A 50-year-old woman with a history of hypothyroidism, hypertension, asthma, diabetes, and chronic pain was brought in by ambulance with two to three days of “sinus pain,” neck pain, fever, and increasing trouble breathing. She reported that the pain was most intense in her neck and that her glucose was out of control. She denied any cough or sore throat.
Her vitals were notable for a temperature of 38.9°C, heart rate of 130 bpm, blood pressure of 130/70 mm Hg, respirations of 28 bpm, and an oxygen saturation of 92% on room air. She had a normal posterior oropharynx and normal dentition. She had mild erythema to the anterior portion of her neck with exquisite tenderness to palpation. She did not have any crepitus, and had full range of motion of her neck, though movement was painful.
The patient also had audible stridor at rest, spoke in short sentences, and said her voice sounded normal to her. Breath sounds were clear bilaterally in the bases. She was tachycardic without a murmur, and the rest of her exam was unremarkable. An example of this condition is shown in the photograph (not this patient).
Find the diagnosis and case discussion on next page.
Diagnosis: Deep Neck Infection
Stridor, pain with moving the neck, fever, drooling, and voice change should raise concern about deep neck infection (DNI) and associated airway compromise. The site of the infection can sometimes be elicited by history, narrowed by risk factors, and suspected on exam, but diagnostic imaging is frequently necessary to determine which deep space is involved. This may involve emergent consultation and airway management before imaging for a critically ill patient or one with impending airway loss.
It is important to understand the anatomy of the fascial planes that make up the deep neck to understand the common infections that can occur there. All the fascial planes extend from their various attachments on the skull caudally to the chest and mediastinum. These also include the superficial cervical fascia and deep cervical fascia. All the fascial barriers are designed to prevent infection from spreading, and they can force swelling medially to the more easily distensible tissues surrounding the airway. As infection progresses, fascial barriers are also broken down. (Clin Radiol 2011;66:876.)
Neck pain and swelling are the symptoms of DNI most frequently reported, followed by odynophagia and fever. (Otolaryngol Clin North Am 2008;41:459.) Any patient presenting with these symptoms should be suspected to have a DNI. Trismus, dyspnea, and dysphagia should also raise the level of concern for DNI. Not surprisingly, risk factors associated with DNI include immunosuppressive states such as diabetes, HIV, and chronic glucocorticoid use. One study also reported a high percentage of smokers in the cohort of patients with cervical necrotizing fasciitis. (Intensive Care Med 2015;41:1256.)
The first priority in patients with suspected DNI is to assess the airway and degree of airway compromise; EPs must recognize early that these are high-risk airways. Consultation with otolaryngology, anesthesiology, or surgery is recommended before proceeding with intubation if time and resources allow. Significant trismus, upper airway edema, distorted landmarks, thin-walled abscesses that can rupture, and friable tissue can make initial airway attempts difficult. One review recommended awake fiberoptic nasal or oral intubation rather than primary tracheostomy under local anesthesia as first-line airway management. (Otolaryngol Clin North Am 2008;41:459.) This may not be possible in all settings, but the importance of a careful approach to the airway with thoughtful sedation, positioning, and backup airway management plans cannot be overstated.
The mainstay of treatment for DNI includes broad-spectrum antibiotics and surgery. Some studies argue that hyperbaric treatment should be standard of care. (Eur Arch Otorhinolaryngol 2016;273:4461.) A review of deep neck infections found most were polymicrobial from oropharyngeal or odontogenic origins. Streptococcus species (specifically S. milleri and S. viridans) and Staphylococcus aureus are the most common aerobic bacteria. Anaerobic bacteria include Peptostreptococcus and Bacteriodes fragilis. Early empiric antibiotics should include beta lactamase-resistant penicillin or penicillin plus a beta lactamase inhibitor such as imipenem or piperacillin/tazobactam, and an antibiotic effective against anaerobes such as clindamycin. Patients known to have MRSA and in high-risk populations such as IV drug users should receive vancomycin. (Otolaryngol Clin North Am 2008;41(3):459.)
Cervical necrotizing fasciitis (CNF) is one of the less common but more severe deep neck infections. Its incidence is estimated to be approximately two cases per million people annually, and no large studies or reviews are available because it is so rare. One of the largest studies, a cohort study of 160 patients, found 16 percent of the patients had diabetes. The source of infection for 48 percent of the patients with CNF was pharyngeal followed by dental in 29 percent. (Intensive Care Med 2015;41:1256.)
Another study of 59 patients reported a pharyngeal source in 39 percent and a dental one in 34 percent. (Eur Arch Otorhinolaryngol 2016;273:4461.) Approximately half of the CNF cases were monomicrobial and primarily gram-positive cocci. The other half were polymicrobial with a mix of aerobic and anaerobic flora. Complications, specifically mediastinitis, bilateral extension of disease, and involvement of the internal jugular, were common in 50 percent of patients. (Intensive Care Med 2015;41:1256.) Unfortunately, this study does not specify the amount or duration of oral glucocorticoid treatment associated with complicated outcomes.
The patient was started on broad-spectrum antibiotics (ampicillin/sulbactam, clindamycin, and vancomycin). She was unable to lie flat, and we felt her airway was too tenuous to take her to the CT scanner without securing her airway. We did get a portable x-ray of her neck as part of the initial assessment. It shows airway narrowing and deviation to the left and evidence of soft tissue swelling.
We decided to send her to the OR for an awake fiberoptic intubation and then proceed to the CT scanner. A representative CT of her neck is shown. She became hypotensive while in the CT scanner and was taken immediately back to the operating room for debridement. Her tissue cultures grew gram-positive cocci. The patient had a largely unremarkable hospital course other than returning to the OR for a repeat washout on day 3. She was discharged on day 17.
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