinal epidural abscess of cervical location: report of four cases. Eur Neurol 45(4):249–253. doi: 10.1159/000052137 PubMedCrossRefGoogle Scholar
  63. 63.
    Krishnan A, Patkar D, Patankar T, Shah J, Prasad S, Bunting T, Castillo M, Mukherji SK (2001) Craniovertebral junction tuberculosis: a review of 29 cases. J Comput Assist Tomogr 25(2):171–176. doi: 10.1097/00004728-200103000-00003 PubMedCrossRefGoogle Scholar
  64. 64.
    Reihsaus E, Waldbaur H, Seeling W (2000) Spinal epidural abscess: a meta-analysis of 915 patients. Neurosurg Rev 23(4):175–204; discussion 205PubMedCrossRefGoogle Scholar
  65. 65.
    Gordon RJ, Lowy FD (2005) Bacterial infections in drug users. N Engl J Med 353(18):1945–1954. doi: 10.1056/NEJMra042823 PubMedCrossRefGoogle Scholar
  66. 66.
    Darouiche RO (2006) Spinal epidural abscess. N Engl J Med 355(19):2012–2020. doi: 10.1056/NEJMra055111 PubMedCrossRefGoogle Scholar
  67. 67.
    Davis DP, Wold RM, Patel RJ, Tran AJ, Tokhi RN, Chan TC, Vilke GM (2004) The clinical presentation and impact of diagnostic delays on emergency department patients with spinal epidural abscess. J Emerg Med 26(3):285–291. doi: 10.1016/j.jemermed.2003.11.013 PubMedCrossRefGoogle Scholar
  68. 68.
    Curry WT Jr, Hoh BL, Amin-Hanjani S, Eskandar EN (2005) Spinal epidural abscess: clinical presentation, management, and outcome. Surg Neurol 63(4):364–371 discussion 371PubMedCrossRefGoogle Scholar
  69. 69.
    Muckley T, Schutz T, Kirschner M, Potulski M, Hofmann G, Buhren V (2003) Psoas abscess: the spine as a primary source of infection. Spine 28(6):E106–E113. doi: 10.1097/00007632-200303150-00021 PubMedCrossRefGoogle Scholar
  70. 70.
    Hanigan WC, Asner NG, Elwood PW (1990) Magnetic resonance imaging and the nonoperative treatment of spinal epidural abscess. Surg Neurol 34(6):408–413. doi: 10.1016/0090-3019(90)90245-K PubMedCrossRefGoogle Scholar
  71. 71.
    Brook I (2007) Microbiology and principles of antimicrobial therapy for head and neck infections. Infect Dis Clin North Am 21(2):355–391 viPubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2009

Authors and Affiliations

  1. 1.Division of Critical Care, Department of MedicineUniversity of British ColumbiaVancouverBCCanada
  2. 2.Division of Infectious DiseasesSt. Paul’s HospitalVancouverCanada
  3. 3.Intensive Care Unit, Royal Columbian HospitalNew WestminsterCanada
  4. 4.Division of Infectious Diseases, Department of MedicineUniversity of British ColumbiaVancouverBCCanada
  5. 5.Division of Infectious DiseasesVancouver HospitalWest VancouverCanada

Personalised recommendations