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A 32-year-old man (Figure 28–1) 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 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, and aside from his remaining prescription of the penicillin and hydromorphone, he was on no medications. He had no known allergies.

FIGURE 28–1.

This 32-year-old man presented with dysphagia, dysphonia, and dyspnea. There was marked swelling of 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

The management of the patient whose airway is compromised due to a deep neck infection is a challenge for even the most experienced practitioner. Fortunately for acute care providers, these present relatively infrequent. A typical ENT referral center may see only one to three adult cases per year requiring airway management. As in this case, the deep neck infection is often odontogenic. Intravenous drug abuse is another important cause. Most patients are aged 40 to 60 and there is a predominance of males.1 Many cases of deep neck infections do not have an identifiable etiology.2 Diabetes mellitus may also be a risk factor and its presence tends to be associated with more aggressive infection.3,4

Do All Deep Neck Infections Require Airway Intervention?

Most patients with deep neck infections can be managed conservatively without surgical intervention and do not require intervention to maintain the patient's airway.5,6 A conservative approach with antibiotics and depending on the etiology, steroids may be all that is required. Even epiglottitis in the adult population only rarely will require airway manipulation in the form of intubation or tracheotomy. The most common deep space neck infections seen in the ED are tonsillar or peritonsillar and usually represent a cellulitis that can be successfully treated with antibiotics alone. Small, localized abscesses, such as peritonsillar abscesses, are often treated with needle aspiration or incision and drainage, followed by antibiotics. Although patients may present with altered phonation and upper airway dyspnea, airway compromise is very rare. Postoperative neck infections may present acutely and can be associated with an airway distorting neck hematoma. The diagnosis is usually obvious clinically; however, CT allows further delineation of the pathology.

Interestingly, there has been a case report of an over-inflated King ...

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