ent.deep-neck-space-infection.core.v1PRODUCTION

ent.deep-neck-space-infection.core.v1

Deep neck space infection (retropharyngeal / parapharyngeal / Ludwig — airway + sepsis triage, CT space-mapping, IV broad-spectrum ± surgical source control)

general_internal_medicineacutesubacuteadultpediatric

Hard-required inputs

0 / 9

Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Frame as deep fascial-neck-space infection (retropharyngeal / parapharyngeal / prevertebral / submandibular-Ludwig / masticator / parotid / carotid-sheath) by source (odontogenic, tonsillar/pharyngeal, salivary, foreign-body, IVDU). The dominant tasks are AIRWAY-FIRST recognition, CT space-mapping, broad-spectrum IV cover, and surgical source control. The controlled-airway algorithm, the localised PTA drainage ladder, the upstream pharyngitis pathway, and the sepsis bundle are routed OUT by engine_id, not re-authored here.

Inputs

Actions

Advance rule

Set

Advance when

deep-space scope + suspected source framed; airway/PTA/pharyngitis/sepsis ownership flagged for routing by engine_id

Patient inputs (16)

floor_of_mouth_elevation_or_tongue_displacement*symptom • CONTEXT

Brawny floor-of-mouth elevation with tongue protrusion/posterior displacement is the cardinal Ludwig sign and the single strongest difficult-airway predictor in submandibular-space disease (Dowdy Anesth Prog 2019 PMID 31184944)

trismus_present*symptom • CONTEXT

Trismus localises masticator/parapharyngeal/submandibular involvement, predicts difficult oral access for both exam and airway, and discriminates deep-space spread from uncomplicated pharyngitis (Sheikh Clin Otolaryngol 2023 PMID 37147934)

neck_stiffness_torticollis_dysphagia*symptom • CONTEXT

Neck stiffness / torticollis / odynophagia out of proportion / refusal of neck extension localises retropharyngeal-prevertebral spread and is a descending-mediastinitis precursor (Hu Medicina 2022 PMID 36556959 — retropharyngeal/anterior-visceral spread predicts DNM)

temperature*vital • CONTEXT

Fever supports a suppurative process and severity class; high fever + rigors raises the bacteraemia/Lemierre concern (Charlton J Laryngol Otol 2024 PMID 39434660)

diabetes_mellitus*history • CONTEXT

not present

Diabetes is an independent predictor of complications, multispace involvement, and prolonged hospitalisation in deep-neck infection — lowers admission/CT/surgical threshold (Bandol Medicina 2025 PMID 39859111 — DM strongly associated with complications p<0.001; Wu Sci Prog 2021 PMID 34191640 — rising DM rate)

airway_compromise_features*symptom • RED_FLAGS

Stridor, "can't lie flat", tripod posture, drooling/pooled secretions, or rapidly progressive distress is the do-NOT-delay airway-emergency trigger; floor-of-mouth elevation predicts a difficult airway (Bridwell/Long Am J Emerg Med 2020 PMID 33383265; Dowdy Anesth Prog 2019 PMID 31184944)

chest_back_pain_dyspnoea_mediastinal*symptom • RED_FLAGS

Pleuritic chest/back pain, dyspnoea, or widened mediastinum suggests descending necrotising mediastinitis — recognise then route to cardiothoracic (Hu Medicina 2022 PMID 36556959 — untreated mortality up to 85%)

lemierre_features_neck_vein_tenderness_septic_emboli*symptom • RED_FLAGS

Rigors, anterior-neck-vein tenderness/cord, pleuritic chest pain, and septic pulmonary emboli after an oropharyngeal infection suggest Fusobacterium internal-jugular septic thrombophlebitis (Lemierre's) (Tiwari Cureus 2023 PMID 37724228; Wright South Med J 2012 PMID 22561543)

sbp*vital • RED_FLAGS

Hypotension on adequate fluids with a deep-neck source → systemic toxicity / septic shock; recognise then route OUT to id.sepsis.core.v1 (SSC — sepsis pathway not authored here)

contrast_ct_neck_to_mediastinumimaging • BRANCHING_WORKUP

not present

Contrast CT neck (extended to chest if any mediastinal feature) is the space/abscess-mapping and descending-mediastinitis instrument; POCUS is an adjunct when the patient cannot lie flat (Sheikh Clin Otolaryngol 2023 PMID 37147934 — CT in 78%; Bridwell/Long Am J Emerg Med 2020 PMID 33383265)

immunocompromisehistory • CONTEXT

not present

Immunosuppression / transplant broadens the pathogen spectrum (incl. atypical/fungal), blunts containment, and is strongly associated with complications — lower imaging/source-control threshold (Bandol Medicina 2025 PMID 39859111)

ivdu_or_instrumentation_or_foreign_bodyhistory • CONTEXT

not present

IV drug use (jugular-route seeding, unusual organisms incl. S. aureus/MRSA) and recent instrumentation/foreign body change the source, organism, and carotid-sheath-erosion risk (Sheikh Clin Otolaryngol 2023 PMID 37147934)

crplab • INITIAL_WORKUP

Markedly elevated/rising CRP predicts surgical drainage need, mediastinal extension, and prolonged hospitalisation (Arslan J Investig Med 2022 PMID 35760449 — CRP >133 mg/L; Hu Medicina 2022 PMID 36556959 — CRP 340.9 vs 190.1 mediastinal vs not)

wbc_with_differentiallab • INITIAL_WORKUP

Neutrophilic leukocytosis supports a suppurative process and feeds the severity / mediastinitis-risk chain (Wu Sci Prog 2021 PMID 34191640 — higher leucocyte counts over time)

anticoagulation_or_bleeding_diathesishistory • TREATMENT

not present

Anticoagulation / bleeding diathesis changes the drainage risk-benefit and is central to the unresolved Lemierre internal-jugular-thrombosis anticoagulation debate (Adedeji Ann Pharmacother 2020 PMID 32909436)

pregnancyhistory • TREATMENT

not present

Antibiotic-safety gating for the empiric regimen (β-lactam/β-lactamase-inhibitor + clindamycin generally preferred; weigh metronidazole) and a difficult-airway modifier in late pregnancy (Aliabadi Eur J Transl Myol 2022 PMID 36268928 — odontogenic antibiotics in pregnancy)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (8)

8 need judgement

informationallife_threateningairway_obstruction_secure_and_route_controlled_airway
Stridor, "can't lie flat", drooling/pooled secretions, floor-of-mouth elevation with tongue displacement, or rapidly progressive distress — impending deep-neck/Ludwig airway obstruction (Bridwell/Long Am J Emerg Med 2020 PMID 33383265; Dowdy Anesth Prog 2019 PMID 31184944)
Trigger could not be auto-evaluated — needs clinician judgement.
informationallife_threateningdescending_necrotizing_mediastinitis
Pleuritic chest/back pain, dyspnoea, widened mediastinum, retropharyngeal/anterior-visceral spread, or very high/rapidly rising CRP (e.g. ~340 vs ~190 mg/L mediastinal vs non-mediastinal) (Hu Medicina 2022 PMID 36556959 — untreated mortality up to 85%)
Trigger could not be auto-evaluated — needs clinician judgement.
informationallife_threateninglemierre_internal_jugular_septic_thrombophlebitis
Rigors, anterior-neck-vein tenderness/cord, pleuritic chest pain, and septic pulmonary emboli after an oropharyngeal infection — Fusobacterium necrophorum internal-jugular septic thrombophlebitis (Tiwari Cureus 2023 PMID 37724228; Wright South Med J 2012 PMID 22561543)
Trigger could not be auto-evaluated — needs clinician judgement.
informationallife_threateningcervical_necrotizing_fasciitis_route_out
Rapidly spreading neck erythema/induration with crepitus, dishwater discharge, pain out of proportion, or cutaneous anaesthesia — cervical necrotising fasciitis (Sheikh Clin Otolaryngol 2023 PMID 37147934 — a recognised DNSI complication theme)
Trigger could not be auto-evaluated — needs clinician judgement.
informationallife_threateningcarotid_sheath_erosion_sentinel_bleed
Carotid-space involvement on CT with a sentinel/herald bleed (oral/aural/wound), expanding pulsatile neck mass, or cranial-nerve palsy — impending carotid blow-out (Sheikh Clin Otolaryngol 2023 PMID 37147934 — carotid-sheath involvement theme)
Trigger could not be auto-evaluated — needs clinician judgement.
informationalseveresystemic_toxicity_route_to_sepsis
qSOFA ≥2, hypotension on adequate fluids, or NEWS2/SIRS-positive systemic toxicity with the deep-neck source (SSC)
Trigger could not be auto-evaluated — needs clinician judgement.
informationalseveremultispace_or_retropharyngeal_prevertebral_spread
≥2 deep neck spaces, or retropharyngeal/prevertebral/anterior-visceral involvement on CT, ± gas formation — the mediastinitis precursor and surgical-drainage indication (Arslan J Investig Med 2022 PMID 35760449 — ≥2 spaces / gas indicate surgical drainage; Hu Medicina 2022 PMID 36556959)
Trigger could not be auto-evaluated — needs clinician judgement.
informationalmoderateimmunocompromised_or_diabetic_high_risk
Diabetes, immunosuppression, or transplant with deep-neck infection — broader pathogen spectrum, more multispace involvement, higher complication and prolonged-hospitalisation rates, lower CT/surgical/ICU threshold (Bandol Medicina 2025 PMID 39859111 — DM/immunocompromise associated with complications p<0.001; Wu Sci Prog 2021 PMID 34191640 — rising DM rate)
Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Deep neck space infection — airway-secure → surgical source control → IV broad-spectrum (anaerobe + strep + MRSA) + Lemierre anticoagulation branch

axis: dnsi_airway_source_control_broad_spectrumstep 1 - Step 1 — Airway-first: secure the airway before anything else if threatened

Selected step "Step 1 — Airway-first: secure the airway before anything else if threatened" — Stridor, "can't lie flat", drooling, floor-of-mouth elevation/tongue displacement, or rapidly progressive distress — Ludwig and retropharyngeal disease are difficult-airway scenarios

controlled_definitive_airway_flexible_awake_with_surgical_backup
first line
airway_management
triggers: stridor, cannot_lie_flat, floor_of_mouth_elevation, drooling, progressive_distress
Bridwell/Long Am J Emerg Med 2020 (PMID 33383265) — first-line airway approach is flexible intubating endoscopy with preparation for a surgical airway; Dowdy Anesth Prog 2019 (PMID 31184944) — Ludwig is a predicted difficult airway: do NOT force supine / blind oral intubation; mark external airway landmarks. The controlled-airway algorithm itself is routed to ent.epiglottitis.core.v1.

ed playbook — drug actions (4)

1. controlled definitive airway (flexible/awake, surgical-airway backup)
procedure • airway • once; continuous vigilance
trigger: Threatened airway / Ludwig / retropharyngeal disease (Bridwell/Long Am J Emerg Med 2020 PMID 33383265)
Airway-first; Ludwig is a predicted difficult airway — do not force supine / blind oral intubation
2. ampicillin-sulbactam IV (empiric backbone)
rxcui 1009148
3 g • IV • q6h
trigger: All deep-neck infection — strep + anaerobe cover (Sheikh Clin Otolaryngol 2023 PMID 37147934)
Streptococcal + oral-anaerobe (incl. Fusobacterium) backbone
3. vancomycin IV (add MRSA cover if IVDU / healthcare exposure / severe)
rxcui 11124
15-20 mg/kg • IV • q8-12h AUC-guided
trigger: IVDU / healthcare exposure / prior MRSA / severe disease
Empiric MRSA cover for the IVDU/severe phenotype
4. clindamycin IV (penicillin anaphylaxis backbone)
rxcui 2582
600-900 mg • IV • q8h
trigger: Severe penicillin allergy
Strep + anaerobe backbone substitute; add MRSA/Gram-negative per source; C. difficile counsel

Auto-drafted A&P note

Subjective

- Possible entry pathways: Neck swelling / induration with pain, fever, dysphagia, odynophagia and trismus over 1-5 days — the cardinal deep-neck-space-infection presentation (Sheikh Clin Otolaryngol 2023 PMID 37147934; Charlton J Laryngol Otol 2024 PMID 39434660); Bilateral submandibular brawny induration with floor-of-mouth elevation, tongue protrusion/displacement and drooling — Ludwig's angina, a do-not-delay airway emergency (Bridwell/Long Am J Emerg Med 2020 PMID 33383265; Dowdy Anesth Prog 2019 PMID 31184944); Upstream ENT engine flagged deep-space / airway red flags and routed IN by engine_id (reciprocal entry from ent.pharyngitis.core.v1 / ent.peritonsillar-abscess.core.v1 / ent.epiglottitis.core.v1) (Sheikh Clin Otolaryngol 2023 PMID 37147934).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Deep neck space infection (retropharyngeal / parapharyngeal / Ludwig — airway + sepsis triage, CT space-mapping, IV broad-spectrum ± surgical source control)** (ent.deep-neck-space-infection.core.v1).
Phenotype framing: Terminal differential with pivot findings: deep-neck-space abscess vs peritonsillar abscess (peritonsillar-localised bulge + uvular deviation, neck supple — route to ent.peritonsillar-abscess.core.v1) vs epiglottitis (supraglottic, near-normal oropharynx, "thumbprint" — route to ent.epiglottitis.core.v1) vs uncomplicated pharyngitis/tonsillitis (symmetric, no trismus / floor-of-mouth elevation / neck stiffness — route to ent.pharyngitis.core.v1) vs cervical lymphadenitis (discrete mobile tender node, no fascial-space tracking on CT) vs infected branchial/thyroglossal congenital cyst (longstanding cystic lesion in a typical location, recurrent, less toxic) vs cervical necrotising fasciitis (crepitus, dishwater discharge, pain out of proportion) vs Lemierre (IJ thrombus + septic emboli pivot).
Scope: Frame as deep fascial-neck-space infection (retropharyngeal / parapharyngeal / prevertebral / submandibular-Ludwig / masticator / parotid / carotid-sheath) by source (odontogenic, tonsillar/pharyngeal, salivary, foreign-body, IVDU). The dominant tasks are AIRWAY-FIRST recognition, CT space-mapping, broad-spectrum IV cover, and surgical source control. The controlled-airway algorithm, the localised PTA drainage ladder, the upstream pharyngitis pathway, and the sepsis bundle are routed OUT by engine_id, not re-authored here.

No severity triggers fired against current inputs.

Plan

Regimen axis: **Deep neck space infection — airway-secure → surgical source control → IV broad-spectrum (anaerobe + strep + MRSA) + Lemierre anticoagulation branch** — step "Step 1 — Airway-first: secure the airway before anything else if threatened".
1. controlled_definitive_airway_flexible_awake_with_surgical_backup (airway_management, first line) — Bridwell/Long Am J Emerg Med 2020 (PMID 33383265) — first-line airway approach is flexible intubating endoscopy with preparation for a surgical airway; Dowdy Anesth Prog 2019 (PMID 31184944) — Ludwig is a predicted difficult airway: do NOT force supine / blind oral intubation; mark external airway landmarks. The controlled-airway algorithm itself is routed to ent.epiglottitis.core.v1.

Setting playbook (ed) — Recognise + secure a threatened airway, screen + route the catastrophic complications, CT-map the space(s), start IV broad-spectrum cover, and mobilise urgent ENT/OMFS surgical source control (Bridwell/Long Am J Emerg Med 2020 PMID 33383265; Sheikh Clin Otolaryngol 2023 PMID 37147934)
2. controlled definitive airway (flexible/awake, surgical-airway backup) procedure airway once; continuous vigilance — Threatened airway / Ludwig / retropharyngeal disease (Bridwell/Long Am J Emerg Med 2020 PMID 33383265) (Airway-first; Ludwig is a predicted difficult airway — do not force supine / blind oral intubation)
3. ampicillin-sulbactam IV (empiric backbone) 3 g IV q6h — All deep-neck infection — strep + anaerobe cover (Sheikh Clin Otolaryngol 2023 PMID 37147934) (Streptococcal + oral-anaerobe (incl. Fusobacterium) backbone)
4. vancomycin IV (add MRSA cover if IVDU / healthcare exposure / severe) 15-20 mg/kg IV q8-12h AUC-guided — IVDU / healthcare exposure / prior MRSA / severe disease (Empiric MRSA cover for the IVDU/severe phenotype)
5. clindamycin IV (penicillin anaphylaxis backbone) 600-900 mg IV q8h — Severe penicillin allergy (Strep + anaerobe backbone substitute; add MRSA/Gram-negative per source; C. difficile counsel)

Non-pharmacologic actions:
- Urgent ENT/OMFS referral for surgical source control of a drainable collection (Sheikh Clin Otolaryngol 2023 PMID 37147934 — drainage ~81%)
- Do NOT delay airway control or surgical source control for imaging/antibiotics (Bridwell/Long Am J Emerg Med 2020 PMID 33383265)
- Send blood + intra-operative deep-space aspirate cultures incl. anaerobic/Fusobacterium media
- IV fluids + analgesia for drooling/odynophagia-related dehydration

AVOID / contraindication checks:
- Penicillin anaphylaxis block ampicillinsulbactam piptazo ceftriaxone (use clindamycin ± metronidazole ± MRSA agent — backbone substitution)
- Clindamycin c diff counsel (lincosamide C. difficile risk)
- Metronidazole alcohol disulfiram reaction counsel
- Vancomycin AUC guided dosing and renal monitoring (Inker NEJM 2021 race free eGFR for AUC dosing)
- Linezolid serotonin syndrome and myelosuppression monitoring
- Lemierre anticoagulation is debated decide case by case not routine (Adedeji Ann Pharmacother 2020 — efficacious/safe but controversial; 6 12 wk if used)
- Pregnancy prefer betalactam or clindamycin weigh metronidazole (Aliabadi Eur J Transl Myol 2022 — odontogenic antibiotic safety in pregnancy)
- Do not delay airway or surgical source control for antibiotics (Bridwell/Long Am J Emerg Med 2020 — airway + source control are primary)

Monitoring

Regimen monitoring:
- improvement expected within 48-72h of source control plus antibiotics (Sheikh Clin Otolaryngol 2023 PMID 37147934)
- rising CRP or new chest back pain reimage CT neck to chest for DNM (Hu Medicina 2022 PMID 36556959)
- continuous airway vigilance reobstruction and tracheostomy decisions (Kim J Oral Maxillofac Surg 2021 PMID 34582808 — maintained orotracheal intubation favoured over upfront tracheotomy)
- delayed Lemierre watch rigors septic pulmonary emboli neck vein tenderness (Tiwari Cureus 2023 PMID 37724228)
- carotid sheath sentinel bleed watch in carotid space involvement
- renal dose recheck for betalactam vancomycin metronidazole (Inker NEJM 2021)

Setting (ed) monitoring:
- Continuous airway re-check; return precautions for airway, mediastinitis, Lemierre
- CRP/WBC baseline; very high/rising CRP → extend CT to chest (Hu Medicina 2022 PMID 36556959)

Follow-up plan: Definitive source eradication (dental extraction/endodontics for an odontogenic source, tonsillectomy candidacy if recurrent tonsillar source, salivary-duct management); diabetes optimisation (DM is a recurrence + complication driver — Bandol Medicina 2025); IVDU harm-reduction / addiction referral; ENT/OMFS follow-up; counsel return precautions for re-accumulation, airway, mediastinitis, and Lemierre. Anticoagulation-duration follow-up if a Lemierre IJ thrombus was treated (Adedeji Ann Pharmacother 2020 — 6-12 wk).
- Close-out criterion: definitive source-eradication plan + comorbidity optimisation + follow-up + return precautions documented

Monitoring phase: Expect improvement within 48-72 h of adequate source control + antibiotics; persistent fever, rising CRP, new chest/back pain, or expanding neck → re-image (CT neck-to-chest) for inadequate drainage / new space / descending mediastinitis, do NOT silently extend antibiotics. Continuous airway vigilance (re-obstruction, tracheostomy decisions — Kim J Oral Maxillofac Surg 2021 favoured maintained orotracheal intubation over upfront tracheotomy). Watch for delayed Lemierre (septic pulmonary emboli) and carotid sentinel bleed.

Disposition

Current setting: ed — Recognise + secure a threatened airway, screen + route the catastrophic complications, CT-map the space(s), start IV broad-spectrum cover, and mobilise urgent ENT/OMFS surgical source control (Bridwell/Long Am J Emerg Med 2020 PMID 33383265; Sheikh Clin Otolaryngol 2023 PMID 37147934)

Disposition criteria:
- Admit ALL deep-neck-space infection; ICU for threatened/secured airway, mediastinitis, septic shock, multispace disease, or significant comorbidity (Charlton J Laryngol Otol 2024 PMID 39434660 — ICU ~32%)
- Route OUT by engine_id if airway / mediastinitis / Lemierre / sepsis positive (carryover: CT space map, CRP, organism, airway status)

Escalation triggers (move to higher acuity):
- Airway obstruction → secure airway + route the controlled-airway doctrine to ent.epiglottitis.core.v1 (Dowdy Anesth Prog 2019 PMID 31184944)
- Descending mediastinitis (chest/back pain, very high CRP, anterior-visceral/retropharyngeal spread) → cardiothoracic + ICU (Hu Medicina 2022 PMID 36556959)
- qSOFA ≥2 / hypotension → id.sepsis.core.v1 (SSC)
- Lemierre features → ensure anaerobic cover; ID + case-by-case anticoagulation discussion (Adedeji Ann Pharmacother 2020 PMID 32909436)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Stridor, "can't lie flat", drooling/pooled secretions, floor-of-mouth elevation with tongue displacement, or rapidly progressive distress — impending deep-neck/Ludwig airway obstruction (Bridwell/Long Am J Emerg Med 2020 PMID 33383265; Dowdy Anesth Prog 2019 PMID 31184944)
- [LIFE_THREATENING] Pleuritic chest/back pain, dyspnoea, widened mediastinum, retropharyngeal/anterior-visceral spread, or very high/rapidly rising CRP (e.g. ~340 vs ~190 mg/L mediastinal vs non-mediastinal) (Hu Medicina 2022 PMID 36556959 — untreated mortality up to 85%)
- [LIFE_THREATENING] Rigors, anterior-neck-vein tenderness/cord, pleuritic chest pain, and septic pulmonary emboli after an oropharyngeal infection — Fusobacterium necrophorum internal-jugular septic thrombophlebitis (Tiwari Cureus 2023 PMID 37724228; Wright South Med J 2012 PMID 22561543)

Citations

- No single society "deep neck space infection guideline" exists; operating authority set — Sheikh et al systematic review & qualitative evidence synthesis of DNSI assessment/management (Clin Otolaryngol 2023, 60 studies) + Charlton et al UK 53-case DNSI cohort (J Laryngol Otol 2024) + Asairinachan et al Australian 422-patient DNSI cohort (ANZ J Surg 2025) + Arslan et al DNI laboratory/imaging treatment-strategy study (J Investig Med 2022) + Hu et al risk factors for descending necrotising mediastinitis in deep neck abscess (Medicina 2022) + Kim et al optimal airway management in DNM (J Oral Maxillofac Surg 2021) + Ma et al multidisciplinary DNM treatment (J Int Med Res 2019) + Bridwell/Long Ludwig's angina evidence-based review (Am J Emerg Med 2020) + Dowdy et al Ludwig's angina anaesthetic/airway management (Anesth Prog 2019) + Tiwari Lemierre's 21st-century review (Cureus 2023) + Adedeji et al Lemierre anticoagulation systematic review (Ann Pharmacother 2020) + Wright et al Lemierre syndrome (South Med J 2012); all WebSearch/PubMed reconciled 2026-05-17 [PMID:37147934](https://pubmed.ncbi.nlm.nih.gov/37147934/)
- Cited evidence (PMID 39434660) [PMID:39434660](https://pubmed.ncbi.nlm.nih.gov/39434660/)
- Cited evidence (PMID 39812241) [PMID:39812241](https://pubmed.ncbi.nlm.nih.gov/39812241/)
- Cited evidence (PMID 35760449) [PMID:35760449](https://pubmed.ncbi.nlm.nih.gov/35760449/)
- Cited evidence (PMID 36556959) [PMID:36556959](https://pubmed.ncbi.nlm.nih.gov/36556959/)

Last reconciled with current guidelines: 2026-05-17.

References

No single society "deep neck space infection guideline" exists; operating authority set — Sheikh et al systematic review & qualitative evidence synthesis of DNSI assessment/management (Clin Otolaryngol 2023, 60 studies) + Charlton et al UK 53-case DNSI cohort (J Laryngol Otol 2024) + Asairinachan et al Australian 422-patient DNSI cohort (ANZ J Surg 2025) + Arslan et al DNI laboratory/imaging treatment-strategy study (J Investig Med 2022) + Hu et al risk factors for descending necrotising mediastinitis in deep neck abscess (Medicina 2022) + Kim et al optimal airway management in DNM (J Oral Maxillofac Surg 2021) + Ma et al multidisciplinary DNM treatment (J Int Med Res 2019) + Bridwell/Long Ludwig's angina evidence-based review (Am J Emerg Med 2020) + Dowdy et al Ludwig's angina anaesthetic/airway management (Anesth Prog 2019) + Tiwari Lemierre's 21st-century review (Cureus 2023) + Adedeji et al Lemierre anticoagulation systematic review (Ann Pharmacother 2020) + Wright et al Lemierre syndrome (South Med J 2012); all WebSearch/PubMed reconciled 2026-05-17 — PMID:37147934
Cited evidence (PMID 39434660) — PMID:39434660
Cited evidence (PMID 39812241) — PMID:39812241
Cited evidence (PMID 35760449) — PMID:35760449
Cited evidence (PMID 36556959) — PMID:36556959