Deep Space Neck Infections: Retropharyngeal Abscess, Ludwig Angina, Lemierre Syndrome

Deep Space Neck Infections: Retropharyngeal Abscess, Ludwig Angina, Lemierre Syndrome

Amy Caggiula

Tjoson Tjoa


The anatomy of the deep space of the neck allows for the rapid spread of infections along fascial planes. Owing to their proximity to several vital airway and circulatory structures, these infections were usually fatal prior to the modern antibiotic age (Figure 14.1). The region posterior to the alar fascia extends from the oropharyngeal region into the posterior mediastinum to the level of the diaphragm. Because of this potential highway of rapid spread, this compartment is referred to as the “danger space.” Even now, deep space neck infections pose unique diagnostic and management obstacles, because it is often difficult to visualize affected structures on physical exam. Edema and obscuration of anatomic landmarks add to the challenge. Without prompt diagnosis and initiation of treatment, morbidity and mortality remain high.


Retropharyngeal Abscess

Retropharyngeal abscess (RPA) is generally considered a disease of children, affecting approximately 4.6/100 000 in the United States annually. Most RPAs present in children under age 6,1 because retropharyngeal lymph nodes involute around years four to five of life. A true RPA in an adult patient is most often caused by a penetrating injury into the retropharyngeal space. Otherwise, similar infections in adults, usually stemming from pharyngeal or dental origin, generally result in parapharyngeal rather than RPAs.

Owing to its anatomic location, physical exam diagnosis of RPA can be challenging but important to consider. A missed diagnosis of a deep space neck infection, particularly those involving the retropharyngeal space, can have devastating consequences for the surrounding vasculature, mediastinum, airway, and esophagus. If left untreated, infections in the retropharyngeal space lead to mediastinitis, thrombophlebitis of the internal jugular vein (Lemierre syndrome), erosion into the carotid arteries, sepsis, and death.

Ludwig Angina

Ludwig angina is a rapidly progressive cellulitis involving the floor of the mouth and soft tissues of the neck. Before the widespread use of antibiotics, this gangrenous infection was frequently fatal. Mortality remains high, even in more modern times, and can range from 8% to 50% depending on
the promptness of diagnosis and aggressive early management.2 Most fatalities are caused by airway compromise rather than overwhelming sepsis. The degree of edema and tongue displacement can pose a significant airway challenge, so swift identification and advanced airway planning is crucial to preventing morbidity and mortality.

Lemierre Syndrome

Lemierre syndrome describes a condition of thrombophlebitis of the internal jugular vein and bacteremia secondary to an anaerobic infection, typically originating in the oropharynx. It can ultimately lead to the development of life-threatening septic emboli. It was first described by Andre Lemierre in 1936 through a series of 20 patients with throat infection that exhibited a 90% mortality rate.

Lemierre syndrome predominantly affects healthy young adults and in most cases is caused by Fusobacterium necrophorum, a gram-negative, non-spore-forming obligate anaerobe. In the antibiotic era, the prevalence of this disease has decreased dramatically, although there has been a recent uptick in the number of case reports.3 Delays in treatment are common, likely because of the high frequency of routine throat infections that are appropriately not treated with antibiotics. Lemierre syndrome can be life-threatening, with mortality rates between 5% and 22%, highlighting the importance of prompt recognition of the condition.3


Retropharyngeal Abscess

Early diagnosis of RPA can be difficult because several disease entities present similarly, and inflamed overlying structures can obscure direct visualization of the posterior pharynx. As such, the medical provider must have a high index of suspicion for deep space infection with specific signs and symptoms (Table 14.2).

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Apr 18, 2023 | Posted by in OTOLARYNGOLOGY | Comments Off on Deep Space Neck Infections: Retropharyngeal Abscess, Ludwig Angina, Lemierre Syndrome

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