Diagnosis
There are a variety of spaces in the neck that can become infected: peritonsillar, retropharyngeal, submandibular. They can all dissect down the neck, into the chest, back into the epidural space, as well as lead to airway obstruction.
Epidemiologic Risks
Poor dentition, trauma, esophageal perforation (tortilla chips and bones), chemotherapy and radiation.
And Leopard attacks, with enough to warrant a review of the literature (PubMed)
microbiology
Abscesses: Streptococci (especially milleri group) + anaerobes + HACEK (Haemophilus species, Aggregatibacter species, Cardiobacterium species, Eikenella species, and Kingella species).
gram-negative aerobic rods like E. coli and Klebsiella are less common except in diabetics (PubMed), or the dentition is really rasty: rotting black nubs of teeth. And they always have a significant other, who, I presume, kisses them.
Lemierre’s Disease: septic thrombophlebitis of the internal jugular. The patient presents with a sore throat, fevers, and septic emboli on CXR; due to Fusobacterium necrophorum (PubMed) but occasionally other anaerobes or other organisms. I have seen a smattering of S. aureus causing Lemierre’s.
Empiric Therapy
CT ASAP.
Drain the pus, perhaps combined with steroids, is perhaps the best therapy (PubMed).
Abscesses: Call ENT. They need to be drained. I tend to suggest a third-generation cephalosporin like ceftriaxone PLUS metronidazole.
Alternatives include a carbapenem OR penicillin/beta-lactamase inhibitors OR a quinolone PLUS metronidazole. In place of metronidazole, clindamycin can be used.
For Lumpy Jaw and Lemierre’s, see each illness.
Pearls
They say never put a mirror in the back of the throat to look at the vocal cords as you can precipitate obstruction. I have seen it twice in my career, with disastrous results. So for once, they are right. I suppose I am now part of the they.
1-5% will have underlying cancer (PubMed), especially in older patients.
Rants
One of my few areas of magical thinking: if you put a tracheostomy kit in the room, the patient will never need it.
Curious Cases
Relevant links to my Medscape blog
Let The Chips Fall Where They May
Last Update: 08/03/18.