CHAPTER 73

#### KEY POINTS

• A thorough knowledge of the deep cervical fascial spaces and their interrelationships and anatomic routes of spread is a prerequisite to optimal management of life-threatening head and neck infections.

• The microbial etiology of deep infections of the head and neck is complex and typically polymicrobial.

• The development of marked asymmetry in the course of a submandibular space infection should be viewed with great concern, since it may be indicative of extension to the lateral pharyngeal space.

• In immunocompromised patients, the classical manifestations of infection, such as edema and fluctuance at the local site and features of systemic toxicity, may be absent.

• β-lactam-β-lactamase inhibitor or penicillin in combination with metronidazole is the antibiotic regimen of choice for odontogenic deep neck infections, but immunocompromised patients require a broader-spectrum against organisms such as Staphylococcus aureus and enteric gram-negative rods.

• Chronic sinusitis, otitis, and mastoiditis are the most important causes of parameningeal infection and intracranial suppuration. Computed tomography is the single imaging technique proven to be the most useful for the diagnosis of these conditions.

Life-threatening infections of the head, neck, and upper respiratory tract have become less common in the post-antibiotic era. Consequently, many physicians are unfamiliar with these conditions. Furthermore, with widespread use of antibiotics and profound immunosuppression in some patients, the classical manifestations of these infections are often altered. Features of systemic toxicity, such as chills and fever, and local signs, such as edema and fluctuance, may be absent. Thus, physicians unfamiliar with these entities may underestimate their extent and severity. In this chapter, the key clinical manifestations of several life-threatening infections of the head, neck, and upper respiratory tract are highlighted, and the critically important anatomic relationships that underlie their diagnosis and management are emphasized.

#### GENERAL ANATOMIC CONSIDERATIONS

Life-threatening infections of the head, neck, and upper respiratory tract most commonly originate from suppurative complications of dental, oropharyngeal, or otorhinolaryngeal infections. From these sites, infection may extend along natural fascial planes into deep cervical spaces or vascular compartments (Fig. 73-1).1 The deep cervical fascia ranges from loose areolar connective tissue to dense fibrous bands. It invests muscles and organs, thus forming planes and spaces. Notably, these fascial planes both separate and connect distant areas, thereby both limiting and directing the spread of infection. These infections may be fatal either by local airway occlusion or by direct extension to vital structures such as the mediastinum or carotid sheath. Otorhinocerebral infections may cause intracranial suppuration such as cerebral or epidural abscess, subdural empyema, and cavernous or cortical venous sinus thrombosis (Fig. 73-2).2 A thorough knowledge of the deep fascial spaces, their interrelationships, and the potential anatomic routes of infection is a prerequisite to understanding the etiology, manifestations, and complications of life-threatening head and neck infections. Such knowledge will not only provide valuable information on the nature and extent of infection but will also suggest the optimum surgical approach ...

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