Deep neck abscess: a retrospective review of 210 cases

Effective surgical drainage of a massive retropharyngeal abscess via an incision in the posterior wall of the oropharynx under local anesthesia

INTRODUCTION

A retropharyngeal abscess is a deep neck infection, uncommon in adults but more prevalent in children. This report details a rare case of a huge retropharyngeal abscess in an adult female, effectively managed by an incision in the posterior oropharyngeal wall under local anesthesia.

CASE PRESENTATION

A 76-year-old woman with hypertension, diabetes, ischemic heart disease, and total thyroidectomy presented with sudden neck swelling, dyspnea, stridor, and dysphagia. Examination and imaging revealed a large retropharyngeal abscess. The abscess was drained through an incision in the posterior wall of the oropharynx using a local anesthetic, yielding immediate symptom relief. Cultures identified Streptococcus and Staphylococcus aureus, leading to adjusted antibiotics. The patient showed significant improvement, with resolution of respiratory distress and reduced inflammation.

DISCUSSION

The retropharyngeal space, containing lymph nodes and connective tissue, extends from the skull base to the superior mediastinum, communicating with the carotid sheath and parapharyngeal space. Effective management of a critically ill, immunocompromised patient with a resistant retropharyngeal abscess was achieved using an intraoral approach and intravenous antibiotics. This method avoids general anesthesia and minimizes postoperative complications. CT scans are essential for assessing disease extent and planning surgery. Our case highlights the successful treatment of a large abscess with minimal risks.

CONCLUSION

Drainage of retropharyngeal abscesses via the intraoral approach under local anesthesia can be considered a valuable method for high-risk patients who are not candidates for general anesthesia. Additionally, we presented a rare case of an exceptionally large retropharyngeal abscess.

Risk factors for life-threatening complications of head and neck space infections: A systematic review and meta-analysis

OBJECTIVE

The present systematic review was performed to identify risk factors associated with life-threatening complications of head and neck space infections (LCHNSI) within the included studies and assess the magnitude of their impact on patients.

METHODS

We systematically searched PubMed, Web of Science, EmBase, Scopus and CNKI for articles that reported risk factors associated with life-threatening complications of head and neck space infections from inception to 14 December 2023. Only factors reported in at least three papers were considered in the meta-analysis. Pooled odds ratio (OR) and 95 % confidence interval (CI) were calculated using fixed effects model and random effects model. The between-study heterogeneity of effect size was quantified using the Q statistic and I2. In addition, subgroup analysis stratified by study characteristics and sensitivity analysis were performed to explore the potential sources of heterogeneity and the stability of the results.

RESULTS

The review included a total of 29 studies. The results revealed that the risk factors which associated with LCHNSI were included diabetes mellitus (OR = 3.31, 95 % CI: 2.49-4.40), total leukocyte count(≥15 × 109/L) (OR = 1.21, 95 %CI: 1.04-1.42), multiple space involvement (OR = 4.32, 95 %CI: 3.47-5.38), combined systemic diseases (OR = 9.94, 95 %CI: 6.30-15.67), advanced age(≥60) (OR = 3.90, 95 %CI: 2.80-5.44), dyspnoea (OR = 23.39, 95 %CI: 12.41-44.10), high temperature(≥39°C) (OR = 3.23, 95 %CI: 2.02-5.17), retropharyngeal space involvement (OR = 3.62, 95 %CI: 2.06-6.35), parapharyngeal space involvement (OR = 4.62, 95 %CI: 2.27-9.42).

CONCLUSIONS

According to the current analysis, diabetes mellitus, total leukocyte count(≥15 × 109/L), combined systemic diseases, multiple space involvement, advanced age(≥60), dyspnoea, high temperature (≥39 °C), retropharyngeal space involvement, parapharyngeal space involvement were the risk factors for LCHNSI. To mitigate the incidence of LCHNSI, clinical staff should carefully manage these risk factors, ensure prompt diagnosis, and implement timely preventive measures.

A global science mapping analysis on odontogenic infections

OBJECTIVES

Odontogenic infections are common and a topic of core interest for dentists, and maxillofacial surgeons. The aim of this study was to conduct a bibliometric analysis of the global literature on odontogenic infection and explore the top 100 most cited papers to identify the common causes, sequelae and management trends.

METHODS

Following a comprehensive literature search, a list of top 100 most cited papers was created. The VOSviewer software (Leiden University, The Netherlands) was used to create a graphical representation of the data, and statistical analyses were performed to analyze the characteristics of the top 100 most cited papers.

RESULTS

A total of 1,661 articles were retrieved with the first article published in 1947. There is an exponential upward trend on the number of publications (R2 = 0.919) and a majority of papers are in English language (n = 1,577, 94.94%). A total of 22,041 citations were found with a mean of 13.27 per article. The highest number of publications were recorded from developed countries. There was a male predilection in the reported cases and the most common sites included the submandibular and parapharyngeal spaces. Diabetes mellitus was identified as the commonest co-morbidity. Surgical drainage was ascertained to be the preferred method of management.

CONCLUSIONS

Odontogenic infections remain prevalent and have a global distribution. Although prevention of odontogenic infection through meticulous dental care is ideal, early diagnosis and prompt management of established odontogenic infections is important to avoid morbidities and mortality. Surgical drainage is the most effective management strategy. There is lack of consensus regarding the role of antibiotics in the management of odontogenic infections.

Tuberculosis of the Cervical Vertebrae With Retropharyngeal and Parapharyngeal Abscesses Due to Staphylococcus aureus and Mycobacterium tuberculosis in an Adult: A Report of a Rare Case

Tuberculosis is a disease with presentations both in the lungs and at other extrapulmonary sites. While pulmonary tuberculosis constitutes a significant proportion of total tuberculosis cases, extrapulmonary cases with infections at rare sites are also documented. Herein, an exceedingly rare case of tuberculosis of the cervical vertebrae with retropharyngeal and parapharyngeal abscesses due to Staphylococcus aureus and Mycobacterium tuberculosis in a young Indian male is presented. The rarity of the locations of the lesions with coinfections with two bacteria made the diagnosis challenging. Besides, the potential for a retropharyngeal abscess to compress the airway is an emergency situation. However, the ultimate diagnosis was achieved with the help of a radiograph of the neck, contrast-enhanced computed tomography of the neck, fine-needle aspiration cytology, and a cartridge-based nucleic acid amplification test. He was initiated on appropriate antibiotics and antituberculous chemotherapy per his weight.

Spontaneous retropharyngeal abscess presenting as delirium in a frail older woman: a case-based review

INTRODUCTION

Retropharyngeal abscess (RPA) is an uncommon infection in older people, which usually presents with localized upper airway symptoms.

CASE PRESENTATION

We present a case of RPA in a 69-year-old frail woman with co-morbidities, who presented atypically with delirium. She initially complained of general symptoms of malaise, body aches and general decline. Her symptoms progressed to hypoactive delirium before she started to localize her complaints to the upper airway. The delirium presentation of RPA is not commonly reported in the literature. Co-morbidities and frailty are likely to be the underlying risk factors for delirium presentation in this case. Most of the RPA cases reported in older people in the literature presented typically with localized symptoms, however these cases had lower burden of morbidities and reported no frailty. In our case report, poor mouth hygiene and dental caries were thought to be the source of infection. Early intervention with antibiotic treatment for total of four weeks resulted in a full recovery.

CONCLUSION

RPA may present with delirium in older people with frailty and co-morbidities. Poor oral hygiene and dental caries, if left untreated, may progress into serious deep space neck infection.

Deep neck space infections in end-stage renal disease patients: Prevalence and mortality

Deep neck space infections (DNSI) are severe infections within the layers of neck fascia that are known to be associated with underlying immunocompromised states. Although uremia associated with kidney disease is known to cause immune system dysfunction, DNSI in patients with kidney disease has been poorly studied. This study investigated the prevalence of DNSI and the associated risk of mortality within the United States end-stage renal disease (ESRD) population, using a retrospective cohort study design and the United States Renal Data System database of patients (ages 18-100) who initiated dialysis therapy between 2005 and 2019. International Classification of Disease-9 and -10 codes were used to identify the diagnosis of DNSI and comorbid conditions. Of the 705,891 included patients, 2.2% had a diagnosis of DNSI. Variables associated with increased risk of DNSI were female sex, black compared to white race, catheter, or graft compared to arteriovenous fistula (AVF) access, autoimmune disease, chronic tonsillitis, diagnoses in the Charlson Comorbidity Index (CCI), tobacco use, and alcohol dependence. DNSI diagnosis was an independent risk factor for mortality, which was also associated with other comorbidity factors such as older age, catheter or graft compared to AVF access, comorbidities in the CCI, tobacco use, and alcohol dependence. Because of the increased mortality risk of DSNI in the ESRD population, health professionals should encourage good oral hygiene practices and smoking cessation, and they should closely monitor these patients to reduce poor outcomes.

Management of cervicofacial infection: a 7-year retrospective study

OBJECTIVE

We aimed to describe and analyze the epidemiologic and clinical variables associated with, treatment for, and development of cervicofacial infection (CFI).

STUDY DESIGN

We retrospectively examined 201 patients older than 14 years who had met the CFI diagnostic criteria and whose treatment required hospitalization and intervention under general anesthesia at our hospital. We performed chi-square tests to compare proportions in categorical variables and either the Student t test or the Wilcoxon signed-rank test to compare quantitative variables. We performed an analysis of variance to compare 3 or more categories and either Pearson or Spearman correlation coefficient analysis to examine the correlations between quantitative variables.

RESULTS

The majority (85.07%) of the CFIs were of odontogenic origin. The mean hospitalization length was 4.58 days. Patients with diabetes who used tobacco and/or alcohol had a significantly longer length of hospitalization and several postoperative complications.The most common symptoms were pain, trismus and toothache. Symptoms of fever and nausea were associated with longer hospitalization. The most affected anatomic spaces were submandibular and pterygomandibular. Buccal and infraorbital, temporal, and parotid spaces were associated with longer hospitalization.

CONCLUSIONS

Most CFIs are of odontogenic origin. Diabetes and tobacco and alcohol use are important risk factors. Treatment should be surgical and target the cause of infection. Timely referrals are important when patients present symptoms compatible with CFI for immediate treatment.

Ludwig's Angina: Higher Incidence and Worse Outcomes Associated With the Onset of the Coronavirus Disease 2019 Pandemic

Background: Ludwig's angina (LA) is a diffuse cellulitis of the submandibular space and adjacent tissues. During the coronavirus disease 2019 (COVID-19) pandemic, odontogenic treatments were often delayed because of the implementation of safety measures to avoid the spread of the virus. We hypothesized that delayed odontogenic treatments associated with the onset of the COVID-19 pandemic would be associated with an increase in the incidence of LA and worse outcomes related to these infections. Patients and Methods: Patients from June 2018 to June 2022 with computed tomography images suggestive of LA and confirmed by ear, nose, throat (ENT) consult were included. We abstracted demographics, outcomes, clinical management, and microbiology. Patients were stratified into pre-COVID and COVID-onset. Our primary outcome, incidence of LA, was defined as: (new LA cases) ÷ (ED evaluations of oral or dental infections × 1.5 years). Results: In the pre-COVID group, we identified 32 of 1,301 patients with LA for an incidence of 0.02 per year. The COVID-onset group consisted of 41 of 641 patients, with an incidence of 0.04 per year. In the COVID-onset group, progression to necrotizing fasciitis was more likely (0% vs. 15%; p < 0.024), and they returned to the operating room for repeated debridement (3% vs. 22%; p < 0.020). Likewise, hospital length of stay, intensive care unit (ICU) length of stay, and ventilator days were higher (4.3 ± 3.5 vs. 9.5 ± 11.3; 1.1 ± 1.2 vs. 9.5 ± 7.1; 0.3 ± 1 vs. 3.6 ± 7.1; p < 0.001). Conclusions: Although the prognosis for dental infections diagnosed early is generally favorable, we observed a notable increase in the incidence of LA after the onset of the COVID-19 pandemic. Moreover, complications stemming from these infections became more severe in the COVID-onset era. Specifically, the likelihood of necrotizing fasciitis showed a substantial increase, accompanied by an increased risk of respiratory failure and mediastinitis.

Ludwig's angina and acute myocardial infarction: A case report

Ludwig's angina was first described in 1839 by German physician, Wilhelm Frederick Von Ludwig as a rapidly and fatal progressive gangrenous cellulitis and edema of the soft tissues of the neck and floor of the mouth with rapid spread to other places like anterior mediastinum. However, Type 2 acute myocardial infarction (MI) due to Ludwig's angina has not been documented. A 62-year-old male presented to the emergency department with visible anterior neck swelling for 1 week, which was preceded by a tooth arch 1 week prior, the patient presented with a high grade fevers, dysphonia, dysphagia, and facial swelling. No history of trauma. He reported in the past 24 h prior to evaluation, a steady progression of pain intensity with rapid progression and anterior neck skin erythema and swelling. The pain was exacerbated by rotation of the neck, tongue protrusion, and speaking. On examination, there was a visible anterior neck swelling measuring 10.0 × 3.0 cm in widest dimensions, exquisitely tender to palpation with a positive temperature gradient, skin hyperpigmentation and firm in consistency, no crepitus, fluctuance, or induration. Tongue appeared elevated with sublingual edema and pooling of secretions. No stridor. A chest and neck ultrasound scan revealed an extensive abscisic mass from the submandibular, neck, sternal notch, and right clavicular region with the largest pockets measuring 2.11 × 0.8 cm, 2.03 × 0.62 cm, 1.50 × 1.1 cm, with noted submandibular, subclavicular and deep and superficial cervical lymph nodes, the largest measuring 1.23 × 1.63 cm in dimensions. A neck-CT scan with contrast revealed a pronounced subcutaneous tissue localized collection extending to both submandibular spaces measuring about 5.5 × 12.5 × 9.5 cm with mural enhancement. The upper chest cuts showed moderate pleural effusions and a paracardial hypodense well-defined lesion measuring 7.5 × 2.5 cm with mild pericardial effusion. The patient was referred to the ear, neck and throat, ENT surgeon for urgent drainage of the abscess, which was done successfully and about 300 mL of hemorrhagic pus was drained. Then transferred to highly dependent unit, (HDU) for IV antibiotic administration and vital observations, prior to that electrocardiogram, ECG showed a normal sinus rhythm. The following day in HDU, the patient started experiencing a chest pain of sudden onset radiating to the upper jaws, left forearm and throbbing in nature, palpitations and started becoming diaphoretic. Blood pressure was 150/70 mmgh and pulse of 120 bpm. ECG readings demonstrated ST-elevation, at lead 11, V2, and V3, cardiac Troponin I and CK-MB were elevated 10.0 ng/mL, (<0.4 ng/mL) and 150.0 IU/L, (5-25 IU/L) respectively. The patient was started on medications to relief acute ischemic pain these included, sublingual nitroglycerin 0.6 mg, morphine 5 mg intravenous slowly, antithrombotic, and beta-adrenergic blockade. He was kept in HDU later with heparin 80 U/kg bolus and 8 U/kg continuous infusion and was taken for coronary angiogram which demonstrated no any coronary artery occlusion. The patient later on started to register improvement and later discharged on medications for follow-up. On follow-up, the subsequent ECG showed persistent atrial fibrillation and patient was discharged on P2Y12 inhibitor, clopidogrel, 75 mg, and beta-blocker, metoprolol 50 mg. Over the past three decades, mortality rates for acute MI have increased significantly, One common subtype, type 2 MI is noted and driven by a myocardial oxygen supply and demand mismatch in the absence of coronary thrombosis. T2MI can occur with or without obstructive coronary disease like in this patients with angiographically normal coronary arteries. T2MI is increasingly recognized because of various septic pathophyisologies that cause increased myocardia oxygen demand. Evidence of myocardial ischemia especially those with sepsis are likely to develop myocardial injury. T2MI is frequent and explains a significant increase in clinical practice. A consensus is needed about how the diagnosis is established, to facilitate evidence-based therapies geared toward improving outcomes.

Pancreatitis with infected pseudocyst presenting as a prevertebral abscess with spontaneous rupture into the oesophagus

The development of a prevertebral abscess due to an infected pancreatic pseudocyst and its spontaneous rupture into the oesophagus is a rare complication. We report a man who presented with odynophagia, dyspnoea and abdominal pain. Contrast-enhanced CT showed evidence of pancreatitis and a prevertebral space abscess communicating with the pancreas through the oesophageal hiatus. The patient was diagnosed to have a prevertebral abscess with chronic pancreatitis. Surgical drainage was planned, but the patient died of spontaneous drainage of the prevertebral abscess into the oesophagus and aspiration of the collection into the lungs.

Antibiotic resistance of the bacterial spectrum of deep space head and neck infections in oral and maxillofacial surgery - a retrospective study

OBJECTIVES

The aim of this study was to evaluate the current resistance situation concerning routinely used antibiotics for treatment in odontogenic abscesses.

MATERIALS AND METHODS

This retrospective study assessed patients with deep space head and neck infections who were treated by surgical intervention under general anesthesia at our department. The target parameter was the ascertainment of the resistance rates in order to identify the bacterial spectrum, sites in the body, length of inpatient stay, and the age and sex of the patients.

RESULTS

A total of 539 patients, 268 (49.7%) males and 271 (50.3%) females were included in the study. The mean age was 36.5 ± 22.1 years. There was no significant difference between the two sexes with regard to the mean duration of hospitalization (p = 0.574). The predominant bacteria in the aerobic spectrum were streptococci of the viridans group and staphylococci, in the anaerobic spectrum Prevotella and Propionibacteria spp. Rates of resistance to clindamycin were between 34 and 47% in both the facultative and obligate anaerobic spectrum. Increased resistance was likewise found in the facultative anaerobic spectrum, with 94% resistance to ampicillin and 45% to erythromycin.

CONCLUSION

Due to the increasing levels of resistance to clindamycin, their use in empiric antibiotic treatment for deep space head and neck infections should be viewed critically.

CLINICAL RELEVANCE

Resistance rates continue to increase compared to previous studies. The use of these antibiotic groups in patients with a penicillin allergy needs to be called into question and alternative medications sought.

Pediatric Cervicofacial Necrotizing Fasciitis-A Challenge for a Medical Team

Cervical necrotizing fasciitis is a very rare complication of a bacterial infection that can have a dental cause. This type of infection typically affects fascial plane, which has a poor blood supply and can affect soft tissue and cervical fascia and can spread quickly causing infection of mediastinum. Initially, in the first stage, the overlying tissues are unaffected, and this can delay diagnosis and surgical intervention. Incidence in children is extremely rare and can be frequently associated with various other general pathologies that decrease the immune system response. We present a case of a young 12-year-old boy diagnosed with this type of infection in the head and neck as a complication of a second inferior molar pericoronitis. The treatment and the management of the case was difficult not only due to the presence of the infection but also because of the prolonged intubation.

Impact of Treatment on Systemic Immune-Inflammatory Index and Other Inflammatory Markers in Odontogenic Cervicofacial Phlegmon Cases: A Retrospective Study

Cervicofacial odontogenic infections can have an aggressive evolution with life-threatening complications. Management in many cases can be a challenge for clinicians, implying an extra focus on individual inflammatory parameters. The aim of this study is to evaluate the evolution of inflammatory markers for the included diagnosed odontogenic cervicofacial phlegmon cases at the moment of hospitalization and after receiving surgical and pharmaceutical treatment.

MATERIALS AND METHODS

A total of 39 patients diagnosed with odontogenic cervicofacial phlegmons that were admitted to the Maxillofacial Surgery Department of the Emergency Hospital from Timisoara were included in the study. The main focus was the parameters represented by the systemic immune-inflammatory index (SII) based on neutrophil, platelet, and lymphocytes count; the neutrophil-lymphocyte ratio (NLR); C-reactive protein level (CRP); and white blood cell count (WBC) before and after the treatment as potential prognosis factors.

RESULTS

The results of the study after analyzing the included parameters revealed a significant difference between the calculated values of the SII, NLR, CRP, and WBC at admission and at time of discharge, being directly influenced by the treatment.

CONCLUSIONS

SII, NLR, CRP, and WBC dynamic changes in severe cervicofacial odontogenic infections can be influenced by receiving accurate surgical and pharmacological treatment, with the potential to become future severity prognosis indexes.

Clinical Profile and Outcome of Head and Neck Abscesses in 68 Patients at a Tertiary Care Centre

An abscess in head and neck region causes life threatening complications which may result in death. Because of challenging early recognition and wide range of its presenting features the present study was carried out to study in detail the clinico- demographic profile of the patients with head and neck abscesses. An observational cross sectional study was carried out on 68 cases of head and neck abscesses in a tertiary care center in Maharashtra. Out of 68 cases, 43(63.23%) were males and 25(36.77%) were females. Around 57% of the cases were in the age group of 11 to 40 years. 36(52.94%) cases had abscesses in the neck region while 32(47.06%) cases had it in the head region. Majority of the cases were of submandibular abscesses (18; 26.47%) followed by mastoid abscess (11;16.18%), Ludwig's angina (9;13.24%) and others. Most common etiology was odontogenic in origin (24; 35.29%) followed by otogenic (23; 33.82%). Pain and swelling (56; 82.35%) were the most common presenting features followed by fever (32, 47.06%) and others. 25% cases had history of diabetes mallitus. Incision and drainage was the most common mode of treatment used. Majority abscesses can be treated successfully by incision and drainage with the cover of antibiotics. Diabetic cases of abscesses can be managed successfully without any complications or prolonged hospital stay with good sugar control.

The assessment and management of deep neck space infections in adults: A systematic review and qualitative evidence synthesis

OBJECTIVES

To summarise current practices in the diagnosis and management of deep neck space infections (DNSIs). To inform future studies in developing a framework in the management of DNSIs.

DESIGN

This review was registered on PROSPERO (CRD42021226449) and reported in line with PRISMA guidelines. All studies from 2000 that reported the investigation or management of DNSI were included. The search was limited to English language only. Databases searched included AMED, Embase, Medline and HMIC. Quantitative analysis was undertaken with descriptive statistics and frequency synthesis with two independent reviewers. A qualitative narrative synthesis was conducted using a thematic analysis approach.

SETTING

Secondary or tertiary care centres that undertook management of DNSIs.

PARTICIPANTS

All adult patients with a DNSI.

MAIN OUTCOME MEASURES

The role of imaging, radiologically guided aspiration and surgical drainage in DNSIs.

RESULTS

Sixty studies were reviewed. Thirty-one studies reported on imaging modality, 51 studies reported treatment modality. Aside from a single randomised controlled trial, all other studies were observational (n = 25) or case series (n = 36). Computer tomography (CT) was used to diagnose DNSI in 78% of patients. The mean percentage of management with open surgical drainage was 81% and 29.4% for radiologically guided aspiration, respectively. Qualitative analysis identified seven major themes on DNSI.

CONCLUSIONS

There are limited methodologically rigorous studies investigating DNSIs. CT imaging was the most used imaging modality. Surgical drainage was commonest treatment choice. Areas of further research on epidemiology, reporting guidelines and management are required.

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.

Advanced imaging of head and neck infections

When head and neck infection is suspected, appropriate imaging contributes to treatment decisions and prognosis. While contrast-enhanced CT is the standard imaging modality for evaluating head and neck infections, MRI can better characterize the skull base, intracranial involvement, and osteomyelitis, implying that these are complementary techniques for a comprehensive assessment. Both CT and MRI are useful in the evaluation of abscesses and thrombophlebitis, while MRI is especially useful in the evaluation of intracranial inflammatory spread/abscess formation, differentiation of abscess from other conditions, evaluation of the presence and activity of inflammation and osteomyelitis, evaluation of mastoid extension in middle ear cholesteatoma, and evaluation of facial neuritis and labyrinthitis. Apparent diffusion coefficient derived from diffusion-weighted imaging is useful for differential diagnosis and treatment response of head and neck infections in various anatomical sites. Dynamic contrast-enhanced MRI perfusion may be useful in assessing the activity of skull base osteomyelitis. MR bone imaging may be of additional value in evaluating bony structures of the skull base and jaw. Dual-energy CT is helpful in reducing metal artifacts, evaluating deep neck abscess, and detecting salivary stones. Subtraction CT techniques are used to detect progressive bone-destructive changes and to reduce dental amalgam artifacts. This article provides a region-based approach to the imaging evaluation of head and neck infections, using both conventional and advanced imaging techniques.

Deep Neck Space Infections: Current Trends and Intricacies of Management?

This study aims to describe the current epidemiological and etiological trends for deep neck space infections (DNIs) with an objective to understand the intricacies of their management. In this retrospective analytical study records of 52 patients with DNIs were reviewed. Patients having superficial abscess, peritonsillar abscess and abscess due to trauma/surgical procedure were excluded. Various epidemiological and etiological parameters (Demography, site, presentation, etiology, association with co-morbidities, bacteriology) and management guidelines (need for surgical interventions for DNIs and airway management, hospital stay duration, treatment outcome and complications) were reviewed and analyzed. Study recorded preponderance of DNIs in males (male:female = 1.6:1) and in younger generation (50% of patients presenting in first 2 decades). Commonest etiology being odontogenic infections (38.46%) followed by URTIs and tonsillopharyngitis (19.23%). Submandibular space involvement was noted in 42.3% cases followed by parapharyngeal space involvement in 21.15%. Nearly 55% cases of submandibular space involvement were because of odontogenic causes. 69.23% culture specimens reported no growth. 61.53% patients were diagnosed with anaemia. Up to 80% required open surgical drainage. All received broad spectrum antibiotics as a starting regime. No severe complications were recorded. Understanding the current epidemiological and etiological trends can help in early and definitive diagnosis of DNIs. Empirical starting treatment regime including broad spectrum antibiotics (till sensitivity pattern is availed) and maintaining low threshold for required surgical intervention are required to manage DNIs satisfactorily. Selected cases should be given conservative trials with close monitoring.

Management of deep neck infections in adults and importance of clinical and laboratory findings

This study aimed to analyze laboratory and radiological imaging results in the prediction of treatment strategy in patients with deep neck infections. Eighty-three patients (55 (66.3%) men, mean age: 38.2±14.5 years) were included in the study. Patients were divided into three groups according to the treatment strategy: group 1 received only antibiotic treatment, group 2 underwent abscess drainage with needle puncture in addition to antibiotic treatment, and group 3 underwent surgical drainage with antibiotic treatment. Laboratory outcomes, imaging methods, duration of hospital stay, treatment strategy, and clinical outcomes were analyzed.According to the laboratory results, complete blood count values did not vary among the three groups, but C reactive protein (CRP) and erythrocyte sedimentation rate (ESR) values were higher in group 3 (p<0.01). Based on receiver operating characteristic (ROC) analysis, the cut-off levels for CRP and ESR associated with the need for surgical drainage were 133 mg/L and 42.5, respectively. According to radiological imaging results, the number of involved neck spaces was significantly different among the three groups (p=0.03), and group 3 had more spaces involved when compared with groups 1 and 2 (p=0.04). Gas formation in the neck tissues was noted in 10 patients in group 3 and 5 patients in groups 1 and 2 (p=0.02). ESR and CRP levels were higher in patients who underwent surgical drainage. In patients with deep neck space infections, the involvement of two or more neck spaces and gas formation on radiological images might indicate surgical drainage as a treatment strategy.

The Efficacy of Pyogenic Cavity Aerobic Therapy with Negative Pressure Drainage in the Treatment of Deep Neck Space Infections

Objective

To determine the effectiveness of pyogenic cavity aerobic therapy with negative pressure drainage in the treatment of deep neck space infections (DNSI).

Methods

The study was a prospective, observational analysis of 36 cases of DNSI at a tertiary care center. The patients were divided into two groups according to the treatment method. Group A was treated with pyogenic cavity aerobic therapy with negative pressure drainage and included 13 patients (6 males and 7 females), while group B was treated with traditional incision debridement drainage and included 23 patients (12 males and 11 females). The average hospitalization days and doctors’ workload (ie, average days of postoperative dressing changes) were analyzed and compared between the two groups.

Results

The mean hospitalization days in the traditional dressing group were 26.74 ± 3.39 days, while the average days of postoperative dressing change were 25.91 ± 3.43 days. In contrast, the averages for hospitalization days and days of postoperative dressing changes in the pyogenic cavity aerobic therapy plus negative pressure drainage were 11.08 ± 2.11 and 3.69 ± 0.21 days, respectively. All 36 patients were cured. Compared with the group B, group A had a shorter hospital stays and lower doctor workloads (P < 0.001).

Conclusion

Pyogenic cavity aerobic therapy is an effective and simple method for changing dressings after DNSI. This therapy, when combined with negative pressure drainage, shortens hospitalization days and days that require a dressing change. This has reduced the workload of clinical doctors and pain experienced by patients. This therapy also has a high degree of safety and a very satisfactory curative effect.

The Pathogenic Bacteria of Deep Neck Infection in Patients with Type 1 Diabetes, Type 2 Diabetes, and Without Diabetes from Chang Gung Research Database

Deep neck infection (DNI) is a lethal emergent condition. Patients with types 1 and 2 diabetes mellitus (T1DM and T2DM, respectively) are predisposed to DNI and have poorer prognoses. The mainstay of the treatment is surgical drainage and antibiotics; however, the pathogenic bacteria of T1DM-DNI have not been studied before. We obtained the data of 8237 patients with DNI who were hospitalized from 2004 to 2015 from the Chang Gung Research Database, which contains multi-institutional medical records in Taiwan. Using diagnostic codes, we classified them into T1DM-DNI, T2DM-DNI, and non-DM-DNI and analyzed their pathogenic bacteria, disease severity, treatment, and prognosis. The top three facultative anaerobic or aerobic bacteria of T1DM-DNI were Klebsiella pneumoniae (KP, 40.0%), Viridans Streptococci (VS, 22.2%), and methicillin-sensitive Staphylococcus aureus (MSSA, 8.9%), similar for T2DM (KP, 32.2%; VS, 23.3%; MSSA, 9.5%). For non-DM-DNI, it was VS (34.6%), KP (9.8%), and coagulase-negative Staphylococci (8.7%). The order of anaerobes for the three groups was Peptostreptococcus micros, Prevotella intermedia, and Peptostreptococcus anaerobius. Patients with T1DM-DNI and T2DM-DNI had higher white blood cell (WBC) counts and C-reactive protein (CRP) levels, more cases of surgery, more cases of tracheostomy, longer hospital stays, more mediastinal complications, and higher mortality rates than those without DM-DNI. Patients in the death subgroup in T1DM-DNI had higher WBC counts, band forms, and CRP levels than those in the survival subgroup. Patients with DM-DNI had more severe disease and higher mortality rate than those without DM-DNI. KP and Peptostreptococcus micros are the leading pathogens for both patients with T1DM-DNI and those with T2DM-DNI. Clinicians should beware of high serum levels of infection markers, which indicate potential mortality.

Prognostic factors for descending necrotizing mediastinitis development in deep space neck infections-a retrospective study

OBJECTIVES

Descending necrotizing mediastinitis (DNM) is the most serious complication of deep neck infections (DNI). The objective of this retrospective study was to evaluate prognostic factors for DNM development in deep space neck infections.

METHODS

The study enrolled patients admitted to the Emergency Center of Vojvodina with the diagnosis of multispace DNI with or without DNM either as the primary diagnosis or with discharged diagnosis after surgical treatment during 7-year period. The data were obtained from patient medical records.

RESULTS

After final analysis total of 141 charts were randomized for statystical analysis, 124 charts in DNI and 17 in DNI + DNM groups. The most common cause of infection in both groups was odontogenic. On multivariate regression analysis of collected data infection of retropharyngeal, pretracheal and carotid space, C-reactive protein and procalcitonine values were statistically significant predictors for DNM development.

CONCLUSIONS

Treatment and diagnosis of DNM requires multidisciplinary approach, with prompt clinical and radiological examinations, empirical broad spectrum antibiotic therapy and radical surgical debridement. Multispace neck infection and especially infection of retropharyngeal, carotid and pretracheal spaces are the most sensitive predictors for DNM development in deep space neck infections.

CLINICAL RELEVANCE

If the infection from deep neck spaces reach retropharyngeal, carotid or pretracheal space, the DNM is probable to occur.

TRIAL REGISTRATION

ClinicalTrials.gov ID NCT04865003. Date of registration 27.4.2021.

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.

Deep Neck Infections: Demographic and Clinical Factors Associated with Poor Outcomes

INTRODUCTION

Deep neck infections (DNIs) are abscesses located in the profound spaces of the neck and constitute one of the most common otolaryngological life-threatening emergencies. The aim of this study is to review the clinical and demographic data of patients with DNI and identify factors associated with prolonged hospitalization, reoperation, and mortality.

METHODS

Retrospective review and analysis of 75 patients with DNI admitted from January 2015 to December 2019 in a tertiary referral hospital.

RESULTS

Of 75 patients, 50 (66.6%) were males and 25 (33.3%) females. Age ranged from 18 to 91 years with a mean of 41.79 (±15.48). DNIs were odontogenic in 49 patients (65.3%). History of diabetes mellitus (DM) was positive in 26 patients (34.6%). The submandibular space was involved in 57 patients (76%). Streptococcus spp. were isolated in 35 patients (46%). Intubation for airway preservation was needed in 21 patients (28%) and tracheostomy in 6 (8%). Mediastinitis presented in 8 patients (10.67%), with a mortality rate of 62.5% (n = 5). Mean hospital stay was 9.13 days (±7.2). DM (p = 0.016), age (p = 0.001), BMI classification 3, 4, and 6 (p = 0.041), and intensive care unit (ICU) admission (p = 0.009) were associated with a longer stay. Surgical drainage was performed after 1.71 days (±1.65). Surgical reintervention was needed in 6 cases (8%) and was associated with temporal (p = 0.001) and masticator (p = 0.002) space involvement and DM (p = 0.009). Overall mortality was 8% and decreased to 1.5% when mediastinitis was excluded. Mediastinitis (p = 0.001), ICU admission (p < 0.0001), Streptococcus spp. (p = 0.019), and low hemoglobin levels (p = 0.004) were associated with mortality.

DISCUSSION/CONCLUSION

DNIs are entities associated with high morbimortality. Mediastinitis and airway obstruction are life-threatening possible complications and should be promptly evaluated. Low HB could be used as a predicting factor for mortality.

Deep neck infections with and without mediastinal involvement: treatment and outcome in 218 patients

Purpose

Infections of the deep neck, although becoming scarcer due to the widespread use of antibiotics, still represent a dangerous and possibly deadly disease, especially when descending into the mediastinum. Due to the different specialities involved in the treatment and the heterogenous presentation of the disease, therapeutic standard is still controversial. This study analyzes treatment and outcome in these patients based on a large retrospective review and proposes a therapeutic algorithm.

Methods

The cases of 218 adult patients treated with deep neck abscesses over a 10-year period at a tertiary university hospital were analyzed retrospectively. Clinical, radiological, microbiological and laboratory findings were compared between patients with and without mediastinal involvement.

Results

Forty-five patients (20.64%) presented with abscess formation descending into the mediastinum. Those patients had significantly (all items p < 0.0001) higher rates of surgical interventions (4.27 vs. 1.11) and tracheotomies (82% vs. 3.4%), higher markers of inflammation (CRP 26.09 vs. 10.41 mg/dl), required more CT-scans (3.58 vs. 0.85), longer hospitalization (39.78 vs 9.79 days) and more frequently needed a change in antibiotic therapy (44.44% vs. 6.40%). Multi-resistant pathogens were found in 6.67% vs. 1.16%. Overall mortality rate was low with 1.83%.

Conclusion

Despite of the high percentage of mediastinal involvement in the present patient collective, the proposed therapeutic algorithm resulted in a low mortality rate. Frequent CT-scans, regular planned surgical revisions with local drainage and lavage, as well as an early tracheotomy seem to be most beneficial regarding the outcome.

Risk of Postoperative Bleeding in Tonsillectomy for Peritonsillar Abscess, as Opposed to in Recurrent and Chronic Tonsillitis-A Retrospective Study

Tonsillectomy is a routine surgery in otorhinolaryngology and the occurrence of postoperative bleeding is not a rare complication. The aim of this retrospective, observational, analytic, cohort study is to compare the incidence of this complication for the most common indications. A group of patients indicated for tonsillectomies for peritonsillar abscess (group I) was compared to a group of patients indicated for chronic and recurrent tonsillitis (group II). There are a lot of pathophysiological differences in patients indicated for acute tonsillectomy for peritonsillar abscess and in patients indicated for elective tonsillectomy for chronic or recurrent tonsillitis. No technique to minimize the risk of bleeding after tonsillectomy has been found and a large part of postoperative bleeding occurs in postoperative home-care, which makes this issue topical. In total, 2842 unilateral tonsillectomies from the years 2014–2019 were included in the study. Bleeding occurred in 10.03% and, surprisingly, despite completely different conditions in the field of surgery (oedema, acute inflammation in peritonsillar abscess), there was no statistically significant difference between incidence of postoperative bleeding in the studied groups (p = 0.9920). The highest incidence of bleeding was found in the patients of group I on the eighth postoperative day, with those aged 20–24 years (p = 0.0235) being the most at risk, and in group II, on the sixth postoperative day, with those aged 25–29 years (p = 0.0128) and 45–49 years (p = 0.0249) being the most at risk.

Experiential learning in simulated parapharyngeal abscess in breathing cadavers

Purpose

Education in airway management is a fundamental component of anesthesiology training programs. There has been a shift towards the use of simulation models of higher fidelity for education in airway management. The goal of this study was to create a novel cadaveric model of a simulated parapharyngeal abscess with features of a difficult airway such as distorted anatomy and narrow airway passages presenting as stridor. The model was further assessed for its suitability for enhanced experiential learning in the management of difficult airways.

Methods

Cadaver heads were modified surgically to simulate parapharyngeal abscess. Airtight torso of the cadaver was connected to an Oxylog ventilator to simulate respiratory movements—the opening and closing of air channels with breaths in a patient with parapharyngeal abscess. Advanced airway workshop facilitators conducted directed one-to-one learning, and provided feedback to participants. A paper-based feedback was obtained from 72 participants on their confidence level, and the realism, attractiveness, beneficial, and difficulty levels of the simulated cadaveric models.

Results

The modified cadavers were reliable in simulating difficult airways. The majority of participants (91%) reported an increase in confidence level for management of the difficult airway after the experience with the modified cadavers and found the models realistic (93%), attractive (92%), beneficial (93%), and difficult (85%).

Conclusions

Surgical modifications of cadavers to simulate difficult airways such as parapharyngeal abscess with edema and stridor can be incorporated into advanced airway management courses to enhance experiential learning in airway management by awake fibreoptic intubation, and promote patient safety.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00540-021-02904-0.

Diagnostic Performance of Different Simulated Low-Dose Levels in Patients with Suspected Cervical Abscess Using a Third-Generation Dual-Source CT Scanner

The aim of this study was to investigate the effects of dose reduction on diagnostic accuracy and image quality of cervical computed tomography (CT) in patients with suspected cervical abscess. Forty-eight patients (mean age 45.5 years) received a CT for suspected cervical abscess. Low-dose CT (LDCT) datasets with 25%, 50%, and 75% of the original dose were generated with a realistic simulation. The image data were reconstructed with filtered back projection (FBP) and with advanced modeled iterative reconstruction (ADMIRE) (strengths 3 and 5). A five-point Likert scale was used to assess subjective image quality and diagnostic confidence. The signal-to-noise ratio (SNR) of the sternocleidomastoid muscle and submandibular gland and the contrast-to-noise ratio (CNR) of the sternocleidomastoid muscle and submandibular glandular fat were calculated to assess the objective image quality. Diagnostic accuracy was calculated for LDCT using the original dose as the reference standard. The prevalence of cervical abscesses was high (72.9%) in the cohort; the mean effective dose for all 48 scans was 1.8 ± 0.8 mSv. Sternocleidomastoid and submandibular SNR and sternocleidomastoid muscle fat and submandibular gland fat CNR increased with higher doses and were significantly higher for ADMIRE compared to FBP, with the best results in ADMIRE 5 (all p < 0.001). Subjective image quality was highest for ADMIRE 5 at 75% and lowest for FBP at 25% of the original dose (p < 0.001). Diagnostic confidence was highest for ADMIRE 5 at 75% and lowest for FBP at 25% (p < 0.001). Patient-based diagnostic accuracy was high for all LDCT datasets, down to 25% for ADMIRE 3 and 5 (sensitivity: 100%; specificity: 100%) and lower for FBP at 25% dose reduction (sensitivity: 88.6-94.3%; specificity: 92.3-100%). The use of a modern dual-source CT of the third generation and iterative reconstruction allows a reduction in the radiation dose to 25% (0.5 mSv) of the original dose with the same diagnostic accuracy for the assessment of neck abscesses.

18F-fluorodeoxyglucose positron emission tomography/computed tomography findings in descending necrotizing mediastinitis and cervical vertebral osteomyelitis in a cancer patient: A case report

RATIONALE

A deep neck infection (DNI) with descending necrotizing mediastinitis (DNM) has great clinical importance because of its high morbidity and mortality, particularly when associated with predisposing underlying disease. With the expanding clinical use of F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT), it may be necessary to perform FDG PET/CT for immediate diagnosis and treatment of DNM. To the best of our knowledge, this is the first case report of DNI with DNM diagnosed based on FDG PET/CT findings.

PATIENT CONCERNS

A 65-year-old man who underwent chemotherapy for stage IV lung cancer complained of sore throat, fever, and mild pain in the right upper arm for 4 days before admission.

DIAGNOSES

FDG PET/CT revealed retropharyngeal abscess with acute osteomyelitis of the vertebral bodies of C4 and C5 and DNM. In blood and sputum cultures, Klebsiella pneumoniae was isolated. DNI with DNM was diagnosed based on contrast-enhanced neck and chest CT.

INTERVENTIONS AND OUTCOME

Because of his underlying condition, antibiotic therapy with ceftriaxone and ciprofloxacin was started. There was initial improvement, but the patient died after 2 weeks from sepsis and multiorgan failure.

LESSONS

The findings of DNI with DNM on FDG PET/CT were as follows: as an acute infection, DNM showed more severe uptake relative to the average maximum standardized uptake value of brown fat or physiologic muscle; showed the prevertebral uptake pattern rather than the paravertebral uptake pattern of brown fat; and showed continuous patterns of hypermetabolic lesions from the retropharyngeal/parapharyngeal space to the thoracic prevertebral space.

Negative pressure drainage-assisted irrigation for maxillofacial space infection

OBJECTIVE

In this study, the clinical effect of negative pressure drainage-assisted irrigation (NPDI) technique was evaluated in treating maxillofacial space infection (MSI) by comparing with traditional technique.

METHOD

A prospective study was conducted in 58 patients with MSI. The patients were randomly divided into two groups based on different treatment techniques. Thirty patients receiving NPDI were included in NPDI group, and 28 patients receiving traditional technique were included in traditional group. Case data (gender, age, etiology, concurrent illness, diabetes, involved spaces, preoperative white cell count, airway control method) and clinical effect (postoperative hospital stay, total cost of admission) for the two groups were analyzed.

RESULTS

Patients in both groups were cured clinically. There were no significant differences in gender, age, etiology, concurrent illness, diabetes, involved spaces, preoperative white cell count, and airway control method in NPDI group and traditional group (p > .05). The postoperative hospital stay and the total cost of admission in the NPDI group were significantly lower than the traditional group (p < .001).

CONCLUSION

Negative pressure drainage-assisted irrigation used in the treatment of MSI can shorten the postoperative hospital stay, reduce the total cost of admission, and show favorably clinical effect. It is a clinically recommended method for MSI.

Spontaneous, Non-Traumatic Retropharyngeal Abscess Complicated by Spinal Osteomyelitis and Epidural Abscess in Immunocompetent Adult: Management and Proposal Pathophysiological Mechanism

Retropharyngeal abscess (RPA) in adults is a potentially life-threatening condition that relates in most of the cases with local trauma. Non-traumatic RPA complicated by spinal osteomyelitis and epidural abscess is a rare entity in immunocompetent adults and represents an emergency medical condition when the patient develops neurologic symptoms. This article presents a case of non-traumatic RPA complicated by spinal osteomyelitis and epidural abscess in a 77-year-old male with the free past medical history. We highlight the importance of early and meticulous daily drainage as well as sequential MRI scanning for early diagnosis, treatment and follow-up for signs of vertebral involvement. The patient had a full recovery and was subsequently discharged with per os four-month antibiotic treatment. The definitive mechanism is unclear for non-traumatic cases with “hematogenous path” being the closest description. Spontaneous RPA can develop from bacteria infection spread of adjacent structures, local inflammatory process and microthrombosis formation can impair the blood supply of vertebral and intervertebral disks.

Epidemiological and Microbiological Aspects of the Peritonsillar Abscess

Peritonsillar abscess (PTA) is the most common complication of tonsillitis. Cultivation usually reveals a wide spectrum of aerobic and anaerobic microbiota. This retrospective study compared PTA incidence and the spectrum of individual microbial findings in groups of patients divided by gender, age, and season. Of the 966 samples cultivated, a positive cultivation finding was detected in 606 patients (62.73%). Cultivation findings were negative in 360 (37.27%), meaning no pathogen was present or only common microbiota was cultivated. The highest incidence of PTA was found in group I patients (19–50 years) (p ≤ 0.0001) and the most frequently cultured pathogens was Streptococcus pyogenes (36.23%). Gender seemed to have an influence on the results, with higher incidence found in males (p ≤ 0.0001). The analysis of correlation between PTA incidence and season did not yield statistically significant results (p = 0.4396) and no statistically significant differences were observed in individual pathogen frequency. PTA had a higher incidence in adult males and a slightly higher incidence in girls in childhood. The following findings are clinically significant and have implications for antibiotic treatment strategy: (1) the most frequently cultivated pathogen was Streptococcus pyogenes; (2) an increased incidence of anaerobes was proven in the oldest group (>50 years).

Retropharyngeal Abscess. Clinical Review of Twenty-five Years

INTRODUCTION

Retropharyngeal abscess is a serious condition. Its rare occurrence, thus sharing symptoms with other processes, make it a diagnostic challenge for the clinician. Therefore, it is critical to make an early diagnosis to prevent delaying treatment and avoid complications.

OBJECTIVES

To gain knowledge of the epidemiology, pathogenesis, clinical manifestations, the most commonly implicated microorganisms, the type of treatment used, morbidity and mortality of retropharyngeal abscesses at a tertiary institution over the last 25 years.

METHODS

A retrospective study was conducted by reviewing medical records of all patients diagnosed with retropharyngeal abscess in a single centre between 1 January 1990 and 31 February 2016. Thirty-three patients were included in our study. Data such as personal history, present illness, diagnoses and treatment procedures were collected from the medical records.

RESULTS

The incidence during the years of study was 0.2 cases/100 000 inhabitants/year. Personal medical histories most often associated were alcoholism, smoking, diabetes and obesity. The most common aetiology found was impaction of a foreign body (especially fishbone). The most common presenting symptoms were odynophagia and neck pain accompanied by fever. Preventive tracheotomy was performed in the initial management of the patient in 9 cases (27%). The most frequent complication was descending necrotizing mediastinitis. Surgical drainage of the abscess was required in 27 patients (82%), especially with external approaches (17 cases). Two patients had sequelae: paralysis of unilateral vocal cord and Horner's syndrome. No mortality was observed in the patients of the study.

CONCLUSION

Retropharyngeal abscesses must be considered medical-surgical emergencies as they are likely to produce serious complications. We must pay attention to the warning symptoms such as odynophagia and cervical pain, associated or otherwise with dyspnoea, stridor, trismus, and neck stiffness. Advances in diagnostic and therapeutic procedures together with advances in critical care have been a key factor in improving the prognosis and mortality of these patients.

Tubercular Retropharyngeal Abscess With Pott's Disease in an Elderly Male Patient

Retropharyngeal abscess (RPA) is a life-threatening emergency due to its potential to cause airway compression. It is rare in the elderly and occurs mostly in immunocompromised patients, or as a complication of instrumentation. We are reporting the case of a 70-year-old male who presented with sudden onset breathing difficulty with a history of dysphagia for three months. The clinical examination revealed a bulge in the posterior pharyngeal wall. A lateral-view radiograph of neck revealed retropharyngeal soft tissue density with carious spine. The patient was successfully treated by trans-oral incision and drainage of the abscess under local anesthesia. Diagnosis of tuberculosis was confirmed by positive acid-fast staining and cartridge-based nucleic acid amplification test (CBNAAT). The patient improved significantly following the initiation of anti-tubercular therapy.

Ludwig's angina and steroid use: A narrative review

BACKGROUND

Ludwig's angina, a rapidly progressive cellulitis causing airway obstruction, has traditionally been managed with antibiotics and surgical intervention. More controversial is the use of steroids in the management of patients with this condition. This article summarizes the literature of steroid use in the management of Ludwig's angina.

METHODS

The study used a narrative review method alongside the PRISMA guidelines for systematic reviews. PubMed, Ovid Medline, Cochrane, and Web of Science were searched for cases of Ludwig's angina with documented steroid use in patient management. Inclusion criteria were articles in the English language with direct patient outcomes. There were 17 articles selected with 31 patient cases.

RESULTS

Most reports of steroid use in Ludwig's angina in the literature are case reports, with one retrospective review, and one letter to the editor. Dexamethasone was the steroid of choice in most cases reviewed. All patient cases reported used antibiotics alongside their steroid use, and 27 out of 31 patient cases required surgery. Most patients recovered with no further sequelae or complications. Three (9.68%) patients suffered mortality due to unrelated causes.

CONCLUSIONS

Primary literature reporting the use of steroids in the management of Ludwig's angina includes few cases. While the role steroids have in these cases remains uncertain, the articles summarized do not suggest an adverse influence, and may suggest a benefit.

A Severe Case of Ludwig's Angina with a Complicated Clinical Course

Ludwig's angina is a cellulitis of the submandibular, sublingual, and submental spaces, which tends to spread rapidly along fascial planes. The most common cause is a dental infection, although any other oropharyngeal infection has the potential to develop into Ludwig's angina. The most feared complication of Ludwig's angina is airway obstruction. Treatment involves early recognition so that an airway can be secured, initiation of antibiotics, and, finally, potential surgical debridement. We describe the case of a 57-year-old male with multiple comorbidities who was seen by a provider three times for dental pain prior to his admission for Ludwig's angina. Upon his index admission, he was found to have Ludwig's angina with impending airway obstruction. He required an emergency surgical airway debridement and extraction of multiple teeth. Although the patient eventually recovered, his hospital stay was prolonged and marked by multiple complications. This case is an example of a severe presentation of Ludwig's angina and the difficulties faced by the medical team in managing this condition. Early recognition and rapid intervention are paramount in the management of this serious condition.

Deep Neck Space Infections: A Retrospective Study of 183 Cases at a Tertiary Hospital

Objective

Our study was performed to identify the clinical findings, risk factors, and complications of deep neck space infections (DNSI) at our center and compare our experience with the experiences of others.

Methods

Retrospectively, 183 cases of DNSI met our inclusion criteria from 2000 to 2018 at King Abdulaziz Medical City (KAMC) in Jeddah, Western Region, Saudi Arabia.

Results

In our study, analysis showed that males are more likely to have DNSI (88.7%). The most common site of infection is the peritonsillar abscess (30.6%). Dental infections were found to be the most common etiological factor for DNSI (42.6%). Streptococcus pyogenes was found to be the most common microorganism (39.3%) followed by Staphylococcus aureus (21.3%). Diabetes and hypertension (45.2% and 23.7%, respectively) are the most commonly associated disorders in patients with DNSI. Extension to another space was the most common complication of DNSI.

Conclusion

Despite the wide usage of antibiotics, DNSI still occur and are life-threatening conditions that need urgent management to avoid unpleasant complications.

Sialolithiasis with abscess: An uncommon presentation of a Ludwig's angina mimic

Sialolithiasis represents the most common issue of the salivary gland, ranging from asymptomatic to airway compromising. In rapidly progressing, completely obstructive salivary stones, the presentation can mimic emergent oropharyngeal diseases, primarily Ludwig's angina. We present a case of a large and obstructive sialolith with abscess whose initial presentation was concerning for Ludwig's angina with impending airway compromise. While a common complaint, emergency providers should be aware of the nefarious presentation of an everyday complaint.

Deep neck space infections: an upward trend and changing characteristics

PURPOSE

This study reviews our experience with deep neck space infections (DNIs) requiring surgical intervention, including cervical necrotizing fasciitis. The aim of the study was to identify predisposing and aggravating factors of the disease and recognize the possible factors that can lead to life-threatening complications and slow down the healing process.

METHODS

We compare the results to previous data from 1985 to 2005 to find possible alterations and changing trends. The characteristics of four lethal cases are described. This retrospective analysis includes patient data from 2004 to 2015 in tertiary referral hospital and in total, 277 patients were found.

RESULTS

Surgical drainage through a neck opening ± intraoral incision was made in 215 (77.6%) patients, an intraoral incision was only made in 62 patients (22.4%). ICU care was needed in 66 (23.8%) cases. Odontogenic etiology (44.8%) was the most common origin. The most common comorbidity was a psychiatric disorder and/or dementia and occurred in 55 (19.9%) patients. Patients with underlying illnesses were more likely to be admitted to the ICU (p = 0.020), required a longer ICU stay (p = 0.004) and repeated surgery (p = 0.009). Gas formation seemed to be predictive of a more severe course of infection. Early extraction of the odontogenic foci was related to a lower length of stay (LOS) (p = 0.039).

CONCLUSION

The annual numbers have risen from 14 to 24 cases per year when compared to previous data. DNIs remain a cause of lethal complications; the mortality was 1.4% and overall complications occurred in 61 (22.0%) patients.

An intubated 7-month-old infant with a retropharyngeal abscess and multidrug-resistant Streptococcus mitis

The profile of antimicrobial resistance (ie, antibiogram) may be disparate between children and adults. An infant developed severe deep neck infection with a multidrug-resistant microbe. The microbe was more drug-resistant in children than in adults, in our hospital. Treatment of a child should be guided by the antibiogram obtained from children.

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.

A Perspective of Clinical Behaviour and Management of Deep Neck Space Infections (DNSI): The Clinical Conundrum

The diagnosis and management of deep neck space infections remain a challenging task for otolaryngologists. A retrospective observational analysis of 137 cases of deep neck infections at a tertiary care centre was reviewed. We present 137 treated cases of DNSIs in a retrospective 5 years clinical study conducted in the department of otolaryngology at a tertiary care center from January 2012 to December 2016. Demographic information, Socio-economic data, etiopathogenesis, clinical presentation, spaces involved, diagnosis, and treatment strategies, associated morbidities, course and complications were analysed and compared with past experiences. Odontogenic and salivary gland infections causes were the most common source of DNIs. Major complication observed was skin defect. In this study, submandibular space infection was found to be the most common space involved in DNSI. Pain (100%) was the most common clinical complaint followed by neck swelling (65.69%). Staphylococcus aureus (38 cases) was the most common micro-organism isolated. Surgical intervention was the main modality of treatment and there was one mortality. DNSIs are fairly common challenging and potentially lethal entities which can lead to severe complications in a very short time, should there be delay in its prompt diagnosis and management. Computerized Tomography Scan (CT scan) with contrast is the investigation of choice in diagnosing DNSIs. Assessment of airway control must take precedence.

The Result of Treatment of Deep Neck Infection in Patients Referred According to Public Health System

There are many factors that result in the treatment of deep neck infection (DNI). This study aims to compare the results of DNI treatment between referred and walk-in patients. This retrospective cohort study reviewed the data of 282 DNI patients. The peritonsillar abscesses and limited intraoral abscesses were excluded. The outcome of treatment such as duration of hospital stay, the expense of treatment, morbidity, and mortality were reviewed during staying in the hospital. A total of 282 patients were included in this study, there were 152 referred patients and 130 walk-in patients. Patients who were sent to have treatment results were not significantly different from those who had come directly to the hospital regardless of the length of stay, the cost of medical treatment, complications, and death due to complications with sepsis (P = .013). However, the referred patients exhibited a risk to have sepsis 1.1 times more than the patients who went straight to the medical specialists (univariate analysis risk ratio [RR]: 1.1, 95% confidence interval [CI]: 0.8-1.3; P = .620). The results were confirmed in the multivariate analysis after adjusting for age, gender, diabetes, chronic renal failure, cirrhosis, and dental care. It was found that the risk to have sepsis in the "refer in" group was 1.1 times more than the other group (multivariate analysis RR: 1.1, 95% CI: 0.8-1.3; P = .658). In conclusion, the results of treatment in referred patients were not different from walk-in patients. Deep neck infection patients at hospitals that do not have a specialized doctor will receive appropriate treatment because of the effective DNI referral system according to public health systems. However, in referred patients, sepsis should be maintained prior to delivery.