Cir Cir 2013;81:279-286.

Deep neck abscess. Factors related

to reoperation and mortality
Gabriela Obregn-Guerrero,1 Jos Luis Martnez-Ordaz,2 Eduardo Moreno-Aguilera,2
Martha Ramrez-Martinez,1 Juan Francisco Pea-Garca,1 Claudia Prez-lvarez1
Abstract
Background: Deep neck abscesses are major complications that arise from odontogenic, pharyngeal, or cervicofacial foci, mainly
in patients with morbidities that facilitate the spread to other spaces. Many of these patients require surgical treatment. Appropriate
evaluation and surgical drainage are required to obtain the best results. We undertook this study to identify factors that relate to
reoperation and mortality in patients submitted to surgical treatment due to deep neck abscess.
Methods: We carried out a review of all patients with deep neck abscess who underwent surgical treatment in a Head and Neck Surgery
Department in a third-level hospital during a 2-year period.
Results: There were 87patients; 44 were female. The median age was 49years old. Thirty-five patients (40%) had comorbidities,
diabetes mellitus being the most common and found in 30 (34%) patients. Twenty-one patients (24%) require reoperation (primarily
due to inadequate surgical drainage). Risk factors identified with it were presence of comorbidities (mainly diabetes mellitus) (p <0.05),
multiple deep neck space involvement (p <0.001) and an ASA score of three or above (p <0.01). Eight patients died with a mortality rate
of 9%. Factors related to mortality were multiple deep neck space involvement (p <0.01), bilateral involvement (p <0.05) and reoperation
(p <0.001).
Conclusion: Appropriate evaluation of deep neck abscesses and complete surgical drainage of all deep neck abscesses are primordial
to avoid reoperation and to improve survival.
Key words: deep neck abscess, deep neck infection.

Introduction
The history of deep neck abscesses is traced to the time of
Greek and Roman medicine. It is a process of infectious
origin, forming a collection of necrotic and purulent material that can spread through different tissue planes. The
structures that make up the neck (muscles, bones, vessels,
nerves, etc.) are wrapped by multiple fascias that make up

1
2

Servicio de Ciruga de Cabeza y Cuello,

Servicio de Gastrociruga, Hospital de Especialidades, Centro
Mdico Nacional Siglo XXI, Instituto Mexicano del Seguro Social,
Mxico, D.F., Mexico

Correspondence:
Dr. Jos Luis Martnez Ordaz
Hospital de Especialidades
Centro Mdico Nacional Siglo XXI
Instituto Mexicano del Seguro Social
Av. Cuauhtmoc 330, 3 Piso
06725 Mxico, D.F., Mexico
Tel: 56-27-69-00, ext 21436
E-mail: jlmo1968@hotmail.com
Received: 1-16-2013
Accepted: 4-29-2013

the spaces or compartments in which an abscess can form.1

The spaces are described in Table1; 50-70% of cases originate due to an endodontic infection. Other causes include
upper respiratory infection, trauma (generally during the
pediatric age),2 parotiditis, foreign body, history of instrumentation and administration of intravenous drugs.3 The
cause is unknown in 20% of cases.4,5
There are various factors that may influence disease progression and increase morbidity and mortality: age, comorbidities, space affected (anterior visceral and vascular have a
greater probability of extension towards the mediastinum).6
Patients with diabetes mellitus have a greater predisposition
because of the decrease in the immune response (deficiency
in phagocytosis, chemotaxis or polymorphonuclear adherence, deficient response to cytokines and damage in the antioxidant system).7 Patients with immunological disorders
(HIV infection, treatment with steroids or chemotherapy)
have a greater risk of atypical presentation, which evolves
to more serious complications. Therefore, timely identification and appropriate treatment should be carried out so as
to minimize risk.8
The clinical picture is varied. The most frequent presentations are fever, pain, inflammation, general malaise, odynophagia, dysphagia and, according to the
space involved, trismus, dysphonia or dyspnea.1,8,9 Treat-

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Obregn-Guerrero G et al.

Table1. Deep neck spaces

Space

Borders

Submandibular

Inferior: The margin of the inferior mandible and the anterior and posterior bellies of the digastric.
Subdivided by the myohyoid muscle in the sublingual and submaxillary spaces.
Superior: mandibular symphysis and lateral, anterior bellies of both digastrics

Submentonian
Parapharyngeal

Masseter

With the shape of a cone, apex below the lesser cornu of the hyoid bone and superior base at the level
of the base of the skull. The medial border is the lateral wall of the pharynx and the ascending branch of
the mandible, the pterygoid muscle and the parotid gland. Subdivided by the styloid process in the preand poststyloid spaces.
Lateral, the masseter muscle and medial, the ascending branch of the mandible

Pterygoid

Medial, the pterygoid muscles and lateral, the ascending branch of the mandible

Temporal

Subdivided into two parts: a) superficial: between the superficial fascia of the temporal and the temporal
muscle, (b) deep: between the temporal muscle and the periosteum of the temporal bone

Parotid

Between the glandular tissue and its capsule, formed by the deep cervical fascia

Buccal

Medial to the buccinator muscle and oropharyngeal fascia and the cheek laterally

Retropharyngeal

Between the oropharyngeal fascia and the alar fascia, extending from the skull base to the level of T2

Dangerous

Between the alar and prevertebral fascia, from the skull base to the diaphragm

Prevertebral

Between the prevertebral fascia and the vertebral bodies, extends along the entire length of the spine

Vascular

Formed by the three layers of the deep cervical to containing the carotid artery, the internal jugular vein
sympathetic cervical chain and the IX, X, XI, and XII cranial nerves; it extends from the base of the skull
to the mediastinum

Peritonsillar

Anterior between the palatine tonsil and the superior constrictor muscle of the pharynx and posterior
tonsillar pillars
Between the prethyroid muscles and the esophagus; contains the thyroid gland, the trachea, the
anterior wall of the esophagus; extends from the thyroid cartilage to the superior mediastinum reaching
up to the aortic arch and pericardium

Visceral

Posterior triangle
Mediastinum

Inferior to the superior face of the mid-third of the clavicle, posterior to the anterior margin of the
trapezius and anterior to the posterior margin of the sternocleidomastoid
Extrapleural anatomic compartment in the center of the chest between the right and left lungs, behind
the sternum and the costochondral junctions and in front of the vertebral bodies and of the most
posterior slope of the bony ribs

ment includes intravenous administration of antibiotics,

treatment of the airway and surgical drainage (when indicated).4 In all cases, medical treatment should be appropriate to the specific causal agent; however, in order
to do this it is necessary to have corresponding cultures
that may be able to show the development of microorganism even after 72 h. It is recommended that empiric
broad spectrum antibiotic treatment can reach Gram positive, Gram negative, and anaerobic bacterias.10 Some established schemes include penicillin with a -lactamase
inhibitor plus metronidazole, cefotaxime plus metronidazole or ceftriaxone plus clindamycin; carbapenem such
as imipenem and meropenem may also be indicated. The
most frequent reports are of polymicrobial infections.7

Different studies found a predominance of Gram positive

microorganisms in the cultures, specifically Streptococcus alpha hemolyticus (43%) and Staphylococcus epidermidis (23%).9,11-14
Surgical treatment is indicated in patients with airway
involvement, abscess >3 cm that includes paravertebral, anterior visceral or vascular spaces, or when it affects more
than two spaces; patients with mediastinitis or thrombosis
of the internal jugular vein; and patients without response to
medical treatment in the first 24 to 48h.8,9,15
Small and unilocular abscesses (<3cm) can be removed
with ultrasound or computed tomography (CT)-guided aspiration. Yeow et al.16 proposed an alternative treatment with
drainage by aspiration or insertion of an ultrasound-guided

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Deep neck abscess

catheter, with resolution of the abscess in 87%. Herzon and

Martin17 were successful in 80% of the cases.
The objective of this study was to identify prognostic
factors associated with reoperation and mortality of patients
with diagnosis of deep neck abscess operated on in a tertiary level hospital.

Materials and Methods

We carried out a longitudinal, retrospective, observational
and comparative study based on the review of the records of
all patients with a diagnosis of deep neck abscess and who
were surgically intervened (initially) in the Department of
Head and Neck Surgery of the Specialty Hospital, CMN Siglo
XXI, Instituto Mexicano del Seguro Social (IMSS) between
January 1, 2009 and December 31, 2010. Demographic data
were obtained from all patients: age, gender, etiology, comorbidity (diabetes mellitus, systemic arterial hypertension,
chronic kidney failure, heart disease), time of evolution and
clinical picture (trismus, dysphonia, dyspnea, odynophagia
and dysphagia), findings of physical examination (affected
areas, number of affected areas and bilateralism), diagnostic
tests: chest x-ray (mediastinal widening and/or pleural effusion), CT (affected areas, number of spaces and bilaterality).
Data were collected in regard to the surgical treatment
(intervention by cardiothoracic surgery, ASA scale, intubation and number of attempts, requirement of urgent tracheostomy, areas affected and bilateralism), intraoperative
complications (vascular lesion, fistula into the oral cavity),
postoperative evolution (length of hospital stay, days of
intubation, tracheostomy postintubation, stay in intensive
care), the results of cultures and the prescribed antibiotics
(type of antibiotic and if there was a change of antibiotics).
The purpose was to identify factors related to reoperation
and mortality. For this reason, our dependent variables were
as follows:
Mortality: death during hospitalization or 30 days postoperative related to deep neck abscess
Reoperation: new surgical intervention secondary to incomplete drainage, progression or any complication, with
the exception of patients requiring tracheostomy
Independent related factors or independent variables
were age, gender, type of comorbidities, etiology, spaces
affected, number and bilaterality (clinical and tomographic), intervention by physicians from the Department of Cardiothoracic Surgery, ASA scale, intubation and number of
attempts, intraoperative complications and stay in the intensive care unit. Univariate statistical analysis was done
with Fisher exact test for nominal variables and Student t

test for continuous variables; p <0.05 was considered to be

significant.

Results
During the study period there were 90 patients admitted to
the hospital with the diagnosis of deep neck abscess. Three
patients were excluded: two due to prior drainage at another
institution and the third due to spontaneous drainage towards
the oral cavity. Only 87 patients were considered for this
study. Included were 44 (50.5%) females and 43 (49.4%)
males with an average age of 49years (17-82years). There
were 40% of patients (35) who had comorbidities: DM in
30 patients (34%), systemic arterial hypertension in 11 patients (12%), chronic renal insufficiency in four patients
(4%), ischemic cardiomyopathy in two patients (2%) and
HIV infection in one patient (1%).
The average time of progression of the clinical picture
was 9 days (range: 1-30 days). The most frequent clinical
data were increase in volume (83patients) (95%), pain (65
patients) (75%), fever (52 patients) (60%), trismus (40 patients) (46%), odynophagia (33 patients) (38%) and dysphagia (20 patients) (23%). The origin of the deep neck abscess
was dental in 30 patients (34%), upper respiratory infection in 15 patients (17%) and salivary gland infection in
twopatients (2%). For the remaining 40 patients (46%) no
cause was found and these were considered to be idiopathic.
Table2 lists the spaces most affected in accordance with the
findings on physical and CT examinations (not done in five
patients). The most commonly affected spaces on physical
examination were submaxillary (60 patients) (68%) followed by submandibular (38 patients) (43%), parotid and
anterior visceral (19 patients) (21%) each. On the CT, findings were submaxillary (60patients) (73%), parapharyngeal
(51 patients) (62%), vascular (34 patients) (41%), visceral
(31 patients) (37%) and submandibular (27 patients) (32%).
There were spaces that were not identified on physical examination and were indeed revealed on tomographic images, the most frequent being the parapharynx, pterygoid,
masseter, retropharynx, vascular, visceral and mediastinum.
(Figure1). Chest x-ray showed mediastinal widening in 18
patients (20%), only four with mediastinitis, and pleural effusion in eight patients (9%). Deep neck abscess was bilateral in 31 patients (36%) according to physical examination
and in 24 patients (29%) according to CT.
Surgical Data
An ASA scale of III or higher was found in 33 patients
(38%); 23% (20 patients) required two or more attempts

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Obregn-Guerrero G et al.

Table 2. Comparison of affected spaces found by

physical exploration and CT in 87 patients
operated for deep neck abscess

Neck space

Physical
exploration
(n = 87)

CT
(n = 82)

Submaxillary

60

60

0.540

Submentonian

38

27

0.151

Parapharyngeal

51

0.000

Parotid

19

20

0.694

Pterygoid

21

0.000

Masseter

25

0.000

Visceral

19

31

0.023

Prevertebral

0.302

Retropharyngeal

21

0.000

Vascular

34

0.000

Pterygomaxillary fossa

0.302

Periamygdaloid

0.281

Mediastinum

11

0.000

Buccal

0.143

Sublingual

0.227

Posterior triangle

0.072

Bilateral

31

24

0.473

CT, computed tomography.

at intubation and in four patients (5%) it was necessary to

do a tracheostomy because orotracheal intubation was not
possible. Seventeen patients (20%) had postoperative complications, 16 patients with fistula in the oral cavity and one
patient with a vascular lesion. In three cases (3%), multidisciplinary management was necessary with the participation
of the cardiothoracic surgery service because of mediastinitis that warranted a thoracotomy or sternotomy. There were
40 cases (45%) who required support from the intensive
care unit staff; average stay in the ICU was 9 days (range:
1-29 days).
In 60 patients there was a culture report: 41 were positive
(68%) and 19 were without identified growth (32%). The
most commonly identified organism was Staphylococcus
epidermidis (Table 3).
Reoperation
Twenty-one (24%) of 87 patients were reoperated. In nine
patients the indication was improper initial drainage, sev-

Figure 1. Computed tomography of the neck where the following can

be observed: (A) Collection in the submaxillary spaces (sm), parapharyngeal (pp) and retropharyngeal (rp). (B) Collection in submentonian and submaxillary spaces (s). (C) Gas in the left posterior triangle
(pt). (D) Collection and gas in the posterior mediastinum (pm).

en due to disease progression and seven for new surgical

washing. Patients who warranted reoperation had significantly more spaces affected on physical examination or
by CT and comorbidity (particularly diabetes mellitus).
Other factors associated with higher likelihood of reoperation were involvement of five or more spaces as demonstrated by CT, damage to the parapharyngeal, visceral,
retropharyngeal and vascular spaces, and ASA scale of III
or higher (Table 4).
Mortality
The average number of hospital days was 13. Eight of the
87 patients (9%) died and had a greater number of spaces
involved (four or more according to CT) and bilaterality.
Spaces most frequently affected were submandibular, visceral and retropharyngeal (Table 5).

Discussion
Deep neck abscess is a condition that is often seen in emergency consultations in the Head and Neck Surgery Service.
It is an infectious process that forms a collection of puru-

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Deep neck abscess

Table 3. Microorganisms isolated by culture in 60

patients operated on for deep neck abscess
Microorganism

Gram-positives (total)

21

35

6
5
2
1
1
1
1
1
1
1
1

10
8.3
3.3
1.6
1.6
1.6
1.6
1.6
1.6
1.6
1.6

11

18.33

5
3
1
1
1

8.3
5
1.6
1.6
1.6

8.2

4
1

6.6
1.6

6.7

2
1
1

3.3
1.6
1.6

19

31.6

Staphylococcus epidermidis
S. aureus
Streptococcus anginosus
S. warneii
Streptococcus agalactiae
Streptococcus pyogenes
Streptococcus sanguis
Streptococcus sp
Corynebacterium sp
Propionibacterium acnes
Gram +
Gram-negatives (total)
Acinetobacter baumanii
Bacteroides sp
Stenotrophomonas martophilia
Enterobacter cloacae
Burkholderia cepacia
Anaerobics (total)
Peptostreptoccocus
Anaerobic
Fungi (total)
Candida albicans
Candida sp
C. glabrata
No development (total)

lent material localized in any of the neck spaces. When not

treated in a timely manner, this condition could cause diverse complications that increase morbidity and mortality.
Without predominance of gender, these abscesses will
frequently arise from dental infections; however, on many
occasions (as in our patients) the underlying cause was not
found. It is known that it is related to inherent conditions
of the patient. The co-morbidity most frequently associated
with deep neck infection was diabetes mellitus.
Although the majority of patients had increased volume,
this anomaly could only be used as referral for the treatment. Physical examination underestimates the extent of
disease in 70% of the patients.18

CT is currently the studio of choice for diagnosis, and it

has been reported that in combination with physical examination it has a sensitivity of 95% and a specificity of 80%
for diagnosis. Magnetic resonance imaging has not demonstrated any advantage over CT.1,4,8
Many spaces can only be classified through physical examination because they are found in a deep position, and
this may delay diagnosis and timely treatment. This was
demonstrated with the comparison we made with the findings on physical examination and CT. There are spaces such
as the vascular, pterygoid and parapharyngeal, which are
practically identified only on CT. This is important for the
localization and precise extent of the abscesses and to then
define the appropriate procedure for the complete draining
of all affected areas. It is also not advisable to be guided
only by purulent material because even 25% of the affected
spaces did not contain any pus despite being shown in the
CT.17 There are some spaces such as visceral, vascular and
retropharyngeal that, due to their communication towards
the mediastinum, allow for their rapid dissemination with
an increased risk of mortality. We did not find that mediastinitis was a factor related to mortality. Our patients mainly
had involvement of the superior mediastinum and drainage
was performed via cervical incision. Mediastinal drainage via thoracotomy or sternotomy is indicated primarily
for involvement of the inferior mediastinum (severely ill
patients) and appearance of other complications such as
osteomyelitis.10 Our findings coincide with other national
and international studies where the most affected spaces
were parapharyngeal, submandibular and submandibular
(36%).4,13,14
One of our goals was to determine the factors related
with reoperation. Clinical history has an important role;
50% of reoperated patients had diabetes mellitus. This is
a factor that is related with a more complicated presentation of the condition. In addition, the general condition
of the patient is more complicated with an ASA scale
of III or IV in about two-thirds of reoperated patients.
The number of affected spaces is also related, on average, to close to twice the spaces affected in patients who
required reoperation (6.3 vs. 3.8). Two-thirds of the patients reoperated had involvement of the parapharyngeal,
visceral and vascular spaces, indicating that it is more
complicated to perform proper drainage, perhaps associated with their location and anatomic relationships. All
the above factors must be taken into account in the first
procedure so that it is sufficient and to avoid new interventions (in half of the reoperated cases, the initial
surgery was incomplete).
Our second objective was to identify factors related with
mortality. The mortality reported in this study was 9%,
similar to that reported by other authors with a range of

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Obregn-Guerrero G et al.

Table 4. Analysis of factors related with reoperation in 87 patients operated on for deep neck abscess
Clinical, laboratory and surgical data

Reoperated
(n = 21)

Not reoperated
(n = 66)

Univariate analysis
p

Age (years) (average SD)

53.8 15.7

48.5 16.6

.201

Male

35

.317

Female

13

31

.317

Comorbidities

Gender

13

22

.024

Diabetes mellitus

12

18

.018

SAH

1.000

CRI

.568

.427

Time of disease evolution (average SD)

Cardiopathy

6.8 4.4

9.5 8.2

.156

Affected spaces PE
(average SD)

3 1.3

2.2 1.6

.033

Number of spaces CT
(average SD)

6.3 2.8

3.6 2

.000

Bilateral

15

.094

Submaxillary

14

46

.774

Submentonian

10

17

.099

Parapharyngeal

17

34

.018

Parotid

14

.554

Pterygoid

15

.769

Masseter

19

1.000

Visceral

14

17

.001

CT

Prevertebral

.244

Retropharyngeal

10

11

.007

Vascular

14

20

.004

Pterygomaxillary fossa

1.000

Periamygdaloid

1.000

Mediastinum

.449

Buccal

1.000

Supraclavicular

1.000

Sublingual

1.000

Posterior triangle

1.000

39

.010

Spaces by CT 5 or >
Cardiothorax

.553

ASA III or IV

13

20

.009

SD, standard deviation; PE, physical exploration; CT, computed tomography.

ASA, risk scale according to the American Society of Anesthesiology; SAH, systemic arterial hypertension; CRI, chronic renal injury.

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Deep neck abscess

Table 5. Analysis of factors related with mortality in 87 patients who were operated on for deep neck abscess

Clinical, laboratory and surgical data

Age (years) (average SD)

Died
(n = 8)

Died
(n = 79)

Univariate
analysis
p

55.8 17.4

49.2 16.4

.280

Gender
Male

40

.713

Female

39

.713

Comorbidities

31

.709

Diabetes mellitus

27

1.000

SAH

10

1.000

CRI

1.000

Cardiopathy

1.000

Time of disease evolution (days) (average SD)

7.12 1.8

7.9

.490

Spaces affected
PE (average SD)

2.6 1.5

2.3 1.6

.681

Number of spaces
CT (average SD)

7.7 2.3

3.9 2.2

.000

CT
Bilateral

19

.044

Submaxillary

53

.676

Submentonian

21

.014

Parapharyngeal

43

.022

Parotid

19

.672

Pterygoid

19

1.000

Masseter

23

1.000

Visceral

25

.048

Prevertebral

1.000

Retropharyngeal

16

.024

Vascular

28

.061

Pterygomaxillary fossa

1.000

Periamygdaloid

1.000

Mediastinum

.291

Buccal

1.000

Supraclavicular

1.000

Sublingual

.268

Posterior triangle

1.000

Spaces according to CT 4 or >

37

.007

Cardiothorax

.227

Reoperated

14

.000

ASA III or IV

28

.282

SD, standard deviation; PE, physical exploration; CT, computed tomography; ASA, scale of risk according to the American Society of
Anesthesiology; SAH, systemic arterial hypertension; CRI, chronic renal insufficiency.

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Obregn-Guerrero G et al.

611.2%, which can increase to 4050% when there is mediastinitis.9,13,14

The relationship between mortality and reoperation reinforces the previous comments. The same spaces were once
found to be associated factors (parapharyngeal, visceral,
retropharyngeal and vascular); therefore, it is important to
identify them preoperatively for proper drainage. Due to
their relationships, these spaces tend to spread more easily. CT also found that bilaterality and having four or more
affected spaces (no patient with three or fewer spaces involved died) are factors that favor progression.
In conclusion, deep neck abscess is a serious infection
that can spread and rapidly become worse; therefore, it
is required that the initial evaluation be complete, with
surgical drainage for best results. Our study sheds some
tomographic and clinical data that on the initial assessment of the patient may suggest a poorer evolution,
sometimes with need of reoperations or even with risk
of death. This study is limited to the population of our
hospital; however, it can offer guidelines for new studies of this disease.
References
1. Lugo JA, Sols OA. Abscesos de los espacios profundos de cuello y
su complicacin hacia el mediastino: comunicacin de dos casos. An
Orl Mex 2007;52:34-38.
2. Etchevarren V, Bello O. Retropharyngeal abscess secondary to
traumatic injury. Pediat Emerg Care 2002;18:189-191.
3. Ocasio-Tascn ME, Martnez M, Cedeo A, Torres-Palacios A,
Alicea E, Rodrguez-Cintrn W. Ludwigs angina: an uncommon
cause of chest pain. South Med J 2005;98:561-563.
4. Campos LA, Hernndez DN, Barrn MA. Frecuencia y topografa de
los abscesos profundos de cuello. An Orl Mex 2009;54:129-134.

5. Manzo E, Mendez G, Hernndez GA, Salvatierra A, Vzquez MA.

Abscesos profundos de cuello. Etiopatogenia y morbi-mortalidad.
Rev Asoc Mex Med Crit Terap Inten 2005;19:54-59.
6. Boscolo-Rizzo P, Marchiori C, Montolli F, Vaglia A, Da Mosto MC.
Deep neck infections: a constant challenge. ORL J Otorhinolaryngol
Relat Spec 2006;68:259-265.
7. Lin HT, Tsai CSS, Chen YL, Liang JG. Influence of diabetes mellitus
on deep neck infection. J Laryngol Otol 2006;120:650-654.
8. Vieira F, Allen SM, Stocks RM, Thompson JW. Deep neck infection.
Otolaryngol Clin North Am 2008;41:459-483.
9. Marioni G, Staffieri A, Parisi S, Marchese-Ragona R, Zuccon A,
Staffieri C, et al. Rational diagnostic and therapeutic management
of deep neck infections: analysis of 233 consecutive cases. Ann Otol
Rhinol Laryngol 2010;119:181-187.
10. Ridder GJ, Maier W, Kinzer S, Teszler CB, Boedeker CC, Pfeiffer J.
Descending necrotizing mediastinitis: contemporary trends in etiology,
diagnosis, management, and outcome. Ann Surg 2010;251:528-534.
11. Hope GJA, Morales CM. Microbiologa y factores predisponentes en
los abscesos profundos del cuello. An Orl Mex 2009;54:85-91.
12. Ramrez-Martnez ME, Pea-Garca JF, Marn-Mndez JA, CastroIbarra S, Jurado-Reyes J. Absceso profundo de cuello, un reto
teraputico. Cir Gen 2004;26:282-285.
13. Suehara AB, Gonalves AJ, Alcadipani FAM, Kavabata NK,
Menezes MB. Infeces carvicais profundas: anlise de 80 cases.
Rev Bras Otorrinolaringol 2008;74:253-259.
14. Yang SW, Lee MH, Lee YS, Huang SH, Chen TA, Fang TJ. Analysis
of life-threatening complications of deep neck abscess and the
impact of empiric antibiotics. ORL J Otorhinolaryngol Relat Spec
2008;70:249-256.
15. Brook I. Microbiology and principles of antimicrobial therapy for head
and neck infections. Infect Dis Clin North Am 2007;21:355-391.
16. Yeow KM, Liao CT, Hao SP. US-guided needle aspiration and
catheter drainage as an alternative to open surgical drainage for
uniloculated neck abscesses. J Vasc Interv Radiol 2001;12:589-594.
17. Herzon FS, Martin AD. Medical and surgical treatment of
peritonsillar, retropharyngeal, and parapharyngeal abscesses. Curr
Infect Dis Rep 2006;8:196-202.
18. Reynolds SC, Chow AW. Life-threatening infections of the
peripharyngeal and deep fascial spaces of the head and neck. Infect
Dis Clin North Am 2007;21:557-576.

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