Neck Abscesses and Deep Neck Infections

Nodal group


Common areas draining to nodal group


Inferior to chin, superior to hyoid

Lower lip, floor of mouth, apex of tongue


Inferior to mandible, superior to hyoid

Cheek, lower lip, gums, anterior tongue


Upper neck, near angle of mandible and posterior digastric muscle

Tonsils, posterior oral cavity and oropharynx

Deep cervical

Deep to SCMa and in proximity to the cervical jugular vein

Tongue, trachea, nasopharynx, nasal cavities, palate, esophagus, other nodes in neck

Post auricular

Posterior to auricle and superior to the insertion of the SCM



Base of scalp at insertion of trapezius


Posterior cervical

Posterior to SCM, anterior to trapezius, superior to supraclavicular nodes

Above clavicle in lower neck posterior to SCM

Thorax and abdomen

a SCM sternocleidomastoid muscle

Cervical Fascial Spaces

Another important concept in understanding infectious disease in the neck is the facial envelopes or “spaces” of the neck (Table 14.2) [4, 5]. These fascia divide the neck into a collection of spaces. There is a superficial and a deep cervical fascia. The deep cervical fascia contains three layers, the superficial, the middle and the deep layers. The spaces superior to the hyoid are the parapharyngeal , submandibular, parotid, masticator, and peritonsillar spaces. Inferior to the hyoid is the anterior visceral space. Extending the length of the neck are the retropharyngeal, “danger” space, and prevertebral spaces. The source of infection as well as presenting signs and symptoms are impacted by the contents of the affected space [4]. Infectious processes can spread easily within the fascial space or envelope in which the disease originates, but can also extend to neighboring spaces as disease progresses. Extension of infection into the spaces that extend the length of the neck can spread disease far beyond its origin and thus cause life-threatening complications.

Table 14.2
Cervical anatomy deep neck spaces

Relation to hyoid


Borders of the fascial envelope

Space contents

Superior to hyoid

Parapharyngeal (Prestyloid compartment is anterior and Retrostyloid is posterior)

Base of skull superiorly, deep to the pharyngeal constrictor muscle, pretracheal fascia medially, hyoid bone inferiorly, and laterally the mandible, pterygoid muscles and the superficial cervical fascia

Prestyloid: fat, lymph nodes, connective tissue

Retrostyloid: Carotid sheath; IX, X, XII cranial n; lymph nodes lateral to carotid sheath; and cervical sympathetic chain

Submandibular (Submaxillary portion is above the mylohyoid and Sublingual portion is below)

Mucosa of the floor of mouth and the superficial layer of the deep cervical fascia

Submandibular and sublingual glands, lymph nodes, mylohyoid and digastric m, lingual n, hypoglossal n (cranial n XII)

Parotid (incomplete space; connects with parapharyngeal space)

Superficial layer of the deep cervical fascia splits to enclose parotid gland (closure is incomplete)

Parotid gland, cranial n VII, lymph nodes

Masticator (anterior and lateral to the parapharyngeal space)

Superficial layer of the deep cervical fascia splits to enclose the mandible and muscles of mastication

Mandible (dental structures), masseter, temporalis, internal pterygoid, inferior alveolar vessels and nerves, mandibular nerve

Peritonsillar (bordered by the tonsil, the tonsillar pillars and the superior constrictor muscles)

Not a fascial envelop


Inferior to hyoid

Visceral vascular (sometimes referred to as the “highway” of the neck and extends the length of the carotid sheath)

Space within carotid sheath composed of all three layers of deep cervical fascia; connects most neck contents

Carotid a, Jugular v, Vagus n (cranial n X)

Extend length of neck

Retropharyngeal (extends from the skull base to the first or second thoracic vertebra)

Space within the middle layer of the deep cervical fascia and the alar layer of the deep layer of the deep cervical fascia

Retropharyngeal nodes

Dangerspace (skull base to posterior mediastinum; deep to the Retropharyngeal space)

Space within the alar and prevertebral layers of the deep cervical fascia and the alar division of the deep layer of the deep cervical fascia

Loose connective tissue

Prevertebral (extends from the skull base to the coccyx; deep to the Danger space)

Space deep to the Danger space, within the prevertebral fascia; posterior to the alar division of the deep layer of the deep cervical fascia

Longus colli m

Key: a artery, v vein, m muscle

Clinical Manifestations, Evaluation and Management

Suppurative Cervical Lymphadenitis

Lymphadenitis is seen in association with a variety of pharyngeal, dental, skin or other head and neck infections [6]. Cervical adenitis with abscess formation or suppurative cervical lymphadenitis may develop in some cases of lymphadenopathy. Microorganisms penetrate the skin or mucosal surfaces of the head or neck and are cleared via lymphatic vessels to regional lymph nodes. In the lymph nodes T cell proliferation results node enlargement. In response to invasion of bacterial, viral, mycobacterial or fungal pathogens, additional inflammatory cells, specifically neutrophils, may be recruited to the site of infection. In most instances, disruption of mucosal tissues can result in subsequent invasion by group A streptococcus, other colonizing pathogens or oropharyngeal flora (anaerobes) In other instances pathogens invade the nodal tissue hematogenously, as might be the case with Staphylococcus aureus. Cervical lymphadenitis occurs as a result of host inflammatory responses to this invasion. Lymphadenitis may progress to abscess formation as the host defenses attempt to contain the infection. Typically abscess material consist of cellular debris from necrotic tissue, inflammatory cells and microorganisms. The inflammatory cellular infiltrate may form an abscess wall. Although most cervical lymphadenopathy is viral in etiology, suppuration of an inflamed lymph node is suggestive of primary or secondary bacterial infection with abscess formation. These infections are most often due to group A streptococcus and other streptococci, S. aureus or anaerobes as outlined in Table 14.3.

Table 14.3
Laboratory and diagnostic evaluation


Examples of positive findings

These findings may help diagnose

CBC with differential

Elevated white blood cell count and/or left shift

Infectious lesions

Atypical lymphocytes

Mononucleosis or malignancy

C-reactive protein


Non-specific but helpful for following response to therapy; if normal, consider non-inflammatory mass

Sedimentation rate


Non-specific but helpful for following response to therapy

If normal, consider non-inflammatory mass

Rapid Strep or throat culture

Positive for Streptococcus pyogenes or group A Streptococcus

Strep throat and adenitis

Rapid influenza test


Acute influenza adenitis, but does not rule our secondary bacterial adenitis

Rapid adenovirus test


Acute adenoviral adenitis but does not rule out secondary bacterial adenitis

Cat scratch serology

Elevated Bartonella henselae or B. quintana titers

Cat Scratch disease

EBV serology

Elevated EBV VCA IgM

Acute mononucleosis syndrome

CMV serology

Elevated CMV IgM

Acute mononucleosis syndrome

Tuberculin skin test

Induration and erythema

Tuberculosis or non-tuberculous mycobacterial infection (see Chap. 13)

Interferon gamma release assay (IGRA)


Tuberculosis (see Chap. 13)

The diagnostic evaluation of a child with an inflammatory neck mass, suspected cervical neck abscess, or suspected deep neck infection involves a detailed history, physical examination, laboratory studies and if indicated, diagnostic imaging. Helpful historical data includes the age of the child, the duration of illness and mass, the specific associated symptoms involving the upper respiratory tract, and the presence of any symptoms suggestive of a systemic process [7]. Furthermore it is helpful to determine if there has been a change in size or consistency (firm vs. soft) of the mass, presence of fever, recent upper respiratory infection. An exposure history is important to determine if the child has had any animal contact, specifically with kittens or cats, close contact with anyone at risk for tuberculosis, or household members with recurrent boils or soft tissue infection as might be present in cases of methicillin resistant S. aureus (MRSA).

The physical inspection of the neck should include the dimensions and location (midline or lateral) of the mass. If the lesion is lateral then it is further described by nodal group or “level” as outlined in Table 14.1. The presence of an overlying discoloration, sinus or fistula, tenderness, palpable consistency (i.e. soft or firm), and its mobility, including the direction of mobility is also important. Tender lesions are commonly inflammatory and a soft or fluctuant consistency is suggestive of either an infected cyst or an abscess. Careful inspection of nasal passages, pharynx, and oral cavity (including teeth and gums) should be performed to determine a possible source of lymphadenitis. The presence of tonsillar exudate is not diagnostic of bacterial infection and can be present in viral (i.e. EBV or adenovirus) infection (Fig. 14.1). Likewise, the absence of exudate does not exclude infection due to group A streptococcus. Careful examination of the scalp and skin should be performed looking for evidence of infected bites, impetigo, or a papule as may be seen in cat scratch disease.


Fig. 14.1
Exudative pharyngitis with EBV infection

The remainder of the physical examination may provide additional clues as to the etiology of an inflammatory neck mass or a systemic illness. For instance, an enlarged spleen is often associated with mononucleosis and a conjunctivitis and rash may be present in children with adenovirus or Kawasaki disease. A scarlatiniform rash or diffuse erythroderma may be consistent with group A streptococcal infection.

Following a thorough history and physical examination additional diagnostic studies and ancillary laboratory testing may be needed prior to surgical intervention. In specific infections (i.e. tuberculosis) this may prevent unnecessary surgery. Table 14.4 summarizes diagnostic and laboratory testing that may be useful in evaluating a child with neck abscess or deep neck infection.

Table 14.4
Diagnostic imaging


Examples of positive findings


Lateral neck ultrasound

Node enlargement, hypoechoic center suggestive of abscess

No radiation or sedation

Less specific anatomic information

Computed tomography with contrast

Node enlargement, phlegmon, defined abscess, contiguous inflammation

Radiation, sedation for small children

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Nov 5, 2016 | Posted by in OTOLARYNGOLOGY | Comments Off on Neck Abscesses and Deep Neck Infections
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