Severe soft tissue infections of the head and neck: a primer for critical care physicians

Chronic Sphenoiditis With Deep Neck Space Extension: Case Report With Review of the Literature and Postulated Mechanisms for Extracranial Extension

Isolated primary sphenoid sinusitis is a rare occurrence, estimated to make up less than 3% of sinus infections. The posterior anatomic location of the sphenoid makes treatment challenging when it becomes infected. Complications involving intracranial extension to surrounding structures often result in cranial nerve deficits due to their proximity. A single case of chronic sphenoiditis with direct extracranial extension into the prevertebral space is reported with a discussion on clinical presentation, diagnosis, and management. A 46-year-old female patient with diffuse headaches radiating into the neck and throat was evaluated in the office. Computed tomography demonstrated sphenoiditis with direct extension into the prevertebral space. Imaging revealed a purported route of direct extension through the clinoid and directly into the clivus to form an abscess in the longus colli muscle. The patient underwent endoscopic surgical management including drainage of the prevertebral abscess and has since made a full recovery. This is the first reported case of direct extension of sphenoiditis into the prevertebral space. The findings highlight the importance of aggressive treatment of chronic sphenoid infections to prevent detrimental complications. Computed tomography imaging proved an advantageous imaging modality to demonstrate bony erosion and sinus tracts from the skull base to the deep neck space.

Risk factors for difficult ventilatory weaning in intensive care patients with cervical cellulitis

PURPOSE

Cervical cellulitis is an infrequent but serious infection. The management of the upper airways is difficult, at the actual time of intubation but also regarding the necessity of maintaining mechanical ventilation. The objective of this study is to identify risk factors on admission to the intensive care unit for difficult ventilatory weaning in patients with cervical cellulitis.

METHODS

Between January 2013 and December 2018, this retrospective observational study was performed in an intensive care unit with 10 beds in a university hospital recognized as a reference center for the management of cellulitis. All intensive care patients receiving mechanical ventilation after surgery for cervical cellulitis were eligible. Difficult ventilatory weaning was defined as mechanical ventilation lasting more than 7 days or failure of extubation as established by the WIND 2017 study.

RESULTS

We included 120 patients with severe cervical cellulitis. The median age was 43 years. Eighteen patients (16%) presented mediastinal extension. The risk factor for difficult ventilatory weaning (n = 49) in multivariate analysis was a high level of procalcitonin on admission (OR at 1.14[1.005-1.29]; p<0.042) and the protective factor was surgery in an expert center (OR at 0.11[0.026-0.47]; p<0.003). Eight patients required a tracheotomy in our study: 3 patients during surgery and at a later time for the other 5 of our 8 patients.

CONCLUSION

No intensive care studies have investigated ventilatory weaning risk factors in patients with cervical cellulitis. Yet simple criteria seem to predict this risk. It is now necessary to confirm them by a multicenter prospective study.

Retropharyngeal Abscess in a Fourteen-Month-Old Child Presenting with Dysphagia and Obstructive Sleep Apnea: A Case Report

Retropharyngeal abscess is a relatively uncommon midline deep neck space infection that extends from the base of the skull to the posterior mediastinum, situated between the buccopharyngeal and alar fascias. In this case report, we present a 14-month-old previously healthy female patient who had a high-grade fever for 7 days, associated with neck stiffness and restriction of neck movements to the right side. Her parents noticed decreased oral intake associated with dysphagia, muffled quality of voice, and obstructive sleep apnea. However, the patient had no clinical signs of mechanical obstruction on examination. A contrast-enhanced computed tomography scan of the neck showed a large retropharyngeal septated fluid collection measuring 8 × 3 × 6 cm, which was categorized as a large retropharyngeal abscess that was complicated by descending mediastinitis. The patient was taken immediately to the operation theater for incision and drainage under general anesthesia, after which she was started on intravenous antibiotics.

A case of intracranial vasospasm in a patient with extensive retropharyngeal cellulitis

Retropharyngeal cellulitis/abscesses are deep neck infections that may become life-threatening if airway compromise occurs. This condition is more common in children than in adults, and associated intracranial vessel narrowing has been reported. We report an adult patient with extensive retropharyngeal cellulitis and intracranial vasospasm. The patient was a 62-year-old woman who presented with fever, sore throat, and neck pain. She also had uncontrolled type 2 diabetes mellitus. Leukocytosis, prolonged erythrocyte sedimentation rate, elevated C-reactive protein, and hyperglycemia were present on admission. Computed tomography and contrast-enhanced magnetic resonance imaging revealed severe swelling in the nasopharyngeal, retropharyngeal, prevertebral, and bilateral carotid spaces. Gadolinium enhancement extended to the middle cranial fossa and visceral space. Multiple stenoses in several intracranial vessels was also identified. Intravenous antibiotic therapy was initiated, the patient's symptoms resolved, and repeat imaging confirmed improvement. Intracranial vasospasm should be considered in patients with retropharyngeal cellulitis.

Life-threatening complications of Ludwig's angina: a series of cases in a developed country

Ludwig's angina is a deep neck space infection defined as a rapidly progressive bilateral cellulitis of the submandibular space. In spite of being an uncommon entity in developed countries and the reduction of mortality and morbidity due to modern era of antibiotics, improved imaging and airway management, it is still an important and potentially life-threatening condition. The authors present 3 cases of Ludwig's angina that occurred in a developed country, and that required admission in intensive care unit and extensive surgical and medical treatment.

Wisdom Tooth's Revenge: Retropharyngeal Abscess and Mediastinitis after Molar Tooth Extraction

Retropharyngeal abscess is potentially associated with high morbidity and mortality as a result of its direct anatomical connection with the mediastinum. Therefore, knowledge of the relevant anatomy is essential for recognizing the presence and extent of disease in a timely manner. In this case report, we aim to review the pertinent anatomy and patterns of spread of infection from a full blown deep neck space infection to result in mediastinitis and empyema.

Prevertebral neck abscess with Salmonella sandiego: a case presentation and literature review

We describe an unusual case of a 58-year-old man with type 2 diabetes mellitus (T2DM) developing sepsis secondary to a prevertebral neck abscess. Following cross-sectional imaging, the patient underwent surgical drainage. Salmonella sandiego was isolated from urine, blood and pus cultures. Salmonella species neck infections represent a rare cause of focal salmonellosis, though have been reported in the literature. This is the first reported case of S. sandiego causing neck abscess. The case highlights an atypical presentation of salmonellosis, with the surprising finding of a neck abscess on cross-sectional imaging without evidence of co-existing significant discitis or osteomyelitis.

Acinetobacter Prevertebral Abscess: Presenting as Dysphagia in a Diabetic Patient

Acinetobacter species frequently causes nosocomial infection, particularly in patients receiving invasive ventilation at intensive care units for a prolonged period. Odynophagia is a rare, initial clinical manifestation of prevertebral abscess which subsequently develops when the abscess extends into the retropharyngeal space causing a midline bulge of the posterior pharyngeal wall. Here, we present and discuss a patient with uncontrolled diabetic mellitus who presented with severe odynophagia and dysphagia. He was diagnosed to have prevertebral abscess caused by a rarely reported bacteria, Acinetobacter baumannii.

Otolaryngologic Emergencies in the Primary Care Setting

Most otolaryngology-related complaints are straightforward and easily recognized and treated. However, given the proximity of the ears, nose, and throat to numerous vital structures in the head and neck, the potential for serious consequences exists if disease processes go unrecognized and untreated. This article serves to familiarize the primary care provider with the clinical presentation of various complications associated with common otolaryngologic complaints. Clinicians who care for patients presenting with otolaryngologic complaints should keep these entities in mind and attempt to rule out any serious complication.

Imaging anatomy of deep neck spaces

This article presents a comprehensive analysis of the neck fascia and neck spaces that are formed by the interplay of the different fascial layers. Because a solid and thorough understanding of the anatomy and relationship of the various neck spaces is so valuable in diagnosing and treating diseases of the neck, this information organizes the anatomic areas of the neck beginning with and overview, followed by extent, anatomic relationship, and contents. Detailed enhanced computed tomography images display the anatomic areas of the neck.

Dental and related infections

Emergency physicians should be comfortable treating most dental and related infections. In this article, we outline recommended techniques to perform a dental examination, explore common pathologies, recommend pain and antibiotic management strategies and review common pitfalls. How to avoid overprescribing opioid analgesics is discussed in depth, along with recent studies to support this strategy.

Conservative treatment in isolated penetrating cervical esophageal injury: case report

Non-iatrogenic traumatic cervical esophageal perforations are usually hard to manage in the clinical setting, and often require a careful and individualized approach. The low incidence of this particular problem leads to a restricted clinical experience among most centers and justify the lack of a standardized surgical approach. Conservative treatment of esophageal perforation remains a controversial topic, although early and sporadic reports have registered the efficacy of non-operative care, especially following perforation in patients that do not sustain any other kind of injuries, and who are hemodynamically stable and non-septic. We report a case of a patient sustaining a single cervical gunshot wound compromising the cervical esophagus and who was treated exclusively with cervical drainage, enteral support and antibiotics.

Predictors of severity in deep neck infections admitted to the intensive care unit

A retrospective study was performed on adult patients admitted for surgical drainage of deep neck infections and admitted to the intensive care unit (ICU) during a period of 52 months. Severe infection was defined as septic shock/severe sepsis, mediastinitis, empyema or necrotising fasciitis. Complicated course was defined as ICU stay >8 days, reintubation, tracheostomy, renal replacement therapy, critical illness, myopathy or mortality. Chi-square or Fisher's exact test were used to assess differences and the significance level was controlled for multiple comparisons applying Bonferroni's correction. Fifty-four patients were studied. Variables associated with severe infection (43%) were abscess location (retropharyngeal [52 vs 7%; P<0.001] or multiple [52 vs 13%; P=0.002]), Acute Physiology and Chronic Health Evaluation II>7 (78 vs 13%; P<0.001), Simplified Acute Physiology Score II>29 (73 vs 21%; P<0.001) and first ICU day Sequential Organ Failure Assessment score>2 (77 vs 21%; P<0.001). Variables associated with complicated course (56%) were: parapharyngeal location (60 vs 8%; P<0.001)], Acute Physiology and Chronic Health Evaluation II>7 (67 vs 14%; P=0.001), Simplified Acute Physiology Score II>29 (62 vs 18%; P=0.002) and Sequential Organ Failure Assessment score>2 (68 vs 17%; P<0.001). Serious complications occur frequently in patients with deep neck infections surgically drained and admitted to the ICU. Higher severity scores are associated with both severe infection and a complicated course. Retropharyngeal and parapharyngeal locations are associated with severe infection and a complicated course respectively.

Factors associated with length of stay and hospital charges for patients hospitalized with mouth cellulitis

OBJECTIVE

Dental conditions that are neglected could progress to infectious lesions that are severe enough to require hospital admission for treatment. The objective of this study was to examine outcomes in patients hospitalized for cellulitis and abscesses of mouth in the USA in year 2008.

STUDY DESIGN

The nationwide inpatient sample for the year 2008, a component database of the Healthcare Cost and Utilization Project, was used for the current study. All hospital discharges with a primary diagnosis for cellulitis or abscess of mouth (ICD-9-CM code 528.3) were selected for analysis. Outcomes, including length of stay in hospital (LOS) and hospitalization charges, were computed from the database and projected to national levels by using the discharge weight variable. The predictor variables were composed of sets of heterogeneous variables grouped into the following categories: demographic, health-related (comorbid conditions), hospital-specific, and insurance-related. The primary outcome variables were LOS and hospital charges. Multivariable linear regression analysis models were used to examine the association between predictor and outcome variables.

RESULTS

A total of 4,044 hospital discharges were attributed primarily to cellulitis or abscess of mouth. About 45% of these discharges occurred in those aged between 18 and 45 years. The mean length of stay in hospital was 3.9 days, and the mean hospital charge was $24,290. The total USA hospitalization charge was close to $98 million. Private insurance plans were the major payers, accounting for $31 million of hospitalization charges. About 88% of all hospitalization were discharged routinely after treatment, and 2% were transfered to another short-term hospital.

CONCLUSIONS

This study examines outcomes in patients hospitalized for cellulitis or abscess of mouth. Future studies must focus on identifying cohorts that are more prone to developing odontogenic infections that are severe enough to warrant hospitalization.