Deep neck abscesses--changing trends

Management of 112 hospitalized patients with spreading odontogenic infections: correlation with DMFT and oral health impact profile 14 indexes

OBJECTIVE

The aim of this study was to report our experience in treating patients affected by spreading odontogenic infections and to discuss their management and outcome.

STUDY DESIGN

Demographic and clinical information was collected from hospitalized patient records. Decayed, missing, and filled teeth (DMFT) index was calculated for 45 randomly selected patients. Statistical analysis was used to search for associations among multiple variables.

RESULTS

Statistical analysis of the variance by univariate test found significant associations between a longer hospital stay and patients >30 years old (P < .05) and patients with the presenting symptoms of dysphagia and/or dyspnea (P < .05). Statistical analysis using Fisher exact test found significant associations between patients with a DMFT index >10 and female patients (P < .05), patients >30 years old (P < .005), and a hospital stay >4 days (P < .0005).

CONCLUSIONS

Rapid resolution of the infection was appreciated when removal of the cause, drainage of the infection, and intravenous antibiotics were performed.

Microflora in maxillofacial infections--a changing scenario?

PURPOSE

Advances in isolation and culturing techniques have brought the role of anaerobic bacteria-causing maxillofacial infections to the fore. Recent literature also favors the role of anaerobes in maxillofacial infections. A prospective clinical and microbiological study was designed to check the validity of such claims.

PATIENTS AND METHODS

This study included 88 patients who fulfilled the inclusion criteria. Pus was obtained by aspirating the involved spaces and culture and sensitivity tests were performed to determine the microbes involved and their sensitivity to various antibiotics.

RESULTS

Upon isolating the various organisms causing infection, it was found that 68.2% were aerobes, 13.6% were mixed infections, and 9.1% were anaerobes. Streptococcus and Peptostreptococcus species were the most common among aerobes and anaerobes, respectively. On determining sensitivity to penicillin, 81.3% were sensitive and 18.8% were resistant. Coagulase-negative Staphylococcus and Staphylococcus aureus were predominantly resistant to penicillin.

CONCLUSION

Analysis of the results indicated no change in microflora-causing infections in the maxillofacial region and penicillin remains the drug of choice in treating these infections.

Deep Neck Infections of Congenital Causes

Objectives. To review cases of deep neck infections with underlying congenital etiology with special emphasis on their clinical presentations and the computed tomographic findings and to discuss the various therapeutic modalities employed for such lesions.

Study Design. Case series with chart review.

Settings. Alexandria University Hospital, Egypt.

Subjects and Methods. The authors retrospectively reviewed the clinical, imaging, and operative records of deep neck infection cases presented to their department in the past 10 years. Deep neck infection cases due to congenital causes were included in the study.

Results. Of the 249 cases of deep neck infections admitted to the authors’ department in the past 10 years, 39 patients were diagnosed with deep neck infections due to congenital causes. Patients were classified into 2 groups. In group 1 (29 patients), computed tomography revealed the presence of infected cystic swelling in the neck that was classified as second branchial cyst (16 patients), third and fourth branchial cysts (8 patients), and thyroglossal cyst (5 patients). Group 2 (10 patients) presented with recurrent attacks of deep neck infection with a history of incision and drainage several times. Radiological and operative findings revealed the presence of congenital pyriform fossa sinus.

Conclusion. Computed tomography is helpful in diagnosing infected congenital cysts and its types. Infected congenital cysts could be excised completely under an umbrella of antibiotics. Recurrence of deep neck infections should alert the physician to the possibility of underlying congenital lesions. Thorough clinical and radiological assessment is mandatory to rule out the possibility of a congenital pyriform fossa sinus.

Extraluminal perforation complicating foreign bodies in the upper aerodigestive tract

OBJECTIVES

Ingestion of a foreign body is a common problem in nearly all otolaryngology practices. One of the uncommon complications of ingested foreign bodies is penetration and migration of the object, which may lead to serious morbidity and/or death. This study will evaluate the presentation, complications, and management of different sites of penetration.

METHODS

We present a retrospective study of a series of 11 patients who presented with a penetrating foreign body of the upper aerodigestive tract in the past 10 years.

RESULTS

All of the patients had radiologic evidence of a foreign body, but negative findings on rigid endoscopy. A computed tomographic scan was done to confirm the presence of a penetrating foreign body. The foreign body was lodged in the extrapharyngeal tissue in 6 patients, was lodged in the upper thyroid pole in 2 patients, had penetrated a Zenker's diverticulum in 2 patients, and had migrated to the thoracic retroesophageal tissue in 1 patient. All patients underwent extraction of the foreign body by an external approach.

CONCLUSIONS

Although the occurrence is rare, impacted foreign bodies in the upper digestive tract can perforate and migrate into the soft tissue of the neck. In the presence of negative findings on endoscopy, a computed tomographic scan of the neck is essential for the prompt diagnosis and management of perforating foreign bodies.

Parapharyngeal abscess in children: five year retrospective study

Lateropharyngeal and retropharyngeal abscesses are potentially life threatening infections in children

Aim

To review the etiologic, clinical, and imaging signs of lateropharyngeal and retropharyngeal abscesses in children as well as treatment-outcomes and complications using a surgical trans-oral approach.

Method

Retrospective analysis of 11 children, hospitalized in the last 5 years, with a diagnosis of lateropharyngeal (n = 8) and retropharyngeal (n = 3) abscesses, ages ranging from 0 to 12 years old. Charts and CT scans were reviewed.

Result

The average age of presentation was 3.3 years. Neck stiffness (64%) and odynophagia (55%) were the most common symptoms. Fever (64%), stiff neck (64%), bulging of the oropharyngeal wall (55%), mass in the neck (55%) and lymphadenopathy (36%) were the most prevalent physical findings. All these patients were submitted to surgical drainage using a trans-oral approach in the first 48 hours after admission. About 82% of the patients showed improvement after 48 hours, and 100% after 72 hours, without any complications.

Conclusion

Based on the good clinical outcomes and low incidence of complications, the present study suggests that antibiotic therapy complemented with a timely surgical treatment, is a valid treatment option in refractory parapharyngeal abscesses.

Changes in admission rates for spreading odontogenic infection resulting from changes in government policy about the dental schedule and remunerations

The government changed the system of payment to general dental practitioners on 1 April 2005 from a fee/item to a banding system. The figures collected have shown that there has been a 62% increase in the number of patients who require admission for surgical treatment of spreading odontogenic infections compared with the 3-year period before this date.

Surgical management of retropharyngeal abscesses

CONCLUSION

Retropharyngeal abscess (RPA) is a rare, potentially life-threatening disease, requiring appropriate otorhinolaryngologic as well as radiologic diagnostics, and medical and surgical intervention by a transoral, transcervical or transnasal approach in a multidisciplinary setting.

OBJECTIVES

The risks and benefits of surgical intervention in patients with RPA were assessed. The main outcome measure was the clinical resolution of the abscess.

PATIENTS AND METHODS

A retrospective chart review was performed at a tertiary care university hospital over a period of 28 months. Eleven patients aged 1 to 68 years with the diagnosis of RPA were included.

RESULTS

All patients presented with restricted cervical mobility and all patients had CT and/or MRI scan on admission. The mean abscess volume was 9.4 cm(3). Surgical intervention was performed in all cases, including transoral (n=5), transcervical (n=3) or combined transoral and transcervical (n=2) drainage. In one patient RPA close to the skull base was drained by an MRI-guided transnasal approach. All patients recovered; however, there was one recurrence and in one case surgical tracheotomy was unavoidable during the course of disease. Growth of streptococcal species was verified in six of the examined abscesses. Abscessing lymphadenitis, infection of a cervical cyst, and previous ganglionar local opioid analgesia treatment were identified as causative factors.

Management of deep neck infection by a transnasal approach: a case report

Introduction

Deep neck infection is a life-threatening condition, and intravenous antibiotic therapy is preferable in the early stages of the disease. However, in the advanced stages, surgical drainage should be performed. Although several surgical treatment strategies are available, it is necessary to standardize treatment according to the patient's general condition and history.

Case presentation

We report the case of a 68-year-old man with a deep neck abscess and with severe diabetes mellitus and inflammation. Computed tomography identified a deep neck infection extending from the level of the epipharynx to that of the hyoid bone. We performed surgical drainage by transnasal endoscopy. The patient exhibited no evidence of either recurrent disease or post-surgical complications within 30 months of follow-up.

Conclusions

This case report provides evidence that transnasal endoscopic drainage should be recommended as a standard approach in patients with a deep neck abscess and with a severe general condition, diabetes mellitus, and inflammation.

Ludwig's angina in the pediatric population

As many as 1 in 3 of cases of Ludwig's angina occur in children and adolescents, and pediatricians are therefore ideally situated to detect these individuals at an early stage of their potentially life-threatening disease. The early identification and referral of children afflicted with Ludwig's angina to tertiary care centers allows for the rapid initiation of medical therapy and the consultation of those emergency services critical to providing such patients with optimal diagnostic and therapeutic interventions. This review provides an overview of the anatomical and pathophysiological considerations in Ludwig's angina and describes practical management principles to assist pediatricians in the diagnosis and treatment of this disease. Included in this review is an evidence-based algorithm for airway management.

[Abscess of the parapharyngeal space]

The abscess of parapharyngeal space is very dangerous health condition graving numerous complications such as: jugular vein thrombosis, mediastinitis, arterial bleeding. This state originates most frequent during the acute pharyngitis, and especially acute tonsillitis. The aim of our study was to review the clinical sings, computed tomography scans and outcome of parapharyngeal space infection. 3 patients treatment in our Department were underwent surgical drainage and aggressive antibiotic therapy. One patient was treated solely with intravenous antibiotic therapy. The average time of hospitalization was 16 days. No one complication was observed.

Deep neck abscess: an analysis of microbial etiology and the effectiveness of antibiotics

The objective was to demonstrate the aerobic and anaerobic microbiology of deep neck space abscess and to analyze the coverage rate of different empiric antimicrobial agents. A retrospective review of hospitalized patients with deep neck abscess diagnosed at a tertiary-care, general hospital between April 2001 and October 2006. The study enrolled 100 patients. The bacterial cultures of 89 patients yielded positive results (89%). The predominant aerobes were viridans streptococci, Klebsiella pneumoniae, and Staphylococcus aureus. The predominant anaerobes included species of Prevotella, Peptostreptococcus, and Bacteroides. Five different combinations of empiric antibiotics, namely regimen 1: penicillin G and clindamycin and gentamicin, regimen 2: ceftriaxone and clindamycin, regimen 3: ceftriaxone and metronidazole, regimen 4: cefuroxime and clindamycin, and regimen 5: penicillin and metronidazole, were compared using the antimicrobial susceptibility of 89 cases. The coverage rates of regimens 1, 2, 3, 4, and 5 were 67.4%, 76.4%, 70.8%, 61.8%, and 16.9%, respectively. The coverage of regimen 5 was considerably worse than that of the other four regimens (p < 0.001). Regimen 2 was significantly better than regimen 4 (p < 0.001). Regimen 2 had better coverage than regimens 1 (p = 0.096) and 3 (p = 0.302), but the difference was not statistically significant. This study demonstrates the bacteriology of deep neck abscess and analyzes the coverage rate of different empiric antimicrobial agents. Regimens 1, 2, and 3 could be good candidates for empiric antibiotics. Pathogen-directed antimicrobial therapy should be adjusted after the culture results are obtained.

Deep neck infections: a retrospective review of 112 cases

The purpose of this study was to review our recent experience with deep neck infections and compare it to the experiences in the available literature. A total number of 112 charts of patients treated for deep neck infections at the department of otolaryngology of our hospital between August 1996 and September 2007 were retrospectively reviewed. All the relevant clinical charts including presentation, origin and site of deep neck infection, radiological, and bacteriological studies and interventions along with demographic profile, details of hospital stay, and outcomes were evaluated. The findings were compared to those in the available literature. Until 2002, we had nearly constant number of patients annually but since then we have found an increasing number of them. The most common presenting symptom was neck swelling (88.4%). Fever was present in 63.4 and 78% had leukocytosis. The most common known cause was dental infection (31.3%) and in 32.1% of them origin remained unknown. The most commonly encountered site was the submandibular space and 23.2% of patients had two or more involved spaces. Exactly 20.5% were treated with intravenous antibiotic therapy alone whereas 79.5% had surgical procedures with successful results in 98.2% of them. Diabetes mellitus was diagnosed in 20.5% of cases. There was no case of known primary or acquired immunodeficiency. We had two deaths from septic shock but there was not any other complication. Mean hospitalization time was 7 days. Deep neck infections remain potentially lethal infections if they are not diagnosed early and treated promptly. Widespread diffusion of empirical broad-spectrum oral antibiotic and anti-inflammatory treatments may cause masked presentations of deep neck infections without swelling, fever, or leukocytosis. Our tailored approach (medical or medical and surgical) based on clinical and radiological evidence was successful in 98.2% of the patients with a short mean hospitalization time.

Deep neck infection - analysis of 80 cases

Deep neck infections are serious diseases that involve several spaces in the neck. The most dreadful complication is descending necrotizing fasciitis, which needs early diagnosis and aggressive treatment.

Aim

To analyze 80 treated cases of deep neck infection and propose a schematic guideline for managing this disease.

Method

The authors present a retrospective analysis of 80 treated cases of deep neck infection, from June 1997 to June 2003.

Results

Odontogenic and tonsilar causes were the more frequent ones. Submandibular and parapharyngeal spaces were the most frequent location of deep neck infection. Staphylococcus aureus and Streptococcus sp were the microorganisms more commonly isolated.

Conclusions

Airway control should be priority in managing deep neck infections and if the patient has to be submitted to surgery special care should be taken at the moment of intubation - when curare must never be used. CT scan is the gold-standard imaging evaluation for the diagnosis of deep neck infection. Morbi-mortality is high when associated with septic shock and mediastinitis. Our mortality rate was 11.2% and only one, in five patients with mediastinitis, survived.

Challenging airways in deep neck space infections

Skilful airway management is critical in deep neck space infections. Although relatively uncommon, this spectrum of disease presents a clinical challenge for otolaryngologists and anesthetists. There is currently no universal agreement on the ideal method of airway control for these patients because this depends on various factors including available local expertise and equipment. We review the literature and discuss the available options of airway management in these head and neck emergencies. Special consideration is given to awake fiberoptic intubation and tracheotomy under local anesthesia. Relevant anatomy, route of spread and microbiology of deep neck space infections are also briefly discussed.

Perforating and Migrating Pharyngoesophageal Foreign Bodies: A Series of 5 Patients

Ingestion of a foreign body is a problem seen in nearly all otolaryngologic practices. One of the least common complications of foreign-body ingestion is penetration and migration, which may lead to serious morbidity or even death. We report the findings of a retrospective review of a series of 5 patients who had presented with a complete foreign-body penetration. All of them had radiologic evidence of a foreign body, but findings on rigid endoscopy were negative. Computed tomography is the radiologic study of choice to identify penetrating foreign bodies. The foreign bodies in all 5 patients were extracted via an external approach.

Otolaryngologic emergencies in the outpatient setting

Disease processes involving the ear, nose, and throat account for millions of office visits to primary care physicians per year. Because of their proximity to the airway as well as critical neurologic and vascular structures, the disease process in each individual case carries the potential for significant complications. Fortunately, improvements in medical care have significantly reduced the prevalence of these complications. As a result of their relative rarity, most physicians may be unfamiliar with the clinical presentation of these entities. This article familiarizes the physician with the pathophysiology and clinical presentation of the more commonly encountered otolaryngologic complications. The physician should seek to rule out the presence of the aforementioned complications in each patient who presents with an otolaryngologic complaint. Any suggestion of their presence should prompt an immediate referral to a subspecialist or an emergency department. It is hoped that continued familiarization with these' disease processes will maintain them as rare entities of medical practice.

Retropharyngeal Abscess Presenting as Benign Neck Pain

OBJECTIVE

To present a case of an uncommon presentation of cellulitis of the neck as benign neck pain.

CLINICAL FEATURES

A 44-year-old man had severe neck pain and headaches for 2 weeks with an unknown cause. Minimal response to chiropractic treatment leads to coordination of treatment with the patient's primary care physician. Laboratory assessment and magnetic resonance imaging initially were viewed as insignificant but were repeated and showed a retropharyngeal abscess.

INTERVENTION AND OUTCOME

Chiropractic treatment did not reduce the patient's neck pain as expected. Fusion of C1 to C2 was eventually performed.

CONCLUSION

Neck pain is a common reason for patients to seek chiropractic care. This case shows an uncommon differential diagnosis for a patient who does not respond quickly to chiropractic treatment for neck pain.

Spectrum and management of deep neck space infections: an 8-year experience of 234 cases

OBJECTIVE

To study the clinical course and outcome of deep neck infections (DNI), with special emphasis on microbiology and histopathology.

STUDY DESIGN

Two hundred thirty-four patients with DNIs were included in this study. Patients with peritonsillar or dental infections, infections arising from salivary glands, as well as subjects with abscesses caused by neck trauma were excluded.

METHODS

Clinical analysis of all patients with DNIs who were treated between January 1, 1997 and May 31, 2005 in a single center.

RESULTS

In 13 patients, the DNI was the first manifestation of a malignant tumor. In 17 cases, the DNI was associated with cat-scratch disease (CSD). Six patients suffered from tuberculosis, and in another 7, an infected lateral cleft cyst was found. In 176 patients, the origin of DNI remained unclear.

CONCLUSIONS

Our results demonstrate that CSD, tuberculosis, and malignant tumors must be considered as possible causes of DNIs. The current study represents one of the largest series of DNIs in the modern medical literature.

EBM RATING

C.

Infecciones cervicales profundas: etiología, bacteriología y terapéutica

Deep neck infections are dangerous for its potential ease to fascial spread, sepsis, and upper airway obstruction. This article reviews 77 cases of deep cervical infection, focus on etiological, clinical and therapeutic aspects. The most frequent location was the submaxillary area (29%), followed by the parapharyngeal space (28%), floor of the mouth (27%) and retropharyngeal (14%) spaces. Etiology was dental in 32%; pharyngoamigdalar infection in 27%; foreign bodies in 13%. In 22% the cause is unknown. Two or more bacteria were isolated in 72%, with Streptococcus B haemolytic being the most frequent germ. All patients were treated with intravenous broad-spectrum antibiotics. Surgical drainage was needed in 54%, and tracheotomy in 18%. Four patients developed mediastinitis, and one died as a consequence of it. The incidence of deep neck infections has decreased after the itroduction of antibiotics but they still may be lethal especially when life-threatening complications occur. Early recognition and management are necessary.

Carotid space infection: A case report

A case of isolated carotid space abscess is reported here for its rarity. No identifiable cause was detected in this case. Management involved incision and drainage of the abscess, close monitoring for the signs of complications and 8 weeks long antibiotic coverage. The only stigma of the abscess six months after presentation is a unilateral vocal cord palsy. A brief review of relate literature is also included.

Profile of neck cellulitis-Clinician's dilemma

Cellulitis neck may be the only presenting feature of an underlying disease in the upper aerodigestive tract. Inflammation in the head and neck region spreads through potential neck spaces to the surface by direct extension or by lymphatic spread. Four cases of cellulitis neck who presented in the emergency department and progressed with variable clinical course are reported in this paper. After initial treatment with parenteral broad spectrum antibiotics, investigations revealed underlying disease and appropriate treatment was instituted. The importance of detailed clinical examination, investigations and key management protocols are highlighted.

Extracranial internal carotid artery pseudoaneurysm

Extracranial internal carotid artery aneurysms are very uncommon entities. We present the case of a young girl who was transferred to our institution after development of a neck mass after Quincy tonsillectomy. The literature on extracranial carotid artery aneurysms is reviewed and reported.

Airway management in adult patients with deep neck infections: a case series and review of the literature

Patients with deep neck infections, especially those with Ludwig's angina, may die as a result of airway management mishaps. Skillful airway management is critical, but a safe method of airway control in these patients is yet to be established. We subjected patients with deep neck infections to fiberoptic tracheal intubation by using topical anesthesia to provide general anesthesia for surgical interventions. Patient characteristics and techniques for intubations were recorded on a special data-collection form. Of the 26 patients, 17 had Ludwig's angina, and 9 had other types of deep neck infections. Three patients were tracheally intubated while in the sitting position, 2 in Fowler's position, and 21 in the supine position with the head up 10 degrees-15 degrees. Tracheal intubations were successful in 25 patients: 19 nasally and 6 orally. After surgery, seven patients were kept tracheally intubated, and five patients had tracheostomies. Complications were limited to three cases of mild epistaxis and four oversedations with transient hypoxemia. Twelve patients remembered part of the procedure, and two considered it unpleasant. Tracheal intubation with a flexible bronchoscope by using topical anesthesia is highly successful in adult patients with deep neck infections. Tracheostomy using local anesthesia is recommended if fiberoptic intubation is not feasible, if the clinician is not skillful in the use of awake fiberoptic intubation, or if intubation attempts have failed.

Drainage of retro-parapharyngeal abscess: an additional indication for endoscopic sinus surgery

Deep neck abscesses are life-threatening conditions, in early stages preferably treated by intravenous antibiotic therapy; in advanced stages, surgical drainage is mandatory. We report two cases of retro-parapharyngeal abscess with prevalent retronasopharyngeal extension in two men aged 60 and 82, both of whom underwent transnasal endoscopic drainage. The main surgical steps were incision of the posterior pharyngeal mucosal wall, widening of the incision, drainage of purulent collection and careful dissection and removal of the necrotic tissue. The first patient, with an abscess associated with chronic otitis media and presenting hypoglossal nerve palsy, quickly recovered from pharyngodinia, otalgia and trismus. Twenty-six months after surgery, he is symptom-free, with hemitongue atrophy due to denervation as the only residual sign. The second patient, affected by skull base osteomyelitis secondary to malignant external otitis, after a first successful drainage, underwent a second endoscopic procedure for the reoccurrence of an abscess in the contralateral retroparapharyngeal space. Twelve months after the first surgery, the patient reported an improvement of symptoms, except for persistent dysphonia related to vagal nerve palsy. At follow-up MR, another abscess was detected in the left retro-parapharyngeal space. In selected cases of abscess, transnasal endoscopic drainage may be an effective alternative to external approaches. Minimal morbidity, the absence of cervical or palatal scars and a short hospitalization time can be considered as important advantages in comparison to external approaches. Patients with abscess secondary to skull base osteomyelitis require close imaging surveillance because of the difficulty of definitive control of the disease.

Retropharyngeal and parapharyngeal infections in children: the Toronto experience

OBJECTIVE

To review the Hospital of Sick Children, Toronto's experience of the diagnosis and management of retropharyngeal and parapharyngeal infections with particular emphasis on the role of computed tomography (CT) imaging in diagnosing the presence of an abscess.

METHODS

A retrospective analysis of all patients diagnosed with retropharyngeal and parapharyngeal infections from 1987 to 1999 was performed. Demographic data, presenting symptoms, season of presentation, management and complications were reviewed. The CT scans of 27 patients who underwent surgical treatment were retrospectively examined by two neuroradiologists who were blinded to the patient's history and outcome. The sensitivity, specificity and predictive values for the specific features and overall assessment were calculated.

RESULTS

Fifty-four children were identified. There were 46 retropharyngeal infections, 6 parapharyngeal infections and 2 patients had both retropharyngeal and parapharyngeal infections. All patients were treated with parenteral antibiotics. Thirty-seven patients underwent surgical drainage and in 27 there was a positive finding of pus. The retrospectively assessed CT scans of the 21 patients who underwent surgery were found to have a sensitivity of 81% in detecting an abscess by CT scan but the specificity was 57%. There were four complications including mediastinitis, aspiration pneumonia, internal jugular vein thrombosis and common carotid artery aneurysm. All patients recovered but abscess recurred in five patients.

CONCLUSION

Not all patients with retropharyngeal and parapharyngeal abscesses require surgery. Whilst CT scans are helpful in diagnosing and assessing the extent of these infections they are not always accurate in detecting an abscess. A decision to drain an abscess should therefore not be made based solely on the CT findings.

Deep neck infection: Analysis of 185 cases

PURPOSE

This study reviews our experience with deep neck infections and tries to identify the predisposing factors of life-threatening complications.

METHODS

A retrospective review was conducted of patients who were diagnosed as having deep neck infections in the Department of Otolaryngology at National Taiwan University Hospital from 1997 to 2002. Their demographics etiology, associated systemic diseases, bacteriology, radiology, treatment, duration of hospitalization, complications, and outcomes were reviewed. The attributing factors to deep neck infections, such as the age and systemic diseases of patients, were also analyzed.

RESULTS

One hundred eighty-five charts were recorded; 109 (58.9%) were men, and 76 (41.1%) were women, with a mean age of 49.5 +/- 20.5 years. Ninety-seven (52.4%) of the patients were older than 50 years old. There were 63 patients (34.1%) who had associated systemic diseases, with 88.9% (56/63) of those having diabetes mellitus (DM). The parapharyngeal space (38.4%) was the most commonly involved space. Odontogenic infections and upper airway infections were the two most common causes of deep neck infections (53.2% and 30.5% of the known causes). Streptococcus viridans and Klebsiella pneumoniae were the most common organisms (33.9%, 33.9%) identified through pus cultures. K. pneumoniae was also the most common infective organism (56.1%) in patients with DM. Of the abscess group (142 patients), 103 patients (72.5%) underwent surgical drainages. Thirty patients (16.2%) had major complications during admission, and among them, 18 patients received tracheostomies. Those patients with underlying systemic diseases or complications or who received tracheostomy tended to have a longer hospital stay and were older. There were three deaths (mortality rate, 1.6%). All had an underlying systemic disease and were older than 72 years of age.

CONCLUSIONS

When dealing with deep neck infections in a high-risk group (older patients with DM or other underlying systemic diseases) in the clinic, more attention should be paid to the prevention of complications and even the possibility of death. Early surgical drainage remains the main method of treating deep neck abscesses. Therapeutic needle aspiration and conservative medical treatment are effective in selective cases such as those with minimal abscess formation.

Parapharyngeal abscess: diagnosis, complications and management in adults

Parapharyngeal abscess may cause life-threatening complications. Peritonsillar abscess and tonsillitis may result in parapharyngeal abscess. Since the introduction of antibiotics, the incidence of parapharyngeal abscess secondary to tonsillitis and peritonsillar abscess has decreased dramatically. We present five cases of parapharyngeal abscess resulting from tonsillitis and peritonsillar infection extending to the parapharyngeal space in adult patients. Two were complicated by mediastinitis despite early treatment by wide spectrum antibiotics. We believe that early diagnosis and aggressive antibiotic treatment with early surgical drainage in cases associated with pus collection are the key points in preventing serious and fatal complications. We emphasize the diagnostic role of computerized tomography (CT) scan and the importance of early and proper drainage of these abscesses.

A Review of Ludwig's Angina for Nurse Practitioners

PURPOSE

To discuss the causative factors, clinical course, and current treatment modalities for Ludwig's angina, a submandibular cellulitis, and to raise nurse practitioners' (NPs') awareness of this condition.

DATA SOURCES

Recent clinical articles, research, case studies, and medical texts.

CONCLUSIONS

Ludwig's angina may be fatal. Early diagnosis, aggressive antibiotic therapy, and management involving a multidisciplinary team approach are imperative for the patient to progress without complications.

IMPLICATIONS FOR PRACTICE

Education and awareness are crucial for successful diagnosis of and management of treatment for Ludwig's angina. Although NPs have a limited role in the treatment of Ludwig's angina, their ability to recognize the signs and symptoms will prompt emergency care and treatment and facilitate better outcomes for their clients.

Deep Fascial Space Infection of the Neck: A Continuing Challenge

We present our clinical experience with two complex cases of deep fascial space infections of the neck. The first was a case of cervical necrotizing fasciitis involving the submental space. The second was an infection beginning at the soft palate and extending to the anterior mediastinum. Both infections emanated from an oral source in patients with diabetes mellitus, and both patients required multiple surgical debridements and endotracheal intubation for airway protection. Despite the declining incidence of deep space neck infections, our cases illustrate the challenging diagnostic and treatment dilemmas for the clinician managing patients with diabetes.

Ludwig's angina: a clinical review

Ludwig's angina is caused by a rapidly expanding cellulitis of the floor of the mouth and is characterized by a brawny induration of the floor and suprahyoid region (bilaterally), with an elevation of the tongue potentially obstructing the airway. In the pre-antibiotic era, Ludwig's angina was frequently fatal; however, antibiotics and aggressive surgical intervention have significantly reduced mortality. We reviewed nine patients with Ludwig's angina between July 1996 and June 2002, all of whom presented with fever, neck swelling, bilateral submandibular swelling and elevation of the tongue. In eight patients (89%) a dental infection appeared to be the underlying cause. High-dosage intravenous antibiotics directed towards the suspected causative microorganisms were given to all of the patients: two were treated successfully with conservative medical management, while seven underwent surgical drainage (a tracheotomy was necessary in one patient). Routine aerobic cultures were done on samples of drained material and the predominant microorganisms were Streptococcus species in two patients; there were none in the other five. Two patients had post-operative complications, but all recovered.

Retropharyngeal abscess in children: clinical presentation, utility of imaging, and current management

OBJECTIVE

We sought to describe the clinical presentation of patients with retropharyngeal abscess (RPA), utility of imaging studies, and implications on management.

METHODS

A retrospective chart review was performed at a tertiary-care, pediatric hospital with cases identified by a discharge diagnosis of RPA; posttraumatic RPA cases were excluded. Patients without confirmatory radiographic findings, fluoroscopy, or computed tomography (CT) were excluded.

RESULTS

Sixty-four cases involving 64 patients were studied. The median age of the patients was 36 months; 48 (75%) of the 64 patients were younger than 5 years. The most common chief complaints were neck pain (38%), fever (17%), sore throat (17%), neck mass (16%), and respiratory distress or stridor (5%). In 29 children (45%), it was noted that there was limitation of neck extension, in 23 (36.5%) torticollis, and in 8 (12.5%) limitation of neck flexion. The physical examination revealed stridor with wheezing in only 1 patient (1.5%) and wheezing in 1 other (1.5%). Twenty-seven patients (42%) underwent surgery; 37 (58%) were treated with antibiotics only. Performance of a surgical procedure was significantly associated with CT scan findings. Ten (37%) of 27 patients with defined abscess on CT scan were treated with antibiotics alone. There were no treatment failures in either the antibiotic-only group or the antibiotics-plus-surgery group.

CONCLUSIONS

Children with RPA present with limitation of neck movement, especially difficulty extending their neck to look up. They rarely present with respiratory distress or stridor. CT scan is useful to distinguish patients with RPA from those with retropharyngeal cellulitis. Most patients with retropharyngeal cellulitis and some with RPA can be treated successfully without surgery.

Characterizations of life-threatening deep cervical space infections: a review of one hundred ninety-six cases

PURPOSE

The incidence of deep cervical space infections has decreased after the introduction of antibiotics and improvement of oral hygiene, but they still may be lethal especially when life-threatening complications occur. In this article, we try to find out whether there are predisposing factors related to complicated deep cervical space infections and prolonged hospitalization.

MATERIALS AND METHODS

We conducted a retrospective analysis of medical records of 196 patients with deep neck infections during the period from March 1996 to February 2002. Among the 196 patients, 15 patients developed lethal complications. As for data analysis, multiple regression and logistic regression with dummy variable were used.

RESULTS

In multiple regressions, patients with older age or with neck swelling, trismus, underlying diseases, complications, and C-reactive protein more than 100 microg/mL stayed longer in the hospital, and the P value reached statistical significance (P <.05). In logistic regression, male patients and patients with neck pain had negative correlation, and the P value reached statistical significance (P <.05). Patients with neck swelling and patients with respiratory difficulty had positive correlation, and the P value reached statistical significance (P <.05). That means female patients, patients with neck swelling, and patients with respiratory difficulty were more likely to have complicated deep neck infections.

CONCLUSION

Complicated deep neck infections remain potentially fatal, but the morbidity and mortality can be reduced. Doctors should pay more attention to those high-risk patients; they are female patients, patients with neck swelling, and patients with respiratory difficulty.

Upper airway diseases and airway management: a synopsis

This article summarizes some of the more important upper airway conditions likely to affect airway management. A number of upper airway conditions may present difficult challenges to the anesthesiologist. For instance, infected airway structures may lead to partial airway obstruction, stridor, or even complete airway obstruction. Partial airway obstruction may be mild, as in snoring or nasal congestion, or may be more severe, perhaps requiring the use of airway adjuncts, such as a nasopharyngeal airway. Complete airway obstruction is usually managed by prompt intubation, but surgical airways are sometimes needed as a last resort.

Penetrating injury to the pharynx by a toothbrush in a pediatric patient: a case report

Penetrating injury of the pharynx is rare, but it can cause serious sequelae in children. A 12-month-old boy was impaled with a toothbrush in the retropharyngeal space after falling from a baby-bed. The point of the toothbrush was embedded beside the carotid artery and was removed by endoscopic surgical technique. The patient was discharged without neurological complication or abscess formation. We present a rare case of a penetrating injury by a toothbrush and discuss such injuries.

Infecções dos espaços cervicais: estudo prospectivo de 57 casos

Objetivo: apesar da antibioticoterapia, as infecções dos espaços cervicais profundos continuam a ter grande importância, tanto por sua alta incidência, como pelo risco de complicações. Forma de estudo: clínico, prospectivo. Material e método: descrevem-se neste estudo 57 casos de pacientes com diagnóstico de infecção cervical (celulite, abscesso e fasceíte necrotizante) internados na Enfermaria de Otorrinolaringologia do Hospital das Clínicas da Faculdade de Medicina da USP entre janeiro de 1999 e janeiro de 2001. Cinqüenta pacientes (87,7%) apresentavam abscesso cervical, cinco (8,8%), celulite e dois pacientes (3,5%), fasceíte necrotizante. A infecção odontogênica foi o foco de origem mais prevalente, responsável por 24 casos (42%), seguida das amigdalites (17,5%) e linfadenites (15,8%). Os espaços cervicais mais acometidos foram o submandibular (57,9%), o sublingual (26,3%) e o parafaríngeo (24,6%). Em 53 pacientes realizaram-se culturas das quais 71,7% foram positivas, sendo que 20,8% destas apresentaram flora mista. Os microorganismos mais prevalentes dentre os aeróbicos foi o Streptococcus viridans (41,5%) e, dentre os anaeróbios, Peptostreptococcus micros e Peptostreptococcus sp (5,7% e 3,8%, respectivamente). A associação entre penicilina cristalina e metronidazol foi o tratamento preconizado em 31 pacientes (54,3%). Nos demais, diversos antibióticos como clindamicina, cefalosporinas de terceira geração, cloranfenicol e oxacilina foram utilizados. Cinqüenta e quatro pacientes (94,7%) evoluíram satisfatoriamente, dois (3,5%) apresentaram deiscência da ferida cirúrgica e um (1,7%) foi a óbito por mediastinite. Conclusão: os abscessos cervicais ainda configuram uma importante causa de morbidade em nossa população e suas complicações requerem vigilância para a prevenção e abordagem oportunas, especialmente pelo tratamento mais adequado.

Deep neck abscess: a retrospective review of 210 cases

This study was performed to review our experience with deep neck abscesses (DNAs) and compare it to the experiences in the available literature, and to study changing trends within our patient population. We retrospectively studied 210 patients who had DNAs between 1981 and 1998. Peritonsillar abscesses and limited intraoral abscesses were excluded. Demographics, presentation, etiology, site of abscess, associated systemic diseases, bacteriology, radiology, treatment, airway management, and outcome were reviewed. We compared the entire group to those in the available literature and studied changing trends within this patient population. Dental infection (43%) was the most common cause, followed by intravenous drug abuse (12%) and pharyngotonsillitis (6%). The incidences of intravenous drug abuse and mandibular fractures as causes of DNA were 19% and 8%, respectively, during the period 1981 to 1990, but were only 1% each during the period 1991 to 1998. Streptococcus viridans was the most common pathogen (39% of positive cultures), followed by Staphylococcus epidermidis (22%) and Staphylococcus aureus (22%). Lateral pharyngeal space abscess was the most common DNA (43%), followed by submandibular space abscess, Ludwig's angina, and retropharyngeal space abscess (28%, 17%, and 12%, respectively). Seventy-five percent of patients with true Ludwig's angina underwent tracheotomy. Nondental infections are no longer a significant etiologic factor in DNA. Streptococcus viridans has replaced S aureus and beta-hemolytic streptococci as the most common pathogen. Lateral pharyngeal space abscess was the most common DNA; however, its incidence has progressively decreased over the past decade. Intravenous drug abuse and mandibular fractures are no longer major etiologic factors. Tracheotomy is indicated in patients with Ludwig's angina.

Surgical management of retropharyngeal space infections in children

OBJECTIVE

To study the perioperative management strategies in a large group of pediatric patients undergoing surgical therapy for suppurative adenitis of the parapharyngeal and retropharyngeal spaces.

STUDY DESIGN

Retrospective analysis of all patients treated surgically from January 1, 1989, to December 31, 1998, in a tertiary care pediatric hospital.

METHODS

Charts were reviewed for demographic data, duration and nature of symptoms, radiological workup, surgical approach, complications, duration of medical therapy and antibiotic choice, and bacteriological findings. Computed tomography (CT) results were correlated to surgical findings.

RESULTS

A dramatic increase in the incidence of deep neck space infection was seen during the study period; this increase was congruent with the increase in culture-positive group A beta-hemolytic streptococcal abscesses. More than two-thirds of the patients were boys with the peak incidence being in the 3- to 5-year-old group. The duration of symptoms before presentation was less than might be expected, especially in the younger age groups. Seventy of 73 children were treated with a transoral approach. Sixty-eight of 73 were successfully treated with one operative intervention. Irregularity of the abscess wall was found to be a stronger predictor of the presence of pus than the presence of ring enhancement.

CONCLUSIONS

The current study represents the largest series of pediatric retropharyngeal abscesses in the modern medical literature. Changes in the disease process and in management from the first half of the century to today are reviewed, and recommendations for optimal management presented. The data in this series support a transoral approach to these abscesses unless there is extension lateral to the great vessels.

The changing face of odontogenic infections

PURPOSE

The purpose of this investigation was to compare characteristics of patients hospitalized with odontogenic infections during the 1980s to those of the 1990s.

PATIENTS AND METHODS

This study was a retrospective record review that compared 2 cohorts of patients admitted to the same institution during two 81-month periods, one decade apart. Admission criteria were face or neck swelling suggesting abscess or cellulitis and one or more of the following: temperature above 38 degrees C, white blood cell (WBC) count greater than 10.8 x 10(3)/microL, or concern about airway compromise. Characteristics reviewed were age, gender, race, admission temperature, admission WBC count, fascial space(s) involved, tooth of etiology, duration of hospitalization, and bacteria isolated. Data were compared for statistical significance (P <.05).

RESULTS

No significant differences were found between the 2 cohorts for age, gender, race, admission temperature, admission WBC count, space involvement, or length of stay (P <.05). One tooth (mandibular left first molar) of 52 was involved more frequently in the 1990 group (P <.03). Gram-positive cocci were isolated significantly more frequently from the 1990s patients than from the 1980s patients (P <.03). There were also significant differences (P <.02) between cohorts in the isolation frequency of individual genera, such as alpha-hemolytic Streptococci, coagulase negative staphylococci, Staphylococcus epidermidis, Bacteroides melanogenicus, beta-lactamase positive Bacteroides, Eikenella corrodens, and Neisseria species. Eighty-one percent of the bacteria cultured from the 1990s patients were resistant to one or more common antibiotics; 47% of these organisms were Staphylococcus aureus.

CONCLUSION

No clinically significant differences existed in the characteristics of patients hospitalized with odontogenic infections between the 1980s and the 1990s. Although there were differences in the type and prevalence of bacteria isolated, this was probably a result of changes in nomenclature, identification protocols, and isolation techniques.

US-guided needle aspiration and catheter drainage as an alternative to open surgical drainage for uniloculated neck abscesses

PURPOSE

To prospectively evaluate the effectiveness of ultrasound (US)-guided needle aspiration and catheter drainage as an alternative to open surgical drainage of uniloculated neck abscesses.

MATERIALS AND METHODS

Fifteen consecutive patients (11 female, four male; age range from 18 days to 78 years, mean 42.5 y +/- 22.4) diagnosed with deep neck infections associated with uniloculated neck abscesses were treated. The patients were originally scheduled for surgical incision and drainage after a period of unsuccessful treatment with antibiotics. US-guided needle aspiration (in 10 patients) and US-guided catheter drainage (in five patients) were performed under local anesthesia. Open surgical drainage was performed when US-guided drainage procedures failed.

RESULTS

Surgical open drainage was avoided in 13 of the 15 patients (87%). An average of 6 mL of pus was obtained in patients in the needle aspiration group and 140 mL of pus was drained by catheter. One patient had a recurrent pyogenic lymphadenitis at the same location and was treated successfully by repeated needle aspiration. No complications occurred in this study.

CONCLUSION

In a selected group of patients without imminent airway obstruction, most uniloculated neck abscesses may be managed initially by US-guided needle aspiration and catheter drainage before resorting to open surgical drainage.

[Parapharyngeal abscess: perilaryngeal infrahyoid extension]

Parapharyngeal abscesses are located between the skull base and the hyoid bone. Their infrahyoid extension is usually following the retropharyngeal space, but also can be through the medial aspect of the parapharyngeal space. Thus, surrounding the visceral fascia, they might invade the perilaryngeal and perihypopharyngeal spaces. This results in more significant airway compromise. Computed tomography is essential while locating and evaluating the extension of these infections, specially with regards to the great vessels. We report on 8 parapharyngeal abscesses with perilaryngeal and/or perihypopharyngeal extension. We review their clinical and radiological features, based on computed tomography, as well as their medical and surgical treatment. When medical therapy fails, as they are usually medial to the great vessels, it is possible to perform aspiration and drainage transorally, avoiding the need for cervicotomy, in selected cases.