Chapter 54

• A thorough knowledge of the fascial relations and the potential anatomic routes of infection is a prerequisite to optimal management of deep neck infections.
• The microbial etiology of deep infections of the head and neck is complex and typically polymicrobial. Anaerobes generally outnumber aerobes by a factor of 10:1.
• The development of marked asymmetry in the course of a submandibular space infection should be viewed with great concern because it may be indicative of extension to the lateral pharyngeal space.
• In immunocompromised patients, the classic manifestations of infection, such as edema and fluctuance at the local site and features of systemic toxicity, may be absent.
• Penicillin 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 neuroimaging technique proved 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 postantibiotic era. As a consequence, many physicians are unfamiliar with these conditions. Further, with widespread use of antibiotics and profound immunosuppression in some patients, the classic 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. The situation is made more serious by the fact that these infections often have a rapid onset and may progress to fatal complications. 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 relations that underlie their diagnosis and management are emphasized.

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. 54-1).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 separate and connect distant areas, thereby limiting and directing the spread of infection. These infections may be fatal 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. 54-2).2 A thorough knowledge of the fascial relations and the potential anatomic routes of infection is a prerequisite to understanding the etiology, manifestations, and complications of deep neck infections. Such knowledge will not only provide valuable information on the nature and extent of infection but also suggest the ...

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