Neck Swelling/Edema/Erythema

Ray Gervacio Blanco

When confronted with a patient who has any combination of neck erythema, edema, and tenderness, obtaining a detailed history will narrow down the differential diagnosis. The important points that must be elicited in the history are the following: respiratory symptoms, localized pain, referred pain, recent dental procedures, dental infection, tooth pain, upper respiratory tract infection, recent or previous blunt or penetrating trauma, previous neck surgery, previous carotid surgery or stenting, odynophagia, dysphagia, clinical signs of sepsis, foreign body, instrumentation, and immunosuppression (HIV, cancer, steroids, chemotherapy).

During the physical examination, the following are important points to check: asymmetry of the neck, associated mass, displacement and or compressions of structures, trismus, presence of fluctuant mass, nerve deficits, fever, respiratory symptoms, previous surgery, venous catheters, and trauma.

The airway should always be evaluated and should be secured prior to proceeding to surgical drainage or sending the patient for computed tomography/magnetic resonance imaging (CT/MRI). Although CT and MRI show good anatomical details in regard to structures involved and the extent of the pathology, other imaging such as Panorex may assist in identifying dental infection. Lateral cervical films can evaluate retropharyngeal and pretracheal neck spaces, and a sonogram may be able to guide needle aspiration.

There is no identifiable cause in 22% of deep neck infections, and familiarity with the common oral pathogens and your institution’s antibiotic sensitivity patterns is important in choosing the appropriate antibiotics. Appropriate referral to infectious disease service, vascular surgery, or other subspecialties should be done if clinically indicated.

The differential diagnosis for patients with erythema, edema, and tenderness of the neck can vary widely. For simplicity, this chapter divides patients into groups based upon involvement of superficial or deep spaces, and then the face/head, upper neck, and lower neck. Finally, other causes of erythema, edema, and tenderness are considered.

Infection, Superficial—Face or Neck

Folliculitis: Will present as a “whitehead” infection at the base of the hair.

Carbuncle: Skin infection that often involves a group of hair follicles and may coalesce to form a mass under the skin.

Cellulitis: Will present as a swollen, red area of skin that feels warm and tender and may spread quickly. Lymph nodes that drain the region may be enlarged.

Impetigo

Nonbullous impetigo: Will present as a small blister that develops honeycomb-like crusting.

Bullous impetigo: Results in bulla formation secondary to the Staphylococcus toxin, which results in separation of the epidermis from the underlying layers.

Abscess: Presents with erythema of the overlying skin with a tender and fluctuant mass just below. Deeper abscess may not have a fluctuant mass but may present with erythema and tenderness only.