Neck Infection — Differential Diagnosis — Clinical Pathway: Emergency

Deep Neck Space Infection Clinical Pathway — Emergency Department

Differential Diagnosis for Suspected Deep Neck Space Infection

Deep Neck Infection Diagnosis Clinical Features
Retropharyngeal Abscess
  • Suppurative adenitis in younger children, complication of penetrating trauma in older children (uncommon)
  • Peak age 2 to 4 years
  • Presentation:
    • Fever
    • Neck signs/symptoms (unwillingness to move, especially extension)
    • Dysphagia/odynophagia
    • Respiratory compromise with stridor or wheeze → a late finding
Lateral Pharyngeal Abscess
(Parapharyngeal abscess)
  • Presentation:
    • Fever
    • Trismus (usually present)
    • May have lateral neck swelling
    • Plain radiograph not as reliable
Differential Diagnosis Clinical Features
Epiglottitis/Uvulitis
  • Epiglottitis
    • True airway emergency
    • Rapid onset febrile illness with respiratory distress, drooling, tripoding, and stridor
    • Patients appear clinically ill
  • Uvulitis
    • Inflammation of the uvula
    • Can be infectious or inflammatory
    • Can result from trauma to the uvula
    • Can present with fever, dysphagia, pain, or respiratory symptoms
Peritonsillar Abscess
  • Peak age 12 to 18 years, can occur in younger children
  • Presentation:
    • Sore throat — usually unilateral
    • Fever
    • Trismus — can distinguish PTA from severe pharyngitis
    • Muffled “hot potato” voice
    • Peritonsillar swelling and redness, sometimes with uvular deviation on exam
Ludwig’s Angina
  • A submandibular space infection
  • A known complication of dental infections
    • Significant swelling/pain
    • Trismus
    • Tongue swelling/sublingual edema
    • Can lead to airway obstruction
Angioedema Anaphylaxis
  • Usual onset is soon after exposure to a likely allergen
  • May have visible lip, tongue, or uvular swelling
  • Obstruction can result from edema of deeper airway structures as well (larynx or epiglottis)
  • May have associated stridor or respiratory distress
  • Anaphylaxis Pathway
Tumor
  • Airway symptoms can result from head/neck masses or from mediastinal masses
Bacterial Tracheitis/Viral Croup
  • Croup common in patients 3 months to 3 years of age
    • “Barky” cough, stridor, and hoarse voice
    • Often associated with URI symptoms and fever
  • Tracheitis is a bacterial tracheal infection
    • Febrile illness often occurring as a complication of croup
    • Can occur as a primary infection
    • Common pathogens include streptococcus and staphylococcus
Lemierre’s Disease
  • Infectious thrombophlebitis of the internal jugular vein
  • May have remote foci from septic emboli
  • Associated with recent oropharyngeal infection
  • Commonly caused by anaerobic pathogens such as Fusobacterium
  • Presentation
    • Sore throat
    • Neck mass/neck pain
    • Ill-appearing patient