ConditionEar, nose & throat
Deep Neck Infections
Deep neck infections are bacterial infections that spread into the spaces between the layers of tissue in the neck, forming cellulitis or abscesses. Most start from infected teeth, tonsils or the throat. They cause neck pain and swelling, fever, painful swallowing and difficulty opening the mouth, and can threaten the airway or spread to the chest. They need urgent hospital assessment, intravenous antibiotics and often drainage of pus.
Also called: Deep neck space infection, neck abscess, peritonsillar abscess, retropharyngeal abscess, parapharyngeal abscess, Ludwig's angina
At a glance
- What it is
- Infection and abscess in the deep tissue spaces of the neck.
- Common sources
- Dental infections (especially lower molars), tonsillitis, throat infections, injection drug use.
- Main types
- Peritonsillar, parapharyngeal, retropharyngeal, submandibular (Ludwig's angina).
- Red flags
- Drooling, muffled voice, stridor, unable to open mouth, swelling under the tongue.
- Treatment
- Airway protection, IV antibiotics, surgical or needle drainage, treating the source.
When to get help
Call 911 or go to the ER
- Noisy breathing, difficulty breathing, or needing to sit forward to breathe. Call 911 or your local emergency number
- Drooling or being unable to swallow saliva
- Rapid swelling under the tongue or jaw, a raised tongue, or a firm swollen floor of the mouth (possible Ludwig's angina)
- Chest pain or breathlessness with a neck infection (possible spread to the chest)
- Confusion, very high fever or signs of sepsis
See a doctor within a day or two
- Severe sore throat on one side with a muffled "hot potato" voice and difficulty opening the mouth
- A painful, swollen neck with fever
- Stiff, painful neck movements with fever in a child who will not move the neck
- A toothache with facial or neck swelling
Book a routine appointment
- Recurring tonsillitis or dental infections
How deep neck infections develop
The neck contains layers of connective tissue (fascia) that divide it into spaces. These spaces are connected, so infection can travel from the mouth and throat down into the chest. Infections spread from:
- teeth: the most common source in adults, especially infected lower second and third molars
- tonsils and throat: the most common source in children
- salivary glands
- injury, foreign bodies and surgery in the throat
- injection of drugs into neck veins
- infected lymph nodes
Bacteria are usually a mix of streptococci, staphylococci and anaerobes from the mouth.
Types of deep neck infection
| Type | Location | Typical features |
|---|---|---|
| Peritonsillar abscess | Beside a tonsil | Severe one-sided sore throat, muffled voice, trismus, uvula pushed to the other side; most common in teens and young adults |
| Parapharyngeal abscess | Side of the throat | Neck swelling below the jaw angle, trismus, fever |
| Retropharyngeal abscess | Behind the throat | Mostly children under 5; fever, neck stiffness, refusing to move the neck, drooling, noisy breathing |
| Submandibular / Ludwig's angina | Floor of the mouth and under the jaw | Firm swelling under the chin, raised tongue, airway threat; usually from teeth |
| Danger space and prevertebral infections | In front of the spine | Can spread to the chest (mediastinitis) |
Symptoms
- neck pain and swelling, often on one side
- fever and chills
- sore throat, painful swallowing and difficulty swallowing
- trismus: difficulty opening the mouth
- a muffled voice
- stiff neck or pain turning the head
- drooling
- ear pain
- swelling of the jaw or under the tongue
- noisy or difficult breathing in severe cases
Diagnosis
- Examination of the mouth, throat, teeth and neck, often with a flexible scope through the nose to check the airway.
- CT scan with contrast: the main test to locate abscesses and see how far infection has spread.
- Ultrasound: useful in children and to guide needle drainage.
- Blood tests: white cell count, inflammatory markers, blood cultures and glucose (diabetes increases risk and severity).
- Pus culture from drainage guides antibiotic choice.
Treatment
Airway first
Securing the airway is the top priority. Severe swelling may require a breathing tube placed with a camera while awake, or a surgical airway (tracheostomy) in an emergency.
Antibiotics
Intravenous antibiotics covering mouth bacteria, such as ampicillin-sulbactam or clindamycin, adjusted to cultures. Small, early infections without an abscess may respond to antibiotics alone.
Drainage
- Needle aspiration or incision and drainage for peritonsillar abscess, often done in the clinic or ER.
- Surgical drainage through the mouth or neck for larger abscesses.
- Removal of infected teeth or treatment of the source.
- Tonsillectomy for recurrent peritonsillar abscess.
Supportive care
Pain relief, fluids, and steroids in some cases to reduce swelling.
Complications
- airway obstruction
- mediastinitis: spread of infection into the chest, with high mortality
- jugular vein thrombosis (Lemierre syndrome), with septic clots to the lungs
- erosion into the carotid artery
- sepsis
- aspiration pneumonia if the abscess ruptures
Outlook
With prompt treatment, most people recover fully. Delayed treatment, diabetes, older age and spread to the chest are linked to worse outcomes.
Prevention
- Regular dental checkups and early treatment of tooth decay and abscesses
- Prompt treatment of tonsillitis and dental abscesses
- Good diabetes control
Frequently asked questions
What are the signs of a deep neck infection?
Neck pain and swelling, fever, painful or difficult swallowing, a muffled voice, difficulty opening the mouth and a stiff neck are common signs. Drooling, noisy breathing or swelling under the tongue are emergency warning signs.
What causes a deep neck abscess?
Most come from infected teeth in adults and from tonsil or throat infections in children. Bacteria spread through the tissue spaces of the neck and form a pocket of pus. Injection drug use, injuries and surgery are other causes.
Is a neck abscess an emergency?
Yes, it needs urgent medical care. Swelling can block the airway, and infection can spread to the chest or bloodstream. Treatment in hospital with IV antibiotics and often drainage is usually required.
Can a tooth infection spread to the neck?
Yes. Infections of the lower back teeth can spread below the jaw and into the neck spaces, causing Ludwig's angina or other deep neck abscesses. A toothache with facial or neck swelling, fever or difficulty swallowing needs prompt care.
Sources
This guide was written from current patient and clinical guidance, including:
- American Academy of Otolaryngology-Head and Neck Surgery: Deep neck space infections
- NIH National Library of Medicine (StatPearls): Deep neck infections
- Merck Manual Professional Version: Neck and oral abscesses
- MedlinePlus: Retropharyngeal abscess; Peritonsillar abscess
- American Association of Oral and Maxillofacial Surgeons: Odontogenic infections