Analysis of Life-Threatening Complications of Deep Neck Abscess and the Impact of Empiric Antibiotics

Assessment of the Elderly Adult Patients with Deep Neck Infection: A Retrospective Study

Background: Deep neck infection (DNI) is a potentially lethal infectious disease affecting middle-aged adults and can compromise the airway. There are limited data on the prognosis and outcomes of elderly (aged > 65 years) DNI patients, who tend to be immunocompromised. This study analyzed the clinical characteristics of elderly and adult (aged 18-65 years) DNI patients. Methods: Between November 2016 and November 2022, 398 patients with DNIs, including 113 elderly patients, were admitted to our hospital and enrolled in this study. The relevant clinical variables were investigated and compared. Results: The elderly DNI patients had longer hospital stays (P < .001), higher C-reactive protein levels (P = .021), higher blood sugar levels (P = .012), and a higher likelihood of diabetes mellitus (P = .025) than the adult patients. The higher blood sugar level is an independent risk factor for elderly (odds ratio = 1.005, 95% confidence intervals 1.002-1.008, P < .001). Moreover, the rates of intubation to protect the airway (P = .005) and surgical incision and drainage (I&D; P = .010) were higher in the elderly group. However, there were no group differences in pathogen distributions. Conclusion: The elderly DNI patients in this study had a more severe disease course, and poorer prognosis than the adult patients, as well as higher rates of intubation and I&D. However, the pathogen distributions did not differ significantly between the groups. Prompt intervention and treatment are important for elderly DNI patients.

Assessment of Factors Associated With Long-Term Hospitalization in Patients With a Deep Neck Infection

BACKGROUND

Deep neck infection (DNI) is a severe infectious disorder of deep neck spaces that can cause serious complications. Long-term hospitalization is when a patient spends more time in the hospital than originally expected for a disease. There are few studies assessing the risk factors associated with long-term hospitalization for a DNI. This study investigated the factors causing DNI patients to experience long-term hospitalization.

METHODS

Long-term hospitalization is defined as a length of hospital stay exceeding 28 days (> 4 weeks) in this research. A total of 362 subjects with a DNI between October 2017 and November 2022 were recruited. Among these patients, 20 required long-term hospitalization. The relevant clinical variables were assessed.

RESULTS

In a univariate analysis, C-reactive protein (odds ratio [OR] = 1.003, 95% CI: 1.000-1.007, P = .044), involvement of ≥3 deep neck spaces (OR = 2.836, 95% CI: 1.140-7.050, P = .024), and mediastinitis (OR = 8.102, 95% CI: 3.041-21.58, P < .001) were significant risk factors for long-term hospitalization in DNI patients. In a multivariate analysis, mediastinitis (OR = 6.018, 95% CI: 2.058-17.59, P = .001) was a significant independent risk factor for long-term hospitalization for a DNI. There were no significant differences in pathogens between the patients with and without long-term hospitalization (all P > .05). However, the rates of no growth of specific pathogens were significantly different between patients with and without long-term hospitalization, and those with long-term hospitalization had greater rates of growth of specific pathogens (P = .032). The rate of tracheostomy in patients with long-term hospitalization was higher than for those without (P < .001). Nevertheless, the rates of surgical incision and drainage between patients with and without long-term hospitalization did not achieve statistical significance (P = .069).

CONCLUSIONS

Deep neck infection (DNI) is a critical, life-threatening disease that could lead to long-term hospitalization. The higher CRP and involvement of ≥3 deep neck spaces were significant risk factors in univariate analysis, while concurrent mediastinitis was an independent risk factor associated with long-term hospitalization. We suggest intensive care and prompt airway protection for DNI patients with concurrent mediastinitis.

Factors affecting patients with concurrent deep neck infection and aspiration pneumonia

BACKGROUND

Deep neck infection (DNI) is a life-threatening condition of the deep neck spaces with potential to obstruct the airway. Aspiration pneumonia (AP), which results from aspiration of colonized oropharyngeal or upper gastrointestinal contents, is a respiratory infection that affects the lungs, wherein the air sacs are filled with purulent fluid. The cooccurrence of these two diseases can cause severe damage to the respiratory system, leading to morbidity and mortality. However, the risk factors for concurrent DNI and AP have not yet been investigated. This study aimed to address this issue.

METHODS

A total of 561 DNI patients were enrolled in this study between June 2016 and December 2021. Among these patients, 26 had concurrent DNI and AP at the time of diagnosis. Relevant clinical variables were assessed.

RESULTS

In the univariate analysis, age > 60 years (OR = 3.593, 95% CI: 1.534-8.414, p = 0.002), C-reactive protein (OR = 1.005, 95% CI: 1.001-1.008, p = 0.003), involvement of ≥3 spaces (OR = 4.969, 95% CI: 2.051-12.03, p < 0.001), and retropharyngeal space involvement (OR = 4.546, 95% CI: 1.878-11.00, p < 0.001) were significant risk factors for concurrent DNI and AP. In the multivariate analysis, age > 60 years (OR = 2.766, 95% CI: 1.142-6.696, p = 0.024) and retropharyngeal space involvement (OR = 3.006, 95% CI: 1.175-7.693, p = 0.021) were independent risk factors for concurrent DNI and AP. The group with concurrent DNI and AP had longer hospital stays (p < 0.001) and lower rates of incision and drainage (I&D) open surgery (p = 0.020) than the group with DNI alone. There were no significant differences in pathogens (p > 0.05) between the groups.

CONCLUSIONS

Both DNI and AP can independently compromise the airway, and the concurrence of these two conditions makes airway protection more difficult. Age > 60 years and retropharyngeal space involvement were independent risk factors for the concurrence of DNI and AP. The group with concurrent DNI and AP had longer hospital stays and lower rates of I&D open surgery than the group with DNI alone. There were no differences in DNI pathogens according to concurrent AP status.

Deep Neck Infections: decisional algorithm for patients with multiple spaces involvement

BACKGROUND

Deep Neck Infections (DNIs) spread along fascial planes and involve neck spaces. Recently, their incidence has decreased due to the introduction of antibiotics; nevertheless, complications related to DNIs are often life-threatening.

OBJECTIVE

The purpose of this article is focused on the identification of predisposing factors of these complications, as well as on the development of a reliable therapeutic algorithm.

METHOD

Sixty patients with DNIs were enrolled from 2006 to 2019 for a retrospective study. The exclusion criteria for the present study was cellulitis, small abscesses responding to empiric or specific antibiotic therapy or with involvement of only one deep neck space. During the analysis the following parameters of interest have been evaluated: gender, age, site of origin, pathways of spread, comorbidities, clinical features, bacteriology data, type of surgical approach required, complications, duration of hospitalization and mortality rate. On admission, microbial swab analysis was performed.

RESULTS

Diabetes Mellitus (DM), Chronic Obstructive Pulmonary Disease (COPD), iron deficiency anemia and the involvement of multiple spaces have been associated with a significantly higher risk of developing complications. Most of our patients had polymicrobial infections. All patients underwent surgical drainage. The complication rate had occurred in 56.6% of patients, while death in 18.3%.

CONCLUSION

DNIs represent a medical and surgical emergency with potential serious complications, thus avoiding diagnostic delay is mandatory. Our preliminary data suggest the importance of evaluating the extent of infections because the involvement of multiple spaces requires timely surgery due to the higher risk of complications and mortality.

Factors Affecting the Necessity of Tracheostomy in Patients with Deep Neck Infection

Deep neck infection (DNI) is a serious disease that can lead to airway obstruction, and some patients require a tracheostomy to protect the airway instead of intubation. However, no previous study has explored risk factors associated with the need for a tracheostomy in patients with DNI. This article investigates the risk factors for the need for tracheostomy in patients with DNI. Between September 2016 and February 2020, 403 subjects with DNI were enrolled. Clinical findings and critical deep neck spaces associated with a need for tracheostomy in patients with DNI were assessed. In univariate and multivariate analysis, older age (≥65 years old) (OR = 2.450, 95% CI: 1.163–5.161, p = 0.018), multiple spaces involved (≥3 spaces) (OR = 4.490, 95% CI: 2.153–9.360, p = 0.001), and the presence of mediastinitis (OR = 14.800, 95% CI: 5.097–42.972, p < 0.001) were independent risk factors associated with tracheostomy in patients with DNI. Among the 44 patients with DNI that required tracheostomy, ≥50% of patients had involvement of the parapharyngeal or retropharyngeal space (72.72% and 50.00%, respectively). Streptococcus constellatus (25.00%) was the most common pathogen in patients with DNI who required tracheostomy. In conclusion, requiring a tracheostomy was associated with a severe clinical presentation of DNI. Older age (≥65 years old), multiple spaces (≥3 spaces), and presence of mediastinitis were significant risk factors associated with tracheostomy in patients with DNI. The parapharyngeal and retropharyngeal spaces were the most commonly involved, and Streptococcus constellatus was the most common pathogen in the patients with DNI that required tracheostomy.

A Retrospective Cohort Study of Risk Factors for Descending Necrotizing Mediastinitis Caused by Multispace Infection in the Maxillofacial Region

PURPOSE

Descending necrotizing mediastinitis (DNM) has been the most common life-threatening complication of multispace infection (MSI) in the maxillofacial region owing to the lack of a timely diagnosis and treatment. We assessed the clinical characteristics and diagnosis of odontogenic MSI and evaluated the risk factors for DNM caused by MSI.

PATIENTS AND METHODS

We performed a retrospective cohort study of inpatients with MSI in the maxillofacial region from January 2012 to October 2016. The patients were classified into a non-DNM group and a secondary DNM group. The information collected included gender, age, systemic comorbidities, source of maxillofacial infection, computed tomography imaging data, and laboratory test results. Univariate analysis (t test and χ² test, or the Fisher exact test) and logistic regression analysis were applied.

RESULTS

A total of 296 patients were included. The mortality was 6.3%. On univariate analysis, the following factors were statistically significant: gender (P = .001); age (P = .003); source of infection (P = .004); number of affected spaces (P < .001); involvement of the parotid space (P < .001), submandibular space (P < .001), subgingival space (P < .001), pterygomandibular space (P < .001), parapharyngeal space (P < .001), and retropharyngeal space (P < .001); and percentage of neutrophils (P < .001). On multivariate analysis, the parapharyngeal space (P = .008), source of infection (P = .037), and number of affected spaces (P < .001) were statistically significant.

CONCLUSIONS

Glandular infection, parapharyngeal space involvement, and the presence of multiple affected spaces were risk factors for DNM. Clinicians should vigilantly watch for these factors during clinical treatment and effective measures taken to prevent the occurrence of DNM as soon as possible.

Clinical predictors of descending necrotizing mediastinitis after deep neck infections

OBJECTIVES/HYPOTHESIS

To identify the clinical predictors of descending necrotizing mediastinitis (DNM) secondary to deep neck infections (DNIs) before treatment.

STUDY DESIGN

Retrospective case series.

METHODS

We reviewed 73 patients with DNIs who had been treated with external drainage at our institute between April 2009 and March 2019. We divided these patients into either a DNI group without mediastinitis (n = 55) or a DNM group secondary to DNI (n = 18). We collected clinical data and compared them between the groups, conducting univariate and multiple logistic regression analysis to identify the predictors of DNM.

RESULTS

We identified age, C-reactive protein (CRP), neutrophil percentage, lymphocyte percentage, neutrophil to lymphocyte ratio (NLR), presence of comorbidities, presence of gas, and abscess extension below the hyoid bone as statistically significant by univariate analysis. Moreover, multiple logistic regression analysis showed that age ≥55 years, NLR ≥13, and CRP ≥30 mg/dL were statistically significant.

CONCLUSIONS

We identified age ≥55, NLR ≥13, and CRP ≥30 before DNI treatment as clinical predictors of a DNM complication.

LEVEL OF EVIDENCE

4 Laryngoscope, 130:E567-E572, 2020.

The Association Between Decompensated Liver Cirrhosis and Deep Neck Infection: Real-World Evidence

BACKGROUND

Deep neck infection (DNI) can progress to become a life-threatening complication. Liver cirrhosis, which is related to poor immune conditions, is a likely risk factor for DNI. This study investigated the risk and mortality of DNI in patients with decompensated liver cirrhosis (DLC).

METHODS

We performed a nationwide cohort study using the National Health Insurance Research Database (NHIRD) in Taiwan. We included a total of 33,175 patients with DLC between 2000 and 2013, from the Catastrophic Illness Patient Database, a subsection of the NHIRD, along with 33,175 patients without cirrhosis who were matched in a 1:1 proportion for age, sex, and socioeconomic status. The occurrence of DNI was the primary study outcome. The risk, treatment, and mortalities of DNI were evaluated in the study and comparison cohorts.

RESULTS

DLC Patients had a significantly higher incidence of DNI than noncirrhotic patients (p < 0.001). The adjusted Cox proportional hazard regression showed that DLC was associated with a significantly higher risk of DNI (adjusted hazard ratio, 4.11; 95% confidence interval, 3.16-5.35, p < 0.001). The mortality rate in cirrhotic patients with DNI was not significantly higher than that in noncirrhotic patients with DNI (11.6% vs. 9.8%; p = 0.651).

CONCLUSIONS

This study is the first to investigate the correlation between DLC and DNI. The study findings strongly indicate that DLC is an independent risk factor for DNI. Cirrhotic patients with DNI do not have a significantly poorer survival rate than noncirrhotic patients with DNI. Therefore, physicians should be alert to potential DNI occurrence in DLC patients. Besides this, intensive care and appropriate surgical drainage can yield similar survival outcomes in DLC-DNI and noncirrhosis-DNI patients.

Deep neck infection in patients with and without human immunodeficiency virus: a comparison of clinical features, complications, and outcomes

We retrospectively studied the clinical features, complications, and outcomes of deep neck infections in 31 adult patients with the human immunodeficiency virus (HIV) (HIV group) and 192 patients without (non-HIV group). In the HIV group, the cause was more likely to be odontogenic (21 (68%) compared with 90 (47%); odds ratio (OR) 2.38; 95% CI 1.06 to 5.32). In both groups, the parapharyngeal, submandibular, and masticator spaces, were those most often involved. However, in the HIV group, Ludwig's angina was common, and was the main cause of airway obstruction. Streptococcus pneumoniae, Staphylococcus aureus, and Pseudomonas aeruginosa were most often isolated in the HIV group. Upper airway obstruction tended to be more common in the HIV group (5/31 compared with 13/192). These patients also had a higher risk of other complications (sepsis, mediastinitis, jugular vein thrombosis, and pneumonia) (6/31 compared with 12/192; OR 3.60; 95% CI 1.24 to 10.45), a higher mortality rate (3/31 compared with 2/192), and longer hospital stay (19days compared with 16 days). Factors associated with an increased risk of complications in this group were an age of 55 years or over and a CD4 count of less than 350 cells/mm³. Deep neck infections in these patients are more severe. Dental health care, appropriate empirical antibiotics, early detection, and management of the airway and complications, may improve outcomes.

Rational Diagnostic and Therapeutic Management of Deep Neck Infections: Analysis of 233 Consecutive Cases

Objectives

Although deep neck infections are less common nowadays because of the widespread use of antibiotics, they continue to carry significant morbidity and mortality rates.

Methods

Between 2000 and 2008, deep neck infections were treated in 233 patients at the University of Padova. Cases of peritonsillar abscess, superficial infections, infections due to external neck injuries, and infections in head and neck tumors were excluded. Clinical, radiologic, laboratory, and microbiological assessments were analyzed.

Results

The site of origin was identified in 189 of the 233 cases (81.1%), and the most common cause of deep neck infection was dental infection (39.5%). Intravenous antibiotic therapy was given to 78 patients, and 155 required both medical and surgical procedures. The bacteria most often isolated were gram-positive anaerobic cocci. None of our patients died of the deep neck infection or its complications.

Conclusions

It is worth emphasizing that airway support is the priority in patients with deep neck infections. Empirical antibiotic treatments must cover gram-positive and gram-negative aerobic and anaerobic pathogens. Surgical exploration and drainage may be mandatory in selected cases at presentation or in cases that fail to respond to parenteral antibiotics within the first 24 to 48 hours. It is important to perform cultures during operation to establish the pathogen(s) involved and to obtain an antibiogram to tailor the antibiotic treatment.

Multi-Space Infections in the Head and Neck: Do Underlying Systemic Diseases Have a Predictive Role in Life-Threatening Complications?

PURPOSE

To assess the incidence, risk factors, treatment, and outcomes of life-threatening complications of multi-space infections (LCMIs) in the head and neck.

PATIENTS AND METHODS

This was a retrospective cohort study that enrolled a sample of patients with multi-space infections who were referred from February 2006 through July 2014. The patients were classified into LCMI and non-LCMI groups. The primary predictor in this study was underlying systemic disease. The primary outcome variable was LCMI. Univariate analyses were used for data statistics.

RESULTS

A total of 549 patients were included, and an LCMI was found in 66 patients (12.20%). Descending mediastinitis was the most frequent LCMI (n = 37; 56.06%), followed by airway obstruction (n = 27; 40.91%), pneumonia (n = 12; 18.18%), pericarditis (n = 6; 9.09%), intraorbital infection (n = 2; 3.03%), multiple organ failure (n = 2; 3.03%), intracranial infection (n = 2; 3.03%), and sudden cardiac death (n = 1; 1.52%). Twelve patients with LCMI died during treatment. Elderly patients with an underlying systemic disease more commonly developed an LCMI.

CONCLUSIONS

Multi-space infections in the head and neck can cause several life-threatening complications, and the morbidity of LCMI is considerable. Older age and underlying systemic disease can increase the risk of an LCMI.

Multivariate approach to investigating prognostic factors in deep neck infections

Deep neck infections (DNI) spread along fascial planes and involve neck spaces. Very few studies have investigated potentially prognostic factors using multivariate statistical models. Our aim was to analyze 282 consecutive cases of DNI using multivariate (logistic) statistical models to identify independent significant factors influencing prognosis in terms of complications and long-term hospitalization (>6 days). In our series, only involvement of more than one neck space was independently significant in prognosticating complications of DNI (odds ratio [OR] 2.46). The presence of comorbidities (OR 2.13), non-odontogenic sites of origin (OR 1.88), leukocyte counts above 11.0 cells × 10(9)/L at presentation (OR 3.57), and the need for both medical and surgical treatments (OR 4.66) was significantly and independently prognostic of long hospital stays. Multivariate analysis can distinguish between risk factors and their relative contribution to outcome. The few published studies using multivariate models to analyze DNI prognosis considered quite large cohorts, but no clinical variables persistently revealed an independent significant prognostic role. This evidence seems to underscore the complex interdependence of several clinical variables in contributing to DNI prognosis, and the heterogeneity of the diagnostic/therapeutic approaches adopted.

Just a sore throat? Uncommon causes of significant respiratory disease

We present two uncommon underlying causes of a sore throat which, if missed or delayed in diagnosis, can lead to disastrous consequences. Our first case is of Lemierre's syndrome diagnosed in a 21-year-old man presenting with a 5-day history of sore throat, fever, right-sided pleuritic chest pain and bilateral pulmonary nodules on CT imaging. Fusobacterium necrophorum cultured from peripheral blood and an occluded left internal jugular vein on ultrasound lead to an eventual diagnosis. Our second case presents a 29-year-old woman with a 5-day history of sore throat, fever and right-sided pleuritic chest pain. A left-sided quinsy was diagnosed and aspirated and the patient was discharged home. She represented shortly with worsening pleuritic pain and was found to have a right-sided pleural effusion with descending mediastinitis originating from the tonsillar abscess. Delayed diagnosis resulted in open thoracotomy, decortication and prolonged intravenous antibiotics.

[Peritonsillar infections: prospective study of 100 consecutive cases]

INTRODUCTION

Peritonsillar infection is the most frequent complication of acute tonsillitis. Peritonsillar infections are collections of purulent material, usually located between the tonsillar capsule and the superior constrictor of the pharynx. Peritonsillar infection can be divided into abscess and cellulitis.

MATERIAL AND METHODS

We prospectively analysed the clinical data from 100 patients with peritonsillar infection from 2008 to 2010. The diagnosis of abscess or peritonsillar cellulitis was primarily based on obtaining pus through fine-needle aspiration.

RESULTS

Seventy-seven per cent of patients had no history of recurrent tonsillitis and 55% were receiving antibiotic treatment. Sixty-two cases were peritonsillar abscess and the rest were cellulitis. Trismus, uvular deviation and anterior pillar bulging were statistically associated with peritonsillar abscess (P<.005). All patients were admitted to hospital and treated with puncture-drainage, intravenous antibiotics (amoxicillin/clavulanate in 83% of cases) and a single dose of steroids. All patients were discharged on oral antibiotic therapy. The mean length of hospital stay was 3 days and the recurrence rate was 5%.

CONCLUSIONS

Due to the absence of clinical practice guidelines, there are different therapeutic protocols. According to our experience, puncture-aspiration and administration of intravenous antibiotics is a safe, effective way to treat these patients. To determine the efficacy and safety of outpatient management, controlled studies would be needed.