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American Journal of OtolaryngologyHead and Neck Medicine and Surgery 33 (2012) 56 63

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Deep neck space infections: a retrospective review of 173 cases

Salih Bakir, MDa,, M. Halis Tanriverdi, MDb , Ramazan Gn, MDa ,
A. Ediz Yorgancilar, MDa , Mzeyyen Yildirim, MDa , Gven Tekba, MDc ,
Ylmaz Palanci, MDd , Kaan Meri, MDe , smail Topu, MDa
a

Department of Ear Nose & Throat, Dicle University School of Medicine, Diyarbakir, Turkey
b
Department of Family Medicine, Dicle University School of Medicine, Diyarbakir, Turkey
c
Department of Radiology, Dicle University School of Medicine, Diyarbakir, Turkey
d
Department of Public Health, Dicle University School of Medicine, Diyarbakir, Turkey
e
Department of Radiology, Diyarbakir State Hospital, Diyarbakir, Turkey
Received 25 October 2010

Abstract

Purpose: The purpose of this study is to review our recent experience with deep neck infections and
emphasize the importance of radiologic evaluation and appropriate treatment selection in those patients.
Materials and Methods: The records of 173 patients treated for deep neck infection at the
Department of Otolaryngology and Head and Neck Surgery of Dicle University Hospital during the
period from 2003 to 2010 were retrospectively reviewed. Their demography, symptoms, etiology,
seasonal distribution, bacteriology, radiology, site of deep neck infection, durations of the hospital
admission and hospital stay, treatment, complications, and outcomes were evaluated. The findings
were compared to those in the available literature.
Results: Dental infection was the most common cause of deep neck infection (48.6%). Peritonsillar
infections (19.7%) and tuberculosis (6.9%) were the other most common cause. Pain, odynophagia,
dysphagia, and fever were the most common presenting symptoms. Radiologic evaluation was
performed on almost all of the patients (98.3%) to identify the location, extent, and character (cellulitis
or abscesses) of the infections. Computed tomography was performed in 85.3% of patients. The most
common involved site was the submandibular space (26.1%). In 29.5% of cases, the infection involved
more than one space. All the patients were taken to intravenous antibiotic therapy. Surgical intervention was required in 95 patients (59.5%), whereas 78 patients (40.5%) were treated with intravenous antibiotic therapy alone. Life-threatening complications were developed in 13.8% of cases;
170 patients (98.3%) were discharged in stable condition.
Conclusion: Despite the wide use of antibiotics, deep neck space infections are commonly seen.
Today, complications of deep neck infections are often life threatening. Although surgical drainage
remains the main method of treating deep neck abscesses, conservative medical treatment are
effective in selective cases.
2012 Elsevier Inc. All rights reserved.

1. Introduction
Deep neck space infection (DNI) means infection in the
potential spaces and fascial planes of the neck, either with

Declaration of interest: The authors report no conflicts of interest. The

authors alone are responsible for the content and writing of the manuscript.
Corresponding author. Department of ENT, Dicle University School
of Medicine, 21280, Diyarbakir, Turkey. Tel.: +90 412 2488001/4492.
E-mail address: drsalihbakir@hotmail.com (S. Bakir).
0196-0709/$ see front matter 2012 Elsevier Inc. All rights reserved.
doi:10.1016/j.amjoto.2011.01.003

abscess formation or cellulitis [1]. Despite the prevalence

and the complications incidence of DNI has been diminished
with improved diagnostic techniques and widespread availability of antimicrobial therapy, these infections are still
serious and potentially life threatening today as in the past.
The DNIs may arise from several focuses in the head and
neck, including teeth, adenotonsillar tissue, and salivary
glands [1-3]. The origin of DNI is different in many publications. In the preantibiotic era, most of DNIs arose from
tonsillitis or pharyngitis [2,3]. Today, dental infections are

S. Bakir et al. / American Journal of OtolaryngologyHead and Neck Medicine and Surgery 33 (2012) 5663

the most common causes of DNI [4-6]. The DNIs are

generally polymicrobial. Streptococci, Peptostreptococcus
spp, Staphylococcus aureus and anaerobes are the organisms
most commonly cultured from deep neck abscesses [3,4].
The main complications include respiratory obstruction,
mediastinitis, pleural empyema, pericarditis, jugular vein
thrombosis, and septic shock [4,5]. Complications can even
result in death [4]. The advent of modern imaging techniques
has made it possible to diagnose these complications earlier
and to localize them exactly [5]. Management of deep neck
infections has usually been based on prompt surgical
drainage of purulent abscesses through an external approach
or nonsurgical treatment with on the basis of appropriate
antibiotics [7]. The purpose of this study is to review our
recent experience with DNI and emphasize the importance of
radiologic evaluation and appropriate treatment selection in
those patients.

2. Materials and methods

In this study, the records of 173 patients treated for DNI
at the Department of Otolaryngology and Head and Neck
Surgery of Dicle University Hospital between January 2003
and August 2010 were retrospectively reviewed. Their
demography; symptoms; etiology; seasonal distribution; bacteriology; radiology; site of deep neck infection; durations of
the hospital admission; and hospital stay, treatment, complications, and outcomes were evaluated. The findings were compared to those in the available literature.

3. Results
There were 80 (46.2%) male and 93 (53.8%) female
patients, with a female-to-male ratio of 1.16/1. The mean age
was 25.1 years (15.5) (range, 369 years) (Fig. 1). The
duration of admission ranged from 2 to 33 days with an
average of 6.6 4.7 days.
The seasonal distribution of patients presenting with deep
neck infections: autumn (43.4%), summer (24.3%), spring
(16.8%), and winter (15.6%) (Fig. 2, Table 1).
Pain was present in almost all cases. After pain, the other
common complaint was neck swelling (66%), odynophagia
(48%), dysphagia (44%), fever (35%), dysphonia (28%),
trismus (27%), otalgia (13%), dyspnea (12%), and draining
fistulas in the neck (2%).
Physical examination revealed that 77 patients (45%) had
fever (N37.5C). The white blood cell (WBC) count was
higher than 10 000 cells/mm3 (cells per cubic millimeter) in
98 cases (56%). In addition, 57 patients (33%) had a WBC
count of more than 15 000 cells/mm3, and 23 patients (15%)
had a WBC count of more than 20 000 cells/mm3.
Considering clinical and radiological evidence, the causes
of deep neck infections were identified in 144 patients
(83.2%). The most common cause of deep neck infection

57

Fig. 1. Distribution of age (n = 173).

was odontogenic (84 cases, 48.6%). Odontogenic causes

were diagnosed through dental consultations. Orthopantograms of the mandible were obtained in 26 cases. The second
most common cause of deep neck infection was peritonsillar
abscess (34 cases, 19.7%). In 12 patients, the abscess was
caused by tuberculosis (6.9%), and in 10 patients, an infected
salivary glands were found (5.8%). In 3 patients, abscess
was caused by branchial cleft cyst (1.7%), and in 1 patient,
caused by thyroiditis (0.6%). In the remaining 29 patients
(16.8%), the origin of the DNI remained unclear. The etiology of deep neck infections is recorded in Fig. 3.
There were 4 patients (2.3%) with diabetes mellitus (DM)
in our study. There was no case of known liver, lung, kidney
disease or malignancies, trauma, intravenous drug abuse,
or immunodeficiency.
The results of bacterial cultures were available for 34
of the 96 cases who underwent surgical treatment or
needle aspiration (35.4%). Anaerobic and aerobic cultures
were obtained. Anaerobes account for 5 (14.7%) of the
positive cultures. The cultures of 20 patients (58.8%)
were polymicrobial. The most common bacteries were
anaerobic Peptostreptococcus (21.3%), and Staphylococcus
epidermidis (19.7%).
Radiologic evaluation was performed almost all of the
patients to identify the location, extention, and character
(cellulitis or abscesses) of the infections (170 patients, 98.3%).
In 28 patients (16.5%), ultrasonography was the only imaging
procedure. For 145 DNI patients, computed tomography (CT)
was performed (85.3%), and in 14 of those, an additional
magnetic resonance imaging also was performed. Neck ultrasonography and magnetic resonance imaging of the neck
were performed less relatively to the CT. In 26 patients,
orthopantograms of the mandible were indicated.
According to clinical, surgical and imaging findings, 122
(70.5%) had one involved space. The most common one
involved site was the submandibular space (26.1%), followed
by the peritonsillar space (14.5%), the parapharyngeal space
(11.6%), the submental space (10.4%), the retropharyngeal
space (3.5%), the parotid space (2.9%), the carotid space
(0.5%), the masseter space (0.5%), and the anterior visceral
space (0.5%). In 51 patients (29.5%), the infection involved

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S. Bakir et al. / American Journal of OtolaryngologyHead and Neck Medicine and Surgery 33 (2012) 5663

Fig. 2. The seasonal distribution of DNI patients (n = 173).

more than one space. If 2 or more spaces were concurrently

involved in a significant way, they were classified as extended
spaces. The diagnostic criteria of Ludwig's angina are defined
as the simultaneous involvement of the sublingual, submylohyoid, and submental spaces, either as cellulitis or abscesses.
Twenty-seven patients (15.6%) were evaluated as Ludwig's
angina, and 24 patients (13.9%) were evaluated as extended
spaces. According to clinical and imaging findings, the
distribution of involved spaces and sites is recorded in Fig. 4.
In our department, all patients received antimicrobial
therapy after admission. The antibiotic regimen has to cover
mostly gram-positive aerobes and anaerobes implicated in
deep neck infections, also considering the rising incidence of
polymicrobic infections. Empirical intravenous antibiotics
(-lactamase-resistant -lactam antibiotics, the third-generation cephalosporin antibiotics, metronidazole, clindamycin)
were administered before the culture results were available,
then the antibiotics regimen was modified based on the
culture and sensitivity results. We mostly chose ampicillin/
sulbactam 1.5 g 4 times per day plus metronidazole 500 mg

Table 1
The seasonal distribution of patients according to the origin of DNI
Origin

Seasons

Total

Spring

Summer

Autumn

Winter

No. of %
cases

No. of %
cases

No. of %
cases

No. of %
cases

Dental
15
Tonsil
5
Tuberculosis 0
Unknown
7
Salivary
1
gland
Thyroid
1
Neck cyst
0
Total
29

17.9 24
14.7 6
.0 2
24.1 4
10.0 5
100.0 0
.0 1
16.8 42

28.6
17.6
16.7
13.8
50.0

31
15
10
14
4

36.9 14
44.1 8
83.3 0
48.3 4
40.0 0

16.7
23.5
.0
13.8
.0

84
34
12
29
10

.0 0
33.3 1
24.3 75

.0 0
33.3 1
43.4 27

.0
1
33.3
3
15.6 173

3 times per day. The second most preferred option was

ceftriaxone 1 g 2 times per day plus metronidazole 500 mg
3 times per day. Supportive medical treatments (analgesics
and antipyretics, intravenous fluids, mouthwashes, intravenous steroids) were performed when required. Considering the clinical condition and imaging, 78 patients (40.5%)
were treated with intravenous antibiotic therapy alone,
whereas surgical intervention was required in 95 patients
(59.5%). Distribution of our treatment approach is shown in
Fig. 5 and Table 2. The surgical procedures ranged from a
simple drainage by a topical anesthesia to a wide incision
and drainage with a general anesthesia. In 11 DNI patients
with mediastinitis, we performed mediastinotomy. Patients
with abscesses caused by dental infection were referred
to the Department of Oral and Maxillofacial Surgery for
further treatment.
There were 24 patients (13.8%) who developed lifethreatening complications. Descending mediastinitis (11
patients, 6.3%) was the most frequently occurring complication in our series. Eight patients (4.6%) had upper airway
distress. Of them, 6 patients (3.4%) required temporary
tracheotomy. The other rare but serious complications in our
series were sepsis (3 patients, 1.7%) and thrombosis of the
internal jugular vein (2 patients, 1.1%). All these complications were developed in patients with extended space abscesses and Ludwig's angina abscesses.
The mean duration of hospital stay was 8.9 5.8
days (range, 236 days) (Fig. 6). Crude mortality was
1.7% (3 cases); 170 patients (98.3%) were discharged in
stable condition.

4. Discussion
The current study found that the most common cause of
DNI was dental infections (48.6%). Most reports indicated a
significant prevalence of DNI that were caused by dental

S. Bakir et al. / American Journal of OtolaryngologyHead and Neck Medicine and Surgery 33 (2012) 5663

59

Fig. 3. Distribution of etiology (n = 173).

infections [2,4-6,8]. Parhiscar and Har-El [2] found 43% in

2001, Bottin et al [5] found (42%) in 2003, Huang et al
[4] found (42%) in 2004, Marioni et al [8] found 38.8% in
2008, and Eftekharian et al [6] found 49% in 2009 that the
most common cause of deep neck infection was odontogenic
in DNI.
We found that the second most common cause of deep
neck infection was tonsillar infections (19.7%) (Fig. 3).
Before the widespread use of antibiotics, several studies
showed that most DNI cases (7080%) resulted from com-

plicated tonsillopharyngeal infections [7], whereas nowadays, a decreased incidence (816%) in pharyngotonsillar
onset was described [2,6]. In children, the most encountered
causes still remain acute tonsillitis and pharyngitis [3].
According to some studies, upper airway infections are still
the most common cause of deep neck infections [8-12].
Causes of deep neck infections may differ in various
studies. According to some recent reports, poor dental
hygiene and intravenous drug abuse have become the most
common causes of DNI in adults, followed by foreign body

Fig. 4. Distribution of involved spaces and sites (n = 173).

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S. Bakir et al. / American Journal of OtolaryngologyHead and Neck Medicine and Surgery 33 (2012) 5663

Fig. 5. Distribution of our treatment approach (n = 173).

ingestion and infections of unknown origin [13,14]. Unlike

other reports, the present study showed that, followed by
dental and upper faryngeal infections, tuberculosis infection
was the third common cause (6.9%) (Fig. 3). Today, tuberculosis disease is a still common in our country and the other
developing and underdeveloped countries especially east of
the world. Every organ can be affected by tuberculosis.
Tuberculous involvement of the neck is also possible.
Because of deep neck abscess formation seen on CT in all,
we performed surgical drainage and mass biopsy. Considering the biopsy results, tuberculosis was suspected in 12
patients and then confirmed by other investigations.
Tuberculosis disease should be considered in the differential
diagnosis in patients with DNI.
The age distribution showed that most of our patients
were young and middle aged. As shown in Fig. 1, 80.9% of

our patients were under the age of 40 and 95.4% of patients

were younger than 50 years. The mean age was 25.1 years.
The prevalence of DNI is comparatively high in young and
middle-aged adults in our series. Because dental and tonsil
infections constituted a large part of the etiology in DNI in
our series. These infections are more frequent in younger
ages and middle-aged adults [12].
In our study, there was a slight predominance of women,
whereas other studies showed a male dominancy or an
equal distribution [4-6]. This result is consistent with our
country conditions. According to the Saydam et al. [15]
report, which was supported by the World Health Organization, prevalence of caries was higher in women than in
men in our country.
Our report has not shown association with trauma, intravenous drugs abuse, chemotherapeutic treatments, chronic

Table 2
Distribution of our treatment approach according to the origin of DNI
Origin

Treatment

Total

Antimicrobial
therapy

Dental
Tonsil
Tuberculosis
Unknown
Salivary gland
Thyroid
Neck cyst
TOTAL

Surgery and
antimicrobial therapy

No. of cases

No. of cases

57
10
5
19
3
0
1
95

67.9
29.4
41.7
65.5
30.0
.0
33.3
59.5

27
24
7
10
7
1
2
78

32.1
70.6
58.3
34.5
70.0
100.0
66.7
40.5

84
34
12
29
10
1
3
173

Fig. 6. Distribution of mean hospital stay (n = 173).

S. Bakir et al. / American Journal of OtolaryngologyHead and Neck Medicine and Surgery 33 (2012) 5663

hepatitis, chronic pulmonary diseases, renal insufficiency,

autoimmune disease, or HIV infection, which were described
in some other reports [4,5,16]. There were 4 patients with
DM in our study. Huang et al [4] reported that DM is the
most common risk factor among the systemic disease that
has been associated with the development of deep neck
infections and noted a major incidence (30.3%). However,
our study showed a lower incidence when compared (2.3%).
This situation can be explained by age differences. Huang et
al. [4] reported that the mean age was 49.5 (20.5) years, and
52.4% of the patients were older than 50 years, whereas in
our study, the percentage of patients younger than 50 years
was 95.4, and the mean age was 25.1 years (15.5).
Bottin et al [5] reported that there was a slight preponderance of cases presenting in the summer season (35%), but
in our series, there was an apparent preponderance of cases
presenting in the autumn season (43.4%) (Fig. 2, Table 1).
The most frequent symptoms of our patients were
pain, neck swelling, odynophagia, and dysphagia, which
were similar to other series [5-7]. Although the frequency
of dyspnea is not common relatively than the other
symptoms, the presence of dyspnea may be the sign of
serious complications.
Fever was present in 45%, and 56% had high white blood
cell count of over 10 000 cells/mm3. Neither fever nor
leukocytosis are constant findings in deep neck infections
[6]. Widespread diffusion of empirical broadspectrum antibiotic and anti-inflammatory treatments may cause masked
presentations of deep neck infections without pain, fever, or
leukocytosis [5].
The results of pus cultures from either surgery or needle
aspiration were available in 35.4% of patients; 58.8% of the
positive cultures had polymicrobial growth. Many of our
patients had received antibiotic therapy; before admission,
our clinic might have yielded the significant rate of negative
cultures. The limited number of positive cultures did not
allow any conclusions. The positive cultures in our study
were much similar to the latest reports [5,6,17].
Developing imaging techniques have made the management of deep neck infections better. Contrast-enhanced CT
(CCT) scan is highly sensitive (91%) and very useful to
identify the extent of the deep neck infections and distinguish cellulitis from abscesses [3]. Contrast-enhanced CT
helps to decide whether surgical intervention is indicated
[18]. Those cases with radiologic findings of cellulitis are
supposed to have better prognosis and respond earlier to
medical treatment, whereas those with abscesses behave
more aggressively, have more complications, and may require surgical treatment [7]. However, ultrasonography
cannot always identify small or deep abscess and cannot
provide the specific anatomical information necessary for
surgical intervention [18]. Magnetic resonance imaging has
similar prognostic value to CCT scanning, but it is more
expensive and requires longer scanning time when compared
with CCT, so that not commonly preferred in imaging deep
neck infection [18]. Based on this evidence, we considered

61

CCT to be part of the routine investigation in DNI patients

(85.3%; 145 patients). Based on the clinic and radiological
findings, in 70.5% of patients, the infection involved one
space, and in 29.5% of patients, the infection involved more
than one space (Fig. 4). The most commonly involved site
was the submandibular space (26.1%), which has been
reported as the most commonly involved site in most past
studies [3,6,19,20].
According to our group and most investigators worldwide, management of deep neck abscess has usually been
based on prompt surgical drainage of purulent abscesses
through an external approach [1-6]. On the contrary, Plaza
Mayor et al. [7] suggested broad-spectrum intravenous antibiotics and high-dosed oral or intravenous corticosteroids for
almost all patients with any DNI. In our series, 78 patients
(40.5%) were treated successfully with only intravenous
antibiotic therapy. In the remaining 95 patients (59.5%),
surgical procedures were required (Fig. 5 and Table 2). It has
been stated that, in patients with cellulitis, the infection can
be controlled successfully with IV antibiotics alone in most
DNI cases [6,13,17]. If there is a small amount of abscess
and no impending complications are noted, medical therapy
may be sufficient [6,7,17]. In those cases, medical treatment
did not seem to increase complication rates or mortality
[6,7]. Medical treatment could also be considered in selected
cases [17].
Whenever a DNI patient is admitted, empirical antibiotic
therapy should be administered before the culture results are
available. Empirical antibiotic treatments must cover grampositive and gram-negative aerobic and anaerobic pathogens
[17]. We used usually penicillin or third-generation cephalosporin plus metronidazole or clindamycin combination
depending on the case severity, the most probable focus and
the existence of a previous treatment. This regimen covers
most gram-positive, anaerobic, as well as -lactamaseproducing bacteria [3]. In our clinic, the initial antibiotic
therapy was penicillin and metronidazole usually. Penicillin
should be the drug of choice for aerobic bacteria. We
preferred clindamycin for severe DNI, which provides
adequate therapy against anaerobes that were resistant to
penicilin [1]. The third-generation cephalosporins were used
instead if poor clinical response was noted or when complications had developed [1]. If required, the antibiotics
were modified depending on the result of culture and
sensitivity reports.
In our patients, besides antibiotic therapy, supportive
medical treatment was required because of complaints.
Odinophagia, dysphagia, and fever was common, so
analgesics and antipyretics, intravenous fluids for rehydration, and mouthwashes (in dental and peritonsillar infection)
were provided. Intravenous steroids (methylprednisolone,
60 mg) were used (where possible) because of strong antiinflammatory effects for a few days in patients showing
important local edema and dyspnea.
Medical versus medical and surgical treatment was determined by imaging and clinical progress. In patients with

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S. Bakir et al. / American Journal of OtolaryngologyHead and Neck Medicine and Surgery 33 (2012) 5663

significant abscess formation seen on CT, early open surgical

drainage is the most appropriate method of treating a deep
neck infection [4]. In our department, the treatment of deep
neck infection consists of using only antimicrobial therapy
primarily in the absence of abscess and presence of the
cellulitis and surgical drainage required primarily in the
presence of the abscesses. Surgical exploration may also
required when there is airway compromise, clinical signs of
sepsis occur or if there is poor response to antimicrobial
therapy within the first 48 hours [6,13,17].
The main life-threatening complications include descending mediastinitis, respiratory obstruction, pleural effusion, pneumonia, pericarditis, jugular vein thrombosis,
venous septic emboli, carotid artery rupture, hepatic failure,
adult respiratory distress syndrome, septic shock, and
disseminated intravascular coagulopathy [4,5]. The mortality rate may reach 40%, while these serious complications
occur [4]. Descending mediastinitis is one of the most lifethreatening complications of DNI [14]. In our series, the
most frequently occurring complication was mediastinitis
(11 cases; 6.3%). In three patients with mediastinitis had
developed sepsis. Three of them died related to septic
shock. The remaining 8 patients with mediastinitis recovered with effective intravenous antibiotics after surgical
drainage. In reviewing those 11 mediastinitis cases, we
found the origin arose from dental infection. Surgical
treatment is essential in patients with mediastinitis [21].
Access by cervical incision has a lower risk than
thoracotomy and avoids pleural contamination, whereas
thoracotomy is more invasive and associated with the risk
of respiratory complications that may worsen the prognosis
[21]. In patients with descending mediastinitis, Kinzer et al
[21] performed collar mediastinotomy, whereas Wheatley
et al. [22] recommended transthoracic mediastinal drainage
routinely. In 11 DNI patients with mediastinitis, we
performed mediastinotomy.
Other complications in our series were airway distress and
thrombosis of the internal jugular vein. It is worth emphasizing that airway support is the priority in patients with
deep neck infections [17]. Temporary tracheotomy was
required for 6 patients. The tracheostomy rate was considerably low (3.4%).
Our series had a mean length of hospitalization of 8.9
5.8 days (range, 236 days), which was similar to other
series [5,15,20]. According to our results; the hospitalization
time of patients with dental origin was longer than the other
patients (Fig. 6).
Odontogenic infections comprise one of the most
dangerous causes of DNI [21], because in our series, we
had 3 deaths and 3 of them were related to dental infection.
The mortality rate in our study was 1.7%, which was close to
that of some previous reports [1,4,5,16]. In a recent study,
Marioni et al [17] reported that none of their patients died of
deep neck infection or its complications. Despite the decreasing in death rates, even now, complications of DNIs should
not be underestimated.

5. Conclusion
Despite the wide use of antibiotics, deep neck space
infections are commonly seen. Our results demonstrate that
tuberculosis must be considered as possible causes of DNIs.
Clinical evidence and early radiologic diagnosis with
contrast-enhanced CT provide valuable information in
defining the origin, location and extension of neck infections. Our treatment approach to deep neck infections
(medical or medical plus surgical treatment) was determined
by clinical (presentation, complications, response to antibiotics in the first 48 hours) and radiological evidence.
Although surgical drainage remains the main method of
treating deep neck abscesses, conservative medical treatment
are effective in selective cases. The combination of appropriate intravenous antibiotic therapy, drainage, and securing
of airway are recognized cornerstones of treatment.
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