Deep Space Infections of the Neck: Considerations in Diagnosis and Management

Direct Endotracheal Intubation. The advantages of endotracheal intubation include the speed at which airway control can be achieved, and that it is a nonsurgical procedure. Disadvantages include the potential for failed intubation, inability to bypass upper airway obstruction, requirement for mechanical ventilation, and subglottic stenosis.

Tracheostomy. This surgical intervention allows for the bypass of upper airway obstruction. It is a very secure airway, there is less need for sedation and mechanical ventilation, and it allows for earlier transfer out of the critical care unit.²⁵ Tracheostomy carries inherent risks such as pneumothorax, bleeding, subglottic stenosis, fistula formation, and unsightly scarring. Training and comfort with airway management procedures, as well as available hospital resources such as anesthesiology, fiberoptic equipment, and critical care resources, also have an impact. 

Conventional endotracheal intubation is often difficult in patients with deep space neck infections, and direct laryngoscopy may precipitate acute airway collapse. Blind nasal intubation carries a considerable risk of damage to the swollen and fragile pharyngeal mucosa, with bleeding, abscess perforation, and complete upper airway obstruction as possible outcomes. Tracheostomy while the patient is awake remains the gold standard in airway management for deep space neck infections, but achieving adequate anesthesia can be problematic. Patients are frequently ill, panic stricken, and hypoxic.^2,26

Fiberoptic Intubation. In the awake patient, fiberoptic intubation overcomes some of the problems associated with tracheostomy. The procedure requires the patient to sit in front of the operator. The head-up position prevents the tongue and pharynx from collapsing backwards and obstructing the view. However, this technique is not without risk. A good understanding of the equipment, proficiency in its use, and knowledge on how to best preserve airway patency is mandatory. Anecdotal surveys suggest that many anesthetists and emergency care providers do not feel confident using fiberoptic scopes due to lack of training and infrequent chances for exposure.² This is a key skill that the ED must learn and practice to maintain.

Conclusion

Despite the significant decrease in the incidence of deep space neck infections, these infections still do occur as a spectrum of pathology, with many patients initially presenting to the ED. Since these infections often lack outward visual findings on physical examination, bedside ultrasound and consultation with an otolaryngologist should be obtained as soon as an abscess is suspected. Timely diagnosis and intervention are essential to prevent life-threatening complications such as airway compromise, jugular vein thrombosis, mediastinal involvement, pneumonia, septic shock, and intracranial extensions. In all cases of deep space neck infection, the EP should anticipate an early critical course.

Dr Leigh is a clinical associate in the Mayo Clinic department of emergency medicine and Mayo Clinic Health System Hospitals, Rochester, Minnesota. Dr Bellew is a second-year emergency medicine resident at the Mayo Clinic, Rochester, Minnesota. Dr Wangsgard is a simulation fellow at the Mayo Clinic department of emergency medicine, Rochester, Minnesota. Dr Cabrera is an assistant professor in the department of emergency medicine at the Mayo Clinic, Rochester, Minnesota.