Synopsis
Recognise impending upper-airway obstruction, avoid destabilising examination, secure the airway with senior anaesthetic and ENT expertise, and combine intravenous antimicrobials with drainage of deep collections.
- Airway safety comes before diagnostic certainty; keep a distressed patient upright and avoid procedures that may precipitate obstruction.
- Adult epiglottitis often presents with severe throat pain, dysphagia, muffled voice and minimal oropharyngeal findings; stridor is a late warning.
- Deep-neck infection follows tonsillar, dental, salivary, traumatic or instrument-related infection and may spread between fascial planes into the mediastinum.
- Flexible nasendoscopy is performed only by an experienced team where immediate airway rescue is available; unstable patients proceed to controlled airway management.
- Contrast CT neck and chest maps deep collections after the airway is secure; imaging must not delay intervention in a deteriorating patient.
- Start intravenous ceftriaxone-based or local broad oral-flora treatment after blood cultures when safe, adding anaerobic and resistant-organism cover by source and exposure.
- A mature parapharyngeal, retropharyngeal or odontogenic abscess usually requires drainage and removal of the dental or other source.
- Review frequently for increasing oxygen need, secretion intolerance, swelling, cranial neuropathy, jugular thrombosis and mediastinal extension.
Key red flags
Stridor, drooling, inability to swallow secretions or exhaustion indicates critical airway narrowing requiring immediate expert control.
Trismus, floor-of-mouth elevation, tongue displacement or rapidly spreading submandibular swelling suggests Ludwig angina and difficult intubation.
Neck swelling with chest pain, crepitus or sepsis can indicate descending mediastinitis and needs urgent cross-sectional imaging after airway safety.
Severe pain with little visible tonsillar change can reflect epiglottitis or a deep parapharyngeal process rather than uncomplicated pharyngitis.
Severe odynophagia, drooling, quiet muffled speech and preference to sit forward with little visible pharyngeal inflammation is a high-risk pattern.
Unilateral throat pain, hot-potato voice, uvular deviation and trismus suggests a peritonsillar collection requiring ENT drainage assessment.
Bilateral woody submandibular swelling, raised tongue and dental infection creates rapidly worsening airway difficulty.
Neck stiffness, torticollis, cranial neuropathy, septic emboli or chest symptoms indicates extension beyond superficial pharyngitis.
Investigation priorities
Detect deterioration before complete obstruction.
Management branches
Upper-airway infection is suspected from pain, voice, swallowing or neck findings.
- Keep the patient upright, calm and nil by mouth while experienced anaesthesia and ENT attend with difficult-airway equipment.
- Avoid tongue depression, unnecessary cannulation attempts and unmonitored transfer when obstruction is plausible.
- Obtain rapid observations, glucose and cultures without postponing airway control; use controlled theatre intubation or surgical airway according to anatomy.
- After stabilisation, examine dental, tonsillar, salivary and traumatic sources and choose contrast imaging with the operating team.