Multiple Retained Needles in the Neck of a Drug User: A Case Report

Retained needles are frequently observed in intravenous drug users. However, an incidental discovery of multiple needles at the neck seldom occurs. These foreign bodies remain either asymptomatic or cause local and central complications that can be fatal. We report the case of a 43-year-old male having a medical record of human immunodeficiency virus and hepatitis C who presented to our department with a 3-day history of a febrile lateral neck swelling. He reported a history of repetitive intravenous drug use and previous abscesses that were surgically drained. We noted a left and tender 8 cm neck swelling with torticollis. Computed tomography scan showed a collected myositis of the sternocleidomastoid muscle in association to multiple metallic foreign bodies at the neck that were compatible with the aspect of broken needles. Imagery also showed a thrombosis of the ipsilateral jugular vein. No central embolism of a foreign body was noted. We performed a surgical drainage of the muscular abscess and managed to retrieve a 1 cm broken needle that was retained at the level of the collection. We did not retrieve the other needles since they were asymptomatic. The patient was placed under intravenous antibiotics for 1 week followed by oral amoxicillin-clavulanate with a total regression of the cellulitis. At the further follow-ups, the rest of the foreign bodies remained asymptomatic. Our study emphasizes on the importance of suspecting a retained foreign body in intravenous drug users to ensure an adequate management of the possible complications and to protect the medical team from incidental needle injuries.

Neck Abscess Due to Pocket Shot: Is It Just the Tip of the Iceberg?

A 45-year-old Caucasian male presented to the emergency department for pain and swelling on the left side of his neck for the past 10 days. His medical history revealed that he was an intravenous (IV) drug abuser. Physical examination demonstrated a 5×5 cm red, swollen bump with a positive fluctuation on the left supraclavicular area concerning for an abscess. Fluid aspiration from the abscess was performed, and three sets of blood cultures were obtained, which later all came back positive for methicillin-resistant Staphylococcus aureus (MRSA). His initial blood tests revealed elevated levels of platelets, leukocytes, and C-reactive protein (CRP) and anemia. The computed tomography (CT) scan showed an enlarged pectoralis major with the presence of air. The retrosternal, infraclavicular, and supraclavicular regions also contained air. The clinical diagnosis was therefore supported by the laboratory results and imaging. Additionally, transthoracic echocardiography showed no vegetations, and transesophageal echocardiography was scheduled. Antibacterial treatment was initiated empirically from the emergency room with meropenem and vancomycin, planned for four weeks. Repeat cultures were obtained for the following three days, which were all negative. However, the patient left the hospital against medical advice and did not complete his antibiotic treatment. The risk of a peripherally inserted central catheter (PICC) line being misused for illegal narcotics was considered too high; hence, it was not recommended for continued IV antibiotic therapy at home. Those with a history of intravenous drug use, after using the most accessible injection sites, oftentimes resort to finding alternative and potentially more dangerous injection sites. The major veins of the neck, such as the jugular, subclavian, or brachiocephalic veins, are commonly used. This technique is referred to as a "pocket shot" by intravenous drug abusers (IVDAs). Apart from the apparent abscess, clinicians should oversee for other complications including underlying pus collections, pneumothorax, mediastinitis, osteomyelitis, and hemothorax.

Changing trends of deep neck infections in southern China: A review of 127 cases

This study aimed to review our experience with the clinical characteristics and management of deep neck infections (DNIs) and determine the changing trends of their characteristics over time in southern China. Patients diagnosed with a DNI between January 2009 and December 2018 were screened retrospectively for their demographic characteristics, etiology of infection, site of infection, microbiology, treatment, and complications. In total, 127 patients were included: 41 (32.3%) were treated between 2009 and 2013 (group A), and 86 (67.7%) were treated between 2014 and 2018 (group B). The most common site of infection in group A was the parapharyngeal space (15 patients, 36.6%), while that in group B involved multiple spaces (36 patients, 41.9%). The leucocyte count (×109 cells/L) was 13.23 ± 4.19 in group A and 16.04 ± 4.33 in group B (p < 0.001). Streptococcus viridans was the most common bacteria in both groups. The mean hospital stay was 21.46 ± 33.09 days in group A and 10.44 ± 6.19 days in group B. The rate of diabetes mellitus (DM) in group A was lower than that in group B (8/41 and 33/86, respectively; p = 0.034). Airway obstruction was the most common complication in both groups. DNIs are more likely to show multi-space involvement, affect more DM patients, and be associated with higher leucocyte counts over time. We infer that the duration from morbidity to admission and that from admission to operation play roles in the successful management of DNIs, possibly causing fewer complications, lower mortality rates, and shorter hospital stays. DM patients require increased attention.

Risk Factors Affecting Length of Stay in Patients with Deep Neck Space Infection

OBJECTIVES

Analyze risk factors affecting length of stay (LOS) for patients presenting with deep neck space infections including care by medical versus surgical team.

METHODS

This is a retrospective chart review from January 2005 through May 2018 at the University of Kentucky analyzing factors related to deep neck space abscesses. Patients included adults >18 years old admitted for deep neck space infections undergoing surgical intervention. This study compared effects of treatment on a medical versus surgical service on LOS while accounting for patient confounders. Independent variables included age, gender, tobacco use, medical comorbidities, Charlson comorbidity index, American Society of Anesthesiology (ASA) classification, presence of drain, readmissions, and repeat surgical interventions. Univariate and multivariate analysis were performed.

RESULTS

One hundred sixty-three patients were included in the analysis. LOS was significantly longer for those on medicine services (P < .001). Patients on medicine services had a higher incidence of diabetes (P = .011), higher Charlson comorbidity score (P = .001), and higher incidence of repeat interventions (P = .005). Postoperative LOS remained lower for patients on a surgical service (P = .009) after adjusting for Charlson comorbidity scores. Presence of a drain or tobacco use was not significant between service management (P = .89; P = .63) or LOS (P = .366; P = .225).

CONCLUSION

Increased postoperative LOS was associated with age, diabetes, ASA class, Charlson comorbidity index, and repeat procedures. Patients on a medicine service had longer LOS and higher comorbidity indices. Patients had shorter hospital stays on surgical services after adjusting for comorbidity indices. Use of a drain or presence of tobacco use did not affect LOS.

LEVEL OF EVIDENCE

3 Laryngoscope, 130:2133-2137, 2020.