Deep Neck Space Abscess

Gordon H. Sun and Allen M. Seiden

History

A 4-year-old child was admitted with a 6-day history of a slowly enlarging right-sided neck mass and temperatures of 101° to 102°F. The child has a history of multiple episodes of tonsillitis, the most recent of which was treated about 2 weeks ago with amoxicillin. His other symptoms included difficulty looking from side to side, decreased appetite and oral intake, and occasional noisy breathing when agitated. An older sibling at home had symptoms of a viral upper respiratory infection about 2 weeks ago but was otherwise healthy.

This patient had no other significant medical history, had not suffered any recent insect bites or superficial skin trauma, and was otherwise up to date with immunizations. He had not been treated medically by a physician for his current symptoms, and he was not taking any medications at the time of admission.

On physical examination, the child had a temperature of around 102.5°F and appeared pale and tired but nontoxic. He avoided moving his neck while being examined. The child demonstrated occasional inspiratory stridor and a mildly hoarse cry and cough. There was a small amount of clear rhinorrhea in both nostrils. He was drooling moderately. His oral examination demonstrated very erythematous pharyngeal mucosa, 3+ erythematous tonsils without exudate, and right-sided posterior pharyngeal wall swelling. The tongue and uvula were not edematous and were both midline. No trismus was noted. Over his right posterolateral neck, there was a roughly 3 × 2 cm area of swelling, induration, and redness that was very tender to palpation. A 2 × 1 cm area within this neck mass was fluctuant, although there were no skin breaks and thus no fluid was expressible. No other cervical lymphadenopathy was appreciated.

Differential Diagnosis—Key Points

2. Demographics play an important role in determining the most likely source and microbial cause of the infection. Tonsillitis and pharyngitis are the most common sources of deep neck infections in children, whereas odontogenic infections (from poor dental hygiene) and intravenous (IV) drug abuse are the most common causes of deep neck infections in adults. In children, also consider the possibility that a previously unknown congenital neck lesion has become superinfected, such as a branchial cleft anomaly or thyroglossal duct cyst. In adults with a history of head and neck cancer, or those with significant risk factors thereof, local metastasis or recurrence of squamous cell carcinoma or other cancerous lesions may manifest as an enlarged, necrotic, superinfected cervical lymph node.

3. Numerous other causes of deep neck infections exist that are not necessarily specific to any particular demographic, such as oropharyngeal and neck trauma (from surgery or ballistic injury), iatrogenic injury to the neck (from bronchoscopy or esophagoscopy), salivary gland infection, mastoiditis, foreign body aspiration, and thyroiditis. In up to 22% of cases, no identifiable cause of the infection may be found.

4. Immunocompromise, from human immunodeficiency virus (HIV) infection, long-term steroid use, chemotherapy, diabetes mellitus, or chronic liver and kidney disease, is an important consideration as well. Patients with known HIV infection may present with recurrent neck abscesses, many of which are caused by atypical organisms such as the Mycobacterium avium complex. Sometimes leukopenia, rather than leukocytosis, is seen in immunosup-pressed patients.

5. In this particular case, one frequent complication of tonsillitis is peritonsillar abscess. However, although this child did have poor oral intake, difficulty handling oral secretions, and fever, he did not demonstrate trismus, deviation of the uvula, or asymmetric fullness of the soft palate. Note that although fullness of the neck is often present with a deep neck space abscess, fluctuance is usually not present because of the deep location of these spaces.

Test Interpretation

Initial laboratory testing should include a complete blood count with differential, serum electrolyte (renal profile) levels, and blood cultures if the patient has signs of sepsis. In this case, the patient had an elevated leukocyte count of 21,000/μL, with 80% polymorphonuclear leukocytes. Although this patient did not demonstrate any electrolyte abnormalities, in severely ill patients there may be serum hyperosmolarity.