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Case Report

Bilateral deep neck space infection in pediatric patients:

Review of literature and report of a case
Manish J Raghani, Nisha Raghani1
Department of Dentistry, Maxillofacial Surgery Services, All India Institute of Medical Sciences, 1Dental Surgeon, Raipur, Chhattisgarh, India

The diagnosis and treatment of deep neck
infections is still an enigma for surgeons and
physicians. Because of the complexity and the
deep location of this region, the diagnosis and
treatment in this area is difficult. The anatomy of
deep neck spaces is highly complex and therefore
precise localization of infections in this region is
very difficult. The diagnoses of deep neck space
infection (DNSI) are difficult because of the deep
location of these spaces and are usually covered
by substantial amount of normal superficial
soft tissue. Access: To gain surgical access to
the deep neck spaces, the superficial tissues
must be crossed with the risk of injury to the
neurovascular structures in the neck. Neural
dysfunction, vascular erosion or thrombosis, and
osteomyelitis are some of the complications of
DNSI because of the proximity of nerves, vessels,
bones, and other soft tissues. Deep neck spaces
are communicated with each other and infections
from one space can spread to adjacent space.
DNSI, if not diagnosed early and promptly, may
result in serious consequences even mortality. The
treatment of DNSI with antibiotic therapy and
drainage is most often definitive and recurrence
of these cases is rare.

Keywords: Deep neck space infections, incision

and drainage, submandibular space abscess

Deep neck space infections (DNSIs) can occur at any
age but the pediatric deep neck infections require
more intimate management because of their rapidly
progressive nature.[1] Delay in diagnosis and treatment
may lead to life-threatening complications. The
incidence and morbidity of DNSIs has been significantly
reduced with the introduction of antibiotic therapy.
Concurrent abscess in distinct neck spaces has rarely
been reported in healthy children. Here, a rare case of

Address for correspondence:

Dr. Manish J Raghani,

Department of Dentistry, Maxillofacial Surgery Services, All
India Institute of Medical Sciences, G. E. Road, Tatibandh,
Raipur - 492 099, Chhattisgarh, India.
E-mail: manish_dromfs@yahoo.com
Access this article online
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bilateral neck abscess in a 9-month-old male child is

reported and the clinical presentation along with the
management is discussed with a review of literature.

Case Report
A 9-month-old male child presented with a 3-4 days
history of fever, progressive swellings in both right
and left submandibular spaces and right buccal space.
Clinical examination showed a non-toxic appearance
with a low-grade fever. The swelling was diffuse, soft
to firm in consistency, edematous red and tender,
measuring 3 2 cms on left side, 4 3 cms on right,
and a small 1 1 cms on right cheek besides the corner
of mouth. Mouth opening was adequate but no teeth
were present (erupted) and no significant finding which
could relate to the swelling was found intraorally.
Chest radiography revealed no abnormality, but the
laboratory studies showed a leukocyte count of 18,160/l
with neutrophil dominance and hemoglobin level of
10 g/dl. Neck ultrasound identified bilateral abscess
formation. Medicinal treatment started immediately in
the form of intravenous Ceftriaxone and Metronidazole
and hydration was maintained adequately. But
there was no significant clinical improvement with
medical management alone within first 48 hours.
Subsequently, incision and drainage of the bilateral
submandibular abscesses was done extraorally. Fever
and swelling subsided after surgical drainage and

Journal of Indian Society of Pedodontics and Preventive Dentistry | Jan-Mar 2015 | Vol 33| Issue 1 |


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Raghani: Bilateral deep neck space infection in pediatric patients:Systematic review of literature and report of a case

intravenous antibiotics. Due to uncommon occurrence

of such severe infection in infants, we tried to search
for underlying etiology. According to the parents of
the child, there was no history of any systemic illness.
Peripheral blood lymphocyte subtypes and Ig A, Ig M,
Ig G, Ig E levels were within normal limits. Serologic
studies for TOxoplasmosis, Rubella, Cytomegalovirus
and Herpes (TORCH) simplex virus, Epstein-Barr
virus (EBV), hepatitis, and human immunodeficiency
virus (HIV) were negative. Evaluation for tuberculosis
did not show any abnormality. No clinical evidence of
an underlying immunocompromisation was detected
and the patient was discharged from the hospital with
complete recovery after 2 weeks. Most likely, cause of
the bilateral DNSI in this particular case could be the
upper respiratory tract infection (Tonsillitis) because it
is the most common etiology for DNSI in children.[2-5]

DNSIs are infections in the potential spaces and facial
planes of the neck which could be lymphadenitis,
cellulitis, necrotic node, or abscess in nature.[1,6] Before
the advent of widespread use of antibiotics, 70% of
DNSIs were caused by spread from tonsillar and
pharyngeal infections. Today, tonsillitis remains the
most common etiology of DNSIs in children, whereas
odontogenic origin is the most common etiology in


Causes of deep neck infections include the following:

Tonsillar and pharyngeal infections
Dental infections or abscesses
Oral surgical procedures or removal of suspension
Salivary gland infection or obstruction
Trauma to the oral cavity and pharynx (e. g.,
gunshot wounds, pharynx injury caused by
falls onto pencils or popsicle sticks, esophageal
lacerations from ingestion of fish bones or other
sharp objects)
Instrumentation, particularly from esophagoscopy
or bronchoscopy
Foreign body aspiration
Cervical lymphadenitis
Branchial cleft anomalies
Thyroglossal duct cysts
Mastoiditis with petrous apicitis and Bezold
Intravenous (IV) drug use[7]
Necrosis and suppuration of a malignant cervical
lymph node or mass
As many as 20-50% of deep neck infections have no
identifiable source. Other important considerations
include patients who are immunosuppressed because of
HIV infection, chemotherapy, or immunosuppressant

drugs for transplantation. These patients may have

increased frequency of deep neck infections and
atypical organisms, and they may have more frequent

DNSIs can arise from a multitude of causes. Whatever
the initiating event, development of a DNSI precedes
by one of several paths, as follows:
Spread of infection can be from the oral cavity,
face, or superficial neck to the deep neck space via
the lymphatic system.
Lymphadenopathy may lead to suppuration and
finally focal abscess formation.
Infection can spread among the deep neck spaces
by the paths of communication between spaces.
Direct infection may occur by penetrating trauma.
Once initiated, a deep neck infection can progress to
inflammation and phlegmon or to fulminant abscess
with a purulent fluid collection.
The presenting symptoms and signs of the patient
with a DNSI, as well as the source of infection, will
vary somewhat depending upon which of the spaces
is involved. In a study reported by Coticchia et al.,
the most commonly encountered sites of abscesses in
the head and neck region of pediatric patients were
retropharyngeal or parapharyngeal spaces, followed
by anterior or posterior triangle and submandibular
or submental regions, respectively. Retropharyngeal
or parapharyngeal involvement was more common in
1-year-old children, or older, whereas submandibular or
submental involvement was more common in children
younger than 1 year. However, there are different
results, in different studies, in the literatureregarding the
distribution of abscesses among the spaces of the neck.[8]
Ungkanont et al., reviewed 117 children treated for
deep neck infections during a 6-year period.[9]
The following distribution results were revealed:
Peritonsillar infections (49%)
Retropharyngeal infections (22%)
Submandibular infections (14%)
Buccal infections (11%)
Parapharyngeal space infections (2%)
Canine space infections (2%)
Abscesses of neck may involve many spaces
simultaneously through the potential pathways of
extension as illustrated [Figure1].


The microbiology of deep neck infections usually

reveals mixed aerobic and anerobic organisms, often
with a predominance of oral flora. Both gram-positive
and gram-negative organisms may be cultured.
Contemporary reports from different countries or

Journal of Indian Society of Pedodontics and Preventive Dentistry | Jan-Mar 2015 | Vol 33| Issue 1 |

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Raghani: Bilateral deep neck space infection in pediatric patients:Systematic review of literature and report of a case

areas may reveal different common pathogens.[1]

Most studies have determined the predominance of
streptococcus and Staphylococcusaureus as a causative
organism although often infections are polymicrobial.
On the other hand, the presence of anerobes may be
underestimated because of the difficulty in culturing
them.[2] Streptococcus and normal oropharyngeal
flora were more common in retropharyngeal and
parapharyngeal abscesses because these organisms
are found in the oropharynx. Likewise, one would
expect Staphylococcus aureus to be more common in
anterior and posterior triangle and submandibular
and submental abscesses because this organism is a
common skin contaminant and these regions are more
distant from the oropharynx.[8]

Clinical Presentation

A detailed history should be obtained from a patient of

deep neck infection. Physical examination should focus
on determining the location of the infection, the deep
neck spaces involved, and any potential functional
compromise or complications that may be developing.
A comprehensive head and neck examination should be
performed, including examination of the dentition and
tonsils. The most consistent signs of a DNSI are fever,
elevated white blood cell (WBC) count, and tenderness.
Other signs and symptoms largely depend on the
particular spaces involved and include the following:
Asymmetry of the neck and associated neck
masses or lymphadenopathy, which is present in
almost 70% of pediatric retropharyngeal abscesses
according to a study by Thompson and colleagues
Medial displacement of the lateral pharyngeal
wall and tonsil caused by parapharyngeal space
Trismus caused by inflammation of the pterygoid
Torticollis and decreased range of motion of the
neck caused by inflammation of the paraspinal
Fluctuance that may not be palpable because of
the deep location and the extensive overlying soft
tissueand muscles (e. g., sternocleidomastoid muscle)

Figure 1: Network of patterns of infectious extension within the

potential spaces of the neck (from Gadre et al., 2006 15)[13]

Possible neural deficits, particularly of the

cranial nerves (e. g., hoarseness from true vocal
cord paralysis with carotid sheath and vagal
involvement), and Horner syndrome from
involvement of the cervical sympathetic chain
Regularly spiking fevers (may suggest internal
jugular vein thrombophlebitis and septic
Tachypnea and shortness of breath (may suggest
pulmonary complications and warn of impending
airway obstruction)
Children with DNSIs have minimal signs
and symptoms and also they do not verbalize
their symptoms or cooperate with the physical
examination.[8] The most common signs and
symptoms are a neck mass or swelling, fever,
poor oral intake, and prior symptoms of an upper
respiratory infection such as rhinorrhea or cough.
Other symptoms include: Neck pain, irritability,
decreased neck mobility, sore throat, upper airway
obstructive symptoms, and febrile seizures. In
our case, the patient presented with bilateral
submandibular soft swelling and low grade fever
Computerized tomography (CT) scanning is the
most widely used modality for diagnosing deep
space neck infections because it is less expensive
and readily available.[9] Although CT is helpful both
in determining the presence and location of neck
infections in children, it is less helpful in differentiating
abscess from lymphadenitis and cellulitis. On the
other hand, use of magnetic resonance imaging
(MRI) gives improved soft tissue definition without
the use of radiation but its use is limited due to the
lack of availability and cost.[9,10] Ultrasonography is
also effective in identifying abscess versus cellulitis.
The lateral neck plain X-ray film has been used in
the past as a screening X-ray to look primarily at the
retropharyngeal and prevertebral spaces.

Figure 2: Bilateral submandibular swellings (abscess) also a small

swelling over right buccal region

Journal of Indian Society of Pedodontics and Preventive Dentistry | Jan-Mar 2015 | Vol 33| Issue 1 |


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Raghani: Bilateral deep neck space infection in pediatric patients:Systematic review of literature and report of a case

Figure 3: The swelling was soft and tender with inflammed, red, tense,
shiny skin showing all signs of acute abscess


The mainstays for successful management of deep

neck infections are securing airway, antibiotics, and
surgical drainage. Antibiotics are not substitute for
surgery and incision and drainage are considered
the gold standard for the majority of pediatric deep
neck abscesses.[11] Because of the different causative
organisms, broad-spectrum antibiotics are advocated
in treating deep neck infections.[1] Empirical parenteral
antibiotics should be started before the culture results
become available and then tailored to the culture results
when available. Fortunately, most pediatric DNSIs are
located either in the anterior or posterior triangle of the
neck or in the retropharyngeal area. Surgical drainage
of these abscesses is usually direct and effective.[12]
Needle aspiration of abscess can be used in some cases
but it is not much effective and may require recurrent
aspirations. In my case, we there was no clinical
improvement after antibiotics so I performed external
incision and drainage in which pus was evacuated and
diagnosis of abscess was confirmed. The postoperative
recovery was uneventful.

The treatment of DNSIs with antibiotic therapy and
drainage is most often definitive and recurrence of
these cases is rare. The exception to this rule is the
deep neck infection that occurs in association with a
pre-existing congenital abnormality. So that, in the
patient that presents with a prior history of a similar
deep neck infection or abscess, the level of suspicion
should be raised for an underlying lesion. Imaging,
particularly CT scan, can be extremely helpful in
making the diagnosis in these cases. In a review of
12 cases of recurrent deep neck infection, Nusbaum
et al., found the most common underlying congenital
anomaly to be a second branchial cleft cyst. Other
causes included first, third, and fourth branchial cleft
cysts, lymphangiomas, thyroglossal duct cysts, and a
cervical thymic cyst.

Figure 4: Bilateral neck swellings (submandibular abscesses)

Bullet points
Why this paper is important to pediatric dentists?

This paper (article) describes the details of the deep

neck infections in pediatric patients including various
etiologies, pathophysiology, clinical manifestations,
and treatment of these patients. The etiology is
frequently from oral cavity (carious tooth) and the
submandibular space is involved in most of the cases,
so the pediatric dentist is usually the first person to see
these patients. The purpose of writing this article in
this journal is that the pediatric dentist should be able
to diagnose the deep neck infections cases early and
promptly, so that proper treatment should be started
as early as possible to avoid dangerous consequences
and even mortality.
The case described here is a very small child (9 months
old) for which a pediatric dentist or a maxillofacial
surgeon can be called upon in a hospital to attend
and manage the case. In dentistry, we rarely see such
patients, so I thought of worth mentioning it here.
I think this would be of some help to our pediatric
dentist friends.

1. Huang TT, Tseng FY, Yeh TH, Hsu CJ, Chen YS. Factors
affecting the bacteriology of deep neck infection: A retrospective
study of 128 patients. Acta Otolaryngol 2006;126:396-401.
2. Conrad DE, Parikh SR. Deep neck infections. Infect Disord
Drug Targets 2012;12:286-90.
3. Chang L, Chi H, Chiu NC, Huang FY, Lee KS. Deep neck
infections in different age groups of children. J Microbiol
Immunol Infect 2010;43:47-52.
4. Wang LF, Tai CF, Kuo WR, Chien CY. Predisposing factors
of complicated deep neck infections: 12-year experience
at a single institution. J Otolaryngol Head Neck Surg
5. Poeschl PW, Spusta L, Russmueller G, Seemann R, Hirschl A,
PoeschlE, et al. Antibiotic susceptibility and resistance of the
odontogenic microbiological spectrum and its clinical impact

Journal of Indian Society of Pedodontics and Preventive Dentistry | Jan-Mar 2015 | Vol 33| Issue 1 |

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Raghani: Bilateral deep neck space infection in pediatric patients:Systematic review of literature and report of a case



on severe deep space head and neck infections. Oral Surg Oral
Med Oral Pathol Oral Radiol Endod 2010;110:151-6.
Courtney MJ, Miteff A, Mahadevan M. Management of
pediatric lateral neck infections: Does the adage ... never let
the sun go down on undrained pus... hold true? Int J Pediatr
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Coticchia JM, Getnick GS, Yun RD, Arnold JE. Age-, site-,
and time-specific differences in pediatric deep neck abscesses.
Arch Otolaryngol Head Neck Surg 2004;130:201-7.
Osborn TM, Assael LA, Bell RB. Deep space neck infection:
Principles of surgical management. Oral Maxillofac Surg Clin
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Clin North Am 2008;20:367-80.

11. Meyer AC, Kimbrough TG, Finkelstein M, Sidman JD.

Symptom duration and CT findings in pediatric deep neck
infection. Otolaryngol Head Neck Surg 2009;140:183-6.
12. Naidu SI, Donepudi SK, Stocks RM, Buckingham SC,
Thompson JW. Methicillin-resistant Staphylococcus
aureus as a pathogen in deep neck abscesses: A
pediatriccase series. Int J Pediatr Otorhinolaryngol
13. Gadre AK, Gadre KC. Infections of the deep spaces of the
neck. In: Bailey BJ, Johnson JT, Newlands SD, editors. Head
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How to cite this article: Raghani MJ, Raghani N. Bilateral deep
neck space infection in pediatric patients: Review of literature
and report of a case. J Indian Soc Pedod Prev Dent 2015;33:61-5.
Source of Support: Nil, Conflict of Interest: None declared.

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