A 32-year-old man (Figure 29.1) presented to the emergency department (ED) with dysphagia, dysphonia, and dyspnea. Further inquiry revealed a 1-week history of right-sided jaw pain. This was initially treated with oral antibiotics and analgesics by his family doctor while awaiting an appointment with his dentist. He saw his dentist the preceding day and had an abscessed second molar tooth extracted from his right mandible. Unfortunately, his pain continued and he developed swelling and fever, prompting him to present to the ED. His past medical history was unremarkable. Aside from his recent prescriptions for penicillin and hydromorphone, he was on no medications. He had no known allergies.
This 32-year-old man presented with dysphagia, dysphonia, and dyspnea. There was marked swelling on the right side of the neck. Due to marked discomfort, he was unable to protrude his tongue for proper pharyngeal evaluation.
Discuss the Incidence and Etiology of Deep Neck Infections in Adults
Deep neck infection (DNI) remains a frequently encountered condition in both children and adults.1 Pediatric data from the United States estimates the incidence of DNI at 4.6 per 100,000.2 The management of the patient whose airway is compromised due to a DNI is a challenge for even the most experienced practitioner. Fortunately for acute care practitioners, severe life-threatening presentations of DNI are relatively uncommon.3 As in this case, adult DNI is often odontogenic in origin. Most patients are aged 40 to 60 and there is a predominance of males. Risk factors include diabetes mellitus,4,5 hematological malignancies, and positive HIV status.6,7 In pediatric patients, pharyngotonsillitis remains the most important cause of DNI.1
Discuss the Relevant Anatomic Relationships of the Deep Neck Spaces
A detailed description of the anatomy of the neck is beyond the scope of this chapter; however, a basic understanding is helpful to understand the potential consequences of DNIs. At least 11 deep neck spaces exist within a complex framework of cervical fascial planes. These fascial planes function to contain DNIs so long as their resistance is not overcome. However, once overcome, they serve to direct infectious spread.8 The deep neck spaces are often classified relative to their relationship to the hyoid with those above (including peritonsillar and submandibular), below (including pretracheal), and those that involve the entire neck (including retropharyngeal and danger space) differentiated.
The retropharyngeal space is located posterior to the pharynx and esophagus, running from the skull base to the mediastinum. The alar fascia posterior to this space is the only barrier to infectious spread to the danger space (which allows spread to the superior mediastinum and severe infection in the form of mediastinitis).9 Patients with retropharyngeal infection can present with severe neck ...