Operations of phlegmin and abscesses of neck

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deep neck infection AND drainage

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deep neck space infections surgical drainage airway management guidelines

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PMID: 38616333

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Operations for phlegmon and abscess of the neck

Deep neck infection may be either:

Phlegmon: diffuse infected edema and inflamed tissue, without a pus cavity. It is usually not drainable.
Abscess: a localized collection of pus. It needs source control, usually by aspiration or incision and drainage.

CT with IV contrast maps the involved fascial spaces, but it may not always distinguish phlegmon from pus reliably. An abscess often appears as a low-density, rim-enhancing collection. Cummings Otolaryngology Head and Neck Surgery, p. 1886.

CT appearance of a peritonsillar abscess with low-density collection and enhancing rim

1. Initial principles

Airway comes first
- Look for stridor, dyspnea, drooling, voice change, inability to lie flat, severe trismus, floor-of-mouth elevation, or rapidly increasing swelling.
- Secure the airway early in a controlled setting if it is threatened. Avoid repeated traumatic attempts at intubation.
- Prepare for surgical airway when intubation is unsafe or unsuccessful.
Resuscitation and investigations
- Admit, keep NPO, IV fluids, analgesia.
- CBC, inflammatory markers, blood cultures if septic.
- Contrast-enhanced CT neck, extending to chest when retropharyngeal or danger-space spread is suspected.
- Send aspirated pus or operative specimen for Gram stain, aerobic and anaerobic culture, and sensitivity.
Antibiotics
- Start IV antibiotics covering oral streptococci, anaerobes, and staphylococci.
- Modify after culture results and local resistance patterns.
- Address the source, especially infected teeth, tonsil, salivary gland disease, foreign body, or infected cyst.

2. Treatment of phlegmon

Primary treatment is non-operative, provided there is no airway threat or definite drainable collection:

IV antibiotics
Close airway observation
NPO initially if surgery may become necessary
Repeat examination and imaging if deterioration occurs
Treat the primary source, for example dental extraction when appropriate

Operate/explore despite phlegmon if any of the following occurs:

Threatened airway
Gas in tissues or air-fluid level
Clinical sepsis or rapid progression
Evolving abscess
No response after about 48-72 hours of IV antibiotics

K. J. Lee’s Essential Otolaryngology, p. 710.

3. Indications for operative drainage of a neck abscess

A definite abscess in a deep cervical fascial space
Airway compromise or impending compromise
Large, multiloculated, or spreading collection
Gas-forming infection or necrotizing infection
Failure of medical therapy after 48-72 hours
Mediastinal extension, neurovascular complication, or sepsis

The operative objectives are to drain pus, obtain cultures, irrigate the involved space, establish dependent drainage, and eliminate the primary focus of infection. K. J. Lee’s Essential Otolaryngology, p. 711.

4. Operative options

Type/location	Usual drainage route	Key principle
Small suppurative lymph node	Needle aspiration or small incision	Culture specimen; avoid unnecessary wide dissection
Peritonsillar abscess	Needle aspiration or transoral incision and drainage	Drain intraorally; observe airway and bleeding
Dental/alveolar or buccal space abscess	Intraoral drainage plus extraction of offending tooth	Remove dental source
Submandibular/submental abscess or Ludwig angina	Usually external dependent cervical drainage when pus is present	Airway management and dental source control are priorities
Parapharyngeal abscess	Transoral drainage only if medially located and accessible; otherwise transcervical drainage	Avoid carotid sheath and cranial nerve injury
Retropharyngeal abscess	Often transoral drainage; external route in selected lateral, extensive, or complicated disease	Assess for danger-space/mediastinal extension
Multispace, deep, or recurrent abscess	Transcervical exploration with blunt opening of involved fascial planes	Break loculi, irrigate, place drains, re-image if not improving

5. General operative sequence

This procedure should be performed by an experienced ENT or head-and-neck surgical team, with anesthesia support.

Secure or plan the airway before positioning or induction.
Position for access and prepare both oral cavity and neck when needed.
Choose the least morbid route that provides safe, complete dependent drainage.
Make incision in a skin crease or use transoral access as indicated by the involved space.
Use careful blunt dissection to enter the collection and avoid major vessels and nerves.
Obtain pus for culture before irrigation.
Break down loculations, irrigate, and inspect for communication with other spaces.
Remove the source, such as extraction of an infected tooth or removal of foreign body.
Place a drain or loose packing when ongoing drainage is needed. Do not tightly close a contaminated cavity.
Continue IV antibiotics, monitor airway and sepsis, and re-explore or repeat imaging if clinical improvement does not occur.

6. Postoperative care

Close airway monitoring, sometimes ICU care
IV antibiotics initially, then culture-directed therapy
Daily wound and drain assessment
Monitor for mediastinitis, septic thrombophlebitis of internal jugular vein, carotid complications, aspiration, and recurrent collection
Repeat CT if persistent fever, swelling, leukocytosis, or poor drain output
Remove drains only after output and clinical signs have settled

A 2024 systematic review found that, in selected deep-neck abscesses, ultrasound-guided drainage had a shorter hospital stay than conventional incision and drainage, without a statistically significant difference in recurrence. This is an option only when the collection is accessible and the airway is secure, not for unstable or extensive infection (systematic review, PMID 38616333).

Clinical warning: Deep neck swelling with breathing difficulty, stridor, drooling, voice change, rapidly progressing swelling, or inability to swallow is an emergency requiring immediate ENT/anesthesia assessment.

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