Acute cervico-facial infection in Scotland 2010: patterns of presentation, patient demographics and recording of systemic involvement

Descending necrotizing mediastinitis: etiopathogenesis, diagnosis, treatment and long-term consequences-a retrospective follow-up study

PURPOSE

The primary aim of this retrospective study was to analyze the progression of descending necrotizing mediastinitis (DNM), evaluate the impact of comorbidities on complications and mortality and to observe long-term consequences of DNM on dysphagia and measurements quality of life. DNM is a serious infectious disease that requires multimodal treatment. Current literature varies in conclusions of risk factors, management and outcome of DNM. In addition, little is known about persisting effects on quality of life.

METHODS

Retrospective data analysis of 88 patients with DNM representing the largest single-center study. Recording data of patients and diseases as well as clinical progression from 1997 to 2018. Two questionnaires were sent to the participants to measure quality of life and to detect dysphagia.

RESULTS

88 patients were included. The most frequently found pathogen were Streptococcus spp. (52%). 75% of the patients underwent multiple surgeries, mean count of surgical procedures was 4.3 times. 84% received intensive care treatment. Median length of stay on the intensive care unit was 7 days. 51% had pre-existing comorbidities associated with reduced tissue oxygenation (e.g., diabetes). The most common complication was pleural effusion (45%). During the observation period, the mortality rate was 9%. 12 questionnaires could be evaluated. 67% of the participants were affected by dysphagia at the time of the survey.

CONCLUSIONS

Descending necrotizing mediastinitis (DNM) is a severe disease requiring an immediate initiation of multimodal treatment. Although quality of life usually isn´t impaired permanently, dysphagia may often persist in patients after DNM.

Predictors and risk factors for admission to critical care in cervicofacial infections: a Maxillofacial Trainee Research Collaborative (MTReC) study

Cervicofacial infections carry significant morbidity. Patients present on a broad spectrum of severity, with some requiring outpatient management and others admission to higher level care. Recognition of risk factors is helpful in decision making regarding the need for admission to higher level care. Prospective data were captured on 1002 patients in 25 centres across 17 regions of the United Kingdom (UK) by the Maxillofacial Trainee Research Collaborative (MTReC). Patients admitted to critical care were compared with those who received ward-level care. Multivariate and receiver operating characteristic curve analyses were used to identify predictors for critical care admission. Our results show that the best predictor for critical care admission is the presence of three or more features of airway compromise (AUC 0.779), followed by C-reactive protein (CRP) >100 mg/L (OR 2.70; 95% CI 1.59 to 4.58; p < 0.005), submandibular space involvement (OR 3.82; 95% CI 1.870 to 7.81; p = 0.003), white cell count (WCC) >12 × 10⁹/ dl (1.05; 95% CI 1.01 to 1.10; p = 0.03), and positive systemic inflammatory response syndrome criteria (OR 2.78; CI 1.35 to 5.80; p = 0.006). Admission to critical care is multifactorial, however, the presence of three or more features of airway compromise is the best predictor. Awareness of this alongside other key clinical findings in cervicofacial infections may allow for the early recognition of patients who may require escalation to critical care.

Clinical features and presentation of cervicofacial infection: a Maxillofacial Trainee Research Collaborative (MTReC) study

Cervicofacial infection (CFI) is a common presentation to the Oral and Maxillofacial (OMFS) department and accounts for significant emergency activity. The current study aims to understand the aetiology, management, and clinical features of patients hospitalised with CFI. Our study included all patients admitted for management of CFI from May to October 2017 at 25 OMFS units across 17 UK regions. Data were collected prospectively and included age, comorbidities, prior treatment received, markers of sepsis, and presenting clinical features. One thousand and two (1002) admissions were recorded; 546 (54.5%) were male. Median (range) age was 34 (1-94) years. The most common presenting complaints were trismus (46%) and dysphagia (27%). Airway compromise was present in 1.7% of cases. Odontogenic infection accounted for 822/1002 (82%) admissions. Of those with an infection of odontogenic origin, 453/822 (55.1%) had received previous treatment. Two-thirds of those who had received treatment were managed by antibiotics alone (300/453, 66.2%). Patients met criteria for sepsis in 437/1002 (43.6%) of CFI, and in 374/822 (45.5%) of odontogenic infections. This is the largest study worldwide of patients requiring inpatient management for CFI. Infection due to odontogenic origin is the most frequent reason for admission and nearly half do not seek treatment before presentation. Patients with CFI often present late in their disease and frequently meet criteria for sepsis, requiring timely and aggressive treatment to ensure optimum outcomes. Trismus is an emerging dominant feature with all the implications related to the anaesthetic management of these patients. Knowledge of these factors has implications for the referrer, triage, the emergency department, the anaesthetic team, and members of the OMFS team.

A review of complications of odontogenic infections

Life-threatening infections of odontogenic or upper airway origin may extend to potential spaces formed by fascial planes of the lower head and upper cervical area. Complications include airway obstruction, mediastinitis, necrotizing fascitis, cavernous sinus thrombosis, sepsis, thoracic empyema, Lemierre's syndrome, cerebral abscess, orbital abscess, and osteomyelitis. The incidence of these “space infections” has been greatly reduced by modern antibiotic therapy. However, serious morbidity and even fatalities continue to occur. This study reviews complications of odontogenic infections. The search done was based on PubMed and Google Scholar, and an extensive published work search was undertaken. Advanced MEDLINE search was performed using the terms “odontogenic infections,” “complications,” and “risk factors.”

Diffuse descending necrotising mediastinitis and pleural empyema secondary to acute odontogenic infection resulting in severe dysphagia

We report a case of acute odontogenic sepsis in a 59-year-old man, presenting with diffuse, descending necrotising mediastinitis complicated by pleural empyema. Despite surviving the odds, his recovery was complicated by severe dysphagia, resulting in gastrostomy feeding for 6 months. Until now, severe dysphagia following descending necrotising mediastinitis has been unreported.