Cervical fascial (perimandibular) space infections
Table: Deep space infections
Anterior lateral pharyngeal
Posterior lateral pharynx
*Adapted from Jaworsky D, et al. Crit Care Clin 2013;29:443-463.
- Definition: infection involving the spaces created by facial insertions along the mandible. Presenting symptoms and signs are dictated by the space involved.
- Causes: dental source most common; other reasons include foreign body/trauma, tonsillitis or pharyngitis, malignancy, surgery.
- Presentation: tender swelling along mandible (usually with local and systemic signs of infection).
- Usual presentation: oral pain, neck stiffness, drooling and/or dysphagia.
- Adenopathy is uncommon.
- Trismus usually indicates extension into the lateral pharyngeal space.
- Major spaces involved: submandibular and para-pharyngeal.
- Serious space infections:
- Submandibular or sublingual spaces (including Ludwig’s angina): often with preceding dental condition causing neck swelling, dysphagia, tongue pain.
- Retropharyngeal space: behind esophagus, may spread to posterior mediastinum; not to be confused with the "danger space."
- Lateral pharyngeal space: jugular venous septic phlebitis (Lemierre’s syndrome almost always due to Fusobacterium necrophorum), often with sore throat or neck pain evolving into swelling with development of septic thrombophlebitis of jugular vein with bacteremia and septic emboli to lung.
- Ludwig ’s angina: sublingual and submylohoid spaces with tongue elevation and airway compromise.
- Diagnosis: typical clinical findings plus CT with contrast.
- Differential dx: parotiditis, lymph node infection (cervical lymphadenitis), actinomycosis, peritonsillar abscess.
- Complications: airway obstruction, mediastinitis, sepsis, septic thrombophlebitis, lung abscess, osteomyelitis.
- CT scan with contrast or MRI defines space infections with great clarity.
- Needle aspiration or surgical drainage for bacteriology + cytology.
Life-threatening space infections
- Lemierre’s Syndrome (Fusobacterium necrophorum bacteremia): most respond to antibiotic treatment and do not require anticoagulation, vein ligation or surgical drainage.
- Ludwig’s angina: secure airway (intubation or tracheostomy), antibiotics +/- surgical drainage.
- Retropharyngeal abscess: secure airway (tracheostomy prn) + antibiotics. Surgical drainage needed if not quickly responsive to antibiotics.
- Define anatomic problem: obtain neck CT scan.
- Drainage (surgery or percutaneous with radiographic guidance): consult with ENT or oral surgery. Must get Gram stain and culture.
- Airway protection: consider need of intubation or tracheostomy.
- Abx: should be directed against anaerobes and streptococci, BUT consider MRSA and aerobic GNB in seriously ill or compromised patients.
- Preferred :
- Clindamycin 600 mg IV q8h or 300 mg PO four times a day.
- Cover GNB and/or MRSA in patients who are seriously ill (select from alternatives listed below), but modify based on culture results.
- S. aureus:
- MSSA: oxacillin or nafcillin 2 gm IV q 6h
- Drainage: critical component of treatment. Usually requires surgical drainage.
- Recent reports support that some may be treated solely with percutaneous drainage or drainage by video-assisted thorascopic surgery.
- Dental care: dental infections are usually the underlying cause. Evaluate if tooth needs extraction or other complication of a dental procedure.
- Lemierre’s syndrome: role of surgery and anticoagulants is unclear.
Selected Drug Comments
Penicillin (and amoxicillin) were once regarded as the preferred drug for anaerobic infections above the diaphragm. Resistance is now a problem. Risky choice alone for severe infections.
Active against all nearly clinically significant anaerobes. This is a rational choice. Other beta-lactam/beta-lactamase inhibitors (piperacillin/tazobactam, ticarcillin/clavulanate) are also effective.
Not a good choice. Advantage of this drug is expanded spectrum against P. aeruginosa and other GNB, but these are bacteria that don’t cause these infections. It has poor activity against anaerobes which do account for most of these infections.
Excellent activity against pathogens in the mouth and extensive use in orodental infections. Main concern is GI side effects including C. difficile.
Active vs. all obligate anaerobes and most streptococci, GNB and other bacteria of unknown significance in mixed infections.
Active vs. all obligate anaerobes and most streptococci, GNB and other bacteria of unknown significance in mixed infections.
Reasonably good in vitro activity vs. anaerobes, but clinical experience is limited and other drugs are preferred.
Active vs. most anaerobes; a good choice although experience is limited.
Active vs. most anaerobes, a good choice although experience is limited.
Active vs. vitutally all gram positive bacteria, but main indication is for MRSA.
Pathogen Specific Therapy
1st Line Agent
2nd Line Agent
Basis for recommendation
- Reynolds SC, Chow AW: Severe soft tissue infections of the head and neck: a primer for critical care physicians. Lung 187:271, 2009 Sep-Oct [PMID:19653038]
Comment: Basis for recommendation
- Vieira F et al: Deep neck infection. Otolaryngol Clin North Am 41:459, 2008 [PMID:18435993]
Comment: Deep neck infections: complications include airway obstruction, jugular vein thrombosis, descending mediastinitis, ARDS, sepsis and DIC. Primary sources are dental, salivary gland, foreign body, tonsil infection, malignancy. Bacteriology: mixed oral flora with anaerobes.
- Boucher C, Dorion D, Fisch C: Retropharyngeal abscesses: a clinical and radiologic correlation. J Otolaryngol 28:134, 1999 [PMID:10410343]
Comment: A review of 37 patients in 10 yrs. CT scan showed "cellulitis" without abscess in 25; 13 required surgical drainage for abscesses. Sensitivity of x-ray was 80% and for CT scan it was 100%.
- Bakir S et al: Deep neck space infections: a retrospective review of 173 cases. Am J Otolaryngol 33:56, 2012 Jan-Feb [PMID:21414684]
Comment: Dental infection accounted for 49%, peritonsillar infection -- 20% and TB -- 7% (this was from Turkey)/ Submandibular space was most common; 29% involved more than one space, "life threatening complication" in 14%.
- Gormus N et al: Lemierre's syndrome associated with septic pulmonary embolism: a case report. Ann Vasc Surg 18:243, 2004 [PMID:15253264]
Comment: Case report of a previously healthy 18-year-old girl with CT demonstrated phlebitis of the right internal jugular vein and septic emboli to both lungs. Blood cultures yielded Proteus--most unusual. Symptoms progressed and required surgical decompression.
- Subhashraj K, Jayakumar N, Ravindran C: Cervical necrotizing fasciitis: an unusual sequel of odontogenic infection. Med Oral Patol Oral Cir Bucal 13:E788, 2008 [PMID:19047968]
Comment: Cervical necrotizing fasciitis in adults is associated with infections of molar teeth.
Chow A; Odontogenic infections in the elderly; Infect Dis Clin Pract; 1998; Vol. 6; pp. 587.
Comment: The author notes the predisposition of the elderly and the immunosuppressed to orofacial infections. Superficial infections include those involving the buccal, canine, masticator, submental, and infratemporal spaces--each indicates the responsible tooth. A major concern is spread to deeper and dangerous spaces--submandibular, retropharyngeal, or lateral pharyngeal; alternately they may spread to the meninges, subdural space, or mediastinum.
- Chow AW, Roser SM, Brady FA: Orofacial odontogenic infections. Ann Intern Med 88:392, 1978 [PMID:343682]
Comment: Classic paper by a noted authority. Pathophysiology of the infection is characteristically a dental infection, usually periapical that extends to involve spaces created by fascial insertions along mandible. Presentation is tender swelling that is intra-oral or along mandible.
- Gaspari RJ: Bedside ultrasound of the soft tissue of the face: a case of early Ludwig's angina. J Emerg Med 31:287, 2006 [PMID:16982363]
Comment: Diagnosis was made by bedside ultrasound.
- Duggal P, Naseri I, Sobol SE: The increased risk of community-acquired methicillin-resistant Staphylococcus aureus neck abscesses in young children. Laryngoscope 121:51, 2011 [PMID:21120830]
Comment: Review of 136 pediatric patients who had surgery for deep neck space infections showed 49/118 cultures yielded MRSA.
- Yusa H et al: Ultrasound-guided surgical drainage of face and neck abscesses. Int J Oral Maxillofac Surg 31:327, 2002 [PMID:12190142]
Comment: Eight cases successfully managed by US guided surgical drainages.
- Flynn TR et al: Severe odontogenic infections, part 1: prospective report. J Oral Maxillofac Surg 64:1093, 2006 [PMID:16781343]
Comment: Prospective study of 37 patients hospitalized with severe odontogenic infections. Mean age 35 yrs. Most had caries (65%), lower 3rd molar involvement (68%) and trismus (70%). Penicillin -resistant pathogens were found in 19% and 21% failed penicillin treatment. Average LOS was 5 days. Recommended antibiotic was clindamycin.
- Gonzalez-Beicos A, Nunez D: Imaging of acute head and neck infections. Radiol Clin North Am 50:73, 2012 [PMID:22099488]
Comment: Most common cause of neck abscesses in children and young adults is tonsillar infection. The most common in older persons are odogenic sources. Other sources -- salivary gland, sinuses, middle ear, mastoids, cervical nodes and trauma. CT and MRI are excellent for detection -- especially for deep abscesses and complications -- osteomyelitis, vascular complications and airway narrowing.
- Gupta M, Singh V: A retrospective study of 256 patients with space infection. J Maxillofac Oral Surg 9:35, 2010 [PMID:23139564]
Comment: Review shows major spaces submandibular. All 256 patients recovered, usually within 3 days after treatment started (drainage plus Abx). Cases with trismus delayed.
- Jaworsky D, Reynolds S, Chow AW: Extracranial head and neck infections. Crit Care Clin 29:443, 2013 [PMID:23830648]
Comment: Comprehensive review of the clinical, microbiological, imaging and treatment facets. This includes color photos of spaces and excellent tables.
- Kadhiravan T et al: Lemierre's syndrome due to community-acquired meticillin-resistant Staphylococcus aureus infection and presenting with orbital cellulitis: a case report. J Med Case Reports 2:, 2008 [PMID:19063718]
Comment: Jugular venous thrombophlebitis with pulmonary emboli and respiratory failure in 16 year old girl caused by MRSA in blood cultures.
- Kinzer S et al: Severe deep neck space infections and mediastinitis of odontogenic origin: clinical relevance and implications for diagnosis and treatment. Acta Otolaryngol 129:62, 2009 [PMID:18607917]
Comment: Review of 10 cases of severe perimandibular space infections of odontogenic origin. Most common space: submandibular. Most common pathogens: Bacteroides and Streptococcus. Most common complication: mediastinitis.
- Kirkwood KL: Update on antibiotics used to treat orofacial infections. Alpha Omegan 96:28, 2003 [PMID:14983727]
Comment: Recommendation is clindamycin.
- Maroldi R et al: Emergency imaging assessment of deep neck space infections. Semin Ultrasound CT MR 33:432, 2012 [PMID:22964409]
Comment: Goal of imaging is to confirm diagnosis, define extent, identify complications and distinguish abscess (drainage) from cellulitis (no drainage).
- Barakate MS et al: Ludwig's angina: report of a case and review of management issues. Ann Otol Rhinol Laryngol 110:453, 2001 [PMID:11372930]
Comment: Optimal treatment requires parenteral abx, airway protection and surgical drainage.
- Gutiérrez-Pérez JL et al: Orofacial infections of odontogenic origin. Med Oral 9:280, 2004 Aug-Oct [PMID:15292865]
Comment: Recommendation is for amoxicillin-clavulanate 875/125 q 8h or 2000/125 q 12h.
- Bross-Soriano D et al: Management of Ludwig's angina with small neck incisions: 18 years experience. Otolaryngol Head Neck Surg 130:712, 2004 [PMID:15195057]
Comment: Retrospective review of 121 cases Ludwig's angina - otogenic in 107, diabetes in 46, extension to parapharyngeal space in 62. Treatment included tracheostomy in 34 and NT tube in the rest. Recommendation was neck incision within 12 hours of hospitalization and clindamycin + penicillin.
- Parhiscar A, Har-El G: Deep neck abscess: a retrospective review of 210 cases. Ann Otol Rhinol Laryngol 110:1051, 2001 [PMID:11713917]
Comment: Review of 210 deep neck abscesses. Dental infection was associated with 43%, IDU - 12%. Anatomical locations - lateral pharyngeal space (43%), submandibular space (28%), Ludwig's (17%), retropharyngeal space (12%).
- Inman JC et al: Pediatric neck abscesses: changing organisms and empiric therapies. Laryngoscope 118:2111, 2008 [PMID:18948832]
Comment: Review of 228 consecutive cases of CT proven neck abscesses in children ages 0-17 years. Cause was S. aureusin 48%, 66% of these in recent years were MRSA.
- Kurien M et al: Ludwig's angina. Clin Otolaryngol Allied Sci 22:263, 1997 [PMID:9222634]
Comment: Review of 41 patients - 76% adults. Surgery was required in 81% of adults, and tracheostomy was required in 52% of adults. Mortality rate was 10%.
- Horn J, Bender BS, Bartlett JG: Role of anaerobic bacteria in perimandibular space infections. Ann Otol Rhinol Laryngol Suppl 154:34, 1991 [PMID:1952682]
Comment: Review of 44 perimandibular space infections at Johns Hopkins Hospital over 5 years. Most common spaces were submandibular, peritonsillar and parapharyngeal. Tracheostomy was required in 6, 2 had bacteremia (F. necrophorum) and 2 had septic emboli to lungs. All survived.
- Suehara AB et al: Deep neck infection: analysis of 80 cases. Braz J Otorhinolaryngol 74:253, 2008 Mar-Apr [PMID:18568205]
Comment: Review of 80 cases of space infection in Brazil. Most common spaces were submandibular and parapharyngeal spaces. Most frequent source -- dental and tonsil infection. Standard for evaluation -- CT scan.
- Barker J, Winer-Muram HT, Grey SW: Lemierre syndrome. South Med J 89:1021, 1996 [PMID:8865803]
Comment: Review of a very distinctive syndrome: Usually a previously healthy young adult who presents with sore throat, sepsis, F. necrophorum bacteremia, tenderness at angle of jaw, CT scan showing infection in post compartment of lateral pharyngeal space with jugular vein thrombophlebitis +/- septic emboli, to liver and/or lung. Emphasizes need for surgical drainage and antibiotics.
- Larawin V, Naipao J, Dubey SP: Head and neck space infections. Otolaryngol Head Neck Surg 135:889, 2006 [PMID:17141079]
Comment: Review of microbiology of 103 cases. Predominant pathogens were Peptostreptococcus, Prevotella , aerobic and microaerophilic streptococcus. Most common spaces - submandibular, submental and lateral pharyngeal.
- Rega AJ, Aziz SR, Ziccardi VB: Microbiology and antibiotic sensitivities of head and neck space infections of odontogenic origin. J Oral Maxillofac Surg 64:1377, 2006 [PMID:16916672]
Comment: Review of microbiology of 103 cases. Predominant pathogens were Peptostreptococcus, Prevotella, aerobic and microaerophilic streptococcus . Most common spaces - submandibular, submental and lateral pharyngeal.
- Bondy P, Grant T: Lemierre's syndrome: what are the roles for anticoagulation and long-term antibiotic therapy? Ann Otol Rhinol Laryngol 117:679, 2008 [PMID:18834071]
Comment: Review of the role of anticoagulant therapy for Lemierre's syndrome. Conclusion is that there is no conclusion. Most are treated successfully medically with antibiotics with or without anticoagulants. Surgery for continuing emboli and/or continued propagation of the thrombus.
- Hagelskjaer Kristensen L, Prag J: Human necrobacillosis, with emphasis on Lemierre's syndrome. Clin Infect Dis 31:524, 2000 [PMID:10987717]
Comment: Reviews the classic syndrome. In contrast to report above the emphasis here is on medical management. Anticoagulation is controversial.
- Chow AW: Life-threatening infections of the head and neck. Clin Infect Dis 14:991, 1992 [PMID:1600027]
Comment: Space infections considered serious or life-threatening are submandibular, lateral pharyngeal, retropharyngeal, danger, and prevertebral spaces. The major pathogens are Bacteroides sp, Peptostreptococcus , Prevotella, and Fusobacteria. The serious infections often need immediate surgery; all are treated with antibiotics directed against anaerobes.
- Sinave CP, Hardy GJ, Fardy PW: The Lemierre syndrome: suppurative thrombophlebitis of the internal jugular vein secondary to oropharyngeal infection. Medicine (Baltimore) 68:85, 1989 [PMID:2646510]
Comment: The authors review publications on this disease with the conclusion that typical features are a previously healthy young adult who is critically ill with jugular venous thrombophlebitis, Fusobacterium necrophorum bacteremia, septic emboli to the lung, and abnormal liver function tests.
- Chirinos JA et al: The evolution of Lemierre syndrome: report of 2 cases and review of the literature. Medicine (Baltimore) 81:458, 2002 [PMID:12441902]
Comment: The review includes 109 reported cases. PRESENTATION: fever + sore throat 83%; tender and/or swollen neck 50%, normal exam 50%. MICROBIOLOGY: F. necrophorum 82%, other 6%, "sterile" 13%. DIAGNOSIS: Pul emboli 80%, Fusobacterium bacteremia 82%, CT or MRI. TREATMENT: Authors recommend clindamycin or metronidazole x 3-6 wks; anticoagulation - controversial, ligation of internal jugular vein - needed in 8%.
- Boga C et al: Lemierre syndrome variant: Staphylococcus aureus associated with thrombosis of both the right internal jugular vein and the splenic vein after the exploration of a river cave. J Thromb Thrombolysis 23:151, 2007 [PMID:17221323]
Comment: This is one of the periodic reports of Lemierre's syndrome without F. necrophorum bacteremia. They account for about 5-15% of reported cases.
- SHINN DL, SQUIRES S, MCFADZEAN JA: THE TREATMENT OF VINCENT'S DISEASE WITH METRONIDAZOLE. Dent Pract Dent Rec 15:275, 1965 [PMID:14282973]
Comment: This is the first report of metronidazole use for anaerobic infection. Subsequent studies have failed to identify any agent that performs better in vitro or in vivo, but it is active only against anaerobes. The concern with infections involving oral anaerobes (aspiration pneumonia dental infections, space infections etc) is that most are mixed with microaerophilic and aerobic strep - need penicillin also.
- Lewis MA et al: Prevalence of penicillin resistant bacteria in acute suppurative oral infection. J Antimicrob Chemother 35:785, 1995 [PMID:7559190]
Comment: This paper shows the high rate of resistance to penicillin by oral anaerobes due to beta-lactamase production.
- Caruso PA et al: Odontogenic orbital inflammation: clinical and CT findings--initial observations. Radiology 239:187, 2006 [PMID:16567486]
Comment: Value of CT scan reported - especially periapical lucency.
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